Original Investigation
October 16, 2024
Failure to Rescue Female Patients Undergoing High-Risk Surgery
Catherine M. Wagner, Karen E. Joynt Maddox, Gorav Ailawadi, et al
JAMA Surg. Published online October 16, 2024
doi:10.1001/jamasurg.2024.4574
Question Although it is known that female patients die more often than male patients after high-risk surgery, is this because female patients have more complications or because clinicians fail to rescue female patients from those complications?
Findings In this cohort study of 863 305 Medicare beneficiaries undergoing high-risk surgery, male and female patients experienced similar rates and types of serious complications. However, women were far more likely to die after these complications.
Meaning Female patients undergoing high-risk surgery are more likely to die of postoperative complications than male patients, and efforts to recognize and respond to complications before they result in death may narrow the sex disparity in mortality after high-risk surgery.
Abstract
Importance Female patients have higher mortality rates after high-risk surgery than male patients. It is unknown whether this mortality gap is due to different rates of postoperative complications or if complications are addressed differently by sex, causing complications to lead to death—so-called failure to rescue.
Objective To evaluate sex differences in failure to rescue across high-risk surgical procedures.
Design, Setting, and Participants This retrospective cohort study was conducted using data from Medicare beneficiaries from October 2015 to February 2020 who underwent high-risk vascular or cardiac surgical procedures, including abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement or repair. Data analysis was performed from August 2023 to March 2024.
Exposures The primary exposure was patient sex.
Main Outcomes and Measures The primary outcomes were risk-adjusted rates of complications, 30-day mortality, and failure to rescue, which was defined as a death occurring after a serious complication. Categorical variables are presented as frequencies and proportions and compared using χ2 analysis. Continuous variables were tested for normality and compared using a t test.
Results A total of 863 305 Medicare beneficiaries were included in this study cohort, of whom 304 176 (35.2%) were female. Mean (SD) age was slightly higher in female patients (74.8 [9.3] years) than male patients (73.4 [8.5] years), and female patients had more comorbidities than male patients (≥2 Elixhauser comorbidities, female: 262 809 [86.4%] vs male: 465 231 [83.2%]). Female patients were more likely to receive care at large hospitals and hospitals with a higher surgical case volume. Overall, female and male patients had similar rates of complications (female: 14.98% vs male: 14.37%; adjusted relative risk [aRR], 1.04; 95% CI, 1.03-1.05; P < .001). However, female patients had higher rates of 30-day mortality (female: 4.22% vs male: 3.34%; aRR, 1.26; 95% CI, 1.23-1.29; P < .001) and higher rates of failure to rescue (female: 10.71% vs male: 8.58%; aRR, 1.25; 95% CI, 1.22-1.28; P < .001). A similar pattern was observed when stratified by each procedure.
Conclusions and Relevance In this cohort study among Medicare beneficiaries undergoing high-risk surgery, male and female patients experienced similar rates of serious complications, but female patients with complications were more likely to die. In other words, clinicians fail to rescue female patients with complications after high-risk surgery more often than male patients. Improving the recognition and management of female patients’ complications postoperatively may narrow the sex disparity after high-risk surgery.
