Female patients may be less likely than male patients with comparable clinical characteristics to receive invasive or intensive treatments, according to a scoping review that found recurring sex-based differences in patient management across medical specialties.
Investigators searched PubMed and Embase for English-language, peer-reviewed studies published from 2018 to 2023 that reported measurable differences in care received by patients of different sexes or genders. Studies had to involve actual patients and primary data on clinical management rather than hypothetical patients, clinician attitudes, or differences in access alone. Both researchers independently screened studies against prespecified criteria and conducted quality appraisal. Of 1,112 records identified after duplicate removal, 41 studies were included, including 26 conducted in the US. Thirty-eight were retrospective case series.
The review examined differences in diagnosis, procedures, medications, and other aspects of patient management. The included literature covered multiple specialties, with cardiovascular medicine accounting for 15 studies, followed by neurology, surgery, transplantation, emergency medicine, endocrinology, psychiatry, and other areas.
Among the 38 retrospective case series, 33 (87%) reported a statistically significant treatment difference between male and female patients. Of 29 case series that used multivariable analysis, 25 (86%) found a statistically significant difference. However, 9 of the retrospective studies did not use multivariable analysis, 17 did not include ethnicity in descriptions of their populations, and 13 did not include comorbidities.
The most consistent pattern was lower use of invasive or intensive management among female patients. In cardiovascular studies, female patients were more likely to receive conservative medical management rather than invasive procedures for myocardial infarction, heart failure, and supraventricular tachycardia. They were also less likely to receive lipid-lowering therapy for atherosclerotic vascular disease, although a study of patients with diabetes found no sex difference in lipid-lowering treatment.
Differences also appeared outside cardiovascular care. Male patients with Parkinson disease were more likely to be referred for deep brain stimulation, although sex was not associated with proceeding to surgery once patients had been referred. In 2 studies of liver transplantation, male patients were more likely to receive a transplant. Among patients requiring dialysis, females spent longer with central venous catheters and were less likely to transition to permanent access. Female patients evaluated for emergency general surgery were also less likely to be offered operative management, although outcomes did not differ significantly by sex among patients offered surgery.
The direction of the findings was not uniform across conditions or treatments. Female patients with dementia were more likely to receive treatment, and some studies of diabetes management found no sex-based differences. In emergency medicine, female patients were less likely to receive targeted temperature management following out-of-hospital cardiac arrest or opioids for pain, but 1 study also found that resuscitation was less likely to be terminated in female patients and that they were more likely to survive to hospital admission.
The researchers cautioned that differences in treatment did not necessarily indicate inequity. Treatment variation could reflect appropriate clinical considerations, patient preferences, barriers to accessing care, or systemic inequities, and the available evidence did not consistently establish whether either sex was disadvantaged. The researchers also noted that few studies referred to sex-specific clinical guidelines when assessing differences in management.
The review could not assess treatment according to gender because the underlying medical records contained administrative sex rather than gender information. None of the included studies commented on differences between gender and sex or reported inclusion of intersex patients. Evidence examining intersecting characteristics was also limited, preventing clear conclusions about how sex interacted with factors such as ethnicity.
Other limitations included the predominance of retrospective studies, incomplete adjustment for potential confounders such as ethnicity, comorbidities, and socioeconomic status, and the concentration of evidence in the US, which may limit generalizability across health care systems. The investigators also searched only PubMed and Embase, potentially missing relevant studies indexed elsewhere, and heterogeneity across the included literature complicated synthesis and interpretation.
Overall, the review documented persistent sex-based differences in treatment but could not determine whether the observed patterns reflected appropriate clinical variation or systemic inequities. The researchers called for prospective studies with stronger adjustment for potential confounders and greater attention to gender and intersecting characteristics. “Future research must integrate equity considerations and intersectional analysis into study design, employ rigorous analytical methods, and extend to diverse healthcare systems,” wrote lead author Miriam Veenhuizen, of the University of St Andrews and University of Keele, and her colleague.
The authors reported no specific funding or competing interests.
Source: PLOS One
