Women, Black adults wait longer for ED treatment of chest pain
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Young women and people of color with chest pain waited longer to be seen by physicians independent of clinical features, whereas women were independently less likely to be admitted when presenting with chest pain, researchers reported.
“Chest pain is the most common symptom of heart attack in adults of all ages. Despite a decline in the number of overall heart attacks, this number is rising among young adults. Young women and young Black adults have poorer outcomes after a heart attack compared to men and white adults,” Darcy Banco, MD, MPH, chief resident for safety and quality in the department of medicine at the NYU Grossman School of Medicine, said in a press release. “Whether or not the differences in chest pain evaluation directly translate into differences in outcomes, they represent a difference in the care individuals receive based on their race or sex, and that is important for us to know.”
Women wait longer; receive less treatment
Banco and colleagues analyzed ED visits for 4,152 adults aged 55 years and younger presenting with chest pain, identified in the CDC’s National Hospital Ambulatory Medical Care Survey (2014-2018), an annual, national probability sample of ambulatory visits made to nonfederal short-stay hospitals in the U.S. (records represented 29,730,145 visits). Records were included for analysis if chest pain, chest pain and related symptoms, chest discomfort, pressure, tightness, burning sensation in the chest or heart pain were any of the listed reasons for a visit. Researchers defined race as white or people of color; people of color, of whom 89% were non-Hispanic Black, comprised 37.3% of women and 31.6% of men. The cohort included 56.8% women. Researchers evaluated associations between sex, race and chest pain management. The primary outcome was admission to the hospital or observation; secondary outcomes included wait time, triage acuity, electrocardiography testing, cardiac biomarker testing and administered medications.
The findings were published in the Journal of the American Heart Association.
Researchers found that women were less likely than men to be triaged as emergent (19.1% vs. 23.3%; P < .011) and waited longer to be seen be a provider (mean, 48.1 minutes vs. 37.2 minutes; P < .001). Women were also less likely to have an ECG (74.2% vs. 78.8%; P = .024) or be admitted to the hospital or observation unit (12.4% vs. 17.9%; P < .001). There were no between-group differences in ordering of cardiac biomarkers.
After adjustment, researchers found men were seen in the ED more quickly vs. women (HR = 1.15; 95% CI, 1.05-1.26; P = .004) and were more likely to be admitted (adjusted OR = 1.4; 95% CI, 1.08-1.81; P = .011).
Women were also less likely to be seen by a consulting physician in the ED compared with men (8.5% vs. 12.3%; P = .001). During an ED visit, women were less likely to be prescribed antiplatelet agents (17.1% vs. 21.7%; P = .004) and antianginal medications (8% vs. 11.2%; P = .002).
Treatment differences by race
In analyses stratified by sex, researchers found that Black women waited longer for an initial evaluation by a provider vs. white women (mean, 57.8 minutes vs. 42.7 minutes; P = .006), whereas Black men also waited longer than white men (mean, 44 minutes vs. 34 minutes; P = .006). In regression analysis, Black adults were 18% less likely to be seen by a provider at any given time compared with white adults (HR = 0.82; 95% CI, 0.73-0.93; P = .001). There were no other race-based differences for triage level, electrocardiography testing or cardiac enzyme testing.
“We anticipated we might see differences later on in care (such as calling in a specialist or admitting someone to the hospital), rather than in the early evaluation (such as time to first physician contact and electrocardiogram ordering),” Banco said in the release. “We were also surprised to and differences in wait time by race, as the rate of heart attack among Black adults vs. white adults is similar.”
Harmony R. Reynolds, MD, FACC, FACP, FAHA, associate professor of medicine, associate director of the Cardiovascular Clinical Research Center and director of the Sarah Ross Soter Center for Women’s Cardiovascular Disease at NYU Langone Health, said “minutes count” when a person is experiencing chest pain and may be experiencing an MI.”
“Calling an ambulance is also helpful because emergency medical technicians can treat chest pain and heart attack right away,” Reynolds said in the release. “People who arrive to the ER by ambulance often receive urgent care and attention sooner compared to people who arrive to the ER on their own.”
The researchers wrote that the sex- and race-based differences warrant further study to evaluate their association with clinical outcomes and to identify opportunities for improvement in clinical care.
Reference:
- Women and Black adults waited longer in ER for chest pain evaluation. https://newsroom.heart.org/news/women-and-black-adults-waited-longer-in-er-for-chest-pain-evaluation. Published on May 4, 2022. Accessed on May 4, 2022.
Perspective
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Sherry-Ann Brown, MD, PhD, FACC, FAHA
The authors are to be applauded for their ongoing efforts to assess and address sex and racial/ethnic health disparities. In their study, women and Black individuals have longer wait times in the ED and women are less likely to be admitted for inpatient care or observation. These findings are symptoms of underlying deficiencies at the structural, societal, institutional and individual level.
Unconscious and conscious bias, as well as lack of awareness, contribute to these trends. The study helps raise awareness and the next steps involve looking at both the causal factors and the solutions. The solutions will need to be pervasive across structural, societal, institutional and individual levels.
Collectively, in health care and biomedical science, we need to agree that an overhaul is needed — a reset button — to help us recalibrate our perspectives, understanding and treatment of Black patients and of women. This study lays a foundation for this growth and sheds light on these issues that have long plagued our structural, societal, institutional and individual cultures.
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