Sex differences in the preoperative diagnosis of heart failure: a mixed methods study

Heart failure poses significant perioperative risk, and optimal management begins with an accurate preoperative diagnosis. There is significant diagnostic variation in HF, and one component of such variation may include sex-based differences, potentially arising from biological differences in disease progression versus underrecognized biases in healthcare pertaining to diagnosis and disease course. The authors performed an explanatory sequential mixed methods study with three phases. First, electronic health records of adult patients undergoing surgical procedures at an academic institution from 2015 to 2019 were manually reviewed by a multispecialty panel of physicians involved in heart failure care (cardiologists, cardiac anesthesiologists, intensivists). Preoperative clinical HF diagnoses documented in the medical record were compared to adjudicated HF diagnoses rendered by the multispecialty panel. Characteristics associated with inaccurate diagnoses among female versus male patients were analyzed. Second, survey data were obtained from attending anesthesiologists, nurse anesthetists, and preoperative clinic physician assistants. Survey content included sex-based differences in the perceived importance of HF diagnostic factors, barriers to obtaining diagnostic data, and methods to overcome barriers. In the third phase, clinicians participated in semi-structured interviews, exploring thought processes related to survey results. In the first phase, 1,018 patients were panel-reviewed. A small difference in overall rates of missed diagnoses of heart failure were found for female patients (51.9%) compared to male patients (41.0%); standardized difference = 0.31. Compared to male patients with missed diagnoses, female patients more commonly were older and presented with pulmonary edema, pleural effusions, and hepatomegaly. Conversely, male patients with missed diagnoses were more commonly American Society of Anesthesiologists Physical Status class 1 or 2 and underwent general surgery. In the second phase, among 64 survey respondents, small sex-based differences in perceived barriers to diagnosis existed, including a lack of knowledge in how female patients present with heart failure due to previous underrepresentation in clinical trials, generally sex-neutral diagnostic guidelines, and lower prevalence of female patients with heart failure presenting for surgery. Respondents indicated that knowledge gaps regarding sex-based differences in diagnosis might be best addressed by electronic flagging of patients likely to have heart failure and educational presentations. In the third phase, barriers to diagnoses with a perceived differential impact on female versus male patients included symptom disclosure, clinician training, and underrecognized biases. Sex-based differences in heart failure diagnostic processes emanate from a variety of sources. Clinicians may be receptive to a variety of training and process workflow interventions addressing this issue. Not applicable.