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Sex Differences in the Care Experiences of Patients Hospitalized Due to Ischemic Heart Disease in Alberta, Canada

Open AccessPublished:August 25, 2021DOI:https://doi.org/10.1016/j.cjco.2021.08.011

      Abstract

      Background

      Women with heart disease experience disparities in the diagnosis, treatment, and management of their condition. However, it is unknown whether these sex differences exist with respect to in-hospital patient experience. We examined the comprehensive experience of patients hospitalized due to ischemic heart disease (IHD) across Alberta, Canada, according to sex.

      Methods

      Patients completed a modified version of the Canadian Patient Experiences Survey—Inpatient Care (CPES-IC) within 6 weeks of discharge. We examined 37 questions, including 33 regarding specific care processes and 4 global rating scales. Survey responses were reported as raw “top-box” percentages, that is, the most-positive answer choice to each question. Odds and corresponding 95% confidence intervals of women reporting a top-box response were then calculated for each question, while controlling for demographic and clinical factors.

      Results

      From April 2014 to March 2020, a total of 5795 surveys (1612 women, 4183 men) were completed. Taking the survey margin of error into account, women had lower top-box percentages on 26 of 37 questions. Similar results were obtained for the adjusted odds of reporting a top-box response. Women did not have a higher percentage of top-box responses on any of the questions studied.

      Conclusions

      This study is a Canadian first, which stratified the experiences of hospitalized patients living with ischemic heart disease according to sex. Our results highlighted important sex differences. Future research to understand the mechanisms associated with these observed sex differences in patient-reported experiences is warranted.

      Résumé

      Contexte

      Les femmes atteintes de maladies cardiaques connaissent des disparités en matière de diagnostic, de traitement et de prise en charge de leur maladie. Cependant, on ignore si des différences entre les sexes existent en ce qui concerne l’expérience des patients à l’hôpital. Nous avons examiné l’expérience globale des patients hospitalisés en raison d’une cardiopathie ischémique en Alberta, au Canada, en fonction du sexe.

      Méthodologie

      Les patients ont rempli une version modifiée du Sondage sur les expériences d’hospitalisation des patients canadiens (SEHPC) dans les six semaines suivant leur congé. Nous avons examiné 37 questions, dont 33 concernaient des processus de soins spécifiques, et quatre échelles d’évaluation globale. Les réponses au sondage ont été rapportées sous forme de pourcentages bruts de personnes ayant sélectionné la réponse la plus positive à chaque question. Les rapports de cotes et les intervalles de confiance à 95 % correspondants des femmes ayant sélectionné la réponse la plus positive ont ensuite été calculés pour chaque question, après prise en compte des facteurs démographiques et cliniques.

      Résultats

      D’avril 2014 à mars 2020, un total de 5 795 sondages (1 612 femmes, 4 183 hommes) ont été remplis. Si l’on tient compte de la marge d’erreur du sondage, la proportion de femmes ayant sélectionné la réponse la plus positive est plus faible pour 26 des 37 questions. Des résultats similaires ont été obtenus pour les rapports de cotes ajustés de la sélection de la réponse la plus positive. Les femmes n’ont eu un pourcentage plus élevé de réponse la plus positive pour aucune des questions étudiées.

      Conclusions

      Cette étude, pour laquelle on a stratifié par sexe les expériences des patients hospitalisés atteints de cardiopathie ischémique, est une première au Canada. Nos résultats ont mis en évidence d’importantes différences entre les sexes. Des recherches futures sont justifiées pour comprendre les mécanismes associés à ces différences observées entre les sexes dans les expériences signalées par les patients.
      The Heart and Stroke Report entitled “Ms.Understood” identified that women’s hearts are victims of a system that is not equipped to diagnose, treat, or manage their cardiac conditions.
      Heart and Stroke Foundation of Canada
      2018 Heart Report: Ms.Understood.
      Documented examples have included an incomplete clinical understanding of symptoms of myocardial infarction among women,
      • van der Elde M.Y.
      • Juarez-Orozco L.E.
      • Waardenburg I.
      • et al.
      Sex-based differences in unrecognized myocardial infarction.
      • Brush Jr., J.E.
      • Krumholz H.M.
      • Greene E.J.
      • Dreyer R.P.
      Sex differences in symptom phenotypes among patients with acute myocardial infarction.
      Heart and Stroke Foundation of Canada
      Heart attack signs in women often missed.
      their lower rates of referral to
      • Colella T.J.
      • Gravely S.
      • Marzolini S.
      • et al.
      Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis.
      and attendance in
      • Li S.
      • Fonarow G.C.
      • Mukamal K.
      • et al.
      Sex and racial disparities in cardiac rehabilitation referral at hospital discharge and gaps in long-term mortality.
      ,
      • Supervía M.
      • Medina-Inojosa J.R.
      • Yeung C.
      • et al.
      Cardiac rehabilitation for women: a systematic review of barriers and solutions.
      cardiac rehabilitation programs, and the higher 30-day mortality experienced by women following a major cardiovascular event.
      • Hochman J.S.
      • Tamis J.E.
      • Thompson T.D.
      • et al.
      Sex, clinical presentation, and outcomes in patients with acute coronary syndromes.
      ,
      • Berger J.S.
      • Elliott L.
      • Gallup D.
      • et al.
      Sex differences in mortality following acute coronary syndromes.
      Over the past decade, research has been conducted to better understand and narrow these gaps. Indeed, progress has been made, but disparities persist.
      With the emergence of patient experience as an important indicator of quality of care under the “triple aim framework,”
      • Berwick D.M.
      • Nolan T.W.
      • Whittington J.
      The triple aim: care, health, and cost.
      many healthcare systems now include patient-reported experience measures as part of a suite of key performance indicators. Recently, the Canadian Women’s Heart Health Alliance highlighted that the experiences of women living with cardiovascular disease are poorly understood.
      • Colella T.J.F.
      • Hardy M.
      • Hart D.
      • et al.
      The Canadians Women’s Heart Health Alliance atlas on the epidemiology, diagnosis, and management of cardiovascular disease in women—chapter 3: patient perspectives.
      Although many studies have reported on sex and gender differences in outcomes such as readmission to the hospital, morbidity, quality of life, and mortality,
      • Leung Yinko S.S.L.
      • Pelletier R.
      • Behlouli H.
      • et al.
      Health-related quality of life in premature acute coronary syndrome: Does patient sex or gender really matter?.
      • Norris C.M.
      • Hegadoren K.
      • Pilote L.
      Depression symptoms have a greater impact on the 1-year health-related quality of life outcomes of women post-myocardial infarction compared to men.
      • Norris C.M.
      • Johnson N.L.
      • Hardwicke-Brown E.
      • et al.
      The contribution of gender to apparent sex differences in health status among patients with coronary artery disease.
      • Pelletier R.
      • Humphries K.H.
      • Shimony A.
      • et al.
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      • Pelletier R.
      • Khan N.A.
      • Cox J.
      • et al.
      Sex versus gender-related characteristics: which predicts outcome after acute coronary syndrome in the young?.
      • Pilote L.
      • Dasgupta K.
      • Guru V.
      • et al.
      A comprehensive view of sex-specific issues related to cardiovascular disease.
      whether these sex and/or gender differences extend to the experiences of patients who are hospitalized due to cardiovascular concerns is largely unknown.
      The association between inpatient experience and sex has been examined in a handful of studies. Using data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

      Centers of Medicare and Medicaid Services. HCAHPS Fact Sheet. Available at: https://hcahpsonline.org/globalassets/hcahps/facts/hcahps_fact_sheet_march_2021.pdf. Accessed November 13, 2021.

      survey conducted at 3830 American hospitals, Elliott et al. showed that women had fewer positive experiences with care, particularly in regard to communication about medicines, discharge information, and cleanliness of the hospital room/bathroom.
      • Elliott M.N.
      • Lehrmann W.G.
      • Beckett M.K.
      • et al.
      Gender differences in patients’ perception of inpatient care.
      Similarly, in 2014, Hausmann et al. found that female patients had fewer positive experiences than their male counterparts within 10 of 13 care domains at US Veterans Affairs (VA) hospitals.
      • Hausmann L.R.M.
      • Gao S.
      • Mor M.K.
      • Schaefer Jr., J.H.
      • Fine M.J.
      Patterns of sex and racial/ethnic differences in patient health care experiences in US Veterans Affairs hospitals.
      These findings were congruent with those from a study conducted by Wright et al. a decade earlier.
      • Wright S.M.
      • Craig T.
      • Campbell S.
      • et al.
      Patient satisfaction of female and male users of Veterans Health Administration services.
      Although these 3 studies examined the inpatient setting, they included all patients and were not limited to those receiving cardiac care. More recently, Okunrintemi et al. studied the patient-reported outcomes (including healthcare satisfaction) of US adults with atherosclerotic cardiovascular disease over a 10-year period.
      • Okunrintemi V.
      • Valero-Elizondo J.
      • Patrick B.
      • et al.
      Gender differences in patient-reported outcomes among adults with atherosclerotic cardiovascular disease.
      Using data from the Medical Expenditure Panel Survey, the authors showed that women were more likely to report a poorer patient experience, lower health-related quality of life, and a poorer perception of their health, compared with men.
      To date, no studies have been conducted to show whether these sex-based findings extend to a Canadian cardiovascular cohort. Therefore, we examined the comprehensive experience of patients hospitalized due to ischemic heart disease (IHD) across Alberta, according to sex.

      Methods

      We conducted a quantitative study using a validated survey to explore the sex-specific experiences of Albertans who were hospitalized due to IHD. Survey data from 93 hospitals were linked with clinical data routinely captured in the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD).
      Canadian Institute for Health Information
      Discharge abstract database (DAD) metadata.
      Sex was one of the data elements captured from the DAD. Ethics approval was obtained from the University of Calgary Conjoint Health Research Ethics Board. A waiver of consent was granted due to the retrospective nature of the study. All necessary data were provided by Alberta Health Services (AHS), per a research agreement between the research team and the health authority.

      Participants and procedures

      From April 2014 to March 2020, a random sample of patients completed a modified version of the Canadian Patient Experiences Survey—Inpatient Care (CPES-IC). The CPES-IC was developed by the CIHI in conjunction with various healthcare system partners.
      • Hadibhai S.
      • Lacroix J.
      • Leeb K.
      Developing the first pan-Canadian acute care patient experiences survey.
      ,
      Canadian Institute for Health Information
      Canadian patient experiences survey: inpatient care procedure manual.
      The CPES-IC was based on the HCAHPS, with additional items developed to reflect the Canadian context. As a valid measure of inpatient hospital experience, the CPES-IC has been used in 7 Canadian provinces. A modified, 56-question survey has been administered across Alberta by AHS on a continuous basis since April 2014. Eligible adult patients (aged 18 years or older at the time of hospital discharge) were randomly sampled and completed the survey by telephone within 6 weeks of their discharge from the hospital. Quota-based sampling was used by AHS to obtain a minimum number of responses in each quarter. Every 3 months, 10% of eligible discharges were sampled from the larger hospitals across the province, and a minimum of 12 completed surveys were obtained from the smaller, rural hospitals. Each year, approximately 25,000 surveys were completed across the province (not limited to cardiac patients).
      The CPES-IC asked respondents about multiple aspects of their hospital care. This included admission to the hospital, care in the emergency department (if applicable), care from nurses, care from doctors, the hospital environment, pain control and medications, other processes of care, hospital discharge, and concerns with care. Unlike with the HCAHPS, at the time of writing of this article, no formal CPES-IC domains have been created. Responses to the majority of questions were Likert-type responses (eg, always, usually, sometimes, never), and the most-positive answer choice for each question (eg, always) was referred to as a “top-box” response. Three items on the survey asked respondents to provide numerical ratings of their overall care, overall experience, and the extent to which their hospital stay helped them. Responses to these items were on a scale from zero (worse possible score) to 10 (best possible score). The top-box score for these numerical rating questions was a score of 9 or 10, used is in conjunction with the “net promoter score”—a metric designed to assess consumer loyalty.
      • Reichheld F.F.
      The one number you need to grow.
      Top-box reporting is an accepted and widely used method for reporting CPES-IC
      Canadian Institute for Health Information
      Patient experience in Canadian hospitals—methodology notes.
      and HCAHPS

      Centers for Medicare and Medicaid Services. A note about HCAHPS “boxes.” Available at: https://hcahpsonline.org/en/summary-analyses/#NoteAboutBoxes. Accessed June 8, 2021.

      results, with the aim of attaining a top-box response for quality-improvement purposes. The CPES-IC survey concluded with a demographic section, which asked respondents about their age, highest level of education, and self-reported levels of physical and mental health (eg, excellent, very good, good, fair, poor) at the time of survey completion. The standard CPES-IC survey is publicly available on the CIHI website.
      Canadian Institute for Health Information
      Canadian patient experiences survey—inpatient care.
      Clinical information obtained from the DAD was routinely captured for all inpatient hospital stays across Alberta. Completed CPES-IC surveys were linked with each corresponding inpatient record using exact matches of personal health number, 5-digit hospital code, and discharge date. As part of the DAD, up to 25 clinical diagnoses were coded according to the International Statistical Classification of Diseases and Related Health Problems, tenth revision, Canadian version (ICD-10-CA).
      Canadian Institute for Health Information
      International Statistical Classification of Diseases and Related Health Problems: Tenth Revision, Canada. Volume One—Tabular List.
      Any matched records with a most-responsible diagnosis of I20 through I25 were included in this study. This included I20 (angina pectoris), I21 (acute myocardial infarction), I22 (subsequent myocardial infarction), I23 (certain current complications following acute myocardial infarction), I24 (other acute ischemic heart diseases), or I25 (chronic ischemic heart disease). The most-responsible diagnosis was used, as it is the one diagnosis/condition primarily responsible for the patient being in the hospital.
      Canadian Institute for Health Information
      Discharge abstract database (DAD) metadata.
      IHD was selected as the focus for this study, as it is a well-defined, high-volume cohort, and has been identified as a leading cause of cardiovascular death among Canadian women.
      • Norris C.M.
      • Yip C.Y.Y.
      • Nerenberg K.A.
      • et al.
      State of the science in women’s cardiovascular disease: a Canadian perspective on the influence of sex and gender.

      Analysis

      In this study, we examined the results from 37 survey questions. This included 33 questions about individual care processes and 4 global rating questions—the 3 overall ratings described earlier, and a question about the patients’ willingness to recommend the hospital to family members and/or friends. The 19 items not analyzed as part of this study consisted of screener questions, questions not part of the standard CPES-IC instrument, open-ended questions, and demographic questions used as predictor variables (see below). Results from each question were reported as percentage that were top-box, according to sex (male vs female). The list of questions we studied, their wording as read verbatim to respondents, and the corresponding top-box response for each is provided in Supplemental Table S1.
      In reporting raw (ie, unadjusted) results, corresponding 95% confidence intervals (CIs) were included, as calculated from the survey margin of error.
      • Moore D.S.
      • McCabe G.P.
      Introduction to the Practice of Statistics.
      The CIs from each question were used to assess whether any differences observed between women and men were statistically significant. When the CIs for women vs men did not overlap, the difference was deemed significant.
      Multivariate logistic regression was used to report the adjusted odds of women giving a top-box response to each survey question, as compared men. Analyses controlled for selected demographic and clinical characteristics obtained from the surveys and clinical records. Demographic variables included age group (18-50 years, 51-64 years, 65-74 years, ≥ 75 years), education level (high school or less, college or undergraduate university, postgraduate/professional degree), and self-reported physical and mental health (each classified as excellent/very good, good, fair/poor). Clinical variables included hospital type (cardiac surgery centre, other large urban/regional, rural), admission type (urgent, elective), whether the patient underwent surgery (yes, no), and discharge disposition (discharged home with/without support services, other). Adjusted odds ratios and corresponding 95% CIs were reported. A CI not containing the value of 1.0 was deemed to be a significant result. All analyses were performed using SAS statistical software version 9.4 (Cary, NC) for Windows.

      Results

      Over a 6-year period from April 2014 to March 2020, a total of 5795 surveys from eligible patients were obtained and linked with clinical data. This sample included 1612 women and 4183 men. Demographic and clinical characteristics are presented according to sex in Table 1. Compared with men, female respondents tended to be younger (P < 0.01), have a lower level of educational attainment (P < 0.01), and report poorer physical (P < 0.01) and mental health (P < 0.01). From a clinical perspective, women were more likely to have been admitted urgently (P < 0.01), presented less frequently to a surgical centre (P < 0.01), underwent surgery less frequently (P < 0.01), and were more likely to have been discharged home (with or without support services; P = 0.04). No differences in length of stay were observed between female and male respondents (P = 0.54).
      Table 1Demographic and clinical characteristics (N = 5795 unless otherwise stated)
      VariableWomen, n (%)Men, n (%)P
      Age group, y
       18–50123 (7.6)480 (11.5)< 0.01
       51–64522 (32.4)1723 (41.4)
       65–74488 (30.3)1244 (29.7)
       ≥ 75479 (29.7)727 (17.4)
      Education level (N = 5603)
       High school or less831 (53.6)1917 (47.3)< 0.01
       College or undergraduate university625 (40.3)1677 (41.4)
       Postgraduate/professional degree95 (6.1)458 (11.3)
      Hospital type
       Cardiac surgery centre556 (34.5)1869 (44.7)< 0.01
       Other large urban/regional792 (49.1)1862 (44.5)
       Rural264 (16.4)452 (10.8)
      Admission type
       Urgent1510 (93.7)3721 (89.0)< 0.01
       Elective102 (6.3)462 (11.0)
      Surgical intervention(s)
       Yes725 (45.0)2523 (60.3)< 0.01
       No887 (55.0)1660 (39.7)
      Length of hospital stay, d
       < 3307 (19.0)851 (20.3)0.54
       3–7949 (58.9)2417 (57.8)
       > 7356 (22.1)915 (21.9)
      Discharge disposition
       Home (with or without support)1407 (87.3)3562 (85.2)0.04
       Other205 (12.7)621 (14.9)
      Self-reported physical health (N = 5724)
       Excellent/very good488 (30.7)1537 (37.2)< 0.01
       Good599 (37.7)1532 (37.1)
       Fair/poor504 (31.7)1064 (25.7)
      Self-reported mental health (N = 5766)
       Excellent/very good865 (54.0)2539 (61.0)< 0.01
       Good515 (32.2)1192 (28.6)
       Fair/poor221 (13.8)434 (10.4)
      Table 2 presents the percentage of responses to each question that were classified as top-box, for both women and men. Taking the survey margin of error into account, women had lower top-box percentages on 26 of 37 questions studied. For the global rating questions, women reported that they would “definitely recommend” the hospital to family members/friends less frequently (78.6% vs 84.5%) than did men. On questions pertaining to specific care processes, the largest sex-based differences pertained to being told about possible side effects of new medications (43.2% of women vs 56.4% of men responded “always”), discussing help needed after discharge (76.5% of women vs 88.2% of men responded “yes”), and cleanliness of the hospital room/bathroom (60.1% of women vs 71.4% of men responded “always”). Women did not have a higher percentage of top-box responses on any of the questions we studied.
      Table 2Percentage with a “top-box” response (ie, the most-positive answer choice to a question), according to sex
      Survey itemTop-box responseWomenMenDifference (men–women)
      n% (95% CI)n% (95% CI)
      Global ratings
       Overall rating of care9 or 10160872.0 (69.8––74.2)417375.5 (74.2–76.8)3.5
       Recommendation of hospitalDefinitely yes159578.6 (76.6–80.6)413884.5 (83.4–85.6)5.9
       Helped by hospital stay9 or 10160781.6 (79.7–83.5)416182.8 (81.7–83.9)1.2
       Overall hospital experience9 or 10160575.5 (73.4–77.6)416377.5 (76.2–78.8)2.0
      Admission to hospital
       Information about admissionCompletely44545.8 (41.2–50.4)130156.4 (53.7–59.1)10.6
       Admission was organizedCompletely49081.0 (77.5–84.5)137384.2 (82.3–86.1)3.2
      Care in emergency department
       Information about treatmentCompletely99654.4 (51.3–57.5)257162.6 (60.7–64.5)8.2
       Information about admissionCompletely101855.6 (52.5–58.7)260862.3 (60.4–64.2)6.7
       Waited long to be admittedNo104382.7 (80.4–85.0)267184.8 (83.4–86.2)2.1
       Admission was organizedCompletely103481.5 (79.1–83.9)266283.5 (82.1–84.9)2.0
      Care from nurses
       Courtesy and respectAlways160889.0 (87.5–90.5)417493.0 (92.2–93.8)4.0
       Listening carefullyAlways160877.2 (75.1–79.3)417483.5 (82.4–84.6)6.3
       Explanations to patientAlways160777.8 (75.8–79.8)416781.8 (80.6–83.0)4.0
       Call-button assistanceAlways110570.5 (67.8–73.2)243476.5 (74.8–78.2)6.0
       Timely bathroom assistanceAlways79371.0 (67.8–74.2)140776.8 (74.6–79.0)5.8
      Care from doctors
       Courtesy and respectAlways160685.7 (84.0–87.4)414986.5 (85.5–87.5)0.8
       Listening carefullyAlways159574.7 (72.6–76.8)413780.5 (79.3–81.7)5.8
       Explanations to patientAlways159572.7 (70.5–74.9)415177.1 (75.8–78.4)4.4
      The hospital environment
       Room cleanlinessAlways158860.1 (57.7–62.5)413471.4 (70.0–72.8)11.3
       Room quietnessAlways159851.8 (49.4–54.2)416051.5 (50.0–53.0)–0.3
      Pain control and medications
       Pain controlledAlways95065.3 (62.3–68.3)235170.3 (68.5–72.1)5.0
       Staff helped with painAlways94780.6 (78.1–83.1)235884.9 (83.5–86.3)4.3
       Purpose of new medicationsAlways123672.0 (69.5–74.5)322380.2 (78.8–81.6)8.2
       Side effects of new medicationsAlways120243.2 (40.4–46.0)315656.4 (54.7–58.1)13.2
      Other processes of care
       Communication between staffAlways159867.7 (65.4–70.0)413975.1 (73.8–76.4)7.4
       Staff informed/up to dateAlways158566.3 (64.0–68.6)414572.7 (71.3–74.1)6.4
       Tests/procedures done on timeAlways144676.0 (73.8–78.2)384678.9 (77.6–80.2)2.9
       Information about condition/treatmentAlways159871.0 (68.8–73.2)416677.8 (76.5–79.1)6.8
       Support for anxieties/worries/fearsAlways125363.1 (60.4–65.8)306071.9 (70.3–73.5)8.8
       Patient involvement in careAlways158267.0 (64.7–69.3)410870.4 (69.0–71.8)3.4
       Family/friend involvement in careAlways134973.8 (71.5–76.1)337076.1 (74.7–77.5)2.3
      Hospital discharge
       Help needed after dischargeYes136776.5 (74.3–78.7)351288.2 (87.1–89.3)11.7
       Received written discharge informationYes137079.8 (77.7–81.9)351387.9 (86.8–89.0)8.1
       Understanding of medicationsCompletely152174.0 (71.8–76.2)394679.8 (78.5–81.1)5.8
       Information about postdischarge worriesCompletely156866.3 (64.0–68.6)408774.5 (73.2–75.8)8.2
       Better understanding of conditionCompletely159166.4 (64.1–68.7)412873.0 (71.6–74.4)6.6
      Concerns with care
       Patient had concern(s)No160583.2 (81.4–85.0)417486.4 (85.4–87.4)3.2
      Bold indicates statistically significant difference.
      CI, confidence interval.
      Results from the logistic regression analyses are presented in Table 3. Similar to differences found in the descriptive results, women were less likely than their male counterparts to report a top-box score on 2 global rating questions and 25 processes-of-care questions. Women were less likely to report an overall rating of care of 9 or 10 [adjusted odds ratio (aOR) = 0.86, 95% CI: 0.75-0.99), and they were less likely to “definitely recommend” the hospital to family members/friends (aOR = 0.75, 95% CI: 0.64-0.87). For the questions about specific care processes, women were significantly less likely to report a top-box response when responding to questions regarding having discussions about help needed after discharge (aOR = 0.53, 95% CI: 0.42-0.61), hospital room cleanliness (aOR = 0.56, 95% CI: 0.49-0.64), and being told about the possible side effects of new medications (aOR = 0.58, 95% CI: 0.51-0.67). Women did not report greater odds of reporting a top-box response on any of the questions studied.
      Table 3Adjusted odds of women reporting a “top-box” response (ie, the most-positive answer choice to a question)
      Survey itemaOR (95% CI)
      Global ratings
       Overall rating of care0.86 (0.75–0.99)
       Recommendation of hospital0.75 (0.64–0.87)
       Helped by hospital stay1.08 (0.92–1.08)
       Overall hospital experience0.96 (0.83–1.11)
      Admission to hospital
       Information about admission0.76 (0.60–0.96)
       Admission was organized0.84 (0.63–1.13)
      Care in emergency department
       Information about treatment0.72 (0.61–0.85)
       Information about admission0.81 (0.69–0.95)
       Waited long to be admitted0.90 (0.73–1.11)
       Admission was organized0.87 (0.72–1.07)
      Care from nurses
       Courtesy and respect0.65 (0.53–0.81)
       Listening carefully0.66 (0.57–0.77)
       Explanations to patient0.81 (0.70–0.94)
       Call button assistance0.71 (0.60–0.84)
       Timely bathroom assistance0.73 (0.53–0.91)
      Care from doctors
       Courtesy and respect0.92 (0.78–1.10)
       Listening carefully0.74 (0.64–0.85)
       Explanation to patient0.83 (0.72–0.96)
      Hospital environment
       Room cleanliness0.56 (0.49–0.64)
       Room quietness0.93 (0.82–1.06)
      Pain control and medications
       Pain controlled0.84 (0.70–0.99)
       Staff helped with pain0.75 (0.61–0.93)
       Purpose of new medications0.66 (0.56–0.77)
       Side effects of new medications0.58 (0.51–0.67)
      Processes of care
       Communication between staff0.71 (0.62–0.81)
       Staff informed/up to date0.79 (0.69–0.90)
       Tests/procedures done on time0.89 (0.76–1.03)
       Information about condition/treatment0.74 (0.65–0.85)
       Support for anxieties/worries/fears0.68 (0.59–0.79)
       Patient involvement in care0.89 (0.78–1.01)
       Family/friend involvement in care0.90 (0.77–1.05)
      Hospital discharge
       Help needed after discharge0.52 (0.43–0.61)
       Received written discharge information0.73 (0.61–0.87)
       Understanding of medications0.74 (0.64–0.86)
       Information about postdischarge worries0.73 (0.64–0.84)
       Better understanding of condition0.78 (0.68–0.89)
      Concerns with care
       Patient had concern(s)0.69 (0.58–0.82)
      All models used men as the reference group while controlling for age group, education level, hospital type, admission type, surgery (yes/no), discharge disposition, and self-reported physical and mental health. Statistically significant results are shown in bold.
      aOR, adjusted odds ratio; CI, confidence interval.

      Discussion

      Improving patients’ experiences with care is one of the 3 elements of the Institute for Healthcare Improvement triple-aim framework.
      • Berwick D.M.
      • Nolan T.W.
      • Whittington J.
      The triple aim: care, health, and cost.
      Although they are not the only method for measuring experiences with care, surveys such as the CPES-IC provide a feasible avenue for patients to inform quality-improvement efforts. Additionally, linking surveys with other administrative data sources can allow for a deeper look at the experiences of specific clinical or demographic groups. In this paper, we examined sex differences in the comprehensive experiences of Albertans hospitalized due to IHD. Over the 6-year period, women highlighted many perceived strengths, as well as opportunities for improvement in the care they received. Globally, women reported positive care experiences, with 81.6% responding 9 or 10 (from 0 to 10, with 10 being best) on how their hospital stay helped them. With respect to interactions with staff, 89.0% of women reported that nurses always treated them with courtesy and respect, and 85.7% responded in a similar fashion regarding doctors. Of those who received care in an emergency department prior to their admission, approximately 4 of 5 women reported that their admission to the hospital was completely organized, and that they did not wait long to be admitted. Women also had top-box ratings for items pertaining to staff providing help with pain (80.6% responded “always”), and concerns with care (83.2% had no concerns). However, women also identified several potential areas for improvement. Most notably, these included not always being told about the possible side effects of new medications, a lack of information about their admission to the hospital, help required upon discharge, and the noisy environment during nights in the hospital.
      When compared with men, women reported lower top-box results on over 60% of the items studied. This difference was observed not only in the raw percentages, but also in comparison of the odds of reporting a top-box score, while controlling for a variety of clinical and demographic factors. The results observed in this study also highlight the importance of examining experiences with multiple aspects of care, rather than obtaining just an overall assessment (eg, numerical rating) of experience. In our study, there were no statistically significant differences between the sexes in the overall rating of experience. However, many processes of care, including aspects of communication, information exchange, and discharge planning, differed according to sex.
      The present study adds to work that has been conducted to describe the experiences of women within the healthcare system. To improve aspects of the patient experience, however, it is important to understand that expectations around one’s care, the importance placed upon individual aspects of care (eg, room cleanliness, discharge planning), and the desired style of interaction between patient and provider may differ according to sex. In short, women and men may value different things. In a 2016 study of more than 4000 patients, Teunissen et al. demonstrated that women not only rated their hospital and nurse behaviours more negatively, but also had a greater desire for privacy and experienced pain more frequently than their male counterparts.
      • Teunissen T.A.M.
      • Rotink M.E.
      • Lagro-Janssen A.L.M.
      Gender differences in quality of care experiences during hospital stay: a contribution to patient-centered healthcare for both men and women.
      Similarly, Otani et al. demonstrated that men and women may place varying importance on their relationship with providers in determining their overall satisfaction with their care.
      • Otani K.
      • Buchanan P.R.
      • Desai S.P.
      • Herrmann P.A.
      Different combining process between male and female patients to reach their overall satisfaction.
      These authors found that women tended to rate their experience with nurses as more important to their rating of overall satisfaction, whereas men rated their experience with doctors as having greater importance.
      Additionally, differences in the sex/gender of healthcare providers have been highlighted as a factor that may impact patients’ evaluations of their care. A recent study in an outpatient setting found that female healthcare providers were more likely to be perceived as having communal traits such as empathy, warmth, and consensus-building.
      • Chen H.
      • Pierson E.
      • Schmer-Galunder S.
      • et al.
      Gender differences in patient perceptions of physicians’ communal traits and the impact on physician evaluations.
      Another study that examined patient preferences in primary care providers demonstrated that both male and female patients preferred to see a same-sex care provider, although this preference was more pronounced in men.
      • Fink M.
      • Klein K.
      • Sayers K.
      • et al.
      Objective data reveals gender preferences for patients’ primary care physician.
      In the CPES-IC survey used in our own study, respondents are asked to base their responses on all nurses and doctors with whom they interacted during their hospitalization. We also did not have access to each patient’s care team composition, so we were unable to assess provider characteristics. Future study may be worthwhile to examine these points as a means of improving patient-reported experience.
      In the recently published Lancet Women and Cardiovascular Disease Commission, Vogel et al. note that despite the recognized influence of sex and gender factors on women’s heart health, there has been a “confounding stagnation in the overall reduction of cardiovascular disease burden for women.”
      • Vogel B.
      • Acevedo M.
      • Appelman Y.
      • et al.
      The Lancet Women and Cardiovascular Disease Commission: reducing the global burden by 2030.
      More importantly, they note that distinct strategies are urgently needed to tackle inequities and advance solutions regarding sex-specific differences in outcomes. Our own work has identified that gender roles (eg, providing unpaid care such as caring for children, older parents, or other members of the family) restrict women in their practice of self-care and contribute to worse outcomes.
      • Pilote L.
      • Dasgupta K.
      • Guru V.
      • et al.
      A comprehensive view of sex-specific issues related to cardiovascular disease.
      Addressing patient-reported experiences through a sex and gender lens, such as ensuring women receive discharge planning (help needed after discharge, understanding discharge medications, and information about postdischarge worries) that accommodates the sociocultural factors in their lives may begin to address disparities in cardiovascular care and improve the cardiovascular health of women.
      The study had several methodological strengths. The CPES-IC has been developed as a valid and reliable measure for assessing the experiences of hospitalized Canadians. A standard script and quality-assurance checks were used to ensure that each survey was administered in a standardized way. Prospective respondents were randomly sampled and provided with multiple opportunities to respond at varying times and days throughout the week. Contact was made using information verified by AHS at the time of hospital admission, which included both landline and cellular telephone numbers. The study was conducted with minimal cost, by capitalizing on existing data infrastructure and analytic expertise. Finally, as AHS provides all inpatient hospital care across Alberta, our study findings may be applied provincially.
      Our study has some notable limitations. We were not able to control for disease severity. Previous work has shown that women routinely wait longer to seek cardiac care, and thus may be diagnosed later, with increased severity of illness. A future study linking patient experience data to other clinical variables/timepoints as well as patient-reported outcome measures, such as the Seattle Angina Questionnaire,
      • Spertus J.A.
      • Winder J.A.
      • Dewhurst T.A.
      • et al.
      Development and evaluation of the Seattle Angina Questionnaire: a new functional status measure for coronary artery disease.
      the EuroQol 5-dimension instrument,
      • Johnson J.A.
      • Coons S.J.
      Comparison of the EQ-5D and SF-12 in an adult US sample.
      and the 12-item short-form health survey,
      • Ware Jr., J.
      • Kosinski M.
      • Keller S.D.
      A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity.
      could allow for an exploration of administrative and patient-reported measures of severity and their relation to sex-specific experiences. As an example, Anderson et al. recently demonstrated that greater patient satisfaction was correlated with lower mortality at 6 months postdischarge in a sample of 327 cardiac patients.
      • Anderson P.M.
      • Krallman R.
      • Montgomery D.
      • Kline-Rogers E.
      • Bumpus S.M.
      The relationship between patient satisfaction with hospitalization and outcomes up to 6 months post-discharge in cardiac patients.
      Additional limitations of our study stem from the survey protocol itself. The CPES-IC in Alberta is administered exclusively by telephone. Therefore, our results may differ from those of a postal or e-mail survey. As with all surveys, there is the potential for bias relating to the CPES-IC’s 42-day recall period. However, we feel such bias to be of minimal concern given the testing and widespread use of surveys such as the CPES-IC and the HCAHPS.
      • Giordano L.A.
      • Elliott M.N.
      • Goldstein E.
      • Lehrmann W.G.
      • Spencer P.A.
      Development, implementation, and public reporting of the HCAHPS survey.
      Finally, all surveys were conducted in English, and with patients only, as the survey has not undergone validation with proxy respondents (eg, loved ones, friends). Thus, this approach precluded participation by any non–English-speaking patients, as well as those unable to communicate by telephone.

      Conclusions

      This study is one of the first to stratify inpatient experiences by sex. Our findings suggest that the inequities experienced by women with IHD may be reflected in their experiences of inpatient care. Future research as a means to understand sex differences in patient-reported inpatient hospital experiences is warranted.

      Acknowledgements

      We thank Ms. Ting (Grace) Wang and Dr. Jeff Bakal (Alberta Health Services, Analytics) for their assistance with data acquisition. We also thank the patients for providing their feedback about the healthcare services they received and for their time in completing the survey.

      Funding Sources

      The authors have no funding sources to declare.

      Disclosures

      The authors have no conflicts of interest to disclose.

      Supplementary Material

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