Gender differences in the provision of intensive care: a Bayesian approach

Abstract

Purpose: It is currently unclear whether management and outcomes of critically ill patients differ between men and women. We sought to assess the influence of age, sex and diagnoses on the probability of intensive care provision in critically ill cardio- and neurovascular patients in a large nationwide cohort in Switzerland.

Methods: Retrospective analysis of 450,948 adult patients with neuro- and cardiovascular disease admitted to all hospitals in Switzerland between 01/2012 and 12/2016 using Bayesian modeling.

Results: For all diagnoses and populations, median ages at admission were consistently higher for women than for men [75 (64;82) years in women vs. 68 (58;77) years in men, p < 0.001]. Overall, women had a lower likelihood to be admitted to an intensive care unit (ICU) than men, despite being more severely ill [odds ratio (OR) 0.78 (0.76-0.79)]. ICU admission probability was lowest in women aged > 65 years (OR women:men 0.94 (0.89-0.99), p < 0.001). Women < 45 years had a similar ICU admission probability as men in the same age category [OR women:men 1.03 (0.94-1.13)], in spite of more severe illness. The odds to die were significantly higher in women than in men per unit increase in Simplified Acute Physiology Score (SAPS) II (OR 1.008 [1.004-1.012]).

Conclusion: In the care of the critically ill, our study suggests that women are less likely to receive ICU treatment regardless of disease severity. Underuse of ICU care was most prominent in younger women < 45 years. Although our study has several limitations that are imposed by the limited data available from the registries, our findings suggest that current ICU triage algorithms could benefit from careful reassessment. Further, and ideally prospective, studies are needed to confirm our findings.

Keywords: Cardiovascular disease; Critical illness; Gender bias; Survival; Women.

Fig. 1

Representative populations and peak ages for the full dataset. Peak ages were identified by fitting a skewed normal distribution to observed total patient populations stratified by sex. ICU intensive care unit

Fig. 2

Calculated total probability of admission for men and women for each age category. Age categories in proximity to peak age show the lowest overall probability of admission for both sexes. Bold lines represent median probabilities. Probability of ICU admission plotted for each age group (5 year intervals). ICU intensive care unit

Fig. 3

Binomial analysis of death. Odds and odds ratios are given with 95%-confidence intervals. Baseline is a diagnosis of acute coronary syndrome including cardiac arrest, an average SAPS II of 31.2 and NEMS/LOS of 99.7. P < 0.05*, < 0.01**, < 0.001***. X-axis in logarithmic scale. ICU intensive care unit; SAPS II Simplified Acute Physiology Score II; NEMS Nine Equivalents of Nursing Manpower Use Score; LOS length-of-stay