Gender Bias in Cardiovascular Testing Persists after Adjustment for Presenting Characteristics and Cardiac Risk

Anna Marie Chang, Bryn Mumma, Keara L. Sease, Jennifer L. Robey, Frances S. Shofer, Judd E. Hollander

Research output: Contribution to journalArticle

67 Citations (Scopus)

Abstract

Objectives: Previous studies have found that female patients receive fewer invasive tests for cardiovascular disease than male patients. The authors assessed whether different clinical characteristics at emergency department presentation account for this gender bias. Methods: Patients with potential acute coronary syndrome (ACS) who presented to a university hospital were prospectively identified. A structured data instrument that included demographic information, chest pain description, history, physical examination, chest radiography, and electrocardiogram (ECG) data was completed. Hospital course was tracked daily. Patients received 30-day telephone follow-up. The main outcome was whether the patients received objective evaluation for coronary artery disease after adjustment for cardiac risk, including race, age, total number of risk factors, Thrombolysis in Myocardial Infarction (TIMI) score, ECG, and whether the patient sustained an acute myocardial infarction on index hospitalization. Results: There were 3,514 women (58%) and 2,547 men (42%) studied. They had similar presenting characteristics: chest pain quality (pressure/tightness: female 60% vs. male 59%, p = 0.6), location (substernal: female 82% vs. male 80%; p = 0.2), radiation (female 27% vs. male 26%; p = 0.3), and most associated symptoms. Men had more cardiac risk factors (mean 1.5 vs 1.4; p <0.001), more abnormal ECGs (59% vs. 48%; p <0.001), and a higher TIMI risk score (p <0.001). With respect to the main outcome, men received more cardiac catheterizations (12.6% vs. 6.0%; odds ratio [OR], 2.25; 95% confidence interval [CI] = 1.88 to 2.70) and more stress tests (14.7% vs. 12.3%; OR, 1.22; 95% CI = 1.05 to 1.42). After adjustment for age, race, cardiac risk factors, ECG, and TIMI risk score, men still received more cardiac catheterizations (adjusted OR, 1.72; 95% CI = 1.40 to 2.11) and stress tests (adjusted OR, 1.16; 95% CI = 1.01 to 1.33). Models adjusting for acute myocardial infarction or death, high-risk initial clinical impression, or emergency department disposition found similar results for increased likelihood of cardiac catheterization in men but no difference in stress testing between men and women. Conclusions: Female patients with potential ACS receive fewer cardiac catheterizations than male patients, even when presenting complaint, history, ECG, and diagnosis are taken into account. The gender bias cannot be explained by differences in presentation or clinical course.

Original languageEnglish (US)
Pages (from-to)599-605
Number of pages7
JournalAcademic Emergency Medicine
Volume14
Issue number7
DOIs
StatePublished - Jul 2007
Externally publishedYes

Fingerprint

Sexism
Cardiac Catheterization
Electrocardiography
Myocardial Infarction
Odds Ratio
Confidence Intervals
Acute Coronary Syndrome
Chest Pain
Exercise Test
Hospital Emergency Service
History
Risk Adjustment
Telephone
Radiography
Physical Examination
Coronary Artery Disease
Hospitalization
Cardiovascular Diseases
Thorax
Demography

Keywords

  • acute coronary syndrome
  • chest pain
  • emergency department
  • gender bias

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Gender Bias in Cardiovascular Testing Persists after Adjustment for Presenting Characteristics and Cardiac Risk. / Chang, Anna Marie; Mumma, Bryn; Sease, Keara L.; Robey, Jennifer L.; Shofer, Frances S.; Hollander, Judd E.

In: Academic Emergency Medicine, Vol. 14, No. 7, 07.2007, p. 599-605.

Research output: Contribution to journalArticle

Chang, Anna Marie ; Mumma, Bryn ; Sease, Keara L. ; Robey, Jennifer L. ; Shofer, Frances S. ; Hollander, Judd E. / Gender Bias in Cardiovascular Testing Persists after Adjustment for Presenting Characteristics and Cardiac Risk. In: Academic Emergency Medicine. 2007 ; Vol. 14, No. 7. pp. 599-605.
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abstract = "Objectives: Previous studies have found that female patients receive fewer invasive tests for cardiovascular disease than male patients. The authors assessed whether different clinical characteristics at emergency department presentation account for this gender bias. Methods: Patients with potential acute coronary syndrome (ACS) who presented to a university hospital were prospectively identified. A structured data instrument that included demographic information, chest pain description, history, physical examination, chest radiography, and electrocardiogram (ECG) data was completed. Hospital course was tracked daily. Patients received 30-day telephone follow-up. The main outcome was whether the patients received objective evaluation for coronary artery disease after adjustment for cardiac risk, including race, age, total number of risk factors, Thrombolysis in Myocardial Infarction (TIMI) score, ECG, and whether the patient sustained an acute myocardial infarction on index hospitalization. Results: There were 3,514 women (58{\%}) and 2,547 men (42{\%}) studied. They had similar presenting characteristics: chest pain quality (pressure/tightness: female 60{\%} vs. male 59{\%}, p = 0.6), location (substernal: female 82{\%} vs. male 80{\%}; p = 0.2), radiation (female 27{\%} vs. male 26{\%}; p = 0.3), and most associated symptoms. Men had more cardiac risk factors (mean 1.5 vs 1.4; p <0.001), more abnormal ECGs (59{\%} vs. 48{\%}; p <0.001), and a higher TIMI risk score (p <0.001). With respect to the main outcome, men received more cardiac catheterizations (12.6{\%} vs. 6.0{\%}; odds ratio [OR], 2.25; 95{\%} confidence interval [CI] = 1.88 to 2.70) and more stress tests (14.7{\%} vs. 12.3{\%}; OR, 1.22; 95{\%} CI = 1.05 to 1.42). After adjustment for age, race, cardiac risk factors, ECG, and TIMI risk score, men still received more cardiac catheterizations (adjusted OR, 1.72; 95{\%} CI = 1.40 to 2.11) and stress tests (adjusted OR, 1.16; 95{\%} CI = 1.01 to 1.33). Models adjusting for acute myocardial infarction or death, high-risk initial clinical impression, or emergency department disposition found similar results for increased likelihood of cardiac catheterization in men but no difference in stress testing between men and women. Conclusions: Female patients with potential ACS receive fewer cardiac catheterizations than male patients, even when presenting complaint, history, ECG, and diagnosis are taken into account. The gender bias cannot be explained by differences in presentation or clinical course.",
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N2 - Objectives: Previous studies have found that female patients receive fewer invasive tests for cardiovascular disease than male patients. The authors assessed whether different clinical characteristics at emergency department presentation account for this gender bias. Methods: Patients with potential acute coronary syndrome (ACS) who presented to a university hospital were prospectively identified. A structured data instrument that included demographic information, chest pain description, history, physical examination, chest radiography, and electrocardiogram (ECG) data was completed. Hospital course was tracked daily. Patients received 30-day telephone follow-up. The main outcome was whether the patients received objective evaluation for coronary artery disease after adjustment for cardiac risk, including race, age, total number of risk factors, Thrombolysis in Myocardial Infarction (TIMI) score, ECG, and whether the patient sustained an acute myocardial infarction on index hospitalization. Results: There were 3,514 women (58%) and 2,547 men (42%) studied. They had similar presenting characteristics: chest pain quality (pressure/tightness: female 60% vs. male 59%, p = 0.6), location (substernal: female 82% vs. male 80%; p = 0.2), radiation (female 27% vs. male 26%; p = 0.3), and most associated symptoms. Men had more cardiac risk factors (mean 1.5 vs 1.4; p <0.001), more abnormal ECGs (59% vs. 48%; p <0.001), and a higher TIMI risk score (p <0.001). With respect to the main outcome, men received more cardiac catheterizations (12.6% vs. 6.0%; odds ratio [OR], 2.25; 95% confidence interval [CI] = 1.88 to 2.70) and more stress tests (14.7% vs. 12.3%; OR, 1.22; 95% CI = 1.05 to 1.42). After adjustment for age, race, cardiac risk factors, ECG, and TIMI risk score, men still received more cardiac catheterizations (adjusted OR, 1.72; 95% CI = 1.40 to 2.11) and stress tests (adjusted OR, 1.16; 95% CI = 1.01 to 1.33). Models adjusting for acute myocardial infarction or death, high-risk initial clinical impression, or emergency department disposition found similar results for increased likelihood of cardiac catheterization in men but no difference in stress testing between men and women. Conclusions: Female patients with potential ACS receive fewer cardiac catheterizations than male patients, even when presenting complaint, history, ECG, and diagnosis are taken into account. The gender bias cannot be explained by differences in presentation or clinical course.

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