Chest pain risk assessment may reduce treatment disparities

By Staff Reports

(Victor Valley)– The use of a standardized tool for assessing the risk of serious outcomes in patients with chest pain was associated with women at high risk receiving comparable care to men, according to new research published in the Annals of Emergency Medicine. Care received by women at low and intermediate risk was consistent with current clinical recommendations. Men received more stress testing and were more likely to be hospitalized than women.

The researchers’ goal in this study was to look at gender disparities after developing and implementing a standardized approach to cardiac care for patients in 2016, using the HEART score. The HEART score, which stands for history, electrocardiogram, age, risk factors, and troponin level, is used to determine risk for adults with suspected acute coronary syndrome and based on that risk informs clinical decisions and standard care recommendations.

“Historically, a lot has been published about disparities in cardiovascular care for women, including misdiagnosing them,” said Adam Sharp, MD, MSc. “So, we hypothesized that our standardized approach with more objective risk stratification may reduce or eliminate disparities in care for women. “We found after implementation of the HEART score that women received more appropriate care than men with physicians less likely to recommend low-value cardiac testing for lower and intermediate risk levels, and comparable care for those at high risk.”

This study used data collected from more than 34,000 emergency department visits from May 20, 2016, to December 1, 2017, at 15 emergency departments within Kaiser Permanente in Southern California. The study findings included:

  • Women were hospitalized or received stress tests less frequently than men even after adjusting for HEART score and comorbidities.
  • Women received care consistent with guidelines:
    • Low-risk women were less likely to be referred for stress tests or to be hospitalized than men.
    • High-risk women received similar care to high-risk men.
  • Despite less care, women still had fewer reports of heart attacks or death within 30 days of the emergency department visit than men overall, and particularly among those at low risk.

Dr. Sharp said the study showed that risk stratification by HEART score of emergency department patients with suspected heart attacks may be useful in improving the care of women, and an opportunity to avoid nonrecommended care in low-risk men.  

Kaiser Permanente strives to provide the right care, at the right place and time, and to reduce the amount of nonrecommended care for heart patients and others. Unnecessary and nonrecommended care can have negative effects on patient safety, convenience, and the overall affordability of health care.

“There is always a margin of error with any testing, which requires physicians and patients to weigh the benefits against the risks,” Dr. Sharp said. “More testing in low-risk patients can lead to more invasive tests, which has potential health risks as well as potential time in the hospital. No one wants to take time off to go to the hospital. Especially if it’s unnecessary.”

The study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health) under award R01HL134647.

Other authors on the paper include Salena Marie Preciado, MSc, formerly of the Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena; Benjamin C. Sun, MD, University of Pennsylvania, Philadelphia; Aileen Baecker, PhD, and Yi-Lin Wu, MS, of the Department of Research & Evaluation; Ming-Sum Lee, MD, PhD, Kaiser Permanente Los Angeles Medical Center; Ernest Shen, PhD, Department of Research & Evaluation; Maros Ferencik MD, PhD, Oregon Health and Science University, Portland, Oregon; Shaw Natsui, MD, MPA, New York City Health + Hospitals, New York; Aniket A. Kawatkar, PhD, MS, and Stacy J. Park, PhD, Department of Research & Evaluation; and Rita F. Redberg, MD, MSc, University of California San Francisco, Division of Cardiology, San Francisco.

About the Kaiser Permanente Southern California Department of Research & Evaluation

The Department of Research & Evaluation conducts high-quality, innovative research into disease etiology, prevention, treatment, and care delivery. Investigators conduct epidemiologic research, health services research, biostatistics research, and behavioral research as well as clinical trials. Major areas of study include chronic disease, infectious disease, cancer, drug safety and effectiveness, and maternal and child health. Headquartered in Pasadena, California, the department focuses on translating research to practice quickly to benefit the health and lives of Kaiser Permanente Southern California members and the general public. Visit kp.org/research.

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