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Estimated risk for ACS, but not rates, costs, varies by race, sex
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Despite women and nonwhite patients having lower estimated risk for ACS, they have similar rates of ACS, radiation exposure and costs as men and white patients, according to new data.
In this two-part secondary analysis of patients presenting in EDs with chest pain and shortness of breath, Paul I. Musey Jr., MD, an emergency medicine physician and assistant professor at the Indiana University School of Medicine, and Jeffrey A. Kline, MD, professor of emergency medicine and physiology at Indiana University, analyzed how sex and race/ethnicity influenced risk for ACS and subsequent rates of diagnosis, radiation exposure, total costs at 30 days and 90-day recidivism.
Pretest probabilities
In the first arm, data were stratified by sex (n = 844; 57% women). Mean provider visual analog scales (VAS) for likelihood of ACS were significantly lower in women (14%; 95% CI, 13-16) vs. men (22%; 95% CI, 19-24). ACS probabilities calculated with the online tool PREtest Consult followed a similar pattern with 2.7% (95% CI, 2.4-3.1) for women vs. 6.6% (95% CI, 5.9-7.3) for men.
There was no significant difference between women and men for diagnosis of ACS (women, 3.6%; men, 1.6%), mean chest radiation doses (women, 5 mSv; men, 4.9 mSv), total costs at 30 days ($3,451.24 vs. $3,847.68) or return to the ED within 90 days (both 26%), the researchers wrote.
In the second analysis, stratified by race/ethnicity, similar results were found. Risk for ACS through mean provider VAS scores and PREtest Consult ACS probabilities were significantly lower in nonwhite vs. white subjects (mean nonwhite VAS score = 15%; 95% CI, 13-16; mean white VAS score = 20%; 95% CI, 18-23; nonwhite pretest probability = 3.4%; 95% CI, 2.9-3.9; white pretest probability = 5.3%, 95% CI, 4.7-5.9).
Similarly, between nonwhite and white individuals there were no significant differences in diagnosis of ACS (nonwhite, 3.2%; white, 2.4%), mean chest radiation dose (nonwhite, 4.6 mSv, white, 5 mSv), cost (nonwhite, $3,156.02; white, $2,885.18) or 90-day ED returns (28% vs. 23%).
Hypothesis refuted
The researchers wrote they expected that if differences were found in pretest risk, then subsequent exposure to radiation and costs would be lower, but that was not true.
“This suggests that ED providers may employ their own standard evaluation for the complaint of chest pain irrespective of pretest probabilities,” the researchers wrote. “In other words, there may be a normalization of ACS evaluations across gender and racial groups in response to a number of external pressures: 1) existing efforts at mitigating identified disparities; 2) providers’ aversion to perceived medicolegal consequences of a missed MI; or 3) local practice patterns encouraging standardized chest pain evaluation. We believe that this tends to fit what we see in practice, that the fear of missing a diagnosis of ACS and its medicolegal consequences overrides judicious use of testing commensurate with risk level.” – by Cassie Homer
Disclosures: Musey reports receiving research funding from Trevena. Kline reports consulting for Janssen and Stago Diagnostica and receiving research funding from Mallingkrodt and Roche.
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