Research paper
Effect of gender on evidence-based practice for Australian patients with acute coronary syndrome: A retrospective multi-site study

https://doi.org/10.1016/j.aenj.2017.02.002Get rights and content

Abstract

Background

Early acute coronary syndrome (ACS) care occurs in the emergency department (ED). Death and disability from ACS are reduced with access to evidence-based ACS care. In this study, we aimed to explore if gender influenced access to ACS care.

Methods

A retrospective descriptive study was conducted for 288 (50% women, n = 144) randomly selected adults with ACS admitted via the ED to three tertiary public hospitals in Victoria, Australia from 1.1.2013 to 30.6.2015.

Results

Compared with men, women were older (79 vs 75.5 years; p = 0.009) less often allocated triage category 2 (58.3 vs 71.5%; p = 0.026) and waited longer for their first electrocardiograph (18.5 vs 15 min; p = 0.001). Fewer women were admitted to coronary care units (52.4 vs 65.3%; p = 0.023), but were more often admitted to general medicine units (39.6 vs 22.9%; p = 0.003) than men. The median length of stay was 4 days for both genders, but women were admitted for significantly more bed days than men (IQR 3–7 vs 2–5; p = 0.005).

Conclusions

There were a number of gender differences in ED care for ACS and women were at greater risk of variation from evidence-based guidelines. Further research is needed to understand why gender differences exist in ED ACS care.

Introduction

Coronary heart disease remains the single leading cause of death for women and men in Australia, and a leading cause of disability [1]. Around 54,000 acute myocardial infarctions (AMI) are experienced by Australians each year, which equates to one every 12 minutes [2]. An Australian dies every 27 min due to an AMI [2]. Acute coronary syndrome (ACS) is a spectrum of coronary heart disease which includes AMI and unstable angina [3]. Furthermore, ACS is the most burdensome disease in terms of Australia’s annual health costs, with combined direct and indirect costs estimated to have exceeded $13 billion in 2010–11 [4].

Substantial evidence informs the treatment of ACS [5]. Comprehensive early access to evidence-based practice of ACS improves patient outcomes [6], such as reduced mortality and likelihood of subsequent ACS events [7]. Despite agreement regarding appropriate evidence-based practice for ACS and high levels of awareness of current guidelines by clinicians [8], [9], poor adherence to ACS guidelines has been reported in Australia [8]. Nearly 40% of Australian patients with ACS do not receive recommended evidence-based practice [8], reducing the quality of their care and ultimately patient safety. It has been observed in numerous international studies [10], [11], and more recently in Australian studies [12], that women are provided proportionately fewer guideline based therapies for ACS than men [13], [14]. However, this is difficult to interpret given that women’s ACS management is not usually reported separately to that for men, who experience ACS more frequently than women. [15] Hence, it is possible the figures may camouflage the true state of women’s access to evidence-based ACS practice.

The inaugural Guidelines for ACS management in Australia were released by the National Heart Foundation of Australia (NHFA) and the Cardiac Society of Australia and New Zealand (CSANZ) a decade ago, [16] with subsequent addenda published in 2008 and 2011 [17], [18]. These ACS Guidelines have recently been replaced by the 2016 NHFA and CSANZ Australian Clinical Guidelines for the Management of ACS [19]. The 2016 ACS Guidelines (hereafter, the ‘ACS Guidelines’) represent an extension and update of strengthened evidence underpinning previous versions and are designed to be read in conjunction with the ACS Clinical Care Standards [20]. Both the inaugural and current ACS Guidelines [16], [19], which include preferred maximum timeframes of 90 minutes from first clinical contact to reperfusion treatment are consistent with major international guidelines for management of ACS [21], [22].

The latest ACS Guidelines [19] recommend patients arriving at an emergency department (ED) with chest pain be allocated Australasian Triage Scale Category 2 at triage (to have assessment commenced within 10 min of arrival). As with past ACS Guidelines [16], the current ACS Guidelines suggest the first electrocardiograph (ECG) should be performed and interpreted within 10 min of first clinical contact [19]. Blood biomarkers for myocardial damage (Troponin I or T are preferred) should be drawn and sent for testing upon ED arrival. Guidelines for preferred admission ward are not provided, although patients with ongoing symptoms, subsequent troponin elevation or at low risk of arrhythmias, should receive 24 h of cardiac monitoring or be monitored until successful revascularisation has occurred [19](p. 932). Patients who are at increased risk of arrhythmias or with prior arrhythmias should be considered for more than 24 hours of monitoring [19]. This will usually require patient admission to specialist inpatient units such as coronary care and intensive care where cardiac monitoring is routinely provided. Previous research has found these units afford greater patient safety in ACS than general medical wards [23], [24], [25].

The ACS Guidelines also highlight consideration of specific patient cohorts, such as women, in whom atypical presentations are reportedly more common [19]. It has been widely reported that women with ACS tend to be older [10], [26], and more often present with atypical ACS symptoms compared to men [27]. Women attending the ED report chest pain less often than men [14], [27], which has been blamed for delayed diagnosis and reduced access to pharmacological and interventional management [28], [29]. Reduced access to evidence-based management may have led to more adverse outcomes in women than men, such as higher inhospital mortality [13], [14], [30].

Although the ACS Guidelines acknowledge women’s tendencies to exhibit atypical presentations and adjust ST-segment elevation evaluation on an ECG according to patient gender, neither past nor present Australian ACS Guidelines and ACS Clinical Care Standards are gender specific [16], [18], [19], [20]. Hence, evidence-based ACS care should apply equally to women and men.

Recent Australian research has demonstrated differences in the early ACS care between women and men in terms of triage category allocation [31], and access to reperfusion therapy [12]. Furthermore, women have more inhospital deaths for ST-segment elevation AMI than men (9.1 vs 4.2%; p < 0.001) [12]. These disparities were shown using administrative data [12], [31], thus the researchers could not determine if gender differences in ACS care were related to issues such as delayed presentation, comorbid disease or absence of chest pain on arrival at hospitals. The quality of ACS ED and inhospital clinical care in Australia has not been evaluated with patient-level data from a gender perspective against ACS Guidelines. The aim of this study was therefore, to evaluate if ACS care was different in women and men who were admitted to hospital through an ED against Australian ACS Guidelines.

Section snippets

Design

A retrospective descriptive approach was used to address the study aim. Ethics approval was obtained from Deakin University (Approval: DUHREC 2015-246) and the Eastern Health Human Research Ethics (Approval: LR 97/2015) Committees.

Setting

The study setting was Eastern Health, a major health service in Victoria, Australia. Eastern Health has three acute care sites with emergency departments (EDs) and serves a diverse population of approximately 750,000 people, with its three EDs treating around 143,000

Results

A total of 288 patients were included in the study; half were women (n = 144). The median age for the sample was 77 years; women were older than men (79 vs 75.5 years; p = 0.009). Fewer women were married or living in de facto relationships than men at the time of admission (40 vs 69.4%; p < 0.001). Women more often spoke English than men (86.8 vs 77.1%; p = 0.046). More women were diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI) than men (66 vs 52.1%; p = 0.023) (Table 1). Women

Discussion

Emergency department care for patients with ACS was of a high standard and mostly consistent with Australian ACS Guidelines [19]. As recommended by the ACS Guidelines, patients were given triage category 2 or higher 67% of the time. More than 80% of patients had chest pain scores recorded on arrival and almost every patient had troponin assays taken in the ED. Time to ECG was observed to be close to the recommended 10 min, with a median of 16 min overall. The median time from triage to

Conclusion

In the main, we conclude that ACS care in the EDs was of a high standard, with time to ECG the most obvious area to target for service improvement. There were clear differences in ACS care in the ED provided to women when compared to men. Many of these differences may place women at a disadvantage and could not be explained by demographic or clinical factors. Further prospective, age-matched research is needed to better understand ED clinicians’ decision making during ACS assessment and

Provenance and conflicts of interest

No authors have any conflicts of interest or provenance issues to declare. Professor Julie Considine is a Deputy Editor of the Australasian Emergency Nursing Journal but has not been involved in the review process for this paper.

Funding

This study was funded by Deakin University’s Centre for Quality and Patient Safety Research.

Role of funding source

Whilst the research proposal was reviewed during the grant application process, the funding body had no input into the research design, analysis, findings, and contents of this manuscript or the decision regarding where to publish it.

Author contributions

LK, KP, JR and JC conceived and designed the study. LK conducted the literature review. LK collected the data. LK, MS, JC and KP analysed the data. LK prepared the manuscript. LK, KP, MS, JR and JC critically revised and edited the manuscript draft prior to submission.

Acknowledgement

The development of this research was supported by a competitive grant from the Deakin University, Centre for Quality and Patient Safety (QPS) Research, Faculty of Health. We would like to thank Ms Debra Berry and Ms Monica Beninca for their assistance with data collection and the Eastern Health Cardiology and Emergency Departments for their support.

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