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Original Article

Differences in the Use of Procedures between Women and Men Hospitalized for Coronary Heart Disease

John Z. Ayanian, M.D., M.P.P., and Arnold M. Epstein, M.D., M.A.

N Engl J Med 1991; 325:221-225July 25, 1991

Abstract

Background and Methods.

Previous studies at individual hospitals have reported differences in the use of major diagnostic and therapeutic procedures for women and men with coronary heart disease. To assess whether these differences can be generalized, we performed retrospective analyses of coronary angiography and revascularization (coronary-artery bypass surgery or percutaneous transluminal coronary angioplasty) in women and men hospitalized for coronary heart disease in 1987, using abstract data on 49,623 discharges in Massachusetts and 33,159 discharges in Maryland. We used multiple logistic regression to estimate the adjusted odds of the use of a procedure, controlling for principal diagnosis, age, secondary diagnosis of congestive heart failure or diabetes mellitus, race, and insurance status.

Results.

The adjusted odds of undergoing angiography were 28 percent and 15 percent higher for men than for women in Massachusetts and Maryland, respectively (95 percent confidence intervals for the odds ratios, 1.22 to 1.35 and 1.08 to 1.22). The respective adjusted odds of undergoing revascularization were 45 percent and 27 percent higher for men than for women (95 percent confidence intervals, 1.35 to 1.55 and 1.16 to 1.40). Because these differences could be related to differing thresholds for hospital admission, we performed a second analysis limited to patients with diagnosed acute myocardial infarction (11,865 discharges in Massachusetts and 6894 discharges in Maryland), a group in which all patients would be expected to receive hospital care. The male-to-female odds ratios in both states remained similar in magnitude and were statistically significant for angiography and revascularization.

Conclusions.

These findings demonstrate that women who are hospitalized for coronary heart disease undergo fewer major diagnostic and therapeutic procedures than men. These differences may represent appropriate levels of care for men and women, but it is also possible that they reflect underuse in women or overuse in men. Further study should assess the cause of these differences and their effect on patients' outcomes. (N Engl J Med 1991; 325:221–5.)

Media in This Article

Table 1Clinical and Demographic Characteristics of Patients Hospitalized for Coronary Heart Disease.*
Table 2Rates of Coronary Angiography and Male-to-Female Relative Risks after Stratification for Potential Confounding Variables.*
Article

CORONARY heart disease is a leading cause of morbidity and mortality in the United States among both men and women. Since 1950, the incidence of coronary heart disease has risen among women while it has declined among men.1 Major advances in diagnosis and treatment have contributed to a decline in overall mortality from coronary heart disease in both sexes over the past 20 years.2 However, some evidence suggests that there are systematic differences between women and men in the application of these major advances. These differences are important, because women may not be undergoing beneficial procedures, or alternatively some men may be undergoing invasive procedures that are not clearly beneficial.

Previous reports of differences in the use of procedures to diagnose or treat coronary heart disease in men and in women have focused on two populations: the general population and patients with presumed coronary heart disease. In the general population, men are four to five times more likely than women to undergo coronary-artery bypass surgery, but these differences may be fully explained by the higher prevalence of coronary heart disease in men.3 , 4 Among patients with presumed coronary heart disease, previous studies have found that women with positive radionuclide exercise tests were referred for coronary angiography much less frequently than men5 and that women were referred for coronary-artery bypass surgery at a more advanced stage of disease than were men, resulting in higher perioperative mortality.6 The first of these two studies was based at three hospitals affiliated with one medical school, and the second at a single hospital, so there is uncertainty about whether these findings can be generalized.

The purpose of this study was to assess whether there are sex-related differences in two states in the use of coronary procedures among all patients hospitalized specifically for coronary heart disease. By focusing on patients with presumed coronary heart disease, our approach minimizes the prevalence-related differences that have limited previous population studies. Moreover, the inclusion of all patients hospitalized in two states yields results that can be generalized beyond individual institutions.

Methods

Data Sources and Patient Population

We performed retrospective analyses for all patients from 30 to 89 years of age who were discharged from nonfederal acute care hospitals in Massachusetts and Maryland during 1987, using abstracted discharge data for both states supplied by the Massachusetts Health Data Consortium. Such patient-specific data are routinely collected by the Massachusetts Rate Setting Commission and the Maryland Health Services Cost Review Commission for all patients admitted to acute care hospitals in the two states. Each agency reviews the accuracy of the data as part of the hospital rate-setting process in its state. The data include the principal diagnosis, secondary diagnoses (up to nine in Massachusetts and up to four in Maryland), major procedures (up to five in Massachusetts and up to three in Maryland), age, sex, race, insurance status, the patient's ZIP Code, and the hospital identification number. Because data covering a period of three months in 1987 were not available for one hospital in Massachusetts, data for the same three months in 1986 were imputed (representing 0.1 percent of the discharges in the Massachusetts cohort).

Using the clinically modified ninth revision of the International Classification of Diseases (ICD-9-CM), we included all patients with principal diagnoses of myocardial infarction (ICD-9-CM codes 410.0 through 410.9), unstable angina (codes 411.1 and 411.8), angina pectoris (codes 413.0 through 413.9), chronic ischemic heart disease (codes 414.0, 414.8, and 414.9), and nonrespiratory chest pain (codes 786.50, 786.51, and 786.59). The principal diagnosis was the condition determined at discharge to have been chiefly responsible for the patient's admission to the hospital.

To avoid including more than one hospital admission for any episode of acute illness, we excluded hospitalizations that resulted in the transfer of the patient to another acute care hospital (6710 discharges in Massachusetts and 2581 discharges in Maryland). For patients with coronary heart disease, these transfers were presumably made to obtain critical care services or procedures that were unavailable at the referring hospital. We also excluded patients whose principal residence was not in Massachusetts or Maryland, as well as those whose sex was not specified in the discharge data (one patient in Massachusetts and seven patients in Maryland).

The study population represented 73.3 percent and 77.3 percent of all patients undergoing inpatient coronary angiography in Massachusetts and Maryland, respectively, and 84.5 percent and 94.7 percent of all patients undergoing coronary-artery bypass surgery or percutaneous transluminal coronary angioplasty. Of the 102 acute care medical hospitals for adults in Massachusetts, 19 offered coronary angiography and 11 provided revascularization procedures. In Maryland, 21 of the 56 such hospitals performed coronary angiography, and 5 had facilities for revascularization.

Data Analysis

Our hypothesis was that men were more likely than women to undergo major coronary procedures when they were hospitalized with known or suspected coronary heart disease, even after adjustment for potential confounders. To test our hypothesis, we estimated male-to-female relative risks in each state for coronary angiography (ICD-9-CM codes 37.22, 37.23, and 88.55 through 88.57) and coronary revascularization with either coronary-artery bypass surgery (codes 36.10 through 36.19) or percutaneous transluminal coronary angioplasty (codes 36.00 to 36.02 and 36.05). By 1987 coronary angioplasty was available in the two states in all but one of the hospitals that offered coronary-artery bypass surgery, and the two procedures were generally accepted as therapeutic alternatives for many patients with clinically important coronary heart disease.

The male-to-female relative risks were stratified according to principal diagnosis, age (30 to 49, 50 to 69, or 70 to 89 years), secondary diagnosis of congestive heart failure (ICD-9-CM codes 398.91, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, and 428.0 through 428.9), secondary diagnosis of diabetes mellitus (codes 250.0 to 250.91), race (white or nonwhite, defined as including black, Hispanic, Asian, and American Indian), and insurance status (insured or uninsured) to control for potential confounders of the relation between sex and procedure rates. We compared the distribution of these characteristics in men and women with the chi-square test, and we report two-tailed P values for these comparisons.

For each stratum, the male-to-female relative risk of the use of the procedure was evaluated with the chi-square test. Subsequently, multiple logistic-regression models were constructed for each state in order to calculate male-to-female odds ratios for the use of procedures, with simultaneous adjustment for all potential confounders described in the initial stratified analysis. We report 95 percent confidence intervals for all relative risks and odds ratios. Patients with a principal diagnosis of chest pain (representing 9174 discharges in Massachusetts and 5688 in Maryland) were excluded from the revascularization analysis, because these patients were not candidates for coronary-artery bypass surgery or coronary angioplasty without more definitive diagnoses of coronary heart disease.

After developing the logistic-regression models with all diagnoses included, we evaluated the models for the patients whose principal diagnosis was myocardial infarction. Because of all the conditions in our study this condition has the most explicit diagnostic criteria, the procedure rates were unlikely to be confounded by different thresholds for admission. The standard of care in 1987 for patients with acute myocardial infarction generally resulted in hospital stays of at least seven days.7 , 8 In this analysis we excluded patients who were discharged within five days of admission (1046 discharges in Massachusetts and 710 in Maryland) in order to reduce the occurrence of two types of clinical inaccuracy that have been identified in discharge data for patients with acute myocardial infarction.9 First, some patients who were admitted for suspected myocardial infarction but in whom the diagnosis was ruled out may have erroneously been given a diagnosis of myocardial infarction at discharge. Second, in 1987 patients who were readmitted within eight weeks of an acute myocardial infarction — often for elective coronary angiography — could be given a principal diagnosis of myocardial infarction. Both these sources of inaccuracy should be reduced substantially by the exclusion of patients who were discharged after relatively short hospital stays.

Results

We studied data on 49,623 discharges in Massachusetts and 33,159 discharges in Maryland. The cohorts were 42.6 percent and 45.9 percent female in the two states, respectively. Other summary statistics are presented in Table 1Table 1Clinical and Demographic Characteristics of Patients Hospitalized for Coronary Heart Disease.*. In both states, the women were older than the men, more likely to be nonwhite, more likely to be insured, and more likely to be discharged with a principal diagnosis of unstable angina or chest pain and secondary diagnoses of congestive heart failure and diabetes mellitus. The women were less likely than the men to be discharged with a principal diagnosis of myocardial infarction or chronic ischemic heart disease.

The overall rates of coronary angiography in the Massachusetts and Maryland cohorts, respectively, were 27.5 percent and 28.7 percent for men and 16.1 percent and 17.7 percent for women. For coronary revascularization, the respective rates were 15.5 percent and 14.1 percent for men and 7.4 percent and 6.5 percent for women. For all clinical and demographic strata except a principal diagnosis of chest pain, the men in each state were more likely than the women to undergo coronary angiography and revascularization during hospitalization for known or suspected coronary heart disease (Tables 2Table 2Rates of Coronary Angiography and Male-to-Female Relative Risks after Stratification for Potential Confounding Variables.* and 3Table 3Rates of Coronary Revascularization and Male-to-Female Relative Risks after Stratification for Potential Confounding Variables.*). All these relative risks represent statistically significant differences, as demonstrated by 95 percent confidence intervals that do not include 1.0, except the risks for angiography among patients with chronic ischemia in Massachusetts and for angiography and revascularization among uninsured patients in both states.

Using multiple logistic-regression models to control simultaneously for all the potential clinical and demographic confounders that we analyzed, we found male-to-female odds ratios of 1.28 and 1.15 for angiography in Massachusetts and Maryland, respectively, and odds ratios of 1.45 and 1.27 for revascularization; all ratios were statistically significant (Table 4Table 4Male-to-Female Odds Ratios for the Use of Coronary Procedures.*). When we evaluated the logistic models only for patients with a principal diagnosis of myocardial infarction (11,865 discharges in Massachusetts and 6894 in Maryland), the odds ratios remained similar in magnitude and statistically significant (Table 4).

Discussion

Our results show that men are more likely than women to undergo coronary angiography and revascularization procedures during hospitalization for known or suspected coronary heart disease, even after adjustment for potential clinical and demographic confounding variables. This difference may represent underuse of the procedures in women or overuse in men, or the levels of use could be appropriate for both. At least five factors could account for these sex differences.

First, men may undergo more procedures than women if physicians view coronary heart disease as more severe among men because of their higher incidence of the disease. In the Framingham Heart Study, male-to-female incidence ratios for coronary heart disease ranged from 6.8 in the 35-to-44-year-old age group to 1.1 in the 75-to-84-year-old age group. Once coronary heart disease is clinically manifest, however, the case fatality rate for women exceeds that for men.10 Particularly after a myocardial infarction, women appear to be at increased risk for reinfarction and death; some of this difference may be explained by more advanced age and the severity of disease.11 12 13 14 Coronary angiography after a myocardial infarction reveals similar anatomical findings among women and men.15 Therefore, the prognosis of women hospitalized for coronary heart disease is probably at least as severe as the prognosis of hospitalized men.

Second, the rates at which procedures are performed may be influenced by physicians' perceptions of sex-related differences in risk and efficacy. Early studies of coronary-artery bypass surgery reported higher perioperative mortality for women than men, possibly explained by more technical difficulties and less complete revascularization in women, because their coronary arteries are generally narrower than those of men. Complete relief from symptoms was less common in women than in men, but their long-term survival was equivalent.16 17 18 19 20 Similar findings have been reported for coronary angioplasty.21 Some reports, however, suggest that sex may no longer be an independent predictor of perioperative mortality from coronary-artery bypass surgery, because surgical techniques and perioperative care have improved.6 , 22 , 23 Nonetheless, if physicians continue to view these procedures as more risky or less effective in women than in men, they may recommend angiography and revascularization less readily for women.

A third explanation for the lower procedure rates among women could be higher rates of hospital admission for women with ischemic symptoms in the absence of true coronary heart disease.24 Among patients presenting with chest pain, men are more likely than women to have serious coronary-artery stenoses.25 However, the pattern of procedure use we found among patients with myocardial infarction argues strongly against differences in thresholds for admission as the primary explanation; this diagnosis is well defined and almost always results in an admission when recognized in its acute phase.

Differences in patients' preferences are a fourth possible explanation of our findings. One study noted that women were less likely than men to return to work during the two years after a myocardial infarction; this difference was explained primarily by the women's greater age and their behavioral responses to their illness, not by differences in the severity of illness or functional limitations.26 If women are more willing than men to adapt their lifestyle and use medications to avoid surgery, or if they are more averse to short-term risks, they may decline major procedures more often than men.

Finally, if clinical criteria or patients' preferences do not explain these differences in the use of procedures, the differences may represent a sex bias in the delivery of medical care.5 Such a bias may compromise the clinical outcomes in women who undergo procedures at a later stage of disease,6 or in some men with less severe disease who undergo procedures that offer little or no marginal benefit over more conservative care.

Our findings reflect patterns that may not be limited to coronary procedures. The relative differences that we found are similar in magnitude to the sex differences reported for dialysis and kidney transplantation in patients with end-stage renal disease,27 28 29 30 suggesting the need to understand better how patients' sex influences patterns of medical care.

This study has several limitations. Because the discharge abstracts available to us lacked longitudinal data on inpatient and outpatient care, we could not assess whether the patients underwent procedures before or after the index hospitalizations that we studied. Although we know of no evidence that women are more likely than men to postpone procedures, longitudinal data will be necessary to confirm our findings.

More detailed clinical data will be required to judge the appropriateness of sex differences in procedure rates. Although such differences persist in strata defined by the presence or absence of congestive heart failure and diabetes mellitus, we were unable to control for other clinical factors that influence the use of procedures, such as patients' symptoms, the extent of coronary artery disease as determined by angiography, left ventricular ejection fraction, and exercise tolerance. In one study of patients 65 years of age or older who underwent coronary angiography, no difference was found between women and men with respect to the appropriateness of the procedures performed; however, the converse question of appropriateness in patients who did not undergo angiography was not addressed.31

We believe the consistent differences in rates of coronary procedures according to sex that we found in two states are generalizable, but the overall rates have been lower in the Northeast than elsewhere in the United States.4 Sex differences in the use of procedures may be more or less pronounced in other regions where there is greater overall use.

Our study documents that in two states men who are hospitalized for coronary heart disease are more likely than women to undergo major diagnostic and therapeutic procedures. Thus, women may not have equivalent access to these procedures at a time when the incidence of coronary heart disease among women is increasing. Further study will be necessary to determine whether the differences in rates of procedures reflect appropriate clinical practice or whether the outcomes in women with coronary heart disease are compromised by these differences.

Dr. Ayanian is the recipient of a National Research Service Award from the Agency for Health Care Policy and Research. Supported in part by a grant (1 POl HS 06341) from the Medical Treatment Effectiveness Program of the Agency for Health Care Policy and Research.

We are indebted to Elliot M. Stone and the Massachusetts Health Data Consortium for providing data for this study; to Jennifer A. Brandenburg for assistance with computer programming; and to Jennifer S. Haas, M.D., Anthony L. Komaroff, M.D., Barbara J. McNeil, M.D., Ph.D., Andrew P. Selwyn, M.D., and Joel S. Weissman, Ph.D., for helpful comments on an earlier draft of the manuscript.

Source Information

From the Division of General Medicine (Section on Health Services and Policy Research), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School; the Department of Health Care Policy, Harvard Medical School; and the Department of Health Policy and Management, Harvard School of Public Health; all in Boston. Address reprint requests to Dr. Epstein at the Department of Health Care Policy, Harvard Medical School, 25 Shattuck St., Parcel B, 1st Floor, Boston, MA 02115.

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