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Inequities in surgical outcomes by race and sex in the United States: retrospective cohort study

BMJ 2023; 380 doi: (Published 01 March 2023) Cite this as: BMJ 2023;380:e073290

Rapid Response:

Re: Inequities in surgical outcomes by race and sex in the United States: retrospective cohort study - – Combining Arterial Surgery with Appendicectomy hides inequities by sex

Dear Editor,

While we applaud efforts by Ly et al. [1] to assess inequities in mortality by race and sex, their choice to group eight surgical procedures, which are significantly disparate, both in aetiology and associated risk, lacks appropriate granularity and is consequently misleading[1].

Pooling data for all surgical procedures hides the inequity for arterial surgery, where data from the USA, (including Medicare USA,) and world-wide are consistent in showing the worse outcomes in women[2–6].

Indeed, increased mortality for women is observed following both coronary artery bypass and abdominal aortic aneurysm (AAA) repair[2–6]. For example, analysis of over 1 million patients within the Adult Cardiac Surgery Database of the Society of Thoracic Surgeons from 2011-2020 revealed an attributable risk of female sex for operative mortality of 1.28-1.41[5]. Similarly, data from the Medicare and the American College of Surgeons National Surgical Quality Improvement Program, spanning 2011-2017, demonstrated an increased risk of mortality (adjusted odds ratio 1.7) and morbidity for women after AAA repair[7,8]. In addition, for critical limb ischaemia, limb salvage is lower in women, resulting in much higher amputation rates[6].

Whilst the study by Ly et al highlights the worse outcomes of black men after surgery, it hides the inequalities suffered by women in some surgical specialities and takes no account of race and sex biases in selection for surgery[9]. Appendicectomy should not be combined with arterial surgery in the evaluation of disparities in outcomes by sex. Sadly, through this unfortunate oversight, Ly et al. may perpetuate the very issues they sought to address[1].


1 Ly DP, Blegen MB, Gibbons MM, et al. Inequities in surgical outcomes by race and sex in the United States: retrospective cohort study. BMJ 2023;:e073290. doi:10.1136/bmj-2022-073290
2 Pouncey AL, David M, Morris RI, et al. Editor’s Choice - Systematic Review and Meta-Analysis of Sex Specific Differences in Adverse Events After Open and Endovascular Intact Abdominal Aortic Aneurysm Repair: Consistently Worse Outcomes for Women. European Journal of Vascular & Endovascular Surgery 2021;62:367–78. doi:10.1016/j.ejvs.2021.05.029
3 Shi D, Zhang B, Motamed M, et al. Higher Mortality in Women After Coronary Artery Bypass: Meta-analysis and Bias Analysis of Confounding. Ann Thorac Surg 2022;113:674–80. doi:10.1016/j.athoracsur.2020.11.039
4 Angraal S, Khera R, Wang Y, et al. Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999–2014. J Am Heart Assoc 2018;7. doi:10.1161/JAHA.118.009014
5 Gaudino M, Chadow D, Rahouma M, et al. Operative Outcomes of Women Undergoing Coronary Artery Bypass Surgery in the US, 2011 to 2020. JAMA Surg Published Online First: 1 March 2023. doi:10.1001/jamasurg.2022.8156
6 Mentias A, Vaughan-Sarrazin M, Saad M, et al. Sex Differences in Management and Outcomes of Critical Limb Ischemia in the Medicare Population. Circ Cardiovasc Interv 2020;13. doi:10.1161/CIRCINTERVENTIONS.120.009459
7 Deery SE, Soden PA, Zettervall SL, et al. Sex differences in mortality and morbidity following repair of intact abdominal aortic aneurysms. J Vasc Surg 2016;65:1006–13. doi:10.1016/j.jvs.2016.08.100
8 Erben Y, Bews KA, Hanson KT, et al. Female Sex is a Marker for Higher Morbidity and Mortality after Elective Endovascular Aortic Aneurysm Repair: A National Surgical Quality Improvement Program Analysis. Ann Vasc Surg 2020;69:1–8. doi:10.1016/j.avsg.2020.06.031
9 Mcginigle KL, Browder SE, Strassle PD, et al. Sex-related disparities in intervention rates and type of intervention in patients with aortic and peripheral arterial diseases in the National Inpatient Sample Database. J Vasc Surg 2021;73:2081-2089.e7. doi:10.1016/j.jvs.2020.11.034

Competing interests: No competing interests

17 March 2023
Anna L Pouncey
Vascular Surgeon
Professor Janet Powell
Imperial College London
St Mary's Hospital, Imperial College London