Unmasking sex-based disparities in failure to rescue: Are women at greater risk after major surgery?

Abstract

Sex-based disparities can affect access to care and surgical outcomes. Disparities in postoperative mortality may be related to differences in the management of complications. We sought to define sex-based differences in outcomes after a major complex surgical procedure. Patients who underwent a major surgical procedure between 2017 and 2020 were identified using the Medicare database. Failure to rescue was defined as death occurring after serious complication. Multivariable regression models were used to examine the association between patient sex and postoperative outcomes including failure to rescue. A total of 1,165,265 individuals underwent a major surgerical procedure (abdominal aortic aneurysm repair: n = 283,467, 24.3%; coronary artery bypass grafting: n = 319,527, 27.4%; colectomy: n = 436,315, 37.4%; pneumonectomy: n = 101,378, 8.7%; pancreatectomy: n = 24,578, 2.1%). Median patient age was 74 years (interquartile range: 70-80 years), and most patients were male (57.3%, n = 666,996). Of note, female patients were slightly older (75 years [interquartile range: 70-80 years] vs 74 years [interquartile range: 71-80 years]) and had a higher Charlson Comorbidity Index (>2: 37.9% vs 36.2%) (both P < .001). After surgery, female patients were less likely to experience serious complications (31.2% vs 36.5%; P < .001); however, female patients had higher failure to rescue rates (17.5% vs 15.9%; P < .001). On multivariable analysis, female patients had higher odds of 30-day mortality (odds ratio: 1.11, 95% confidence interval: 1.09-1.13) and failure to rescue (odds ratio: 1.11, 95% confidence interval: 1.08-1.14). On stratified analysis, failure to rescue rates declined with higher hospital volume, but female patients consistently had higher failure to rescue. Higher failure to rescue may explain the higher postsurgery mortality among female patients. Targeted efforts are needed to reduce sex-based disparities in postoperative care.