Author + information
- aDivision of Cardiology, Rhode Island Hospital, Brown Medical School, Providence, Rhode Island
- bSection of Cardiovascular Medicine, Yale University School of Medicine, and Center for Outcomes Research and Evaluation, New Haven, Connecticut
- ↵∗Address for correspondence:
Dr. J. Dawn Abbott, Division of Cardiology, Rhode Island Hospital, 814 APC, 593 Eddy Street, Providence, Rhode Island 02903.
From Hollywood to health care, a movement to ensure equality of the sexes has gained momentum. Disparities in cardiovascular care have long been recognized for several populations including racial and ethnic minorities, socioeconomic groups, and geographic locations. No less remarkable are sex disparities, which impact one-half of the population and result in potentially preventable differences in cardiovascular outcomes. Health care disparities manifest as differences in quality of care and outcomes that are not related to the appropriateness of an intervention, clinical need, or patient preference. In short, disparities reflect bias, not biology. In 2017, a report from the National Quality Forum aimed at health care providers and payers set forth 4 actions to reduce health care disparities: identify and monitor disparities, implementation of evidence-based interventions, development and use of health equity performance measures, and incentivizing health equality (1).
The cardiovascular community has long recognized the importance of translating scientific evidence into clinical practice and accountability for physician and hospital performance. Both the American College of Cardiology and American Heart Association have national registries and programs aimed at aligning stakeholders and improving quality and outcomes. Through intense effort, there has been a decrease in the incidence of acute myocardial infarction (MI) and increased survival over time, but these improvements have not been realized in all populations. Studies have identified sex-based differences in ST-segment elevation myocardial infarction (STEMI) treatment, regularly showing that women are less likely to receive optimal care and are at increased risk of adverse outcomes (2). This is not a new issue—sex-based differences were described more than 2 decades ago, and they have proved remarkably resistant to change. It is often assumed that efforts to improve quality of care for the entire population will reduce disparities. However, otherwise highly successful efforts have had an inconsistent impact on sex disparities. For example, the Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments statewide systems of STEMI care project improved care to a similar degree in women and men such that women continued to have longer door-to-device times than men (3). More disconcerting is a recent report from the STEMI Systems Accelerator project that showed little improvement in the proportion of female patients treated within reperfusion guideline goals, despite substantial improvements in men (4).
In this issue of the Journal, Huded et al. (5) report their experience with a quality improvement initiative designed to improve the care of STEMI patients that had the unintentional benefit of reducing sex-based differences in care and outcomes of STEMI patients. Conducted at a quaternary care center with a large STEMI network, in-hospital outcomes and 30-day mortality in women and men were examined before and after implementation of a care bundle consisting of 4 processes: allowing emergency department activation of the cardiac catheterization laboratory, use of a handoff checklist of guideline-directed medical therapy (GDMT) with antiplatelet and anticoagulant therapy, immediate catheterization laboratory transfer, and a radial first approach. Before the effort to improve quality of care, compared with men, women had significantly longer door-to-balloon (DTB) times, lower rates of GDMT, and higher rates of complications and mortality. After implementation of the protocol, the investigators observed improvements in DTB and GDMT in both sexes, but what was notable was the near elimination of the sex disparity. Furthermore, the improvements were not limited to processes of care, but also were associated with reductions in bleeding complications, transfusions, and tantalizingly, although underpowered for this endpoint, a trend toward lower 30-day mortality.
A closer examination of the study uncovers additional opportunities to decrease disparities in women. In this regional STEMI system, interhospital transfers for primary percutaneous coronary intervention (PCI) accounted for more than two-thirds of the population. In the intervention period, DTB for transfers was significantly shorter in women and men, but the authors did not provide information about the door-in-door-out times for transferring facilities, which is also a STEMI performance measure. As such, it is unclear if the gains made were due to processes at the transferring facility or PCI center. Prior studies have shown that older age and female sex are associated with longer door-in-door-out times and that delay of >30 min is associated with 1.5-fold risk of in-hospital mortality (6). Nonsystem delay in PCI also is independently associated with in-hospital mortality in STEMI and is more common in women (7). In the control period, nonsystem delay occurred in nearly 30% of women at a rate significantly higher than men. The sex difference was not present in the intervention period and investigators are further examining the reasons for nonsystem delay in their patients. These examples emphasize the importance of surveilling for disparities in quality of care among key patient subgroups. However, this information is not always easy to find, measure, or act upon. At present, neither the quarterly benchmark reports nor the online dashboards of the National Cardiovascular Data Registry CathPCI provide information on disparities. Similarly, information on the presence and extent of disparities is notably absent from public reporting efforts such as Hospital Compare. If we agree that disparities are wrong, we must shed more light on the problem and potentially hold organizations accountable for eliminating disparities of care with incentives.
The issue of sex disparities in STEMI and other cardiovascular conditions cannot be solely tackled through system-based strategies because the problem extends beyond the hospital point of care. Women are under-represented in the majority of cardiovascular trials, including in acute coronary syndromes, and the lack of suitably powered sex-specific analyses may lead us to promote therapies that have no benefit to or may even harm women. During the study period, marked changes in procedural anticoagulation were observed that were not part of the quality initiative, but rather based on scientific publications. In the control period, approximately 75% of patients received bivalirudin; this dropped to <4% in the intervention period. The VALIDATE-SWEDEHEART (Bivalirudin versus Heparin in NSTEMI and STEMI in Patients on Modern Antiplatelet Therapy in SWEDEHEART) trial in patients undergoing contemporary PCI for MI supports the change in clinical practice, with some caveats. In this randomized trial of 6,006 patients (90.3% transradial access and universal use of potent P2Y12 inhibition), the composite of death, MI, or major bleeding at 180 days was not different in patients who received bivalirudin compared to heparin monotherapy. The trial enrolled <25% women, and the primary endpoint was lower in women receiving bivalirudin (13.6% vs. 17.1%; 95% confidence interval: 0.6 to 1.0), albeit with a sex and treatment interaction of p = 0.05 (8). Patients in practice are more complex than those in trials. In the present study, 67% had transradial intervention, 19% received a glycoprotein 2b3a inhibitor, and the potency of P2Y12 inhibition was not reported. Therefore, bleeding avoidance strategies other than transradial access may still be required, particularly in women.
Pressures from within and outside of our field will continue to fuel efforts for sex equality. On a research level, the National Institutes of Health now has policies that require the inclusion of female cells and animals in preclinical studies. There are also funding mechanisms for patient-centered and comparative effectiveness research focused on reducing disparities. Last, the cardiovascular profession lacks diversity in race and sex. The American College of Cardiology Task Force on Diversity, formed in 2017, aims to change the culture to be more inclusive and equitable. Ultimately, multiple strategies will need to be brought to bear to close the gender gap in cardiovascular care.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Abbott is the Chair of the American College of Cardiology Cath PCI Research and Publication Committee. Dr. Curtis receives support from the American College of Cardiology and the Centers for Medicare & Medicaid Services.
- 2018 American College of Cardiology Foundation
- ↵A Roadmap for Promoting Health Equity and Eliminating Disparities: The Four I’s for Health Equity. Published Sept 2017. Available at: https://www.qualityforum.org/Publications/2017/09/A_Roadmap_for_Promoting_Health_Equity_and_Eliminating_Disparities__The_Four_I_s_for_Health_Equity.aspx. Accessed March 4, 2018.
- Glickman S.W.,
- Granger C.B.,
- Ou F.S.,
- et al.
- Hinohara T.T.,
- Al-Khalidi H.R.,
- Fordyce C.B.,
- et al.
- Huded C.P.,
- Johnson M.,
- Kravitz K.,
- et al.
- Swaminathan R.V.,
- Wang T.Y.,
- Kaltenbach L.A.,
- et al.
- Erlinge D.,
- Omerovic E.,
- Frobert O.,
- et al.