Q&A: Women less likely than men to receive guideline-directed care during heart surgery
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Key takeaways:
- Compared with men, women having heart surgery are less likely to receive guideline-directed care and more likely to have poor outcomes.
- Efforts to understand how to narrow the gaps in care are underway.
Three studies published recently indicate that women who undergo heart surgery are less likely to receive guideline-directed care and more likely to have poor outcomes compared with men.
In one paper, among patients with preoperative atrial fibrillation undergoing nonmitral cardiac surgery, women were 26% less likely than men to have a guideline-directed concomitant AF procedure.
In another study, among patients with moderate or severe tricuspid regurgitation undergoing a mitral valve operation for degenerative disease, women were 52% less likely than men to have concomitant tricuspid valve repair, and were more likely than men to need a reoperation or to have severe tricuspid regurgitation at 4 years.
In a third paper, among Medicare beneficiaries who had CABG, women were more likely than men to have their procedure at a lower-quality hospital, and the sex disparities in 30-day mortality were greater at lower-quality hospitals than at higher-quality hospitals.
Healio spoke with Catherine M. Wagner, MD, MSc, an integrated thoracic surgery resident at University of Michigan Health who was first author on all three studies, about why women having heart surgery are less likely than men to receive guideline-directed care and what can be done to address the disparity.
Healio: What got your team interested in the issues that led to these three papers?
Wagner: We became interested in gender outcomes disparities because there have been long-standing differences in outcomes between men and women undergoing heart surgery, and we wanted to explore possible sources of these worse outcomes. We found that, No. 1, women may be going to lower-quality hospitals, which could be contributing to their higher rates of mortality, and No. 2, that women undergoing heart surgery are less likely to receive guideline-recommended care. These are two actionable areas that we can impact and change to directly improve care and outcomes for women undergoing heart surgery.
Healio: Why do you think that among patients who had heart surgery, women were less likely to receive guideline-directed care and more likely to have poor outcomes?
Wagner: The guidelines we evaluated were for additional recommended procedures while a patient is already undergoing cardiac surgery. For example, if you bring your car into the mechanic for a transmission problem, they may also notice your brake light is burned out and fix your brake light while fixing your transmission. We found that women who were already undergoing heart surgery for another reason were less likely to have these additional issues fixed, despite guideline recommendations.
The lower rate of guideline-directed care is complex and multifactorial. It may be because women are often higher risk for surgery, which may make surgeons hesitant to add additional procedures — even though these additional procedures are recommended in guidelines. Women may also be going to hospitals or surgeons that are less familiar or comfortable with performing these guideline-recommended procedures. Additional research focused on surgeon-perceived barriers to doing these procedures in women will be important to understand how to narrow these gaps in care.
However, undertreatment of women is a problem throughout many facets of CVD, including medical therapies and transcatheter therapies. This points to a broader, systemic issue of the treatment of women with heart disease. There are recent efforts to increase research in women with heart disease, which I think will be key to improving women’s outcomes overall and narrowing these gaps in outcomes and guideline-directed care.
Healio: Why do the guidelines appear less likely to be followed for female patients than for male patients?
Wagner: While we have successfully increased guideline-directed care over time, there are gaps that remain for women. Guidelines may be less likely to be followed for women because adding an additional procedure can sometimes add additional surgical risk. Because women are often higher risk for heart surgery than men, surgeons may be hesitant to fix additional problems in an already higher-risk patient. Women may also be going to surgeons that are less familiar with performing these additional procedures. It will be important to talk to surgeons to understand how surgeons decide when to do these additional procedures, and understand what surgeons see as a barrier to doing these additional procedures in women to narrow the gap.
Healio: What are the implications for women with heart disease if these disparities remain?
Wagner: Guideline-recommended procedures are in the guidelines because research and trials have found the benefits of these procedures outweigh the risks. We have already made progress in increasing the rate of guideline-recommended procedures over time, but there has been a persistent gap in the receipt of those procedures for women, which could be contributing to their worse outcomes after heart surgery. Now that we have identified this disparity in treatment, we can focus on narrowing the gap and improving outcomes for women undergoing heart surgery.
Healio: What can be done to address the disparities and provide guideline-directed care to women who need heart surgery?
Wagner: The first step to addressing a disparity is identifying it. Now that we have identified this disparity, I have partnered with both with the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and Michigan Medicine to share results with surgeons, identify how we can narrow these gaps in care, and actively measure and track our efforts to eliminate disparities.
Healio: Is there anything else you would like to mention?
Wagner: Cardiac surgery has pioneered the measurement and tracking of outcomes and quality of care. I am excited to be a part of this field that continually strives for improvement and constantly seeks for ways to improve patient care — and I am optimistic that we can narrow the gaps in care that we have identified, and in doing so increase the quality of care we as surgeons provide, and maximize the benefit our patients receive from undergoing heart surgery.
References:
- Wagner CM, et al. Ann Thorac Surg. 2024;doi:10.1016/j.athoracsur.2024.03.032.
- Wagner CM, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2024.14354.
- Wagner CM, et al. J Thorac Cardiovasc Surg. 2024;doi:10.1016/j.jtcvs.2024.04.011.
For more information:
Catherine M. Wagner, MD, MSc, can be reached at cmgilb@med.umich.edu.
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