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Barron R, Mader TJ, Knee A, Wilson D, Wolfe J, Gemme SR, Dybas S, Soares WE. Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial. Ann Emerg Med 2024; 83:123-131. [PMID: 38245227 DOI: 10.1016/j.annemergmed.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 01/22/2024]
Abstract
STUDY OBJECTIVE Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores. METHODS In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison. RESULTS All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66). CONCLUSION Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.
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Affiliation(s)
- Rebecca Barron
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA.
| | - Timothy J Mader
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Alexander Knee
- Department of Medicine, UMass Chan Medical School-Baystate, Springfield, MA; Epidemiology Biostatistics Research Core, Office of Research, Baystate Medical Center, Springfield, MA
| | - Donna Wilson
- Epidemiology Biostatistics Research Core, Office of Research, Baystate Medical Center, Springfield, MA
| | - Jeannette Wolfe
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Seth R Gemme
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | | | - William E Soares
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
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Wang X, Carcel C, Hsu B, Shajahan S, Miller M, Peters S, Randall DA, Havard A, Redfern J, Anderson CS, Jorm L, Woodward M. Differences in the pre-hospital management of women and men with stroke by emergency medical services in New South Wales. Med J Aust 2022; 217:143-148. [PMID: 35831059 PMCID: PMC9541458 DOI: 10.5694/mja2.51652] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/29/2022] [Accepted: 05/10/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES To examine whether pre-hospital emergency medical service care differs for women and men subsequently admitted to hospital with stroke. DESIGN, SETTING, PARTICIPANTS Population-based cohort study; analysis of linked Admitted Patient Data Collection and NSW Ambulance data for people admitted to New South Wales hospitals with a principal diagnosis of stroke at separation, 1 July 2005 - 31 December 2018. MAIN OUTCOME MEASURES Emergency medical service assessments, protocols, and management for patients subsequently diagnosed with stroke, by sex. RESULTS Of 202 231 people hospitalised with stroke (mean age, 73 [SD, 14] years; 98 599 women [51.0%]), 101 357 were conveyed to hospital by ambulance (50.1%). A larger proportion of women than men travelled by ambulance (52.4% v 47.9%; odds ratio [OR], 1.09; 95% CI, 1.07-1.11), but time between the emergency call and emergency department admission was similar for both sexes. The likelihood of being assessed as having a stroke (adjusted OR [aOR], 0.97; 95% CI, 0.93-1.01) or subarachnoid haemorrhage (aOR, 1.22; 95% CI, 0.73-2.03) was similar for women and men, but women under 70 years of age were less likely than men to be assessed as having a stroke (aOR, 0.89; 95% CI, 0.82-0.97). Women were more likely than men to be assessed by paramedics as having migraine, other headache, anxiety, unconsciousness, hypertension, or nausea. Women were less likely than men to be managed according to the NSW Ambulance pre-hospital stroke care protocol (aOR, 0.95; 95% CI, 0.92-0.97), but the likelihood of basic pre-hospital care was similar for both sexes (aOR, 1.01; 95% CI, 0.99-1.04). CONCLUSION Our large population-based study identified sex differences in pre-hospital management by emergency medical services of women and men admitted to hospital with stroke. Paramedics should receive training that improves the recognition of stroke symptoms in women.
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Affiliation(s)
- Xia Wang
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Cheryl Carcel
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Benjumin Hsu
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Sultana Shajahan
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Matthew Miller
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Sanne Peters
- The George Institute for Global HealthOxfordUnited Kingdom
| | - Deborah A Randall
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Alys Havard
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Julie Redfern
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW,School of Health Sciences, Faculty of Medicine and HealthUniversity of Sydney, NSW
| | - Craig S Anderson
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW,Royal Prince Alfred HospitalSydneyNSW
| | - Louisa Jorm
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Mark Woodward
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
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Thompson RC, Al-Mallah MH, Beanlands RSB, Calnon DA, Dorbala S, Phillips LM, Polk DM, Soman P. ASNC's thoughts on the AHA/ACC chest pain guidelines. J Nucl Cardiol 2022; 29:19-23. [PMID: 34782993 DOI: 10.1007/s12350-021-02856-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Randall C Thompson
- St. Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA.
| | | | - Rob S B Beanlands
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | | | | | | | | | - Prem Soman
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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4
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Tummala R, Shah SD, Rawal E, Sandhu RK, Kavuri SP, Kaur G, Khan AT, Mathialagan K, Ajibawo T. In-Hospital Mortality Risk Factor Analysis in Multivessel Percutaneous Coronary Intervention Inpatient Recipients in the United States. Cureus 2021; 13:e17520. [PMID: 34603890 PMCID: PMC8476197 DOI: 10.7759/cureus.17520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives The primary goal of our study is to evaluate the mortality rate in inpatient recipients of multivessel percutaneous coronary intervention (MVPCI) and to evaluate the demographic risk factors and medical complications that increase the risk of in-hospital mortality. Methods We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS, 2016) and included 127,145 inpatients who received MVPCI as a primary procedure in United States' hospitals. We used a multivariable logistic regression model adjusted for demographic confounders to measure the odds ratio (OR) of association of medical complications and in-hospital mortality risk in MVPCI recipients. Results The in-hospital mortality rate was 2% in MVPCI recipients and was seen majorly in older-age adults (>64 years, 74%) and males (61%). Even though the prevalence of mortality among females was comparatively low, yet in the regression model, they were at a higher risk for in-hospital mortality than males (OR 1.2; 95% CI 1.13-1.37). While comparing ethnicities, in-hospital mortality was prevalent in whites (79%) followed by blacks (9%) and Hispanics (7.5%). Patients who developed cardiogenic shock were at higher odds of in-hospital mortality (OR 9.2; 95% CI 8.27-10.24) followed by respiratory failure (OR 5.9; 95% CI 5.39-6.64) and ventricular fibrillation (OR 3.5; 95% CI 3.18-3.92). Conclusion Accelerated use of MVPCI made it important to study in-hospital mortality risk factors allowing us to devise strategies to improve the utilization and improve the quality of life of these at-risk patients. Despite its effectiveness and comparatively lower mortality profile, aggressive usage of MVPCI is restricted due to the periprocedural complications and morbidity profile of the patients.
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Affiliation(s)
- Ravi Tummala
- Internal Medicine, Narayana Medical College, Nellore, IND
| | - Suchi D Shah
- Internal Medicine, Ahmedabad Municipal Corporation's Medical Education Trust Medical College, Ahmedabad, IND
| | - Era Rawal
- Cardiology, Norvic International Hospital, Kathmandu, NPL
| | - Ramneek K Sandhu
- Internal Medicine, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, IND
| | - Swathi P Kavuri
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Gagan Kaur
- Surgery, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, IND
| | - Asma T Khan
- Internal Medicine, Larkin Community Hospital, South Miami, USA
| | | | - Temitope Ajibawo
- Internal Medicine, Brookdale University Hospital Medical Center, New York City, USA
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5
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Thompson RC, Bateman TM, Blankstein R, Di Carli MF, Heydari B, Hung J, Kwong RY, Lindner JR, Nieman K, Dorbala S. A Policy Statement on Cardiovascular Test Substitution and Authorization: Principles of Patient-Centered Noninvasive Testing. J Am Coll Cardiol 2021; 78:1385-1389. [PMID: 34556324 DOI: 10.1016/j.jacc.2021.07.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/13/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Randall C Thompson
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Timothy M Bateman
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Ron Blankstein
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marcelo F Di Carli
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bobak Heydari
- Stephenson Cardiac Imaging Center, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Judy Hung
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA; Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Koen Nieman
- Stanford University School of Medicine and Cardiovascular Institute, Stanford, California, USA
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Musey PI, Bellolio F, Upadhye S, Chang AM, Diercks DB, Gottlieb M, Hess EP, Kontos MC, Mumma BE, Probst MA, Stahl JH, Stopyra JP, Kline JA, Carpenter CR. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med 2021; 28:718-744. [PMID: 34228849 DOI: 10.1111/acem.14296] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/21/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022]
Abstract
This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.
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Affiliation(s)
- Paul I. Musey
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | | | - Suneel Upadhye
- Division of Emergency Medicine McMaster University Hamilton Canada
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA USA
| | - Deborah B. Diercks
- Department of Emergency Medicine UT Southwestern Medical Center Dallas TX USA
| | - Michael Gottlieb
- Department of Emergency Medicine Rush Medical Center Chicago IL USA
| | - Erik P. Hess
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Michael C. Kontos
- Department of Internal Medicine Virginia Commonwealth University Richmond VA USA
| | - Bryn E. Mumma
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA USA
| | - Marc A. Probst
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NY USA
| | | | - Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐SalemNC USA
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine and Emergency Care Research Core Washington University School of Medicine St. Louis MO USA
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7
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Dong C, Wang K, Di Tullio MR, Gutierrez C, Koch S, García EJ, Zevallos JC, Nobo U, Martin RC, Burgin WS, Rose DZ, Romano JG, Goldberger JJ, Sacco RL, Rundek T. Disparities and Temporal Trends in Stroke Care Outcomes in Patients with Atrial Fibrillation: The FLiPER-AF Stroke Study. ACTA ACUST UNITED AC 2019; 2. [PMID: 33313602 DOI: 10.29011/2688-8734.100017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background and Purpose Atrial Fibrillation (AF) is the most common cardiac cause of ischemic stroke. However, the relation between AF and stroke care outcomes in diverse populations is understudied. We aimed to evaluate sex and race-ethnic disparities associated with AF in hospital stroke outcomes utilizing data from the FLorida PuErto Rico Atrial Fibrillation (FLiPER-AF) Stroke Study. Methods The study included 104,308 ischemic stroke cases with available information on AF status enrolled in a state-wide stroke registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the association between AF and stroke outcomes and the modification effects on the associations by sex and by race-ethnicity, adjusted for socio-demographic status, vascular risk factors and stroke severity. Results AF was present in 23% of ischemic stroke cases. AF was associated with worse disability at discharge (OR=1.11, 95% CI, 1.04-1.18), less discharge to home (OR=0.89, 0.85-0.92), and longer length of hospital stay (LOS>6 days, OR=1.53, 1.46-1.60). Interaction analyses showed that the association between AF and less discharge to home was stronger in women than men (p for interaction <0.001), as well as in FL-whites than in FL-blacks, FL-Hispanics or PR-Hispanics (p for interaction=0.002). The association between AF and prolonged LOS was more prominent in PR-Hispanics than in FL-blacks, FL-Hispanics, or FL-whites (p for interaction <0.001). From 2010 to 2016, the effects of AF on hospital length of stay attenuated (p for interaction<0.001). Conclusions AF was associated with poor disability at discharge, less discharge to home, and prolonged hospital length of stay for acute stroke care. The effect of AF on length of stay attenuated over time. Sex and race-ethnic disparities were observed in the effect of AF on being less discharge to home and prolonged hospital stay. Further research is needed to identify and modify the biologic and systems of care contributors to these disparities.
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Affiliation(s)
- Chuanhui Dong
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA.,Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Florida, USA
| | - Kefeng Wang
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA
| | - Marco R Di Tullio
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Carolina Gutierrez
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA
| | - Enid J García
- Endowed Health Services Research Center, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Juan Carlos Zevallos
- Department of Medical and Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Florida, USA
| | - Ulises Nobo
- Hospital HIMA San Pablo, Caguas, Puerto Rico
| | - Ryan C Martin
- Department of Cardiology, University of Washington-Seattle School of Medicine, Washington, USA
| | - W Scott Burgin
- Department of Neurology, University of South Florida Morsani School of Medicine, Florida, USA
| | - David Z Rose
- Department of Neurology, University of South Florida Morsani School of Medicine, Florida, USA
| | - Jose G Romano
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA
| | - Jeffrey J Goldberger
- Division of Cardiology, University of Miami Miller School of Medicine, Florida, USA
| | - Ralph L Sacco
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA.,Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Florida, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Florida, USA.,Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Florida, USA
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Musa T, Darrat Y, Etaee F, Butt M, Czarapata M, McMullen C, Mattingly L, Daoud A, Coy K, Ogunbayo G, Delisle B, Elayi CS. Gender differences in management of patients undergoing catheter ablation of atrioventricular nodal reentry tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:937-941. [DOI: 10.1111/pace.13735] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/28/2019] [Accepted: 05/21/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Thaer Musa
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Yousef Darrat
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Farshid Etaee
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Muhammad Butt
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Melissa Czarapata
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Colleen McMullen
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Lynn Mattingly
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Amro Daoud
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Kevin Coy
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Gbolahan Ogunbayo
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Brian Delisle
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
| | - Claude S. Elayi
- Division of Cardiovascular Medicine, and Veterans Administration Medical Center, Gill Heart & Vascular InstituteUniversity of Kentucky Lexington Kentucky
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9
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Hyun KK, Millett ERC, Redfern J, Brieger D, Peters SAE, Woodward M. Sex Differences in the Assessment of Cardiovascular Risk in Primary Health Care: A Systematic Review. Heart Lung Circ 2019; 28:1535-1548. [PMID: 31088726 DOI: 10.1016/j.hlc.2019.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 03/13/2019] [Accepted: 04/07/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether sex differences exist in the assessment of cardiovascular disease (CVD) risk scores/risk factors in primary health care. DESIGN/METHODS PubMed and EMBASE were systematically searched on 31 January 2017. Clinical trials and observational studies were included if they reported on the assessment of CVD risk score, blood pressure (BP), cholesterol or smoking status in primary health care, stratified by sex. Meta-analyses were performed, using random effects models, to determine differences between sexes, separately for adjusted and unadjusted data. RESULTS Of 14,928 studies found in the search, 22 studies (including 4,754,782 patients) were included in the systematic review with the meta-analysis for quantitative assessment. Overall, the assessment rates of CVD risk score and risk factors were similar in women and men (CVD risk score: 30.7% vs. 35.2% [difference (95% CI): -4.5 (-5.1, -3.9)]; BP: 91.3% vs. 88.5% [2.8 (2.5, 3.0)]; cholesterol: 69.9% vs. 71.0% [-1.1 (-1.5, -0.8)]; and smoking: 85.9% vs. 86.7% [-0.8 (-1.1, -0.5)]). The pooled, adjusted likelihood of having the risk score, BP and cholesterol assessments were comparable between women and men: OR (95% CI): 0.87 (0.70, 1.07); 1.41 (0.89, 2.25); and 1.15 (0.82, 1.60), respectively. However, women were 32% less likely to be assessed for smoking (0.68 [0.47, 1.00]). There was substantial heterogeneity between studies and the risk of publication bias was moderate. CONCLUSION Despite the guideline recommendations, assessment of CVD risk score in primary health care was low in both sexes. Further, women were less likely to be assessed for their smoking status than men, whereas no sex discrepancies were found for BP and cholesterol assessments.
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Affiliation(s)
- Karice K Hyun
- Westmead Applied Research Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia.
| | | | - Julie Redfern
- Westmead Applied Research Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - David Brieger
- Department of Cardiology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - Sanne A E Peters
- The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Mark Woodward
- The George Institute for Global Health, University of Oxford, Oxford, UK; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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10
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Araújo C, Pereira M, Laszczyńska O, Dias P, Azevedo A. Sex-related inequalities in management of patients with acute coronary syndrome-results from the EURHOBOP study. Int J Clin Pract 2018; 72. [PMID: 29271543 DOI: 10.1111/ijcp.13049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 11/29/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Real-world data from different levels of hospital specialisation would help to understand if differences in management between women and men with acute coronary syndrome (ACS) are still a priority target. We aimed to identify sex inequalities in management of patients with different types of ACS. METHODS We analysed 1757 patients with a non-ST-elevation ACS (NSTEACS) and 1184 with ST elevation myocardial infarction (STEMI) or left bundle branch block (non-classifiable (NC) ACS (STEMI/NC ACS group), consecutively discharged from ten Portuguese hospitals with different specialisation levels, between 2008 and 2010. We estimated odds ratios (OR) and 95% confidence intervals (95% CI) for the association between sex and the performance of coronary angiography, reperfusion and revascularisation. RESULTS Among STEMI/NC ACS, men had higher probability of performing coronary angiography than women (adjusted OR = 1.64, 95% CI: 1.11-2.44), while among NSTEACS patients there was no significant difference by sex (adjusted OR = 1.26, 95% CI: 0.99-1.62). In patients who underwent coronary angiography, there was no difference in proportion of women and men submitted to revascularisation, regardless of the ACS type. Although men with STEMI/NC ACS were more likely to undergo reperfusion (crude OR = 2.17, 95% CI: 1.68-2.81), the effect became not significant after multivariable adjustment (adjusted OR = 1.33, 95% CI: 0.96-1.84). CONCLUSION Women diagnosed with STEMI/NC, but not NSTEACS, had lower probability when compared with men to be submitted to coronary angiography. There was no difference in performance of reperfusion and revascularisation by sex.
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Affiliation(s)
- Carla Araújo
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Serviço de Cardiologia, Centro Hospitalar de Trás-os-Montes e Alto Douro, EPE, Hospital de São Pedro, Vila Real, Portugal
| | - Marta Pereira
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Olga Laszczyńska
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Paula Dias
- Serviço de Cardiologia, Centro Hospitalar São João, EPE, Porto, Portugal
| | - Ana Azevedo
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Differences in Presentation, Management and Outcomes in Women and Men Presenting to an Emergency Department With Possible Cardiac Chest Pain. Heart Lung Circ 2017; 26:1282-1290. [DOI: 10.1016/j.hlc.2017.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 11/07/2016] [Accepted: 01/07/2017] [Indexed: 11/20/2022]
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13
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Musey PI, Kline JA. Do Gender and Race Make a Difference in Acute Coronary Syndrome Pretest Probabilities in the Emergency Department? Acad Emerg Med 2017; 24:142-151. [PMID: 27862670 DOI: 10.1111/acem.13131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 10/07/2016] [Accepted: 10/26/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The objective was to test for significant differences in subjective and objective pretest probabilities for acute coronary syndrome (ACS) in a large cohort of chest pain patients stratified by race or gender. Secondarily we wanted to test for any differences in rates of ACS, rates of 90-day returns, cost, and chest radiation exposure after these stratifications. METHODS This is a secondary analysis of a prospective outcomes study of ED patients with chest pain and shortness of breath. We performed two separate analyses. The data set was divided by gender for analysis 1 while the analysis 2 stratification was made by race (nonwhite vs. white). For each analysis, groups were compared on several variables: provider visual analog scales (VAS) for likelihood of ACS, PREtest Consult ACS probabilities, rates of ACS, total radiation exposure to the chest, total costs at 30 days, and 90-day recidivism (ED, overnight observations, and inpatient admissions). RESULTS A total of 844 patients were studied. Gender information was present on all 844 subjects, while complete race/ethnicity information was available on 783 (93%) subjects. For the first analysis, female patients made up 57% (478/844) of the population and their mean provider VAS scores for ACS were significantly lower (p = 0.000) at 14% (95% confidence interval [CI] = 13% to 16%) than that of males at 22% (95% CI = 19% to 24%). This was consistent with the objective pretest ACS probabilities subsequently calculated via the validated online tool, PREtest Consult, which were also significantly lower (p = 0.000) at 2.7% (95% CI = 2.4% to 3.1%) for females versus 6.6% (95% CI = 5.9% to 7.3%) for males. However, comparing females to males, there was no significant difference in diagnosis of ACS (3.6% vs. 1.6%), mean chest radiation doses (5.0 mSv vs. 4.9 mSv), total costs at 30 days ($3,451.24 vs. $3,847.68), or return to the ED within 90 days (26% each). For analysis 2 by race, nonwhite patients also comprised 57% (444/783) of individuals. Similar to the gender analysis, mean provider VAS scores for ACS were found to be significantly lower (p = 0.000) at 15% (95% CI = 13% to 16%) for nonwhite versus 20% (95% CI = 18% to 23%) for white subjects. Concordantly, objective pretest ACS probabilities were also significantly lower (p = 0.000) at 3.4% (95% CI = 2.9% to 3.9%) for nonwhite versus 5.3% (95% CI = 4.7% to 5.9%) for white subjects. There were no significant differences in outcomes in nonwhite versus white subjects when compared on diagnosis of ACS (3.2% vs 2.4%), mean chest radiation dose (4.6 mSv vs. 5.0 mSv), cost ($3,156.02 vs. $2,885.18), or 90-day ED returns (28% vs. 23%). CONCLUSIONS Despite consistently estimating the risk for ACS to be lower for both females and minorities concordantly with calculated objective pretest assessments, there does not appear to have been any significant decrease in subsequent evaluation of these perceived lower-risk groups when radiation exposure and costs are taken into account. Further studies on the impact of pretest assessments on gender and racial disparities in ED chest pain evaluation are needed.
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Affiliation(s)
- Paul I. Musey
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
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14
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Kassim NA, Althouse AD, Qin D, Leef G, Saba S. Gender differences in management and clinical outcomes of atrial fibrillation patients. J Cardiol 2017; 69:195-200. [DOI: 10.1016/j.jjcc.2016.02.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/22/2016] [Accepted: 02/25/2016] [Indexed: 12/22/2022]
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15
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Does gender bias in cardiac stress testing still exist? A videographic analysis nested in a randomized controlled trial. Am J Emerg Med 2017; 35:29-35. [DOI: 10.1016/j.ajem.2016.09.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/20/2016] [Accepted: 09/22/2016] [Indexed: 01/12/2023] Open
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Use of diagnostic coronary angiography in women and men presenting with acute myocardial infarction: a matched cohort study. BMC Cardiovasc Disord 2016; 16:120. [PMID: 27250115 PMCID: PMC4888313 DOI: 10.1186/s12872-016-0248-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/15/2016] [Indexed: 01/27/2023] Open
Abstract
Background Based on evident sex-related differences in the invasive management of patients presenting with acute myocardial infarction (AMI), we sought to identify predictors of diagnostic coronary angiography (DCA) and to investigate reasons for opting out an invasive strategy in women and men. Methods The study was designed as a matched cohort study. We randomly selected 250 female cases from a source population of 4000 patients hospitalized with a first AMI in a geographically confined region of Denmark from January 2010 to November 2011. Each case was matched to a male control on age and availability of cardiac invasive facilities at the index hospital. We systematically reviewed medical records for risk factors, comorbid conditions, clinical presentation, and receipt of DCA. Clinical justifications, as stated by the treating physician, were noted for the subset of patients who did not receive a DCA. Results Overall, 187 women and 198 men received DCA within 60 days (75 % vs. 79 %, hazard ratio: 0.82 [0.67-1.00], p = 0.047).In the subset of patients who did not receive a DCA (n = 114), clinical justifications for opting out an invasive strategy was not documented for 21 patients (18.4 %). Type 2 myocardial infarction was noted in 11 patients (women versus men; 14.5 % vs. 3.8 %, p = 0.06) and identified as a potential confounder of the sex-DCA relationship. Receipt of DCA was predicted by traditional risk factors for ischaemic heart disease (family history of cardiovascular disease, hypercholesterolemia, and smoking) and clinical presentation (chest pain, ST-segment elevations). Although prevalent in both women and men, the presence of relative contraindications did not prohibit the use of DCA. Conclusion In this matched cohort of patients with a first AMI, women and men had different clinical presentations despite similar age. However, no differences in the distribution of relative contraindications for DCA were found between the sexes. Type 2 MI posed a potentiel confounder for the sex-related differences in the use of DCA. Importantly,clinical justification for opting out an invasive strategy was not documented in almost one fifth of patients not receiving a DCA. Electronic supplementary material The online version of this article (doi:10.1186/s12872-016-0248-9) contains supplementary material, which is available to authorized users.
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Graham G. Acute Coronary Syndromes in Women: Recent Treatment Trends and Outcomes. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:1-10. [PMID: 26884685 PMCID: PMC4747299 DOI: 10.4137/cmc.s37145] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/28/2015] [Accepted: 01/02/2016] [Indexed: 11/22/2022]
Abstract
In the USA and internationally, women experience farranging differences with respect to acute coronary syndrome (ACS) and myocardial infarction (MI). Women suffer from more comorbidities than men, such as smoking, obesity, hypertension, diabetes, and poor mental health. They some-times exhibit atypical MI presentation symptoms and are overall less likely to present with chest pain. Women are more likely than men to encounter delays between the onset of symptoms and arrival at the hospital or to guideline treatment. The use of various surgical and pharmacological treatments, including revascularization approaches, also differs. Women, on average, have worse outcomes than men following MI, with more complications, higher mortality rates, and poorer recovery. Internationally, outcomes are similar despite various differences in health care and culture in non-US countries. In this review, we detail differences regarding ACS and MI in women, describing their complex correlations and discussing their possible causes. Educational approaches that are tailored to women might help to reduce the incidence of ACS and MI, as well as outcomes following hospitalization. Although outcomes following acute MI have been improving over the years, women may require special consideration in order to see continued improvement.
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Affiliation(s)
- Garth Graham
- Aetna Foundation, Hartford, CT, USA.; University of Connecticut School of Medicine, Farmington, CT, USA
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18
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Graham G, Xiao YYK, Rappoport D, Siddiqi S. Population-level differences in revascularization treatment and outcomes among various United States subpopulations. World J Cardiol 2016; 8:24-40. [PMID: 26839655 PMCID: PMC4728105 DOI: 10.4330/wjc.v8.i1.24] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/29/2015] [Accepted: 11/04/2015] [Indexed: 02/06/2023] Open
Abstract
Despite recent general improvements in health care, significant disparities persist in the cardiovascular care of women and racial/ethnic minorities. This is true even when income, education level, and site of care are taken into consideration. Possible explanations for these disparities include socioeconomic considerations, elements of discrimination and racism that affect socioeconomic status, and access to adequate medical care. Coronary revascularization has become the accepted and recommended treatment for myocardial infarction (MI) today and is one of the most common major medical interventions in the United States, with more than 1 million procedures each year. This review discusses recent data on disparities in co-morbidities and presentation symptoms, care and access to medical resources, and outcomes in revascularization as treatment for acute coronary syndrome, looking especially at women and minority populations in the United States. The data show that revascularization is used less in both female and minority patients. We summarize recent data on disparities in co-morbidities and presentation symptoms related to MI; access to care, medical resources, and treatments; and outcomes in women, blacks, and Hispanics. The picture is complicated among the last group by the many Hispanic/Latino subgroups in the United States. Some differences in outcomes are partially explained by presentation symptoms and co-morbidities and external conditions such as local hospital capacity. Of particular note is the striking differential in both presentation co-morbidities and mortality rates seen in women, compared to men, especially in women ≤ 55 years of age. Surveillance data on other groups in the United States such as American Indians/Alaska Natives and the many Asian subpopulations show disparities in risk factors and co-morbidities, but revascularization as treatment for MI in these populations has not been adequately studied. Significant research is required to understand the extent of disparities in treatment in these subpopulations.
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Bhave PD, Lu X, Girotra S, Kamel H, Vaughan Sarrazin MS. Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation. Heart Rhythm 2015; 12:1406-12. [PMID: 25814418 PMCID: PMC4787261 DOI: 10.1016/j.hrthm.2015.03.031] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with an increased risk of stroke and death. Uniform utilization of appropriate therapies for AF may help reduce those risks. OBJECTIVE We sought to determine whether significant race and sex differences exist in the treatment of newly diagnosed AF in Medicare beneficiaries. METHODS We used administrative encounter data for Medicare beneficiaries to identify patients with newly diagnosed AF during 2010-2011. Services received after initial AF diagnosis were cataloged, including visits with a cardiologist or electrophysiologist, catheter ablation procedures, and use of oral anticoagulants, rate control agents, and antiarrhythmic drugs. RESULTS Overall, 517,941 patients met study criteria, of whom 452,986 (87%) were white, 36,425 (7%) black, and 28,530 (6%) Hispanic. Male patients comprised 209,788 (41%) of the cohort. In multivariate analysis, there were statistically significant differences in the use of AF-related services by both race and sex, with white patients and male patients receiving the most care. The most notable disparities were for catheter ablation (Hispanic vs white: adjusted hazard ratio [AHR] 0.70; 95% confidence interval [CI] 0.63-0.79; P < .001; female vs male: AHR 0.65; 95% CI 0.63-0.68; P < .001) and receipt of oral anticoagulation (black vs white: AHR 0.94; 95% CI 0.92-0.95; P < .001; Hispanic vs white: AHR 0.94; 95% CI 0.93-0.97; P < .001; female vs male: AHR 0.93; 95% CI 0.93-0.94; P < .001). CONCLUSION Race and sex appear to have a significant effect on the health care provided to this cohort of Medicare beneficiaries diagnosed with AF. Possible explanations include racial differences in access, patient preferences, treatment bias, and unmeasured clinical characteristics.
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Affiliation(s)
| | - Xin Lu
- University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Saket Girotra
- University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Hooman Kamel
- Feil Family Brain and Mind Research Institute, New York, New York; Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Mary S Vaughan Sarrazin
- University of Iowa Hospitals and Clinics, Iowa City, Iowa; Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
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Ashurst JV, Cherney AR, Evans EM, Kennedy Hall M, Hess EP, Kline JA, Mitchell AM, Mills AM, Weigner MB, Moore CL. Research priorities for the influence of gender on diagnostic imaging choices in the emergency department setting. Acad Emerg Med 2014; 21:1431-7. [PMID: 25420885 DOI: 10.1111/acem.12537] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/05/2014] [Accepted: 09/09/2014] [Indexed: 12/14/2022]
Abstract
Diagnostic imaging is a cornerstone of patient evaluation in the acute care setting, but little effort has been devoted to understanding the appropriate influence of sex and gender on imaging choices. This article provides background on this issue and a description of the working group and consensus findings reached during the diagnostic imaging breakout session at the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes." Our goal was to determine research priorities for how sex and gender may (or should) affect imaging choices in the acute care setting. Prior to the conference, the working group identified five areas for discussion regarding the research agenda in sex- and gender-based imaging using literature review and expert consensus. The nominal group technique was used to identify areas for discussion for common presenting complaints to the emergency department where ionizing radiation is often used for diagnosis: suspected pulmonary embolism, suspected kidney stone, lower abdominal pain with a concern for appendicitis, and chest pain concerning for coronary artery disease. The role of sex- and gender-based shared decision-making in diagnostic imaging decisions is also raised.
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Affiliation(s)
- John V. Ashurst
- Department of Emergency Medicine; Lehigh Valley Hospital/USF Morsani College of Medicine; Allentown PA
| | - Alan R. Cherney
- Department of Emergency Medicine; Lehigh Valley Hospital/USF Morsani College of Medicine; Allentown PA
| | - Elizabeth M. Evans
- Department of Emergency Medicine; Lehigh Valley Hospital/USF Morsani College of Medicine; Allentown PA
| | - Michael Kennedy Hall
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Alice M. Mitchell
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Angela M. Mills
- Department of Emergency Medicine; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA
| | - Michael B. Weigner
- Department of Emergency Medicine; Lehigh Valley Hospital/USF Morsani College of Medicine; Allentown PA
| | - Christopher L. Moore
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
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Safdar B, Nagurney JT, Anise A, DeVon HA, D'Onofrio G, Hess EP, Hollander JE, Legato MJ, McGregor AJ, Scott J, Tewelde S, Diercks DB. Gender-specific research for emergency diagnosis and management of ischemic heart disease: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup. Acad Emerg Med 2014; 21:1350-60. [PMID: 25413468 PMCID: PMC6402042 DOI: 10.1111/acem.12527] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 07/20/2014] [Accepted: 07/29/2014] [Indexed: 12/31/2022]
Abstract
Coronary artery disease (CAD) is the most common cause of death for both men and women. However, over the years, emergency physicians, cardiologists, and other health care practitioners have observed varying outcomes in men and women with symptomatic CAD. Women in general are 10 to 15 years older than men when they develop CAD, but suffer worse postinfarction outcomes compared to age-matched men. This article was developed by the cardiovascular workgroup at the 2014 Academic Emergency Medicine (AEM) consensus conference to identify sex- and gender-specific gaps in the key themes and research questions related to emergency cardiac ischemia care. The workgroup had diverse stakeholder representation from emergency medicine, cardiology, critical care, nursing, emergency medical services, patients, and major policy-makers in government, academia, and patient care. We implemented the nominal group technique to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in-person meetings, and Web-based surveys between June 2013 and May 2014. Through three rounds of nomination and refinement, followed by an in-person meeting on May 13, 2014, we achieved consensus on five priority themes and 30 research questions. The overarching themes were as follows: 1) the full spectrum of sex-specific risk as well as presentation of cardiac ischemia may not be captured by our standard definition of CAD and needs to incorporate other forms of ischemic heart disease (IHD); 2) diagnosis is further challenged by sex/gender differences in presentation and variable sensitivity of cardiac biomarkers, imaging, and risk scores; 3) sex-specific pathophysiology of cardiac ischemia extends beyond conventional obstructive CAD to include other causes such as microvascular dysfunction, takotsubo, and coronary artery dissection, better recognized as IHD; 4) treatment and prognosis are influenced by sex-specific variations in biology, as well as patient-provider communication; and 5) the changing definitions of pathophysiology call for looking beyond conventionally defined cardiovascular outcomes to patient-centered outcomes. These emergency care priorities should guide future clinical and basic science research and extramural funding in an area that greatly influences patient outcomes.
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Affiliation(s)
- Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT
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