Gender disparities in intensive care

Gender disparities in intensive care

by Deleted user -
Number of replies: 9

This was the topic of my diploma theses in Vienna. While it was entirely a statistical analysis of numerous variables, I tried to think about a different approach to the topic in the form of a structural interview for this seminar.

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Statistically, slightly more than half of the population in the developed world is female. However, those numbers do not reflect the sex distribution on intensive care units in developed countries. A study conducted by Valentin et al. showed that men were significantly more likely to be transferred to an intensive care unit (ICU) than women. As a matter of fact, during the study period 60% of all patients on Austrian ICUs were male.

Additionally, women were significantly older when being transferred to the ICU than men (66.0 years vs. 59.3 years; p<0.001), had a higher severity of illness – as measured by the SAPS II score –, had a lower overall level of care – as measured by the TISS 28 score –, and a lower chance to receive invasive treatment.

In another study conducted by Dorner et al. length of stay on the ICU was on average significantly shorter for women than for men.

There were, however, numerous limitations that formed an obstacle for giving explanations for gender disparities in those studies. Besides differences in clinical presentation, ethnicity, DNR orders and hospital refunding policy, personal opinions and differences in decision making among the medical staff might have influenced outcome, length of stay or treatment strategies.

 

Valentin, A., et al., Gender-related differences in intensive care: a multiple-center cohort study of therapeutic interventions and outcome in critically ill patients. Crit Care Med, 2003. 31(7): p. 1901-7.

Dorner, T., et al., [Gender specific differences in the frequency of admission to intensive care units, duration of stay and the application of intensive medical care measures in men and women aged 75 years and above in an Austrian region]. Gesundheitswesen, 2010. 72(2): p. e72-5.


Objective: It is the aim of this study to further investigate whether the medical staff is partially responsible for the above mentioned gender disparities due to personal opinion and making different decisions for treatment between men and women.

Study design: this is a structured qualitative and quantitative interview conducted at an ICU in Vienna.

Research question: Are personal opinions and differences in making a decision among doctors between men and women responsible for gender disparities in survival, quality of care and length of stay on Austrian ICUs?

 

The following questions are supposed to show whether the existence of gender disparities is known and whether doctors make different decisions for men and women in certain situations based on their knowledge and experience.

 

Questions:

Do you think there are gender disparities in clinical presentation of symptoms?

Do gender and/or sex influence your decision making?

To what extent do gender disparities exist in the rate of DNRs?

Have you read any publications on gender disparities in intensive care?

Do you know of any other areas of medicine where severe gender disparities exist?

On average how many patients on your ICU are female?

In your opinion, could there be any differences in treatment of an 80 year-old man compared to an 80 year old woman with similar APACHE II values?

Are there any differences between men and women in causes for admission?

Are there any treatments you would not consider for female patients or male patients in certain situations?

Based on your experience which group of patients has the highest chance of full recovery (including age and sex)?

 

In reply to Deleted user

Re: Gender disparities in intensive care

by Deleted user -

To your first question, I see quite a few doctors answering "do you mind elaborating, please." cos it seems too broad a question. In a TV interview, that probably works as you'd have some minutes to explain what you mean. But, in a survey, it wouldn't give you a answer you want. Somehow I feel your sixth question (on average, how many patients on your ICU are female) should begin the questions.

In reply to Deleted user

Re: Gender disparities in intensive care

by Deleted user -

Yes, I can see your point. I was thinking about a general introduction to the topic, to see whether doctors believe in gender disparities or not. In this specific case, I was thinking about cardiovascular diseases. We know that heart attacks show different symptoms in men than in women. We all know the classical symptoms (chest pain, pressure/pain in the left arm,...), but women are by far less likely to show those symptoms. Atypical symptoms like nausea and/or fatigue are far more common in female patients. To be honest, I wouldn't think of a heart attack when examining a female patient with nausea.

I can't find the artical that describes gender disparities in clinical presentation at the moment. I will post it later today.

And I will rephrase my question and add:

Do you think there are gender differences in clinical presentation for certain diseases (e.g. acute coronary syndrome, depression)?

In reply to Deleted user

Re: Gender disparities in intensive care

by Deleted user -

Ok. So, your interviews will be done face-to-face? It doesn't say in your write-up?

In reply to Deleted user

Re: Gender disparities in intensive care

by Deleted user -

Since I would conduct the survey only on one ICU in Vienna, a face-to-face interview seems to be the better choice. If I was aiming for a broader survey around Austria (as it was done by Valentin et al.), I'd go for a a survey form to be sent by mail.

Lots of updates to my original post, but thank you for the input. I really appreciate it.

 

Also, here are two studies regarding gender differences in clinical presentation:

Dey, S., et al., Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart, 2009. 95(1): p. 20-6.

McSweeney, J.C., et al., Women's early warning symptoms of acute myocardial infarction. Circulation, 2003. 108(21): p. 2619-23.

In reply to Deleted user

Re: Gender disparities in intensive care

by Sara Shaw -

I like the approach to thinking about an interview study if you're doing X, or a survey if you'redoing Y... on the one hand you could gather some quite in-depth data from face-to-face interviews in one ICU (perhaps probing more with your questions e.g. not just exploring if people think that gender disparites exist, but also why they think they exist; or asking about how the reading they have done might have changed their practice..... qualitatve research is really helpful for look at questions of WHY or HOW) or you could get more breadth from a survey across ICUs but you'd likely have more focused questions with e.g. 'yes', 'no', 'don't know' responses), like the ones in the orignal post.

This seems quite relevant to some of the other posts that have gone up - hopefully there's more to follow today! - so it would be interesting to hear what others think.

In reply to Deleted user

Re: Gender disparities in intensive care

by Samuel Dafydd Rigby -

I really like this Andreas, an interesting topic. I think a nice addition may be to ask about the environment for the staff in ICU, maybe traditionally a more 'macho' working environment? Maybe this would have a (sub)conscious impact on the descision for referral?

Also, i like the idea of face-face interviewing for this to draw out more detail. I think maybe by doing this there is a risk of the interviewees disclosing information that may be harmful to their career or colleagues. How would you maintain confidentiality if you were to only interview in one ICU in Vienna?

In reply to Samuel Dafydd Rigby

Re: Gender disparities in intensive care

by Deleted user -

You are absolutely right, I didn't think about the problems regarding confidentiality when conducting the interview on only one ICU. I think I'd either have to find a large enough hospital with more than one ICUs or try to conduct the interview on different ICUs around Austria. That would make face-to-face interviews a bit more difficult and costly though.

In reply to Deleted user

Re: Gender disparities in intensive care

by Sandeep Suryadevara Rao -

With regards to the research ethics / confidentiality issues:

I think a study of this type would make a positive impact in terms of encouraging interviewees to think about their decision-making, and start to analyse whether there are unconscious factors that affect their decisions - in terms of gender issues. (particularly question 2)

And I agree that the information received may be more truthful if one can guarantee confidentiality. However question 7 asks whether men and women are treated differently despite having the same APACHE scores. If this were happening without an appropriate medical explanation, and was a conscious process, then it would represent sexism. This would be a misuse of power / negligence, and such practices have to be highlighted in order that all patients have the opportunity to receive the medical attention they require.

If such a practice came to light, then would we (as researchers) not have a duty to report it, in order to maintain patient safety? Because essentially, is that not why we carry out such studies in the first place?

However, if it was suspected that such practice was occurring (deliberately) and nobody was forthcoming in talking about it, I imagine a quantitative audit could highlight the differences in treatment of men and women: comparing interventions used in men and women with the same APACHE scores / other physical parameters

In reply to Sandeep Suryadevara Rao

Re: Gender disparities in intensive care

by Deleted user -

Sadly, men and women are sometimes treated differently, even when they have similar APACHE scores. There are quite a lot of studies dealing with this issue. Of course, there are numerous logical reasons why men and women are sometimes treated differently. Ignoring all the ethical issues for a moment, medical malpractice would only be the case, if there were differences in outcome. And often that is not the case, thankfully. It remains to be a very sensitive, complex and current topic.