Sex and Gender
Background: The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway is a validated accelerated diagnostic protocol (ADP) for Emergency Department (ED) patients with possible acute coronary syndrome (ACS). However, data evaluating sex and race differences in its performance are limited. The objective of this study is to compare safety and effectiveness of the HEART Pathway among women vs men and whites vs non-whites.
Methods: A pre-planned sub-group analysis of the HEART Pathway Implementation Study was conducted. This prospective pre/post study accrued adults with possible ACS from 3 EDs from 11/2013-1/2016. Accrual occurred for 12 months before and after HEART Pathway implementation as an interactive electronic health record decision support tool. Following ADP integration, ED providers prospectively utilized the HEART Pathway to identify patients with possible ACS as low-risk or non-low-risk. The primary safety and effectiveness outcomes were death and myocardial infarction (MI) and hospitalization rates at 30 days, determined from health records, insurance claims, and death index data. Fisher’s exact tests were used to compare proportions between sexes and races. Multivariable logistic regression was used to evaluate the interactions of ADP implementation with sex or race for hospitalization.
Results: A total of 8474 patients were accrued, of which 51.9% were female and 34.0% were non-white. The HEART Pathway identified 32.6% of females as low-risk vs 28.5% of males (p=0.002) and 35.6% of non-whites as low-risk vs 28.0% in whites (p<0.0001). Among low-risk patients, death or MI at 30 days occurred in 0.4% of females vs 0.5% of males (p=0.70) and 0.5% of non-whites vs 0.3% of whites (p=0.69). Post-implementation hospitalization at 30 days was reduced by 6.6% in females (aOR: 0.74, 95%CI: 0.64-0.85), 5.1% in males (aOR: 0.87, 95%CI: 0.75-1.02), 8.6% in non-whites (aOR: 0.72, 95%CI: 0.60-0.86) and 4.5% in whites (aOR: 0.83, 95%CI: 0.73-0.94). Interactions between the HEART Pathway implementation and sex (p=0.24) or race (p=0.23) were not significant for hospitalization.
Conclusion: HEART Pathway implementation is associated with decreased hospitalizations and a very low death and MI rate among low-risk patients regardless of sex or race. Women and non-whites are more likely to be classified as low-risk by the HEART Pathway.