Abstract
Background
Sex-based differences in outcomes after cardiac surgery are consistently reported, with women frequently experiencing higher postoperative morbidity and mortality. While emerging evidence suggests that patient-physician sex concordance may improve outcomes in some medical fields, whether such an effect exists in cardiac surgery is unknown.
Methods
We conducted a nationwide cohort study using data from the Austrian Adult Cardiac Surgery Registry, including all patients undergoing one of four common non-emergent first-time cardiac surgery procedures between 2012 and 2022. The primary outcome was a composite of adverse postoperative outcomes, defined as death, readmission, or complications within 30 days after surgery. Multivariable generalized linear mixed models were used to assess patient-surgeon sex pairing effects.
Results
Among 57,729 patients (27.5% female) treated by 239 surgeons (22.2% female), patient-surgeon sex concordance was present in 63.9% of cases. Female patients had higher rates of the composite primary outcome compared to male patients (13.0% [female surgeon] and 13.3% [male surgeon] versus 11.0% [female surgeon] and 11.3% [male surgeon]). Surgeon sex was not independently associated with the primary composite outcome (aOR for female vs. male surgeon, 0.94; 95%CI, 0.84–1.06; P = 0.28), without significant interaction between patient and surgeon sex (pint=0.61).
Conclusion
In this nationwide cohort, patient-surgeon sex pairing was not associated with postoperative adverse outcomes after adult cardiac surgery. Improving outcomes should therefore center on clinical risk optimization rather than sex concordance.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13019-026-04420-2.
Keywords: Cardiac surgery, Sex differences, Patient-surgeon sex concordance, Postoperative outcomes
Introduction
Differences in clinical outcomes between women and men are a consistent finding in cardiovascular care. Women undergoing cardiac surgical procedures experience higher rates of postoperative morbidity and mortality than men [1, 2]. Proposed explanations include differences in comorbidity burden, symptom presentation, and treatment patterns, but these factors do not fully account for the persistence of disparities in contemporary practice [3–5].
Recent evidence suggests that physician sex may also be associated with outcomes. Studies in non-cardiac surgical and medical settings have reported worse outcomes when patient and physician sex are discordant, and more favorable outcomes for women treated by female physicians [6–10]. Whether such associations extend to complex procedural specialties such as cardiac surgery is uncertain.
Using a nationwide clinical cardiac surgery registry, we evaluated the association between patient sex, surgeon sex, and patient-surgeon sex pairing with operative outcomes in adult cardiac surgery.
Methods
Data source
This analysis used data from the Austrian Adult Cardiac Surgery Registry, a national registry encompassing all adult patients undergoing cardiac surgery in Austria [11–13]. All cardiac surgery centers in Austria participate in the registry, and data entry is performed on-site by dedicated data managers. The registry captures data on demographics, comorbidities, procedural details, adverse events, discharge status, readmission, and mortality at 30 days or during the index admission. It is maintained by the Austrian National Public Health Institute and audited annually to ensure data quality. Annual reports are publicly available [14]. The National Public Health Institute links registry data with the national death index via patients’ social security numbers, enabling complete and accurate capture of mortality.
The study was approved by the institutional review board (Ethics Committee of the Medical University Vienna, protocol # 1288–2024) and individual informed consent was not required. The data that support the findings of this study are available from the corresponding author (S.S.) upon reasonable request.
Study design
The study population consisted of adult patients, aged 18 years and older, who underwent one of four typical, non-emergent, first-time cardiac surgery procedures between January 1, 2012, and December 31, 2022, across all cardiac surgery centers in Austria. Procedures were grouped as isolated coronary artery bypass grafting (CABG); CABG combined with any valve procedure; valve surgery (including concomitant aortic root or ascending aortic procedures such as supracoronary ascending aortic replacement or reduction ascending aortoplasty); and other non-emergent cardiac operations (e.g., isolated ascending aortic procedures).
The primary outcome was a composite of adverse postoperative outcomes, defined as death, readmission, or complication within 30 days after surgery. Complications included postoperative bleeding or tamponade, stroke, acute kidney failure resulting in a new need for renal replacement therapy and sternal wound infections requiring negative pressure wound therapy (NPWT). Definitions follow those of the Austrian Adult Cardiac Surgery Registry and are provided in the Supplementary Material. Secondary outcomes were the individual components of the primary outcome.
Statistical analysis
Categorical data are described as counts and percentages. Continuous data are depicted by the mean (± standard deviation) in case of normal distributions, and by the median (interquartile range) if data are not normally distributed. To compare patient characteristics between female and male patients the two-sample t-test, the Wilcoxon rank sum test, and the chi-square test were used. Comparisons between female and male surgeons were performed using general linear mixed models (for continuous variables) and generalized linear mixed models (for categorical variables). The primary composite outcome was analyzed using multivariable generalized linear mixed models with a binary response distribution and a logit link function. To account for clustering of procedures performed by the same surgeon, surgeon was included as a random effect. To evaluate a potential sex-concordance effect, fixed-effect terms for patient sex, surgeon sex, and their interaction were included. Analyses were done using a model adjusted for center only (Model 1), and a fully adjusted model adjusting for center, age, Euroscore II, BMI, left ventricular ejection fraction, NYHA classification, annual case volume of the center, annual case volume of the surgeon, year of operation, diabetes, smoking, CKD, minimally invasive operation, and for the four procedural groups (Model 2). Effect estimates are presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Secondary outcomes were analyzed using analogous mixed-effects models incorporating the same exposure terms and covariate adjustments. Complete case data were used for all multivariable analyses and were available for 91.4% of patients.
To explore whether the association between surgeon sex and outcomes differed across clinical or procedural characteristics, prespecified subgroup analyses were performed stratified by patient sex. Effect modification was assessed by testing interactions between patient sex, surgeon sex, and the covariate of interest.
Two-sided p-values < 0.05 were considered as indicating statistical significance without multiplicity adjustment. All analyses were performed using SAS version 9.4 (SAS Institute Inc., 2025, Cary, NC, USA).
Results
Characteristics of the study cohort
The study cohort comprised 57,729 patients, of whom 15,876 (27.5%) were female. A total of 239 surgeons contributed to the cohort, including 53 (22.2%) female surgeons. Patient-surgeon sex concordance was present in 36,875 (63.9%) cases (male surgeon-male patient pairs: n = 34,357; female surgeon-female patient pairs: n = 2,518), while 20,854 (36.1%) cases were patient-surgeon sex discordant (male surgeon-female patient pairs: n = 13,358; female surgeon-male patient pairs: n = 7,496). Baseline clinical and procedural characteristics stratified by sex concordance status are shown in Table 1. The number of observations with missing values are shown in Table S1. Overall, female patients were younger than male patients (64 [IQR 54–77] vs. 67 [IQR 59–74] years, p < 0.0001), but had a higher median EuroScore II (2.6 [IQR 1.5–4.7] vs. 1.6 [IQR 1.0-2.9], p < 0.0001) (Supplemental Table S2). Female patients more frequently underwent valve procedures (50.2% vs. 30.2%) and minimally invasive procedures (15.6% vs. 9.2%), while male patients more frequently underwent isolated CABG (52.2% vs. 31.4%). Operative risk as measured by EuroScore II was comparable between patients treated by female surgeons and those treated by male surgeons (1.7 [IQR 1.1–3.4] vs. 1.8 [IQR 1.1–3.4], p = 0.10) (Supplemental Table S3). Female surgeons had lower annual case volumes than male surgeons (49 [IQR 34–71] vs. 61 [IQR 43–87], p = 0.04) and performed a greater proportion of isolated CABG operations (58.6% vs. 44.0%), whereas male surgeons more commonly performed valve (37.8% vs. 25.7%) and combined procedures (16.3% vs. 14.6%).
Table 1.
Characteristics of the study cohort, by surgeon and patient sex
| Total | Concordant surgeon and patient | Discordant surgeon and patient | |||
|---|---|---|---|---|---|
| Male surgeon and male patient | Female surgeon and female patient | Male surgeon and female patient | Female surgeon and male patient | ||
| Patients, no. | 57,729 | 34,357 | 2518 | 13,358 | 7496 |
| Patient characteristics | |||||
|
Age, years, median (IQR) |
69 (60–75) | 67 (59–74) | 71 (64–76) | 72 (64–77) | 67 (59–74) |
|
BMI, median (IQR) |
27.1 (24.4–30.2) | 27.2 (24.7–30.1) | 27.2 (23.9–30.9) | 26.4 (23.2–30.1) | 27.7 (25.0-30.5) |
|
EuroScore II, median (IQR) |
1.8 (1.1–3.4) | 1.6 (1.0-2.9) | 2.5 (1.5–4.4) | 2.6 (1.5–4.8) | 1.6 (0.9–2.8) |
|
LVEF, %, median (IQR) |
55 (50–60) | 55 (50–60) | 55 (50–60) | 55 (52–60) | 55 (48–60) |
| Diabetes, no. (%) | 15,674 (27.2) | 8989 (26.2) | 794 (31.6) | 3221 (24.1) | 2670 (35.7) |
| CKD *, no. (%) | 33,671 (58.5) | 17,843 (52.1) | 1846 (73.4) | 10,303 (77.5) | 3679 (49.2) |
| Smoking**, no. (%) | 16,118 (27.9) | 9817 (28.6) | 674 (26.8) | 2346 (17.6) | 3281 (43.8) |
| Annual case volume, surgeon, median (IQR) | 59 (41–78) | 61 (43–86) | 49 (34–71) | 63 (45–88) | 51 (34–71) |
| Annual case volume, center, median (IQR) | 582 (448–678) | 585 (455–689) | 597 (470–690) | 595 (463–690) | 585 (448–682) |
| Procedure, no. (%) | |||||
| CABG | 26,825 (46.5) | 17,069 (49.7) | 1101 (43.7) | 3890 (29.1) | 4765 (63.6) |
| Valve | 20,608 (35.7) | 11,070 (32.2) | 993 (39.4) | 6969 (52.2) | 1576 (21.0) |
| Aortic valve | 10,436 (18.1) | 5409 (15.7) | 656 (26.1) | 3359 (25.1) | 1012 (13.5) |
| Mitral valve | 4518 (7.8) | 2608 (7.6) | 114 (4.5) | 1606 (12.0) | 190 (2.5) |
| Tricuspid valve | 301 (0.5) | 134 (0.4) | 10 (0.4) | 143 (1.1) | 14 (0.2) |
| Multiple valves | 2921 (5.1) | 1359 (4.0) | 115 (4.6) | 1303 (9.8) | 144 (1.9) |
|
Combined CABG and Valve |
9222 (16.0) | 5695 (16.6) | 362 (14.4) | 2065 (15.5) | 1100 (14.7) |
| Other | 1074 (1.9) | 523 (1.5) | 62 (2.5) | 434 (3.3) | 55 (0.7) |
|
Minimally invasive procedure |
6323 (11.0) | 3481 (10.1) | 249 (9.9) | 2225 (16.7) | 368 (4.9) |
The number of observations with missing values are shown in Supplement Table S1. CABG, coronary artery bypass grafting. BMI, body mass index. CKD, chronic kidney disease. IQR, interquartile range. LVEF, left ventricular ejection fraction. SD, standard deviation
* Chronic kidney disease includes moderate (creatinine clearance > 50 and ≤ 85) and severe (creatinine clearance
≤ 50 mL/min) renal impairment
** Includes former and current smoking
Patient-Surgeon sex concordance status and adverse postoperative outcomes
Female patients had higher rates of adverse postoperative outcomes than male patients (Table 2) with relatively small differences in the rates of postoperative events among female patients treated by male and female surgeons (difference between male and female surgeons, -0.3% to + 0.3%), while male patients treated by male surgeons had modestly higher rates of postoperative events compared with those treated by female surgeons (composite outcome: 11.3% vs. 11.0%; complications: 8.2% vs. 7.6%).
Table 2.
Crude rates (no. [%]) of adverse postoperative outcomes, by surgeon and patient sex
| Concordant surgeon and patient | Discordant surgeon and patient | |||
|---|---|---|---|---|
| Male surgeon and male patient | Female surgeon and female patient | Male surgeon and female patient | Female surgeon and male patient | |
| Composite outcome | 3546 (11.3) | 306 (13.0) | 1598 (13.3) | 778 (11.0) |
| Death | 718 (2.3) | 83 (3.5) | 442 (3.7) | 160 (2.3) |
| Readmission | 722 (2.3) | 67 (2.9) | 312 (2.6) | 188 (2.7) |
| Complications | 2566 (8.2) | 213 (9.0) | 1118 (9.3) | 536 (7.6) |
Associations of surgeon sex with adverse postoperative outcomes adjusted for center only (Model 1) are shown in Supplemental Table S4. In the fully adjusted multivariable mixed-effects model (Model 2), surgeon sex was not independently associated with the primary composite outcome (aOR for female vs. male surgeon, 0.94; 95% CI, 0.84–1.06; P = 0.28) (Table 3). There was no evidence of interaction between patient sex and surgeon sex (P for interaction = 0.61, testing a potential sex concordance effect).
Table 3.
Association between surgeon sex (female versus male [reference]) and adverse postoperative outcomes
| Outcome | Adjusted OR (95% CI) |
P value | P int* |
|---|---|---|---|
| Composite outcome | 0.94 (0.84–1.06) | 0.28 | 0.61 |
| Death | 0.98 (0.79–1.22) | 0.87 | 0.90 |
| Readmission | 1.04 (0.89–1.22) | 0.64 | 0.93 |
| Complications | 0.92 (0.81–1.06) | 0.24 | 0.34 |
Associations as estimated by Model 2
*Interaction of patient sex with surgeon sex
Surgeon sex was also not significantly associated with 30-day mortality, readmission, or complications (Table 3), without interaction between patient and surgeon sex.
The association between surgeon sex and the primary composite outcome was consistent across clinically important subgroups in female and male patients, with no evidence of effect modification by patient characteristics, procedural factors, or surgeon or center volume (Fig. 1).
Fig. 1.
Association between surgeon sex and adverse postoperative outcomes in clinically important subgroups, by patient sex. *Cut-off values were based on median cohort values. No significant interaction (p interaction) between surgeon sex, patient sex and any covariates were detected
Discussion
In this large, nationwide cohort of patients undergoing non-emergent cardiac surgical procedures, surgeon sex was not independently associated with postoperative adverse events. There was no evidence that patient-surgeon sex pairing influenced the risk of the composite outcome or its individual components. These findings were consistent across clinical and procedural patient subgroups as well as surgeon and center case volumes.
Emerging evidence has suggested that patient-physician sex concordance may be associated with improved clinical outcomes, particularly among female patients, whereas sex discordance appears to be most adverse for women [6, 9]. In parallel, multiple studies across surgical and medical specialties have shown that female physicians achieve superior clinical outcomes irrespective of patient sex [6, 8], 15– [9]. In a Swedish study of 150,509 patients undergoing cholecystectomy, Blohm et al. [8] reported higher rates of complications among male surgeons compared with female surgeons, while no significant difference in 30- day mortality was observed. Wallis et al. [17] in a US cohort of 2,902,756 patients undergoing common major surgical procedures (44.4% sex concordant pairs) reported that concordance was associated with slightly lower mortality among female patients but slightly higher mortality among male patients in elective procedures. However, findings have not been consistent across cardiovascular disciplines. In the interventional cardiology space, Yelavarthy et al. [18] in a study including 239,422 PCI procedures performed by 403 (4.5% female) physicians did not find risk-adjusted differences in mortality, acute kidney injury, transfusion rates or major bleedings among female patients undergoing percutaneous coronary intervention (PCI) by operator sex. In contrast, Wallis et al. [6] reported worse outcomes with patient-surgeon sex discordance in a study of 2,902,756 patients undergoing 1 of 21 common surgeries with patient sex acting as an effect modifier, such that female patients treated by male surgeons experienced the greatest risk of the composite outcome of death, readmission or complication within 1 year after surgery (aOR 1.07, 95% CI 1.04–1.09). Notably, the cardiothoracic surgery patient subgroup (7.4%) had higher risk when patient-surgeon discordance was present (aOR 1.10, 95% CI 1.06–1.13). However, these studies included few female physicians (4.5% [18] and 21.2% [7], with the proportion even lower within the cardiothoracic subspeciality), limiting the precision and generalizability of concordance estimates.
Due to the paucity of available data and the underrepresentation of female surgeons [19], evidence regarding patient-surgeon sex concordance in the surgical management of cardiovascular disease is limited. Extending existing literature [20], the present analysis did not identify an independent association between surgeon sex and adverse postoperative outcomes in adult cardiac surgery, nor evidence that patient-surgeon sex pairing modified the association with postoperative adverse events.
Various explanations have been proposed for superior outcomes in patients treated by female physicians. Female physicians are more likely to follow clinical guidelines [21, 22], possess strong communication skills [23, 24], and show a greater inclination to collaborate within interprofessional teams [25]. While these factors may contribute to outcome differences in some settings, their impact may be less apparent in cardiac surgery. Care in this field is delivered within a multidisciplinary, protocol-driven environment in which perioperative management is shared across surgeons, anesthesiologists, perfusionists, nursing staff, and intensive care teams, potentially reducing variability attributable to an individual surgeon.
At the same time, the role of surgeon sex is likely more complex and influenced by multiple factors. Differences in patient characteristics, case mix, and institutional practices may further influence or mask potential associations. As a result, any sex-related differences at the level of the individual surgeon may be attenuated in contemporary cardiac surgical practice, with outcome patterns that differ from those observed in less standardized or more physician-dependent specialties.
Limitations
This study has several limitations. Residual confounding by unmeasured patient-, surgeon- or system-level factors cannot be excluded. Surgeon sex served as a proxy for surgeon-related characteristics, but the registry does not capture elements such as operative experience in sub-specialty procedures or team composition. Outcome assessment was restricted to in-hospital and 30-day events. The proportion of female surgeons reflects female representation in the current workforce [26], but may reduce power to detect modest associations. Procedure categories were broad and residual heterogeneity in case complexity may remain despite adjustment. Finally, institutional factors may also influence the relationship between surgeon characteristics and outcomes. Differences in case complexity, resource availability, and organizational structure across centers may affect outcomes and limit the generalizability of our findings to other healthcare systems. Although cardiac surgery in Austria is delivered within a relatively standardized national framework, such differences should be considered when interpreting these results.
Conclusion
In this nationwide cohort of adults undergoing major non-emergent cardiac surgery, surgeon sex did not influence postoperative outcomes. Efforts to reduce disparities in cardiac surgery should therefore focus on modifiable clinical risk rather than sex-specific operator–patient matching.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The data were collected as part of the diploma thesis of Marija Pljakova.
Abbreviations
- BMI
Body mass index
- CABG
Coronary artery bypass grafting
- CI
Confidence interval
- CKD
Chronic kidney disease
- IQR
Interquartile range
- NPWT
Negative pressure wound therapy
- LVEF
Left ventricular ejection fraction
- (a)OR
(adjusted) Odds ratio
- PCI
Percutaneous coronary intervention
Author contributions
Authors’ contribution: M.A. : Conceptualization; Data curation; Writing-original draft. A.K. : Data Curation; Formal Analysis; Methodology; Writing-original draft. M.P. : Data Curation; Writing-review & editing. P.A. : Data Curation; Writing-review & editing. K.O .: Data Curation; Writing-review & editing. N.K. : Data Curation; Writing-review & editing. D.Z. : Supervision; Writing-review & editing. A.Z. : Data Curation; Writing-review & editing. M.G. : Supervision; Writing-review & editing. S.S. : Conceptualization; Methodology; Supervision; Writing-review & editing. All authors read and approved the final manuscript.
Funding
No funding was received for this work.
Data availability
The data that support the findings of this study are available from the corresponding author (S.S.) upon reasonable request.
Declarations
Ethics approval and consent to participate
The study was approved by the institutional review board (Ethics Committee of the Medical University Vienna, protocol # 1288–2024) and individual informed consent was not required.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available from the corresponding author (S.S.) upon reasonable request.