Healthcare costs for patients undergoing common surgical procedures are significantly higher when the surgery is performed by a male surgeon rather than a female surgeon, data suggested.
A retrospective, population-based cohort study that included more than 1 million adults undergoing any of 25 common surgical procedures found that total healthcare costs assessed at 1 year following surgery were more than $6000 higher when the surgery was performed by a male surgeon. Costs were also higher at 30 and 90 days for patients treated by male surgeons.
"As a male surgeon, I think our results should cause me and my colleagues to pause and consider why this may be," lead author Christopher J. D. Wallis, MD, PhD, assistant professor of surgery at the University of Toronto, told Medscape Medical News.
"None of us believe that the presence of a Y chromosome in surgeons means there are worse outcomes, it's just that generally speaking, men and women, as we have known for decades, practice medicine a little differently. Things like communication style, time they spend with their patients, and even things like guideline adherence are different, and understanding how those differences translate into patient outcomes is the goal of this whole body of work," said Wallis.
The study was published online November 29 in JAMA Surgery.
Explanation Is Elusive
In earlier work, Wallis and his team reported that patients treated by female surgeons had a small but statistically significant decrease in 30-day mortality, were less likely to be readmitted to the hospital, and had fewer complications than those treated by male surgeons. In another study, they found worse outcomes among female patients treated by male surgeons.
In the current study, the researchers examined the association between surgeon sex and healthcare costs among patients undergoing various surgical procedures, including coronary artery bypass grafting, appendectomy, hysterectomy, anterior spinal decompression, and knee replacement. They included all adult patients who underwent these procedures at hospitals in Ontario, Canada, between January 2007 and December 2019 in their analysis.
The study sample included 1,165,711 patients. Of this group, 151,054 patients were treated by a female surgeon, and 1,014,657 were treated by a male surgeon.
After adjusting for patient-, surgeon-, anesthesiologist-, and hospital-related factors, they found that 1-year total healthcare costs were $24,882 for patients treated by male surgeons vs $18,517 for patients treated by female surgeons. Healthcare costs were also higher at 30 days (adjusted absolute difference, $3115) and at 90 days (adjusted absolute difference, $4228).
"This translates into a 9%-10% higher risk of costs with male surgeons compared with women surgeons at these time points," said Wallis.
"This study cannot provide a specific answer as to why these differences are occurring," Wallis said.
"We are currently undertaking more research to better understand the reasons. Our previous studies have shown that patients treated by male physicians have higher rates of death, readmission, and complications. Managing these adverse postoperative events is costly and likely contributes to these differences. Given the size of our study and similar training pathways, we do not think there are technical differences between male and female surgeons. Rather, we are hypothesizing that there may be differences in how physicians practice, make decisions, and consult with patients," he said.
Ultimately, Wallis said he would like his research to prompt "a moment of introspection" among his surgical colleagues.
"Hopefully, these data will provide the impetus for further efforts to make surgery, and medicine in general, a field that is welcoming to women," he said.
Potential Confounding Factors
This study expands the evidence suggesting significant practice differences between male and female surgeons, Ursula Adams, MD, a resident; Caprice C. Greenberg, MD, MPH, chair; and Jared Gallaher, MD, MPH, adjunct assistant professor, all from the Department of Surgery at the University of North Carolina in Chapel Hill, wrote in an accompanying editorial.
They cautioned, however, that "there are many potential confounding factors and possible explanatory mechanisms associated with surgeon sex that make it challenging to untangle influences on costs. Sex may be an easily captured data point, but is understanding the mechanism by which it affects cost the right next step? Surgeons control how and where they practice; they do not have control over their own demographics."
The editorialists added that though recruiting and retaining women in surgery is important, it is not a solution to controlling costs.
"We must provide surgeons with better data to understand how practice approach and decisions affect cost and support for practice improvement. Only with these insights will we ensure patients of male surgeons receive care that is just as cost-effective as that provided by female surgeons, while also helping to bend the cost curve and improve the quality of surgical care," they concluded.
'Admirable' Data Use
Commenting on the findings for Medscape Medical News, Oluwadamilola "Lola" Fayanju, MD, chief of breast surgery at Penn Medicine in Philadelphia, said, "It is interesting that the study was performed in Canada with its different healthcare system." Fayanju did not participate in the study.
"They used administrative data from a national database, and it is admirable that they were able to do that. These data allow us to make large-scale geographical assessments, although they are subject to errors and unmeasured confounders," said Fayanju.
Women surgeons may do things that result in better outcomes, she suggested. "In this study, the women were younger and so perhaps were more up to date. They might have optimized management of their patients in the pre-op phase, including better patient selection, which led to better costs. Or in the post-op phase, they might have made themselves readily accessible. For instance, I remove all barriers about getting in touch with me, and I tell my students to make sure the patient can reach you easily," said Fayanju.
The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care, and the Data Sciences Institute at the University of Toronto. Wallis, Adams, Greenberg, Gallaher, and Fayanju reported no relevant financial relationships.
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