Gender Differences in Health-Related Quality of Life After Coronary

Bypass Surgery: Results From a 1-Year Follow-Up in Propensity-Matched Men

and Women
FRIEDERIKE KENDEL, PHD, ANNE DUNKEL, MA, THOMAS MÜLLER-TASCH, MD, KERSTIN STEINBERG, MSC,
ELKE LEHMKUHL, MD, PHD, ROLAND HETZER, MD, PHD, AND VERA REGITZ-ZAGROSEK, MD, PHD
Objective: To examine whether the predictive value of gender for health-related quality of life (HRQoL) is independent of clinical
health status and depression. Women undergoing coronary bypass surgery generally report a poorer HRQoL than men. Methods:
A total of 990 (20% women) patients completed study questionnaires 1 day before coronary bypass surgery and 1 year after surgery.
Physical aspects of HRQoL were assessed with the Short Form 36 Health Survey. Depression was measured with the self-reported
Patient Health Questionnaire. Propensity score matching was applied to match men and women with respect to 65 clinical variables.
Of 198 women, 157 (79.3%) could be matched to a partner, resulting in an excellent balance of clinical variables between the
matched groups. Results: At baseline, propensity-matched men and women differed in physical functioning (p ⬍ .001) and role
functioning (p ⫽ .007), but not in bodily pain and general health perception. In both men and women, HRQoL outcomes improved
over 1 year. Preoperative depression predicted worse physical HRQoL in all outcomes, except general health perception 1 year after
surgery. After adjusting for depression, gender lost its predictive power with respect to physical functioning. However, compared
with women, men still reported a better role functioning. Conclusion: Our data suggest that gender is a marker for role functioning,
independent of the clinical health status and depression. Rehabilitation measures designed for the specific needs of women might
help to improve their HRQoL. Key words: quality of life, gender, depression, coronary artery bypass graft surgery.

CABG ⫽ coronary artery bypass graft; PF ⫽ physical functioning;
RP ⫽ role functioning; BP ⫽ bodily pain; GH ⫽ general health;
SF-36 ⫽ Medical Outcomes Study 36-Item Short Form Health Survey.
INTRODUCTION
with male patients after surgery (5–7). Yet, the role of gender
over time does not seem consistent if baseline differences in
HRQoL or clinical health parameters are taken into account.
Some studies (8 –10) reported similar trajectories in physical
aspects of HRQoL, despite lower baseline values in women.

T he goal of coronary artery bypass graft (CABG) surgery is

to relieve angina pectoris and to reduce the risk of death
from coronary heart disease. To determine the success of the
surgery, the importance of mortality, morbidity, and rehospi-
talization is unquestioned. However, with a growing popula-
tion of older people and people with multiple comorbidities
undergoing CABG, there has been an increasing interest in
quality of life as a subjective outcome measure. When decid-
ing whether to do bypass surgery, guidelines published by the
American College of Cardiology and the American Heart
Association underline the importance of considering health-
related quality of life (HRQoL) (1). Successful surgery may
enable most patients to resume a much fuller life (2– 4). For
some patients, however, outcome in terms of HRQoL is dis-
appointing, even though their specific goals are achieved. In
particular, studies have shown that female patients report a
significantly poorer HRQoL in several key areas compared
From the Institute of Medical Psychology (F.K., K.S.) and Berlin Institute
of Gender in Medicine (A.D., E.L., V.R.-Z.), Charité-Universitätsmedizin
Berlin, Germany; Department of Psychosomatic and General Internal Medi-
cine (T.M.-T.), University Hospital Heidelberg, Heidelberg, Germany; and
Deutsches Herzzentrum Berlin, (R.H., V.R.-Z.), Berlin, Germany.
Address correspondence and reprint requests to Friederike Kendel, PhD,
Institut für Medizinische Psychologie, Charité Centrum 1 für Human- und
Gesundheitswissenschaften, Charité-Universitätsmedizin Berlin, Luisenstraße
57, 10117 Berlin, Germany. E-mail: friederike.kendel@charite.de
Received for publication July 13, 2010; revision received November 10,
2010.
The study was supported by Grant 01GI0205 from the Federal Ministry of
Education and Research.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text, and links to the digital files are
provided in the HTML text of this article on the journal’s Web site
www.psychosomaticmedicine.org.
The authors have not disclosed any potential conflicts of interest.
DOI: 10.1097/PSY.0b013e3182114d35
Other findings (7,11) suggested a poorer recovery trajectory in
women. A partial explanation for the gender difference in
HRQoL is the older age and the worse overall health status of
women at the time of the surgery. In addition, women in this
age cohort present with several psychosocial risk factors:
They have higher levels of depression, are less educated, and
have less social support (11). To our knowledge, no study so
far has systematically taken into account both a large number
of clinical risk factors and psychosocial factors to explain the
gender difference in HRQoL post CABG.
The aim of this study was to assess gender differences in
physical aspects of HRQoL. We hypothesized that gender
differences in HRQoL would still be apparent after matching
for clinical variables. We further explored the effect of de-
pression on changes in HRQoL.
METHODS
Participants/Procedure
From January 2005 to July 2008, patients undergoing CABG at the
Deutsches Herzzentrum Berlin were approached 1 to 3 days before surgery.
Institutional Review Board approval was obtained. Follow-up questionnaires
were mailed 1 year after surgery. Of 1,917 patients, 1,587 patients fulfilled the
inclusion criteria (age ⬎18 years; ability to read and understand the ques-
tionnaires; planned CABG) and provided their written consent. Of the in-
cluded patients, 113 (6% of the men; 10.8% of the women) died over the
course of the year. A total of 990 (20% women) patients had complete data
from baseline and 1-year follow-up and were included in the analysis (Fig. 1).
Dropout analyses showed that patients who did not continue with the
study, compared with those continuing, had a worse left ventricular ejection
function (51.92 ⫾ 14.32 versus 55.94 ⫾ 13.47; t ⫽ ⫺5.45; p ⬍ .001) and
higher levels of depression (6.63 ⫾ 5.6 versus 5.6 ⫾ 4.28; t ⫽ 4.16; p ⬍
.001), scored lower on the subscale physical functioning (47.23 ⫾ 26.96
versus 55.14 ⫾ 26.56; t ⫽ ⫺5.67; p ⬍ .001), and were more often female than
male (45.2% versus 34.3%; ␹2 ⫽ 14.38; p ⬍ .001).

280 Psychosomatic Medicine 73:280 –285 (2011)

0033-3174/11/7303-0280
Copyright © 2011 by the American Psychosomatic Society
GENDER DIFFERENCES IN HRQOL
Figure 1. Flowchart of participants.
Measures
Comorbidities, clinical risk factors, medications, intraoperative data, and
laboratory parameters were extracted from case report forms. Sociodemographic
and psychosocial data were collected through self-report questionnaires. Quality
of life was assessed with the Medical Outcomes Study 36-Item Short Form
Health Survey (SF-36) (12) (German version: Bullinger) (13). The SF-36 pro-
vides four aspects of physical HRQoL: 1) physical functioning (PF) (limitations
in performing physical activities, including bathing or dressing); 2) role function-
ing (RP) (problems with work or other daily activities as a result of physical
health); 3) bodily pain (BP) (limitations due to pain); and 4) general health
perception (GH) (evaluation of personal health). The scores range from 0 (severe
impairment) to 100 (no impairment). The intercorrelations of these subscales
ranged from r ⫽ .25 to r ⫽ .49 with no significant gender differences between the
correlation coefficients. Depressive symptoms were determined by means of the
nine-item module of the Patient Health Questionnaire (14) (German version:
Löwe et al.) (15), which yields a score ranging from 0 (no depression) to 27
(maximum level of depressive symptoms). Correlations between depression and
HRQoL subscales ranged between r ⫽ .31 and r ⫽ .44. Again, there were no
gender differences between correlation coefficients. Partner status was treated as
a dichotomous variable: living with a partner versus no partner (single, divorced,
widowed, separated). A three-level categorical variable was created to indicate
the different levels of (vocational) education: 1) no vocational training; 2) ap-
prenticeship; and 3) academic.
Propensity Score Matching
In nonrandomized studies, direct comparisons of two distinct groups may
be misleading because the groups may differ systematically. To obtain a
comparable distribution of clinical variables among men and women, we used
the propensity score matching technique. Rosenbaum and Rubin (16) showed
that this technique allows for considering a high number of confounding
variables and that adjustment for a balancing propensity score is sufficient to
produce unbiased estimates of the average group effects.
The propensity score was calculated, using logistic regression. Sixty-five
perioperative characteristics were used as predictors to estimate the probabil-
ity of each patient being female. Greedy matching techniques were applied to
select male counterparts to the female patients by choosing the patient with
the nearest propensity score, i.e., a distance of ⱕ0.25 of the standard deviation
of the propensity score for each pair (16).
Statistical Analysis
In the unmatched sample, gender differences in baseline characteristics were
analyzed, using the ␹2 test for categorical variables and the Student’s t test for
continuous variables. To test the balance of matching variables, the gender
Psychosomatic Medicine 73:280 –285 (2011)
differences in HRQoL subscales and depression in the matched sample, we used
the McNemar test for categorical variables and the paired t test for continuous
variables. Matching generally leads to a decrease in sample size. Therefore, effect
sizes were calculated to allow for an interpretation of gender differences across
the unmatched and matched sample independent of sample sizes.
To determine the association between gender and HRQoL subscales over
time within the matched continuer sample, we performed repeated-measures
analyses of variance. Multiple regression models were fitted to prove whether
gender constituted an independent predictor of physical HRQoL 1 year post
surgery after adjusting for education, partner status, and depression. In all models,
the respective HRQoL baseline value was entered in the first step to account for
the change in HRQoL. The rationale for including education and partner status (as
a marker for social isolation), in addition to depression, was to control for
variables that have been shown to influence the relationship of gender and
HRQoL (11). An ␣ level of p ⬍ .05 (two-tailed) was considered significant for
all analyses. Statistical analyses were performed with SPSS version 17.0.2.
RESULTS
Unmatched Sample
In the unmatched sample, women were less educated, were more
often living alone, and had higher levels of depression. Men and
women differed on a variety of clinical parameters (Table 1; Sup-
plemental Digital Content 1, http://links.lww.com/PSYMED/A31).
Compared with men, women were older, had more edema and a
more frequent history of hypertension, syncope, hepatitis, and
disease of the thyroid gland. They also had lower hemoglobin
levels and received calcium-channel blockers more frequently.
Men suffered more often from hyperuricemia and renal failure;
they had higher cholesterol levels, a lower left ventricular ejec-
tion function, and more frequently got angiotensin-converting
enzyme inhibitors. Other gender differences pertained to the
localization and number of grafts.
Propensity Score Matching
Figure 2 shows the distribution of propensity scores
for women and men, based on clinical characteristics
(Supplemental Table 1/Supplemental Digital Content 1
http://links.lww.com/PSYMED/A31).
The large overlap of propensity scores allowed for match-
ing a high percentage of women. Of 198 women, 157 (79.3%)
could be matched to 157 (19.8%) of 792 men. Clinical char-
acteristics of the matched sample are shown in Table 2 and
Supplemental Table 2 (Supplemental Digital Content 2
http://links.lww.com/PSYMED/A32), respectively. After match-
ing, there were no significant gender differences in any matching
variables. An excellent matching balance was also confirmed by
a decrease in effect sizes in the matched sample as compared with
the unmatched sample.
To determine the influence of psychosocial variables inde-
pendent from the clinical health status, men and women in the
sample were not matched for education, partner status, and
depression. However, the clinical variable matching removed
the gender difference in education (p ⫽ .12). The gender
difference in partner status was still significant (p ⬍ .001), and
depressive symptoms were still more prevalent in women than
in men (p ⬍ .001) (Table 2).
281
 F. KENDEL et al.
TABLE 1. Gender Differences in Unmatched Men and Women in Baseline Characteristics and Perioperative Variables (n ⴝ 990)

Variable Women (n ⫽ 198) Men (n ⫽ 792) p d/␩2

Age, years (mean ⫾ SD) 69.89 ⫾ 9.47 65.98 ⫾ 8.08 ⬍.001 0.44
Education ⱕ9 years (%)a 59.9 45.8 ⬍.001 0.11
Living alone (%)a 52.5 15.7 ⬍.001 0.35
Depression (mean ⫾ SD)a 7.03 ⫾ 4.7 5.25 ⫾ 4.1 ⬍.001 0.40
Body mass index (mean ⫾ SD) 27.96 ⫾ 5.24 27.79 ⫾ 4.09 .67 0.04
LVEF (mean ⫾ SD) 58.39 ⫾ 11.79 55.31 ⫾ 13.83 .002 0.24
Dyspnea on exertion (%) 83.8 70.1 ⬍.001 0.12
Diabetes (%) 39.4 33.0 .09 0.05
Hypertension (%) 94.4 84.8 ⬍.001 0.11
History of myocardial infarction (%) 40.4 43.7 .40 0.03
Current smoking (%) 14.6 18.6 .20 0.04
Renal failure (%) 9.1 14.6 .04 0.07
Previous CABG (%) 5.6 5.4 .94 0.00
Procedure priority: emergent (%) 19.2 24.6 .11 0.05
Number of grafts (mean ⫾ SD) 2.44 ⫾ 1.07 2.89 ⫾ 0.99 ⬍.001 ⫺0.18
HRQoL
Physical functioning (mean ⫾ SD)a 42.5 ⫾ 25.57 58.11 ⫾ 25.94 ⬍.001 ⫺0.61
Role functioning (mean ⫾ SD)a 22.72 ⫾ 34.94 40.25 ⫾ 41.89 ⬍.001 ⫺0.45
Bodily pain (mean ⫾ SD)a 52.92 ⫾ 28.42 60.4 ⫾ 28.81 ⬍.001 ⫺0.26
General health status (mean ⫾ SD)a 49.64 ⫾ 17.67 53.71 ⫾ 17.21 .003 ⫺0.23

Mean differences analyzed with Student t tests (effect size: d); categorical variables with ␹2 test (effect size: ␩2).
a
Variables not included as matching variables.
SD ⫽ standard deviation; LVEF ⫽ left ventricular ejection fraction; CABG ⫽ coronary artery bypass graft; HRQoL ⫽ health-related quality of life.

main effect of time was significant in PF (F(1,312) ⫽ 28.89, p ⬍

Figure 2. Distribution of the propensity score by gender in the unmatched
sample. Based on this score, 79.3% of the women could be matched to men
with similar clinical features.
.001, ␩2 ⫽ 0.09), RP (F(1,312) ⫽ 34.02, p ⬍ .001, ␩2 ⫽ 0.10), BP
(F(1,312) ⫽ 27.36, p ⬍ .001, ␩2 ⫽ 0.08), and GH (F(1,312) ⫽
20.50, p ⬍ .001, ␩2 ⫽ 0.06), providing evidence for an improvement
in all HRQoL subscales over 1 year. Female gender was associated
with lower PF (F(1,312) ⫽ 17.25; p ⬍ .001, ␩2 ⫽ 0.05), RP
(F(1,312) ⫽ 17.02; p ⬍ .001, ␩2 ⫽ 0.05), and BP (F(1,312) ⫽
5.79; p ⫽ .02, ␩2 ⫽ 0.02). The improvement in all HRQoL
subscales over 1 year was similar in men and women with no
significant interaction effects between gender and time.
In a next step, we fitted a series of multiple linear regres-
sion models, including the respective HRQoL baseline value,
education, partner status, depression, and gender (Table 3).
The strongest predictor for each HRQoL subscale was the
respective baseline value. Preoperative depression predicted
worse PF, RP, and BP 1 year after surgery. After adjustment for
covariates and respective baseline HRQoL subscales, female
gender predicted higher impairment in RP 1 year after surgery
(p ⫽ .047), but was not associated with PF, BP, or GH.

Preoperative Quality of Life
In the unmatched sample, the gender differences in all
physical HRQoL subscales were pronounced (Table 1).
Matching for 65 baseline and perioperative characteristics
diminished the gender differences (Table 2). However, pro-
pensity-matched men and women still differed markedly in PF
(p ⬍ .001; d ⫽ 0.43) and RP (p ⫽ .007; d ⫽ 0.32).
Gender Differences in Postoperative HRQoL
Repeated-measures analysis of variance revealed significant
main effects of time and gender on HRQoL (Fig. 3, a–d). The
DISCUSSION
Our results indicate that there are substantial gender dif-
ferences in physical HRQoL both before and after CABG,
with women being more impaired than men in several HRQoL
subdomains. Interestingly, after matching for a large bundle of
clinical variables, the gender differences in physical function-
ing and role functioning decreased but still remained signifi-
cant. Nevertheless, both men and women do experience a
comparable improvement in their HRQoL.
Our findings are consistent with another study (9), which
had also found higher HRQoL scores in men and reported
similar improvements over the first year post CABG in both

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GENDER DIFFERENCES IN HRQOL

TABLE 2. Differences Among Propensity-Matched Men and Women in Baseline Characteristics and Perioperative Variables (n ⴝ 314)

Variable Women (n ⫽ 157) Men (n ⫽ 157) p d/␩2

Age, years (mean ⫾ SD) 68.88 ⫾ 9.25 68.97 ⫾ 7.83 .80 ⫺0.01
Education ⱕ9 years (%)a 57.3 48.4 ⬍.001 0.09
Living alone (%)a 51.0 15.3 ⬍.001 0.38
Depression (mean ⫾ SD)a 7.09 ⫾ 4.79 5.42 ⫾ 3.56 ⬍.001 0.40
Body mass index (mean ⫾ SD) 28.06 ⫾ 5.12 27.66 ⫾ 3.84 .57 0.09
LVEF (mean ⫾ SD) 57.71 ⫾ 12.30 58.63 ⫾ 13.54 .44 ⫺0.07
Dyspnea on exertion (%) 81.5 78.3 .56 0.04
Diabetes (%) 36.9 38.2 .91 0.01
Hypertension (%) 93.0 92.4 1.00 0.01
History of myocardial infarction (%) 45.9 40.8 .37 0.05
Current smoking (%) 15.9 20.4 .40 0.06
Renal failure (%) 9.6 10.8 .85 0.02
Previous CABG (%) 5.7 5.1 1.00 0.01
Procedure priority: emergent (%) 20.3 23.6 .58 0.07
Number of grafts (mean ⫾ SD) 2.57 ⫾ 1.02 2.55 ⫾ 0.98 .91 0.06
HRQoL
Physical functioning (mean ⫾ SD)a 44.8 ⫾ 26.05 55.95 ⫾ 25.59 ⬍.001 ⫺0.43
Role functioning (mean ⫾ SD)a 24.1 ⫾ 35.84 35.88 ⫾ 38.83 .007 ⫺0.32
Bodily pain (mean ⫾ SD)a 54.1 ⫾ 29.24 58.56 ⫾ 28.48 .19 ⫺0.15
General health status (mean ⫾ SD)a 50.47 ⫾ 18.6 52.57 ⫾ 17.98 .30 ⫺0.11

Mean differences analyzed with paired t tests (effect size: d); categorical variables with McNemar test (effect size: ␩2).
a
Variables not included as matching variables.
SD ⫽ standard deviation; LVEF ⫽ left ventricular ejection fraction; CABG ⫽ coronary artery bypass graft; HRQoL ⫽ health-related quality of life.

Figure 3. a–d) Results from repeated-measures analyses of variance: changes in health-related quality of life subscale scores, baseline to 1 year in
propensity-matched men (n ⫽ 157) and women (n ⫽ 157). Range, 0 (severe impairment) to 100 (no impairment). Over 1 year, men and women show a
comparable improvement in physical aspects of health-related quality of life.

genders. The same result was found in two studies with a
follow-up of 6 months (10) and 2 years (17), respectively. In
contrast, no gender differences in quality of life after 1 year
were reported by Hunt and colleagues (18). However, given
the absolute difference in SF-36 scores that equals the one of
the present study, the nonsignificance of the gender difference
may be due to the small number of only 22 women included
in this study. In our study, the strongest improvements in
HRQoL in both genders were in PF, RP, and BP. Changes in
GH were less marked. It may be assumed that positive

Psychosomatic Medicine 73:280 –285 (2011) 283

 F. KENDEL et al.

TABLE 3. Results From Multiple Regression Analysis: Effects of knowledge, there is only one other study (6) that used the pro-
Depression and Gender on Health-Related Quality of Life (HRQoL)a pensity matching technique in this context. However, this was
1 Year After Surgery in the Matched Sample After Adjustment for
only an additional analysis with a limited explanatory power.
Baseline HRQoL (n ⴝ 314)
Women are on average older at the time of the surgery and
Baseline Covariate ␤ 95% CI p have more comorbid illnesses and risk factors. Thus, their initial
situation is less favorable than that of men, which might account
Model 1:b Effects of depression for their reporting a worse HRQoL. As expected, propensity
and gender on the change in
physical functioning matching for a multitude of clinical variables diminished the
Baseline physical functioning 0.48 0.39–0.61 ⬍.001 gender difference in all domains of physical HRQoL. However,
Depression ⫺0.13 ⫺1.47–⫺0.17 .01 the differences in PF and RP were still significant, which indi-
Female gender ⫺0.04 ⫺7.92–3.28 .42 cates that women report worse HRQoL than men, independent
Model 2:b Effects of depression
from baseline health status and perioperative variables. It is
and gender on the change in
role functioning known that there are also gender differences in HRQoL in the
Baseline role functioning 0.26 0.18–0.43 ⬍.001 German norm sample (age group, 61–70 years) (15). This may be
Depression ⫺0.17 ⫺2.79–⫺0.59 .003 partially accounted for by the tendency of women to report a
Female gender ⫺0.11 ⫺19.62–⫺0.12 .047 worse health status, even independently of their actual health
Model 3:b Effects of depression
(27). However, although the gender difference in BP and GH in
and gender on the change in
bodily pain both the healthy norm sample (effect sizes d ⬍0.07) and our
Baseline bodily pain 0.21 0.09–0.34 .001 propensity-matched sample can be classified as small and did not
Depression ⫺0.19 ⫺2.11–⫺0.47 .002 differ considerably among the two samples, the gender difference
Female gender ⫺0.09 ⫺12.38–1.50 .12 in PF and in RP was markedly larger in our sample compared
Model 4:b Effects of depression
with the norm sample (d ⫽ 0.11 and d ⫽ 0.01 in the norm
and gender on the change in
general health perception sample). It seems possible that, particularly for women, the
Baseline general health 0.53 0.43–0.64 ⬍.001 surgery constitutes a stress factor that enlarges the gender differ-
perception ence already known from the healthy population.
Depression ⫺0.04 ⫺0.65–0.28 .43
Female gender ⫺0.06 ⫺6.09–1.64 .26 Role of Depression
a
Range, 0 –100; higher values indicating better HRQoL. To explain the persisting gender differences in HRQoL, we
b
All models adjusted for education and partner status. performed analyses on the role of depression. Depressive symp-
toms were highly predictive of all four components of physical
changes caused by the surgery, e.g., an improvement in pump- HRQoL, except for GH. Depression is closely related to HRQoL
ing capacity and dyspnea, are most likely to be reflected in PF, and overlaps with it to some extent, but the concepts should be
RP, and BP, whereas the perception of GH is more closely distinguished. HRQoL is a measure of a patient’s subjective
associated with comorbid conditions. perception of the functional effect of an illness and its therapy
Other studies (6,7,11,19 –22) do not support the finding of a (28), whereas depression is an affective disorder defined by
similar pace of recovery but rather found a poorer recovery in specific symptoms that may occur in reaction to an illness but
terms of HRQoL in women. In a study of 184 men and 96 may also exist independently from health status. The association
women (7), women did not have the same degree of improve- of presurgical depressive symptoms and HRQoL observed in the
ment after 1 year compared with men. In particular, women were present study is in accord with previous studies, which have
at greater risk for diminished work-related activities. Similarly, in shown the effect of depressive symptoms on HRQoL in patients
one study with a follow-up of 6 months (20) and in another study with coronary artery disease (29) and patients undergoing CABG
with a follow-up of 3 months (5) that matched 40 men and 40 (30,31). Because depression rates in women are double those of
women for age and body surface area, female gender was an men (32), it is probable that depression functions as a mediator
independent predictor for impaired HRQoL after CABG. Finally, between gender and HRQoL.
Peric et al. (23) identified female gender as an independent As expected, adjustment for depressive symptoms reduced the
predictor for the subscale BP. However, the explanatory power gender difference in both PF and BP, although women still
and validity of several studies (18,19,24,25) might be limited by reported significantly worse RP. In the SF-36, RP is represented
either small sample sizes and/or different time frames. For ex- by items such as “accomplishing less than wanted” as a result of
ample, the findings of Vaccarino et al. (11) and Artinian and one’s physical health, or experiencing “difficulty in performing
Duggan (19) referred to a time frame of only 6 weeks to 8 weeks daily activities.” The finding that women feel more restricted in
after surgery. Shortly after surgery, the traditional role demands their daily activities than men after CABG is supported by
may be particularly stressful for women and may thus enhance previous studies with patients recovering from myocardial infarc-
the disparities in HRQoL (26). Moreover, studies differ in their tion (33). One explanation may be that women in this age cohort
more or less systematic and exhausting inclusion of clinical are particularly challenged by resuming their traditional house-
variables. One strength of the present study is the accurate control hold activities soon after discharge from the hospital. Hildingh et
of variables which are possibly confounded with gender. To our al. (34) concluded from a meta-synthesis of seven qualitative

284 Psychosomatic Medicine 73:280 –285 (2011)

GENDER DIFFERENCES IN HRQOL
studies that, after surgery, women thought it was essential to
protect their traditional roles, which they may feel are important
in preserving their identity. However, time spent on household
activities is not necessarily a predictor for worse quality of life in
women (35).
Several limitations in the study should be noted. First, the
measurement of HRQoL is not disease specific. However, the
global instrument allows our results to be compared not only
with outcomes in other diseases but also with outcomes for the
general population. Second, the dropout rate might have given
biased results. Third, this is a monocentric study conducted in
a center with an outstanding reputation. We cannot exclude
the possibility that patients with more severe diseases may
have been referred to this hospital.
CONCLUSION
In conclusion, women do show differences in HRQoL 1 year
after coronary bypass surgery, but with respect to PF, BP, and
GH, this seems to be mainly due to preexisting differences in
clinical health status and depression. However, gender seems to
be an independent marker for RP even after adjustment for all
covariates, which leads to the concept that rehabilitation mea-
sures designed for the specific needs of women might help to
improve their HRQoL. In particular, such interventions as stress
management and attention to family role issues have been pro-
posed for female cardiac patients (36). Further study is needed to
clarify the role of depression in both men and women undergoing
and recovering from CABG surgery.
We thank Elizabeth Morrison for editorial assistance.
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