Care at low-quality hospitals is more common among female Medicare beneficiaries, with a 2-fold increase for the sex disparity in mortality compared to high-quality hospitals, according to a recent study in JAMA Network Open.1
Takeaways
- Female Medicare beneficiaries experience significantly higher 30-day mortality rates compared to male beneficiaries, with disparities worsening at lower-quality hospitals.
- Women are 26% more likely to receive care at low-quality hospitals compared to men, with an odds ratio of 1.26.
- Female patients undergoing high-risk surgeries such as coronary artery bypass grafting have higher rates of comorbidities (91.6% vs. 85.6%) and unplanned surgeries (55.2% vs. 48.7%) than male patients.
- Lower-quality hospitals tend to be for-profit with lower nurse-to-patient ratios, smaller bed sizes, and lower surgical volumes, contributing to poorer outcomes for female patients.
- The study advocates for policies ensuring equitable referral of female patients to high-quality hospitals to address and reduce sex-based disparities in surgical outcomes.
Health equity has a remained a priority among government agencies and health care societies, with increased calls being made for focus on sex disparities over time. Improving high-quality care access has been identified as a method to eliminate disparities.
An example of efforts to reduce sex-based disparities is the US Department of Health and Human Service’s Agency Equity Action Plan.2 The 5 key focuses of the plan are preventing child welfare system involvement, promoting accessible and welcoming health care, improving maternal health outcomes, meeting behavioral health needs, and advancing clinical innovation.
Currently, there is little information about the association between sex disparities and hospital quality.1 Investigators conducted a national study of Medicare beneficiaries receiving high-risk surgery to determine the impact of sex disparities on hospital quality.
Medicare beneficiaries receiving coronary artery bypass grafting between October 1, 2015, and March 31, 2020, were included in the analysis.Participants had at least 3 months of continuous enrollment before surgery and 12 months after surgery.
Undergoing the procedure was identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.Data was obtained from the Medicare Provider Analysis and Review file, including patient demographics and characteristics.
Hospital characteristics such as nurse to patient ratio, hospital size, and teaching status were also obtained.Thirty-day mortality was reported as the primary outcome of the analysis and included in-hospital mortality and death within 30 days postoperatively. The Medicare Denominator File was used to find deaths within 30 days postoperatively outside the hospital.
Hospitals were placed into quintiles by their risk-adjusted rate of 30-day mortality to determine quality of care. Those in the lowest quintile for 30-day mortality were defined as having the highest quality care, while those in the highest quintile were defined as having the lowest quality care.
There were 444,855 beneficiaries included in the analysis, aged a mean 71.5 years. Of beneficiaries, 72.9% were male and 27.1% were female. Rates of 2 or more comorbidities and unplanned surgery were higher in female patients than male patients, at 91.6% vs 85.6%, respectively for comorbidities and 55.2% vs 48.7%, respectively, for unplanned surgery.
Lower-quality hospitals had increased odds of being for-profit and had the lowest nurse to patient ratio, smallest hospital bed size, and lowest coronary artery bypass grafting volume per hospital. The risk of receiving care at the lowest-quality hospitals was 26% greater among female beneficiaries vs male beneficiaries, with an odds ratio of 1.26.
The risk-adjusted mortality was 4.24% for female patients and 2.75% for male patients, leading to an absolute difference of 1.48. This disparity was worsened in lower-quality hospitals, with an absolute difference of 1.01 at the highest-quality hospitals and 2.07 at the lowest-quality hospitals.
These results indicated higher 30-day mortality among female Medicare beneficiaries vs male beneficiaries, with worsened disparity as hospital quality decreases. Investigators recommended policy focused on equitable referral of female patients to high-quality centers to reduce these disparities.
References
- Wagner CD, Ibrahim AM. Sex disparities after coronary artery bypass grafting and hospital quality. JAMA Netw Open. 2024;7(6):e2414354. doi:10.1001/jamanetworkopen.2024.14354
- US Department of Health and Human Services. Agency Equity Action Plan. 2023. Accessed June 11, 2024. https:// www.hhs.gov/sites/default/files/hhs-equity-action-plan.pdf
