Sex Disparities Seen in China for Patients With ACS
General quality-improvement efforts may need to be augmented to address the substandard care provided to women, one expert says.
Among patients hospitalized for ACS in China, women receive lower-quality care and have a greater risk of dying compared with men, according to data from a large quality-improvement initiative.
Women, who tended to present with a higher-risk profile compared with men, were less likely to receive a number of acute treatments as well as interventions for secondary prevention. Though women had a higher rate of in-hospital mortality (2.60% vs 1.50%), that difference was no longer significant after adjusting for clinical characteristics and the inequities in care.
“If we could bridge these gaps in quality of care and eliminate these disparities or inequitable care for women, potentially we could narrow the differences in outcome or even eliminate the sex-based differences in in-hospital mortality,” study co-author Gregg Fonarow, MD (University of California, Los Angeles), told TCTMD. “So that’s a real important action point, and it tells us that the general quality-improvement efforts may need to be augmented with specific targeted efforts to really try and improve the quality of care explicitly in women hospitalized with acute coronary events.”
Some—but not all—prior studies conducted in the United States and elsewhere have identified similar sex-based disparities in the care and outcomes of patients with ACS, but information from China has been limited.
For the current study, published online January 22, 2019, ahead of print in Circulation, Fonarow, lead author Yongchen Hao, PhD (Beijing An Zhen Hospital, China), and colleagues examined registry data from the Improving Care for Cardiovascular Disease in China (CCC)-ACS project, an ongoing quality-improvement initiative of the American Heart Association (AHA) and the Chinese Society of Cardiology modeled after the AHA’s Get With The Guidelines program. The analysis included 82,196 patients (25.6% women) admitted for ACS at 192 hospitals across China between 2014 and 2018.
Compared with men, women were older at presentation (mean age 69 vs 61) and were more likely to have various comorbidities, including diabetes, hypertension, high LDL cholesterol, renal insufficiency, and a history of renal failure. They also took longer to seek care after symptom onset (median 10.1 vs 7.7 hours).
Once they got to the hospital, women were less likely to receive dual antiplatelet therapy (DAPT) at arrival, heparin during hospitalization, and reperfusion therapy for STEMI after multivariable adjustment.
A similar deficit in care was seen regarding interventions for secondary prevention. Even after adjustment for baseline differences, women were less likely to receive DAPT, statins, and ACE inhibitors/angiotensin receptor blockers at discharge or to undergo counseling regarding smoking cessation or cardiac rehabilitation during their hospital stay.
The differences between men and women in terms of clinical characteristics and acute management seemed to play an important role in in-hospital mortality risk, as adjustment for those factors statistically eliminated the sex-based disparity in mortality risk among patients with STEMI (adjusted OR 1.18; 95% CI 1.00-1.41) and those with NSTE ACS (adjusted OR 0.84; 95% CI 0.66-1.06).
Fonarow told TCTMD that the observed differences in care delivered to men and women are notable because these data come from a quality-improvement effort that has sought to empower clinical teams to get better at providing care for patients overall.
As for why women aren’t receiving the same caliber of care, Fonarow said several factors could be contributing. It could be that clinicians are less confident about the evidence supporting use of various interventions in women because female patients have been underrepresented in pivotal trials or that there is a perception that women are more susceptible to treatment side effects or risks, Fonarow said. Sex-based biases could be playing a role as well, he said, pointing out that prior research has shown that women have delayed diagnoses, which might influence the types of acute, time-sensitive therapies they’re able to receive.
“Part of having a specific, targeted quality-improvement effort is to try and uncover and overcome those specific reasons that may be involved in these important treatment differences,” Fonarow said.
In the United States, efforts to resolve sex differences in care and outcomes have involved publications and feedback to hospitals participating in the Get With The Guidelines program to raise awareness of the issue, resulting in a reduction—or elimination in some cases—of the disparities.
In China, Fonarow said, attempts to replicate those results will have to be considered in the context of the country’s culture, medical delivery system, and insurance framework. One specific area researchers are addressing currently is the role of nurses, who are a key part of American healthcare delivery teams, making important contributions in the care and education of patients and delivery of cardiac rehabilitation programs, he said. That type of contribution is not as prevalent in China, however.
“That was an identified area [for improvement] and there is now work going on to really help address that specifically in China, with the hope that that would be a mechanism to help further address some of the gaps in care as well as these specific sex-based differences that we’re observing,” Fonarow said.
Hao Y, Liu J, Liu J, et al. Sex differences in in-hospital management and outcomes of patients with acute coronary syndrome: findings from the Improving Care for Cardiovascular Disease in China (CCC) project. Circulation. 2019;Epub ahead of print.
- The CCC-ACS project is a collaborative program of the AHA and the Chinese Society of Cardiology. The AHA was funded by Pfizer for the quality-improvement initiative through an independent grant. This work was also supported by the Beijing Municipal Administration of Hospitals’ Youth Program.
- Fonarow reports having consulted for Amgen, Bayer, Janssen, and Novartis and serving on the AHA’s Quality Oversight Committee.
- Hao reports no relevant conflicts of interest.