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Referral patterns for coronary artery disease treatment: gender bias or good clinical judgment?
N A Bickell1, K S Pieper, K L Lee
1University of North Carolina, Chapel Hill.
Insights
Gender bias in coronary bypass graft surgery referral exists, with women less likely to be referred when surgery offers minimal survival benefit. Referral patterns suggest potentially more appropriate treatment for women in recent years.
Area of Science:
- Cardiology
- Medical Ethics
- Health Services Research
Background:
- Coronary artery disease (CAD) affects millions globally, with surgical interventions like coronary bypass graft (CABG) surgery being a common treatment.
- Understanding referral patterns for CABG is crucial for ensuring equitable access to care and optimal patient outcomes.
- Previous studies have suggested potential gender disparities in healthcare, necessitating investigation into specific surgical referral practices.
Purpose of the Study:
- To investigate the existence and nature of gender bias in referral for coronary bypass graft surgery.
- To analyze referral patterns based on patient risk for cardiac death and treatment effectiveness.
- To examine temporal trends in gender-based referral patterns for CABG surgery.
Main Methods:
- A historical cohort study was conducted from 1969 to 1984.
- Data included 5795 patients with catheterization-documented coronary artery disease from a referral medical center.
- Referral patterns for men and women were analyzed, stratified by cardiac death risk and treatment effectiveness, with time trends evaluated across three periods.
Main Results:
- Overall, no significant gender difference in surgical referral was observed without risk adjustment (46% men vs. 44% women).
- After adjusting for cardiac death risk, women with low risk were less likely to be referred (OR=1.28), particularly in 1980-1984 (OR=1.73).
- Men were more likely to be referred when surgery offered less survival benefit (OR=1.29), most pronounced in 1980-1984 (OR=1.63).
Conclusions:
- Women are less frequently referred for coronary bypass graft surgery when the procedure offers minimal survival advantage over medical treatment.
- Referral rates are similar for men and women when surgery provides substantial survival benefits for high-risk patients.
- These gender-based referral patterns, especially in recent years, may indicate more appropriate treatment allocation for women based on surgical benefits.
Objective:
To determine whether a gender bias exists in referral for coronary bypass graft surgery among patients with catheterization-documented coronary artery disease.
Design:
Historical cohort study (1969 to 1984).
Setting:
A referral medical center.
Patients:
A total of 5795 patients with catheterization-documented coronary artery disease.
Measurements:
Surgical referral patterns of men and women grouped by risk for cardiac death and by treatment effectiveness. Time trends were evaluated for three periods: 1969 to 1974, 1975 to 1979, and 1980 to 1984.
Results:
Overall, when no adjustment was made for baseline risk for cardiac death, no statistical difference was found between men and women regarding referral for surgery (46% compared with 44%, respectively). When an adjustment was made for such risk, the male-to-female odds ratio for surgical referral was 1.28 (95% Cl, 1.05 to 1.58) among patients with a low risk for cardiac death. This effect was most evident in the 1980 to 1984 period (odds ratio, 1.73; Cl, 1.29 to 2.31). In the high-risk group, the odds ratio was 0.84 (Cl, 0.68 to 1.04), with little change occurring during the study. Men were more likely to be referred for surgery when surgery offered the least survival benefit relative to medical therapy (odds ratio, 1.29; Cl, 1.08 to 1.54). This effect was most pronounced in the 1980 to 1984 period (odds ratio, 1.63; Cl, 1.27 to 2.10).
Conclusions:
Women are less likely than men to be referred for coronary bypass graft surgery among patients with a low risk for cardiac death, in whom surgery offers little or no survival benefit over medical treatment. Women are at least as likely as men to be referred for bypass surgery among more symptomatic and more severely diseased patients, in whom surgery offers the greatest survival benefits. These trends were most prominent in the recent years of the study. Based on surgical survival benefits, these referral patterns may represent more appropriate treatment referral for women than men.
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