Critically Ill Women in India Receive Less Organ Support, Show Similar Mortality

Sex-Based Differences in Critical Care: An Evolving Landscape

Outcomes for critically ill patients vary based on numerous factors, including age, comorbidities, and the specifics of organ support like mechanical ventilation or vasopressors [1, 2, 3, 4, 5, 6]. While clinical guidelines aim to standardize care, the influence of a patient's sex on the receipt of these therapies and subsequent mortality remains an area of active investigation, with some studies suggesting differences in management across various conditions [7, 8]. For example, prior work has shown that patient factors can influence the intensity of care; older adults with dementia in the ICU have similar mortality but receive mechanical ventilation less often than those without dementia [9]. A recent large-scale study from India now provides specific data on how sex assigned at birth correlates with both the provision of life support and survival in a contemporary critical care setting.

A Large-Scale Look at Critical Care in India

To investigate potential sex-based disparities, researchers conducted a retrospective registry-embedded cohort study, a design that allows for the analysis of real-world clinical data from a large patient population. The study drew upon the Indian Registry of IntenSive care (IRIS), encompassing 82,151 adult patients (≥ 16 years old) admitted to 45 different intensive care units (ICUs). The cohort had a median age of 60.0 years (interquartile range, 45.0–70.0), and 38.2% (n = 31,409) of the patients were female. The primary exposure was sex at birth, and the primary outcome was ICU mortality. Secondary outcomes included in-hospital mortality and the use of organ supports like mechanical ventilation, kidney replacement therapy, and vasopressors. To isolate the effect of sex, the investigators used logistic regression models, a statistical method to adjust for prespecified baseline covariates that could otherwise confound the results. A crucial aspect of the study was that baseline characteristics were similar between male and female patients, strengthening the argument that any observed differences were not due to imbalances in initial health status.

Mortality Outcomes Show No Significant Sex-Based Disparity

A central finding of the investigation was the absence of a statistically significant difference in mortality between sexes after adjusting for baseline variables. For the primary outcome of ICU mortality, the rate was 9.5% for females compared to 10.3% for males. The adjusted odds ratio (adjOR) was 0.95 (95% CI, 0.90–1.00; p = 0.07), a result that did not meet the threshold for statistical significance. This pattern held for the secondary outcome of in-hospital mortality, which was 19.4% for females and 20.8% for males (adjOR, 1.00; 95% CI, 0.97–1.03; p = 0.66). These data indicate that within this large Indian cohort, female patients did not experience a higher risk of death during their ICU stay or overall hospitalization. This lack of a mortality difference makes the study's findings on organ support provision particularly noteworthy.

Disparities in Organ Support Provision

While mortality outcomes were similar, the study uncovered stark, statistically significant differences in the application of life-sustaining organ support. The data show that critically ill females were less likely to receive several forms of intensive intervention. Specifically, females received invasive mechanical ventilation less frequently than males (22.2% vs. 26.3%; adjOR, 0.78; 95% CI, 0.75–0.82; p < 0.001). A similar disparity was observed for kidney replacement therapy, which was administered to 4.9% of females versus 6.3% of males (adjOR, 0.73; 95% CI, 0.68–0.78; p < 0.001). The use of vasopressors was also less common in females (19.1% vs. 20.2%; adjOR, 0.95; 95% CI, 0.92–0.99; p = 0.03). In a contrasting finding, females were more likely to receive noninvasive ventilation (11.7% vs. 9.7%; odds ratio, 1.23; 95% CI, 1.18–1.30; p < 0.001). This pattern suggests a potential difference in the clinical approach to respiratory failure, favoring a less invasive strategy for female patients.

Clinical Implications and Consistent Findings

The paradoxical finding that females received less intensive organ support without an associated increase in adjusted mortality presents a clinical puzzle. These results compel clinicians to consider the complex factors that may drive treatment decisions, including unmeasured biological differences, patient or family preferences, or potential systemic biases in care delivery. The differential application of life-sustaining therapies warrants careful reflection on whether current practices are uniformly optimized for all patients. The study's conclusions are strengthened by sensitivity analyses, which are additional statistical tests designed to check if the main results hold true under different assumptions. The researchers report that these analyses were consistent with the primary findings, increasing confidence in the reported associations. Ultimately, this study demonstrates that in a large cohort of critically ill patients in India, females received fewer organ supports but had comparable adjusted mortality to males, highlighting a need for greater awareness and further research into the drivers of these practice patterns to ensure equitable and optimal care.

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