Research paperEffect of gender on evidence-based practice for Australian patients with acute coronary syndrome: A retrospective multi-site study
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 These ACS Guidelines have recently been replaced by the 2016 NHFA and CSANZ Australian Clinical Guidelines for the Management of ACS [19].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.
References (47)
- et al.
Acute coronary syndrome
Crit Care Nurs Clin N Am
(2011) - et al.
Acute myocardial infarction
Lancet
(2008) - et al.
Gender difference in treatment and mortality of patients with ST-segment elevation myocardial infarction admitted to Victorian public hospitals: a retrospective database study
Aust Crit Care
(2015) - et al.
Women and ischemic heart disease: evolving knowledge
J Am Coll Cardiol
(2009) - et al.
Effect of patient sex on triage for ischaemic heart disease and treatment onset times: a retrospective analysis of Australian emergency department data
Int Emerg Nurs
(2014) - et al.
Gender differences in reasons patients delay in seeking treatment for acute myocardial infarction symptoms
Patient Educ Couns
(2005) - et al.
Gendered symptom presentation in acute coronary syndrome: a cross sectional analysis
Int J Nurs Stud
(2012) - et al.
Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients
Ann Emerg Med
(2005) - et al.
Insights from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease
J Am Coll Cardiol
(2006) - Australian Institute of Health and Welfare Australia's health 2016, in Australia's health series no. 15. Australian...
Data and statistics. Information for professionals]
ACS in Perspective: the importance of secondary prevention
MISSION!: optimization of acute and chronic care for patients with acute myocardial infarction
Am Heart J
Australia's Health 2014
Unperceived treatment gaps in acute coronary syndromes
Int J Clin Pract
Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study
Med J Aust
Myocardial ischemia in women: lessons from the NHLBI WISE study
Clin Cardiol
Gender bias in acute coronary syndromes
Curr Vasc Pharmacol
Sex differences in medical care and early death after acute myocardial infarction
Circulation
A comprehensive view of sex-specific issues related to cardiovascular disease
CMAJ
Sex differences in mortality following acute coronary syndromes
JAMA
National Heart Foundation of Australia Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes 2006
Med J Aust
2007 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006
Med J Aust
Cited by (3)
Gender differences in unplanned hospital admission: A population-based approach
2024, Nursing and Health SciencesGender awareness is also nurses' business: Measuring sensitivity and role ideology towards patients
2022, Journal of Nursing Management