Skip to main content
JTCVS Techniques logoLink to JTCVS Techniques
editorial
. 2021 Oct 16;10:129–130. doi: 10.1016/j.xjtc.2021.10.019

Commentary: Gender and outcomes: It's complicated

Thomas A Schwann 1,
PMCID: PMC8691911  PMID: 34984372

graphic file with name fx1.jpg

Thomas A. Schwann, MD, MBA

Central Message.

In patients with coronary artery disease, gender-based differences in care and outcomes exist, but the basis for these differences and possible mitigating strategies warrant further investigation.

See Article page 122.

The first step to correcting a problem is recognizing that one exists. Zwischenberger and colleagues1 focus our attention on the “Inconvenient Truth” regarding gender discrepancies in the surgical care of patients with coronary artery disease. They convincingly point out that based on historical and more contemporary data, gender difference in care do exist and may, at least in part, contribute to the noted suboptimal outcomes among women. Despite the robust published data on the influence of gender on outcomes in cardiovascular disease, it is not clear how much of these outcomes differences are attributable to correctable practice care process patterns versus immutable difference in pathology and physiology.2,3

At the outset, I need to acknowledge that, as a male surgeon, I bring my own gender-specific biases and that the comments that follow must be interpreted in this context. The provocative results that Zwischenberger and colleagues1 highlight beg the question of what is behind the noted differences and how best to drive change in practice patterns to mitigate these discrepancies and thus possibly improve outcomes. Because change in health care occurs at a glacial pace, I suspect that the journey to both goals will not be easy or simple. We need only to look at the efforts to increase the utilization of multiarterial bypass grafting (MABG) in both men and women to understand the challenges associated with driving change. Despite 3 decades of data showing4, 5, 6 improved outcomes, the current utilization remains at roughly 10% of patients undergoing coronary artery bypass grafting (CABG).7 The simple, but I believe erroneous conclusion, is that the noted gender discrepancies in care are somehow intentional and premeditated. More likely, a complex set of factors is at play, not least of which may be less surgeon familiarity with MABG techniques in female patients given the fact that women constitute only 24% of the national CABG cohort of whom less than 10% receive multiple arterial graft. The overall national inexperience with MABG among women, is further complicated by the more technical challenges associated with smaller female arterial conduits and targets8 as well as the increased comorbidities and older age in women compared to men. In the face of increased patient complexity, surgeons practicing in the current risk-averse environment will tend to gravitate to the techniques with which they are most comfortable and thus default to traditional single arterial CABG rather than MABG. Of course the aspirational goal should be to increase both male and female surgeons' comfort with MABG in both genders. Data on the use of MABG by male versus female surgeons is currently unknown.

This report should serve as impetus to critically reexamine our gender-specific practice patterns individually, institutionally, and nationally. If nothing else, a close, critical review of our practice patterns may produce some beneficial results simply by the Hawthorne effect—a well-described phenomenon whereby focusing attention on a given process and the consequent result may by itself improve outcomes due to a variety postulated mechanisms.9 In this spirit, a review of our own results (Table 1), shows a high utilization rate of multiple arterial grafts in patients of both genders and is independent of surgeon gender. Thus disparities in gender based MABG utilization can be mitigated by experienced male and female surgeons. Whether this will effectively narrow the gap in clinically meaningful outcomes warrants furhter investigation.

Table 1.

Coronary artery bypass graft (CABG) procedures in male versus female patients performed by male vs female surgeons at University of Massachusetts-Baystate between January 1, 2020, and June 30, 2021

Variable All surgeons Female surgeon Male surgeon
Total CABG cases 482 110 131
Male patients
 % of CABG 78.01 79.09 76.34
 % of RA use 57.98 56.32 69.00
 % of ITA use 98.94 98.85 100.00
Female patients
 % of CABG 21.99 20.91 23.66
 % of RA use 50.00 52.17 74.19
 % of ITA 98.11 100.00 96.77

RA, Radial artery; ITA, internal thoracic artery.

Footnotes

Disclosures: The author reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

References

  • 1.Zwischenberger B.A., Jawitz O.K., Lawton J.S. Coronary surgery in women: how can we improve outcomes. J Thorac Cardiovasc Surg Tech. 2021;10:122–128. doi: 10.1016/j.xjtc.2021.09.051. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Koch C.G., Khandwala F., Nussmeier N., Blackstone E.H. Gender and outcomes after coronary artery bypass grafting: a propensity-matched comparison. J Thorac Cardiovasc Surg. 2003;126:2032–2043. doi: 10.1016/S0022-5223(03)00950-4. [DOI] [PubMed] [Google Scholar]
  • 3.Enumah Z.O., Canner J.K., Alejo D., Warren D.S., Zhou X., Yenokyan G., et al. Persistent racial and sex disparities in outcomes after coronary artery bypass surgery: a retrospective clinical registry review in the drug-eluting stent era. Ann Surg. 2020;272:660–667. doi: 10.1097/SLA.0000000000004335. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Gaudino M., Benedetto U., Fremes S., Biondi-Zoccai G., Sedrakyan A., Puskas J.D., et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med. 2018;378:2069–2077. doi: 10.1056/NEJMoa1716026. [DOI] [PubMed] [Google Scholar]
  • 5.Lytle B.W., Blackstone E.H., Sabik J.F., Houghtaling P., Loop F.D., Cosgrove D.M. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg. 2004;78:2005–2014. doi: 10.1016/j.athoracsur.2004.05.070. [DOI] [PubMed] [Google Scholar]
  • 6.Schwann T.A., Engoren M., Bonnell M., Clancy C., Habib R.H. Comparison of late coronary artery bypass graft survival effects of radial artery versus saphenous vein grafting in male and female patients. Ann Thorac Surg. 2012;94:1485–1491. doi: 10.1016/j.athoracsur.2012.05.029. [DOI] [PubMed] [Google Scholar]
  • 7.Gaudino M., Rahouma M., Habib R.H., Hameed I., Robinson N.B., Farrington W.J., et al. Surgeons' coronary bypass practice patterns in the United States. J Am Coll Cardiol. 2020;76:1714–1715. doi: 10.1016/j.jacc.2020.07.064. [DOI] [PubMed] [Google Scholar]
  • 8.Lawton J.S., Barner H.B., Bailey M.S., Guthrie T.J., Moazami N., Pasque M.K., et al. Radial artery grafts in women: utilization and results. Ann Thorac Surg. 2005;80:559–563. doi: 10.1016/j.athoracsur.2005.02.055. [DOI] [PubMed] [Google Scholar]
  • 9.Roethlisberger F.J., Dickson W.J. Cambridge University Press; 1939. Management and the Worker. [Google Scholar]

Articles from JTCVS Techniques are provided here courtesy of Elsevier

RESOURCES