Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

Abstract

ObjectiveTo determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED).MethodsAll adults (≥18 years) with non-traumatic chest pain presentations to three EDs in Melbourne, Australia between 2009 and 2013 were retrospectively analysed. Data sources included routinely collected hospital databases. Triage scoring of the urgency of presentation, time to medical examination, cardiac troponin testing, admission to specialised care units, and in-ED and in-hospital mortality were each modelled using the generalised estimating equations approach.ResultsOverall 54 138 patients (48.7% women) presented with chest pain, contributing to 76 216 presentations, of which 26 282 (34.5%) were cardiac. In multivariable analyses, compared with men, women were 18% less likely to be allocated an urgency of ‘immediate review’ or ‘within 10 min review’ (OR=0.82, 95% CI 0.79 to 0.85), 16% less likely to be examined within the first hour of arrival to the ED by an emergency physician (0.84, 0.81 to 0.87), 20% less likely to have a troponin test performed (0.80, 0.77 to 0.83), 36% less likely to be admitted to a specialised care unit (0.64, 0.61 to 0.68), and 35% (p=0.039) and 36% (p=0.002) more likely to die in the ED and in the hospital, respectively.ConclusionsIn the ED, systemic sex bias, to the detriment of women, exists in the early management and treatment of non-traumatic chest pain. Future studies that identify the drivers explaining why women presenting with chest pain are disadvantaged in terms of care, relative to men, are warranted.

Sex-specific effects of implementing a high-sensitivity troponin I assay in patients with suspected acute coronary syndrome: results from SWEDEHEART registry

“…(5) The lower proportion of women as compared with men admitted to CCU may suggest sex referral bias at cardiac emergency unit. This is in line with recent data, showing a systematic sex-bias in the early management of patients with suspected ACS 20 . Accordingly, our results probably reflect the minimum effect on differences in diagnosis, management and outcome between women and men with suspected ACS admitted at CCU.…”

Sex disparities in acute coronary syndrome care: time to move from understanding to action

“…Mnatzaganian5 and colleagues report a retrospective, 5-year, population-based study of patients presenting to three EDs in Melbourne, Australia, with a main or secondary complaint of non-traumatic chest pain (n=76 216 presentations). The investigators examined sex differences in four aspects of care: (1) urgency score assigned by triage nurses; (2) time-to-examination by an ED physician; (3) troponin testing; (4) admission to a specialty unit, as well as in-hospital mortality.…”

“…Continued efforts to address this are certainly warranted. However, focusing solely on patient factors may overlook an important reality: Mnatzaganian et al 5 provide strong evidence that, in fact, once patients present for care at an ED, there remain significant and detrimental shortcomings in the crucial elements of ACS care provided to women, and that ED-based decisions have an impact on mortality.…”

Heartbeat: time for action to eliminate sex disparities in management and outcomes of patients with an acute coronary syndrome

“…Even so, sex disparities persist in management and outcomes of women with chest pain. To better understand whether sex-differences in the initial assessment of patients with non-traumatic chest pain contribute to later adverse clinical outcomes, Mnatzaganian and colleagues1 retrospectively analysed data on 54 138 adults presenting to three emergency departments (EDs) in Melbourne with non-traumatic chest pain. On multivariable analysis, women (49% of patients) were 18% less likely to be triaged as urgent, 16% less likely to be examined by a physician within 1 hour, 20% less likely to have a troponin measured and 36% less likely to be admitted to a specialised care unit.…”

“…But, time’s up. Mnatzaganian and colleagues’ work1 should provide strong motivation to design and test interventions aimed at improving the care provided to women with symptoms of ACS in the first hours after presentation so that their overall outcomes can be improved.’…”