Scientific article 10. APR 2026
Sex differences in patients hospitalized for repair of intact abdominal aortic aneurysms in eleven high-income countries: A cross-sectional cohort study
Authors:
Abstract
Objective
Sex differences in the treatment and outcomes of males and females undergoing intact abdominal aortic aneurysm (AAA) repair have been documented in single-country studies, with females tending to have worse outcomes. However, international comparisons of sex differences across countries using patient-level data and harmonized analytical methods are lacking.
Methods
We conducted a retrospective serial cross sectional cohort study using population-representative administrative data from eleven countries participating in the International Health Systems Research Collaborative (IHSRC) to identify adults aged 66+ hospitalized for intact AAA repair between 2011 and 2019. We compared females and males within each country with respect to age- and comorbidity-adjusted AAA population-adjusted incidence of surgeries, 30-day and 1-year mortality, 30-day readmission, and hospital length of stay (LOS).
Results
Our intact AAA repair cohort sizes differed widely across our 11 countries, ranging from 200,151 in the US (178,777 [78%] EVAR; 21,374 [22%] open repair) to 1,290 in Israel (1,199 [89%] EVAR, 91[11%] open repair). Overall AAA population-adjusted incidence of surgeries (EVAR plus open repairs per 100,000 population per year) were significantly lower for females than males in all countries but the male to female repair ratio within countries differed widely. For example, in the US there were approximately 4.5 male repairs per 1.0 female repair; in Israel the ratio was 10:1. 30-day and 1-year age- and comorbidity-adjusted mortality was higher for females than males in most countries (Switzerland, 1-year mortality: 8.5 female, 5.4 male). Females experienced longer hospital overall (EVAR plus open) LOS (e.g., South Korea, male 17.9 days vs female 23.5 days) and higher rates of hospital readmission (e.g., Israel, male 21.0% vs female 33.6%) than males. These disparities persisted across years and repair subtype.
Conclusions
Compared to males, females had lower AAA population-adjusted incidence of surgeries, higher mortality, higher readmission rates, and longer hospital LOS across 11 diverse high-income countries. However, the magnitude of the female-male differences were surprisingly variable. These findings raise important questions about whether these differences are manifestations of true clinical differences across countries or differences in how males and females are treated in each country. We suggest that countries with larger “gaps” explore the underlying drivers of these differences while simultaneously exploring opportunities to redesign care.
Objective
Sex differences in the treatment and outcomes of males and females undergoing intact abdominal aortic aneurysm (AAA) repair have been documented in single-country studies, with females tending to have worse outcomes. However, international comparisons of sex differences across countries using patient-level data and harmonized analytical methods are lacking.
Methods
We conducted a retrospective serial cross sectional cohort study using population-representative administrative data from eleven countries participating in the International Health Systems Research Collaborative (IHSRC) to identify adults aged 66+ hospitalized for intact AAA repair between 2011 and 2019. We compared females and males within each country with respect to age- and comorbidity-adjusted AAA population-adjusted incidence of surgeries, 30-day and 1-year mortality, 30-day readmission, and hospital length of stay (LOS).
Results
Our intact AAA repair cohort sizes differed widely across our 11 countries, ranging from 200,151 in the US (178,777 [78%] EVAR; 21,374 [22%] open repair) to 1,290 in Israel (1,199 [89%] EVAR, 91[11%] open repair). Overall AAA population-adjusted incidence of surgeries (EVAR plus open repairs per 100,000 population per year) were significantly lower for females than males in all countries but the male to female repair ratio within countries differed widely. For example, in the US there were approximately 4.5 male repairs per 1.0 female repair; in Israel the ratio was 10:1. 30-day and 1-year age- and comorbidity-adjusted mortality was higher for females than males in most countries (Switzerland, 1-year mortality: 8.5 female, 5.4 male). Females experienced longer hospital overall (EVAR plus open) LOS (e.g., South Korea, male 17.9 days vs female 23.5 days) and higher rates of hospital readmission (e.g., Israel, male 21.0% vs female 33.6%) than males. These disparities persisted across years and repair subtype.
Conclusions
Compared to males, females had lower AAA population-adjusted incidence of surgeries, higher mortality, higher readmission rates, and longer hospital LOS across 11 diverse high-income countries. However, the magnitude of the female-male differences were surprisingly variable. These findings raise important questions about whether these differences are manifestations of true clinical differences across countries or differences in how males and females are treated in each country. We suggest that countries with larger “gaps” explore the underlying drivers of these differences while simultaneously exploring opportunities to redesign care.
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About this publication
Published in
Journal of Vascular Surgery
