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(Circulation. 2003;108:2642.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

Sex Differences in Health Status After Coronary Artery Bypass Surgery

Viola Vaccarino, MD, PhD; Zhen Qiu Lin, PhD; Stanislav V. Kasl, PhD; Jennifer A. Mattera, MPH; Sarah A. Roumanis, RN; Jerome L. Abramson, PhD; Harlan M. Krumholz, MD

From the Department of Medicine, Division of Cardiology, Emory University School of Medicine (V.V., J.L.A.) and the Department of Epidemiology, Rollins School of Public Health, Emory University (V.V.), Atlanta, Ga; the Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Conn (Z.Q.L., H.M.K., J.A.M., S.A.R.); and the Department of Epidemiology and Public Health (S.V.K.) and the Section of Cardiovascular Medicine, Department of Medicine (H.M.K.), Yale University School of Medicine, New Haven, Conn.

Correspondence to Viola Vaccarino, MD, PhD, Emory University School of Medicine, Department of Medicine, Division of Cardiology, 1256 Briarcliff Rd, Suite 1 North, Atlanta, GA 30306. E-mail lvaccar{at}emory.edu

Received May 21, 2003; revision received August 25, 2003; accepted August 26, 2003.

	Abstract

Top Abstract Introduction Methods Results Discussion Conclusions References

 
Background— Although previous studies have shown functional improvements in patients who undergo coronary artery bypass graft (CABG) surgery, data are conflicting on whether the gains achieved by women are similar to or less than those achieved by men.

Methods and Results— We compared physical and psychological functional gains and readmission rates between 777 men and 295 women who underwent first CABG consecutively between February 1999 and February 2001. Physical function and mental health were measured by means of the Short Form 36-Item Health Survey (SF-36). At 6 months, both men and women showed, on average, a significant improvement in physical function and mental health, but men improved significantly more than women. After adjustment for baseline characteristics, the mean score improvement in women was half that of men for physical function (7.3 versus 14.0, P=0.0002) and 25% less than that of men for mental health (-3.0 versus 8.9, P=0.026). The absolute rates of adverse outcomes, such as hospital readmission, worsening functional status, and worsening mental health, were significantly higher in women (32.6%, 25.7%, and 17.5%, respectively) than in men (21.2%, 11.1%, and 12.6%, respectively) and remained significantly different in multivariable analysis.

Conclusions— CABG surgery is associated with lower functional gains and higher readmission rates in women compared with men 6 months after operation.

Key Words: bypass • sex • prognosis

	Introduction

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Approximately 180 000 coronary artery bypass graft surgery (CABG) procedures are performed annually on women in the United States, or 28% of the total number performed.¹ Because CABG yields only a small absolute survival benefit relative to medical therapy,² decisions about undergoing this procedure are commonly based on the prospect of obtaining symptom relief and improvement in quality of life. Although functional improvements in patients who undergo CABG have been described,^3–7 previous studies examining these aspects in women, for the most part, have included only small samples of women or patients who underwent surgery during the 1970s and 1980s.^8–16

The objective of this study was to determine whether CABG surgery has a differential impact on the health status and quality of life of men and women. To address this issue, we examined functional gains (both physical and psychological), comparing baseline assessments with those obtained at 6 months after CABG surgery and hospital readmission rates as a measure of the total postoperative morbidity.¹⁷

	Methods

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Patient Population
The methodology of this study has been described previously.¹⁸ Briefly, between February 1999 and February 2001, all patients admitted for their first CABG surgery at Yale New Haven Hospital were screened for this study. Patients younger than 30 years, those with a previous CABG or undergoing concomitant operations, and those with barriers to the interview such as aphasia, impaired mental status, or language other than English were excluded. After surgery, patients completed a baseline interview while still in the hospital. To evaluate physical and psychological functioning, we used the Physical Function (PF) and Mental Health (MH) subscales of the Medical Outcomes Trust Short Form 36-Item Health Survey (SF-36), an established survey instrument that has been validated in patients with coronary heart disease^19–21 and has recognized validity in CABG patients.^22,23 The abstraction of medical charts was performed by use of the Society of Thoracic Surgery instrument and clinical definitions.²⁴

All patients were recontacted by phone at 6 months and asked about their physical and psychological functioning by use of the same instruments as at baseline. Change scores in physical function and mental health from baseline were computed, a positive change score indicating improvement. We also evaluated predefined categorical changes in physical function and mental health. Patients were considered "improved" if they showed a positive change of 5 U in the scale scores, a change considered clinically relevant.²⁵ Conversely, patients were considered "worsened" if their PH or MH score declined by 50 from baseline, whereas in the remainder of cases they were classified as "unchanged." Patients were also questioned about hospital readmissions and primary reason for readmission since discharge from their initial hospitalization for surgery. The institutional review board approved the study, and all patients provided informed consent.

Data Analysis
We used ANCOVA models to calculate mean changes in PF and MH scores from preoperative values to follow-up values in women and men after adjustment for baseline factors (see Table 2). In addition, we used logistic regression models to calculate adjusted probabilities of improvement or deterioration in physical function and mental health as well as hospital readmission after adjustment for the same factors. All tests for statistical significance were 2-tailed, with an level of 0.05. All analyses were conducted with SAS software, release 8.02.

View this table: [in this window] [in a new window]   TABLE 2. Unadjusted and Adjusted Comparisons of Changes in Physical Function, Mental Health and Readmission at 6 Months After CABG Surgery Between Women and Men

	Results

Top Abstract Introduction Methods Results Discussion Conclusions References

 
Study Population
In the study period, 1290 patients met the eligibility criteria. Of these, 1164 (90.2%), 842 men and 322 women, were enrolled.¹⁸ A similar proportion of men (n=22, 2.6%) and women (n=7, 2.2%) died before the 6-month interview and were excluded from the analyses. We also excluded 18 patients who refused the 6-month interview, 11 patients who were too sick to answer questions, and 34 patients who could not be reached within the allotted time window. The final total number of patients enrolled was 1072 (777 men and 295 women). Because of incomplete or missing outcome data, 7 patients were further excluded from the analysis of hospital readmission, 2 patients were excluded from the analyses of changes in functional status, and 46 patients were excluded from the analyses of changes in mental health.

Baseline Characteristics
Women had, overall, a more unfavorable risk profile than men, lower physical function, and lower mental health (Table 1). The number of diseased vessels, however, was lower in women, and the ejection fraction was similar in the 2 groups.

View this table: [in this window] [in a new window]   TABLE 1. Comparison of Baseline Characteristics Between Men and Women

View this table: [in this window] [in a new window]   TABLE 1. Continued

Changes in Physical Function and Mental Health
At 6 months, both men and women showed, on average, a significant improvement in physical function and mental health, but men improved more than women (Table 2). On average, men showed an improvement in physical function that was 3 times higher than women’s. The proportion of patients whose score improved was twice as large in men as in women; conversely, the proportion of patients who worsened was twice as large in women as in men. When analyses were stratified according to approximate quartiles of baseline PF score, women showed a significantly lower PF score than men at follow-up in each stratum (Figure). Analyses of mental health scores showed similar trends (Table 2). These sex differences were only slightly reduced after adjustment for a comprehensive set of baseline covariables. After multivariable analysis, the mean score improvement in women was half that of men for physical function and 25% less than that of men for mental health. In addition, women were 62% more likely than men to show a decline in physical function and in mental health at 6 months with respect to presurgery levels.

View larger version (29K): [in this window] [in a new window]   Mean levels of SF-36 PF score at baseline and at 6 months in men and women after stratification according to approximate quartiles of baseline scores. Probability values refer to differences in 6-month scores between men and women.

Hospital Readmission
Readmission to the hospital in the 6-month follow-up after surgery was common, particularly among women, who experienced 53% higher readmission rates than men (Table 2). Multivariable analysis did not affect sex differences in readmission rates. Patients were able to report the primary reason for hospitalization in 87.8% of these admissions. The rates of readmission because of ischemia or repeat revascularization, as well as readmission for congestive heart failure, were >2.5 times higher in women than in men (Table 3). The only readmissions that were slightly more common among men were those resulting from cardiac arrhythmias.

View this table: [in this window] [in a new window]   TABLE 3. Cause-Specific Hospital Readmission Rates at 6 Months After CABG Surgery in Men and Women

	Discussion

Top Abstract Introduction Methods Results Discussion Conclusions References

 
Our results show a less favorable impact of CABG surgery in women than men, using a broad array of functional and quality-of-life outcome measures at 6 months after the procedure. Women showed smaller functional gains and higher rates of hospital readmission than men. Our data indicate not only that there are important sex-related differences in a broad array of outcomes 6 months after CABG surgery but also that the absolute rates of unfavorable outcomes in women, such as hospital readmission (32.5%), worsening functional status (25.7%), or worsening mental health (17.5%), are higher than one would expect in the face of a mortality rate of only 2.2%. These data should encourage physicians to explore more thoroughly why women do not fare as well as men after CABG.

Previous literature on sex differences in physical and emotional outcomes after CABG surgery has yielded conflicting results. A number of reports have described more symptoms and poorer functioning in women than men at various times after CABG surgery, from 3 months to 5 years.^8–11 In contrast, other studies showed no significant sex differences in symptoms and functional outcomes during the first year after CABG surgery.^12–15 Additional investigations reported more adverse outcomes among women in some dimensions of quality of life but not in others.^16,26

These conflicting results may be explained in part by differences in methodology. All of the negative studies were based on samples including <70 women, thus raising the concern of whether there was sufficient power to detect sex-related outcome differences. Many reports were also based on convenience samples that may have been too selective to provide meaningful information. In addition, many studies, both positive and negative, did not take into account preoperative differences in health status between the sexes. Our study confirms previous observations of more limited physical and psychological gains in women than in men after CABG surgery after taking into account baseline variables such as presurgery health status and physical and psychological functioning.

Women had 53% higher hospital readmission rates than men during the follow-up, a difference that was not explained by differences in other factors. Readmissions because of cardiovascular events, such as subsequent ischemia with or without repeat revascularization and congestive heart failure, were distinctly more common in women than in men, as were admissions because of surgery-related infections. Two previous studies found that female sex was a significant predictor of higher rates of readmission,^27,28 but another study did not find significantly higher readmission rates in women after adjustment for other factors.¹⁷ It should be noted, however, that the long follow-up of the latter study (10 years) might have obscured an effect of sex on CABG-related readmissions that occurred early in the follow-up. Although readmissions in the initial postoperative months are likely to be CABG-related, this may not be true for admissions over a period of years after the procedure.

Why Do Women Fare Worse Than Men After CABG?
If CABG surgery is associated with a less complete revascularization in women than in men, this might result in less symptom relief, lower functional status, and higher readmission rates in women. Indeed, women have been shown to achieve less complete revascularization⁸ and have higher graft occlusion rates^29,30 than men after CABG, although these differences seem to be decreasing in recent years.³¹ These effects have been attributed to women’s smaller coronary arteries, which in turn may make performing anastomoses more difficult and limit graft flow.^32,33 When body surface area, a proxy measure for coronary artery size, was controlled for in studies of hospital mortality, it explained the higher operative mortality among women in some studies^9,34 but not in others.^24,35 In our study, sex-related outcome differences persisted after adjustment for body surface area. However, it should be noted that the latter is only an approximation of coronary artery size, and women have smaller coronary arteries than men independent of body size.^32,36

Another possible explanation lies in potential sex differences in referral for diagnosis and treatment of coronary disease. If women are referred for CABG later in the disease process than men, those women who receive CABG surgery can be expected to have more severe coronary disease than men, leading to worse outcome. The fact that women had, preoperatively, more severe angina class and more congestive heart failure does suggest potential sex differences in referral, as suggested in earlier studies.^34,37,38 However, one would also expect to observe more advanced coronary atherosclerosis in women than men. In contrast, in our study, women had fewer diseased vessels, as has been noted in several previous studies.^8,9,33,39,40 In addition, severity characteristics at presentation and severity of coronary artery disease only partially explained outcome differences at 6 months in our study.

Sex differences in self-reporting of health status might also play a role. Women consistently report worse health than men do,⁴¹ possibly because of cultural and social aspects associated with sex. For example, women are more involved than men with health care and with the monitoring of the health of family members, which might increase women’s concern with physical symptoms. Although these potential differences may in part explain sex differences in cross-sectional evaluations of health, they should not play a major role in those assessed longitudinally or in the differences in readmission rates.

Limitations
A limitation of our study is that our population came from one major teaching hospital. However, we were able to screen for participation all consecutive CABG admissions, and we administered detailed questionnaires. This methodology would have been more difficult in the setting of a multicenter study. Because patients were asked to recall their preoperative health status after surgery, women and men may have differed in their propensity to recall health problems. However, conclusions about changes in health status, measured with scales similar to those used here, are materially unaffected when data on preadmission health status are collected retrospectively.⁴²

Another potential limitation is the use of a general functional status measure, the SF-36, as opposed to instruments specific for coronary heart disease. The latter usually focus on angina-related disability. In our sample, however, more than one third of the patients did not have a history of angina before CABG; therefore, such instruments would have affected our ability to detect functional changes in these patients. In addition, there was a potential for sex-related assessment bias, given that men had a lower prevalence of angina before CABG than women. The SF-36 has been validated extensively in patients with coronary heart disease,^19–21 has been used widely in CABG patients,^22,23 and offers the advantage of assessing health status in other dimensions in addition to physical function, such as mental health.

	Conclusions

Top Abstract Introduction Methods Results Discussion Conclusions References

 
Our results show that CABG surgery is associated with lower functional gains and higher readmission rates in women than men 6 months after operation. These differences are not explained by illness severity, presurgery health status, or other patient characteristics, and special efforts should be directed toward understanding the underlying reasons for these differences in future studies.

	Acknowledgments

 
This study was supported by a grant from the Ethel F. Donaghue Women’s Health Investigator Program, New Haven, Conn, and by a grant from the Quality Care Research Fund, Aetna Foundation, Hartford, Conn.

	References

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