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Coisy F, Olivier G, Ageron FX, Guillermou H, Roussel M, Balen F, Grau-Mercier L, Bobbia X. Do emergency medicine health care workers rate triage level of chest pain differently based upon appearance in simulated patients? Eur J Emerg Med 2024; 31:188-194. [PMID: 38100643 DOI: 10.1097/mej.0000000000001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
BACKGROUND AND IMPORTANCE There seems to be evidence of gender and ethnic bias in the early management of acute coronary syndrome. However, whether these differences are related to less severe severity assessment or to less intensive management despite the same severity assessment has not yet been established. OBJECTIVE To show whether viewing an image with characters of different gender appearance or ethnic background changes the prioritization decision in the emergency triage area. METHODS The responders were offered a standardized clinical case in an emergency triage area. The associated image was randomized among eight standardized images of people presenting with chest pain and differing in gender and ethnic appearance (White, Black, North African and southeast Asian appearance). OUTCOME MEASURES AND ANALYSIS Each person was asked to respond to a single clinical case, in which the priority level [from 1 (requiring immediate treatment) to 5 (able to wait up to 2 h)] was assessed visually. Priority classes 1 and 2 for vital emergencies and classes 3-5 for nonvital emergencies were grouped together for analysis. RESULTS Among the 1563 respondents [mean age, 36 ± 10 years; 867 (55%) women], 777 (50%) were emergency physicians, 180 (11%) emergency medicine residents and 606 (39%) nurses. The priority levels for all responses were 1-5 : 180 (11%), 686 (44%), 539 (34%), 131 (9%) and 27 (2%). There was a higher reported priority in male compared to female [62% vs. 49%, difference 13% (95% confidence interval; CI 8-18%)]. Compared to White people, there was a lower reported priority for Black simulated patients [47% vs. 58%, difference -11% (95% CI -18% to -4%)] but not people of southeast Asian [55% vs. 58%, difference -3% (95% CI -10-5%)] and North African [61% vs. 58%, difference 3% (95% CI -4-10%)] appearance. CONCLUSION In this study, the visualization of simulated patients with different characteristics modified the prioritization decision. Compared to White patients, Black patients were less likely to receive emergency treatment. The same was true for women compared with men.
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Affiliation(s)
- Fabien Coisy
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, CHU de Nimes, University of Montpellier, Nimes, France
| | - Guillaume Olivier
- Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| | | | - Hugo Guillermou
- IDESP, University of Montpellier and INSERM, Montpellier, France
| | - Mélanie Roussel
- Emergency Department, Rouen University Hospital, Rouen, France
| | - Frédéric Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Laura Grau-Mercier
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, CHU de Nimes, University of Montpellier, Nimes, France
| | - Xavier Bobbia
- Montpellier University, UR UM 103 (IMAGINE), Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
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Barron R, Mader TJ, Knee A, Wilson D, Wolfe J, Gemme SR, Dybas S, Soares WE. Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial. Ann Emerg Med 2024; 83:123-131. [PMID: 38245227 DOI: 10.1016/j.annemergmed.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 01/22/2024]
Abstract
STUDY OBJECTIVE Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores. METHODS In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison. RESULTS All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66). CONCLUSION Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.
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Affiliation(s)
- Rebecca Barron
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA.
| | - Timothy J Mader
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Alexander Knee
- Department of Medicine, UMass Chan Medical School-Baystate, Springfield, MA; Epidemiology Biostatistics Research Core, Office of Research, Baystate Medical Center, Springfield, MA
| | - Donna Wilson
- Epidemiology Biostatistics Research Core, Office of Research, Baystate Medical Center, Springfield, MA
| | - Jeannette Wolfe
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Seth R Gemme
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | | | - William E Soares
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
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Zack T, Lehman E, Suzgun M, Rodriguez JA, Celi LA, Gichoya J, Jurafsky D, Szolovits P, Bates DW, Abdulnour REE, Butte AJ, Alsentzer E. Assessing the potential of GPT-4 to perpetuate racial and gender biases in health care: a model evaluation study. Lancet Digit Health 2024; 6:e12-e22. [PMID: 38123252 DOI: 10.1016/s2589-7500(23)00225-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/30/2023] [Accepted: 10/26/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Large language models (LLMs) such as GPT-4 hold great promise as transformative tools in health care, ranging from automating administrative tasks to augmenting clinical decision making. However, these models also pose a danger of perpetuating biases and delivering incorrect medical diagnoses, which can have a direct, harmful impact on medical care. We aimed to assess whether GPT-4 encodes racial and gender biases that impact its use in health care. METHODS Using the Azure OpenAI application interface, this model evaluation study tested whether GPT-4 encodes racial and gender biases and examined the impact of such biases on four potential applications of LLMs in the clinical domain-namely, medical education, diagnostic reasoning, clinical plan generation, and subjective patient assessment. We conducted experiments with prompts designed to resemble typical use of GPT-4 within clinical and medical education applications. We used clinical vignettes from NEJM Healer and from published research on implicit bias in health care. GPT-4 estimates of the demographic distribution of medical conditions were compared with true US prevalence estimates. Differential diagnosis and treatment planning were evaluated across demographic groups using standard statistical tests for significance between groups. FINDINGS We found that GPT-4 did not appropriately model the demographic diversity of medical conditions, consistently producing clinical vignettes that stereotype demographic presentations. The differential diagnoses created by GPT-4 for standardised clinical vignettes were more likely to include diagnoses that stereotype certain races, ethnicities, and genders. Assessment and plans created by the model showed significant association between demographic attributes and recommendations for more expensive procedures as well as differences in patient perception. INTERPRETATION Our findings highlight the urgent need for comprehensive and transparent bias assessments of LLM tools such as GPT-4 for intended use cases before they are integrated into clinical care. We discuss the potential sources of these biases and potential mitigation strategies before clinical implementation. FUNDING Priscilla Chan and Mark Zuckerberg.
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Affiliation(s)
- Travis Zack
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Eric Lehman
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Mirac Suzgun
- Department of Computer Science, Stanford University, Stanford, CA, USA; Stanford Law School, Stanford University, Stanford, CA, USA
| | - Jorge A Rodriguez
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Judy Gichoya
- Department of Radiology, Emory University, Atlanta, GA, USA
| | - Dan Jurafsky
- Department of Computer Science, Stanford University, Stanford, CA, USA; Department of Linguistics, Stanford University, Stanford, CA, USA
| | - Peter Szolovits
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - David W Bates
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Raja-Elie E Abdulnour
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Atul J Butte
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA; Center for Data-Driven Insights and Innovation, University of California, Office of the President, Oakland, CA, USA
| | - Emily Alsentzer
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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4
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Sex Differences in Epidemiology, Care, and Outcomes in Patients With Acute Chest Pain. J Am Coll Cardiol 2023; 81:933-945. [PMID: 36889871 DOI: 10.1016/j.jacc.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/30/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND Discrepancies in cardiovascular care for women are well described, but few data assess the entire patient journey for chest pain care. OBJECTIVES This study aimed to assess sex differences in epidemiology and care pathways from emergency medical services (EMS) contact through to clinical outcomes following discharge. METHODS This is a state-wide population-based cohort study including consecutive adult patients attended by EMS for acute undifferentiated chest pain in Victoria, Australia (January 1, 2015, to June 30, 2019). EMS clinical data were individually linked to emergency and hospital administrative datasets, and mortality data and differences in care quality and outcomes were assessed using multivariable analyses. RESULTS In 256,901 EMS attendances for chest pain, 129,096 attendances (50.3%) were women, and mean age was 61.6 years. Age-standardized incidence rates were marginally higher for women compared with men (1,191 vs 1,135 per 100,000 person-years). In multivariable models, women were less likely to receive guideline-directed care across most care measures including transport to hospital, prehospital aspirin or analgesia administration, 12-lead electrocardiogram, intravenous cannula insertion, and off-load from EMS or review by emergency department clinicians within target times. Similarly, women with acute coronary syndrome were less likely to undergo angiography or be admitted to a cardiac or intensive care unit. Thirty-day and long-term mortality was higher for women diagnosed with ST-segment elevation myocardial infarction, but lower overall. CONCLUSIONS Substantial differences in care are present across the spectrum of acute chest pain management from first contact through to hospital discharge. Women have higher mortality for STEMI, but better outcomes for other etiologies of chest pain compared with men.
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Minissian MB, Mehta PK, Hayes SN, Park K, Wei J, Bairey Merz CN, Cho L, Volgman AS, Elgendy IY, Mamas M, Davis MB, Reynolds HR, Epps K, Lindley K, Wood M, Quesada O, Piazza G, Pepine CJ. Ischemic Heart Disease in Young Women: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 80:1014-1022. [PMID: 36049799 PMCID: PMC9847245 DOI: 10.1016/j.jacc.2022.01.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 01/21/2023]
Abstract
The Cardiovascular Disease in Women Committee of the American College of Cardiology convened a working group to develop a consensus regarding the continuing rise of mortality rates in young women aged 35 to 54 years. Heart disease mortality rates in young women continue to increase. Young women have increased mortality secondary to ischemic heart disease (IHD) compared with comparably aged men and similar mortality to that observed among older women. The authors reviewed the published evidence, including observational and mechanistic/translational data, and identified knowledge gaps pertaining to young women. This paper provides clinicians with pragmatic, evidence-based management strategies for young women at risk for IHD. Next-step research opportunities are outlined. This report presents highlights of the working group review and a summary of suggested research directions to advance the IHD field in the next decade.
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Affiliation(s)
- Margo B Minissian
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA; Brawerman Nursing Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Puja K Mehta
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sharonne N Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ki Park
- University of Florida, Gainesville, Florida, USA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Leslie Cho
- Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky, USA
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, United Kingdom
| | | | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, NYU School of Medicine, New York, New York, USA
| | - Kelly Epps
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Malissa Wood
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Odayme Quesada
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA; Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA
| | - Gregory Piazza
- Harvard Medical School, Division of Cardiovascular Medicine at the Brigham and Women's Hospital, Boston, Massachusetts, USA
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6
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Banco D, Chang J, Talmor N, Wadhera P, Mukhopadhyay A, Lu X, Dong S, Lu Y, Betensky RA, Blecker S, Safdar B, Reynolds HR. Sex and Race Differences in the Evaluation and Treatment of Young Adults Presenting to the Emergency Department With Chest Pain. J Am Heart Assoc 2022; 11:e024199. [PMID: 35506534 PMCID: PMC9238573 DOI: 10.1161/jaha.121.024199] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Acute myocardial infarctions are increasingly common among young adults. We investigated sex and racial differences in the evaluation of chest pain (CP) among young adults presenting to the emergency department. Methods and Results Emergency department visits for adults aged 18 to 55 years presenting with CP were identified in the National Hospital Ambulatory Medical Care Survey 2014 to 2018, which uses stratified sampling to produce national estimates. We evaluated associations between sex, race, and CP management before and after multivariable adjustment. We identified 4152 records representing 29 730 145 visits for CP among young adults. Women were less likely than men to be triaged as emergent (19.1% versus 23.3%, respectively, P<0.001), to undergo electrocardiography (74.2% versus 78.8%, respectively, P=0.024), or to be admitted to the hospital or observation unit (12.4% versus 17.9%, respectively, P<0.001), but ordering of cardiac biomarkers was similar. After multivariable adjustment, men were seen more quickly (hazard ratio [HR], 1.15 [95% CI, 1.05-1.26]) and were more likely to be admitted (adjusted odds ratio, 1.40 [95% CI, 1.08-1.81]; P=0.011). People of color waited longer for physician evaluation (HR, 0.82 [95% CI, 0.73-0.93]; P<0.001) than White adults after multivariable adjustment, but there were no racial differences in hospital admission, triage level, electrocardiography, or cardiac biomarker testing. Acute myocardial infarction was diagnosed in 1.4% of adults in the emergency department and 6.5% of admitted adults. Conclusions Women and people of color with CP waited longer to be seen by physicians, independent of clinical features. Women were independently less likely to be admitted when presenting with CP. These differences could impact downstream treatment and outcomes.
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Affiliation(s)
- Darcy Banco
- Department of Medicine New York University Langone Hospital New York NY
| | - Jerway Chang
- Department of Medicine New York University Langone Hospital New York NY
| | - Nina Talmor
- Department of Medicine New York University Langone Hospital New York NY
| | - Priya Wadhera
- Department of Cardiology Boston University Medical Center Boston MA
| | - Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology Department of Medicine New York University School of Medicine New York NY
| | - Xinlin Lu
- Department of Biostatistics New York University School of Global Public Health New York NY
| | - Siyuan Dong
- Department of Biostatistics New York University School of Global Public Health New York NY
| | - Yukun Lu
- Department of Biostatistics New York University School of Global Public Health New York NY
| | - Rebecca A Betensky
- Department of Population Health New York University School of Medicine New York NY
| | - Saul Blecker
- Department of Medicine New York University Langone Hospital New York NY.,Department of Population Health New York University School of Medicine New York NY
| | - Basmah Safdar
- Department of Emergency Medicine Yale University School of Medicine New Haven CT
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research Leon H. Charney Division of Cardiology Department of Medicine NYU Grossman School of Medicine New York NY
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Johnson AK, Tweet MS, Rouleau SG, Sadosty AT, Hayes SN, Raukar NP. The presentation of spontaneous coronary artery dissection in the emergency department: Signs and symptoms in an unsuspecting population. Acad Emerg Med 2022; 29:423-428. [PMID: 34897898 PMCID: PMC10403148 DOI: 10.1111/acem.14426] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Spontaneous coronary artery dissection (SCAD) has emerged as a common cause of acute coronary syndrome (ACS) in young women, although it is rarely discussed in the differential diagnosis for chest pain in the emergency department (ED). In a population otherwise considered low risk for myocardial infarction, there is a danger of incomplete workup and missed diagnosis. In this study, we aim to describe the clinical presentation of those who present to the ED with SCAD to increase awareness of this potentially fatal diagnosis among emergency practitioners. METHODS Data were queried from the Mayo Clinic "Virtual" Multicenter SCAD Registry, a large multisite international disease registry. The registry includes demographic information as well as data from both medical records and surveys administered following the SCAD event. Symptom presentation was abstracted from survey narrative responses. Data analysis was performed using descriptive statistics. RESULTS Of 1196 subjects included, chest pain was reported during initial SCAD event in 95.7%. Most common chest symptoms descriptors were pain, pressure/weight, and tightness, with radiation most often in one or both arms/shoulders. Other common symptoms included nausea, shortness of breath, and diaphoresis. Most common electrocardiogram (ECG) findings reported were ST elevation, T-wave abnormality, and normal ECG. Initial troponin values were within normal range in 20.1% of patients. CONCLUSION With young healthy women often considered "low risk" for ACS, it is important to understand that SCAD is a cause of ACS, and familiarity with presentation can improve awareness among emergency physicians. Our data can provide insight in helping to identify young women who present with chest pain due to SCAD so they can be appropriately evaluated.
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Affiliation(s)
- Alexis K. Johnson
- Department of Emergency Medicine University of California at San Diego San Diego California USA
| | - Marysia S. Tweet
- Department of Cardiovascular Diseases College of Medicine and Science Mayo Clinic Rochester Minnesota USA
| | - Samuel G. Rouleau
- Department of Emergency Medicine University of California at Davis Davis California USA
| | - Annie T. Sadosty
- Department of Emergency Medicine Mayo Clinic Rochester Minnesota USA
| | - Sharonne N. Hayes
- Department of Cardiovascular Diseases College of Medicine and Science Mayo Clinic Rochester Minnesota USA
| | - Neha P. Raukar
- Department of Emergency Medicine Mayo Clinic Rochester Minnesota USA
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Ashburn NP, Snavely AC, Angi RM, Scheidler JF, Crowe RP, McGinnis HD, Hiestand BC, Miller CD, Mahler SA, Stopyra JP. Prehospital time for patients with acute cardiac complaints: A rural health disparity. Am J Emerg Med 2022; 52:64-68. [PMID: 34871845 PMCID: PMC9029257 DOI: 10.1016/j.ajem.2021.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/29/2021] [Accepted: 11/24/2021] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Delays in care for patients with acute cardiac complaints are associated with increased morbidity and mortality. The objective of this study was to quantify rural and urban differences in prehospital time intervals for patients with cardiac complaints. METHODS The ESO Data Collaborative dataset consisting of records from 1332 EMS agencies was queried for 9-1-1 encounters with acute cardiac problems among adults (age ≥ 18) from 1/1/2013-6/1/2018. Location was classified as rural or urban using the 2010 United States Census. The primary outcome was total prehospital time. Generalized estimating equations evaluated differences in the average times between rural and urban encounters while controlling for age, sex, race, transport mode, loaded mileage, and patient stability. RESULTS Among 428,054 encounters, the median age was 62 (IQR 50-75) years with 50.7% female, 75.3% white, and 10.3% rural. The median total prehospital, response, scene, and transport times were 37.0 (IQR 29.0-48.0), 6.0 (IQR 4.0-9.0), 16.0 (IQR 12.0-21.0), and 13.0 (IQR 8.0-21.0) minutes. Rural patients had an average total prehospital time that was 16.76 min (95%CI 15.15-18.38) longer than urban patients. After adjusting for covariates, average total time was 5.08 (95%CI 4.37-5.78) minutes longer for rural patients. Average response and transport time were 4.36 (95%CI 3.83-4.89) and 0.62 (95%CI 0.33-0.90) minutes longer for rural patients. Scene time was similar in rural and urban patients (0.09 min, 95%CI -0.15-0.33). CONCLUSION Rural patients with acute cardiac complaints experienced longer prehospital time than urban patients, even after accounting for other key variables, such as loaded mileage.
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America.
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America; Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Ryan M Angi
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - James F Scheidler
- Department of Emergency Medicine, West Virginia University, Morgantown, WV, United States of America
| | | | - Henderson D McGinnis
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Chadwick D Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
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Murray E, Roosevelt GE, Vogel JA. Screening for health-related social needs in the emergency department: Adaptability and fidelity during the COVID-19 pandemic. Am J Emerg Med 2021; 54:323.e1-323.e4. [PMID: 34654599 PMCID: PMC8492605 DOI: 10.1016/j.ajem.2021.09.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 01/11/2023] Open
Abstract
Background and objectives We sought to evaluate a screening and referral program for health-related social needs (HRSN) in our ED. Our goals were to (1) quantify successful screenings prior to and during the initial peak of the pandemic, and (2) describe the HRSNs identified. Methods We performed an observational analysis of ED-based screening for HRSN in Medicare and Medicaid patients at our large urban safety-net hospital. Screening was performed by patient navigators utilizing the ten question, validated Accountable Health Communities (AHC) Screening Tool, which screens for food insecurity, housing instability, transportation needs and utility assistance and interpersonal safety. Patients who screened positive for HRSN were provided with handouts listing community resources. For patients with two or more self-reported ED visits in the last 12 months and any identified HRSN, ongoing navigation after discharge was provided utilizing community resource referrals. During the pre-pandemic period from November 1, 2019 – January 31, 2020, screening occurred in-person. Screening during the pandemic from March 1, 2020 – May 31, 2020 occurred remotely via telephone. Descriptive statistics including frequency rates and percentages were calculated. Successful screening was defined as completing the screening survey with a navigator and being triaged to either no assistance, resource handouts, or navigation services. Results Among the adult and pediatric patients screened for HRSN, 158 (16%) qualified for community resource handouts and 440 (44.4%) qualified for patient navigator services. The proportion of patients receiving both resources and care navigation remained similar in the pre- and post-periods of the study, at 227 (45%) and 213 (43.9%) respectively. However, the proportion of ED patients with a HRSN need doubled from 56 (11.1%) in the pre-period to 102 (21%) in the post-period. Food insecurity was the most identified HRSN in both the pre-pandemic period (27.3%) and during the pandemic (35.8%). Conclusion We found that remote HRSN screening for ED patients during the COVID-19 pandemic resulted in similar proportions of successfully completed screenings compared to pre-pandemic efforts. This demonstrates the feasibility of utilizing alternative methods of screening and referral to community resources from the ED, which could facilitate this type of intervention in other EDs. During the pandemic HRSN increased, likely reflecting the economic impact of the pandemic.
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Affiliation(s)
- Evangelia Murray
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.
| | - Genie E Roosevelt
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jody A Vogel
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, USA
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10
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Nerenberg KA, Roeters van Lennep JE. Advancing Sex and Gender Considerations in Perioperative Cardiovascular-Risk Assessment. Can J Cardiol 2021; 37:1912-1914. [PMID: 34461231 DOI: 10.1016/j.cjca.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/13/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Kara A Nerenberg
- Department of Medicine, Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
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Ashburn NP, Smith ZP, Hunter KJ, Hendley NW, Mahler SA, Hiestand BC, Stopyra JP. The disutility of stress testing in low-risk HEART Pathway patients. Am J Emerg Med 2021; 45:227-232. [PMID: 33041122 PMCID: PMC8962568 DOI: 10.1016/j.ajem.2020.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients. METHODS An academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score ≤ 3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing. RESULTS There were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45-3.24) and being male (aOR 1.59, 95% CI 1.02-2.49) were associated with testing. CONCLUSIONS Stress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score.
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States.
| | - Zachary P Smith
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Kale J Hunter
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Nella W Hendley
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States; Departments of Epidemiology and Prevention and Implementation Science, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States
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Sharp AL, Baecker A, Nassery N, Park S, Hassoon A, Lee MS, Peterson S, Pitts S, Wang Z, Zhu Y, Newman-Toker DE. Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method. Diagnosis (Berl) 2021; 8:177-186. [PMID: 32701479 DOI: 10.1515/dx-2020-0049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/03/2020] [Indexed: 12/02/2023]
Abstract
OBJECTIVES Diagnostic error is a serious public health problem. Measuring diagnostic performance remains elusive. We sought to measure misdiagnosis-related harms following missed acute myocardial infarctions (AMI) in the emergency department (ED) using the symptom-disease pair analysis of diagnostic error (SPADE) method. METHODS Retrospective administrative data analysis (2009-2017) from a single, integrated health system using International Classification of Diseases (ICD) coded discharge diagnoses. We looked back 30 days from AMI hospitalizations for antecedent ED treat-and-release visits to identify symptoms linked to probable missed AMI (observed > expected). We then looked forward from these ED discharge diagnoses to identify symptom-disease pair misdiagnosis-related harms (AMI hospitalizations within 30-days, representing diagnostic adverse events). RESULTS A total of 44,473 AMI hospitalizations were associated with 2,874 treat-and-release ED visits in the prior 30 days. The top plausibly-related ED discharge diagnoses were "chest pain" and "dyspnea" with excess treat-and-release visit rates of 9.8% (95% CI 8.5-11.2%) and 3.4% (95% CI 2.7-4.2%), respectively. These represented 574 probable missed AMIs resulting in hospitalization (adverse event rate per AMI 1.3%, 95% CI 1.2-1.4%). Looking forward, 325,088 chest pain or dyspnea ED discharges were followed by 508 AMI hospitalizations (adverse event rate per symptom discharge 0.2%, 95% CI 0.1-0.2%). CONCLUSIONS The SPADE method precisely quantifies misdiagnosis-related harms from missed AMIs using administrative data. This approach could facilitate future assessment of diagnostic performance across health systems. These results correspond to ∼10,000 potentially-preventable harms annually in the US. However, relatively low error and adverse event rates may pose challenges to reducing harms for this ED symptom-disease pair.
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Affiliation(s)
- Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health System Science, Kaiser Permanente School of Medicine, Pasadena, CA, United States
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Najlla Nassery
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Stacy Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ming-Sum Lee
- Kaiser Permanente Southern California, Los Angeles Medical Center, Division of Cardiology, Los Angeles, CA, United States
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Samantha Pitts
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Yuxin Zhu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David E Newman-Toker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Preciado SM, Sharp AL, Sun BC, Baecker A, Wu YL, Lee MS, Shen E, Ferencik M, Natsui S, Kawatkar AA, Park SJ, Redberg RF. Evaluating Sex Disparities in the Emergency Department Management of Patients With Suspected Acute Coronary Syndrome. Ann Emerg Med 2021; 77:416-424. [PMID: 33358395 PMCID: PMC8005458 DOI: 10.1016/j.annemergmed.2020.10.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/02/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE We compare clinical management and outcomes of emergency department (ED) encounters by sex after implementation of a clinical care pathway in 15 community EDs that standardized recommendations based on patient risk, using the History, ECG, Age, Risk Factors, and Troponin (HEART) score. METHODS This was a retrospective analysis of adult ED encounters evaluated for suspected acute coronary syndrome with a documented HEART score from May 20, 2016, to December 1, 2017. The primary outcomes were hospitalization or 30-day stress testing. Secondary outcomes included 30-day acute myocardial infarction or all-cause death (major adverse cardiac event). A generalized estimating equation regression model was used to compare the odds of hospitalization or stress testing by sex; we report HEART scores (0 to 10) stratified by sex and describing major adverse cardiac events. RESULTS A total of 34,715 adult ED encounters met the inclusion criteria (56.0% women). A higher proportion of women were classified as low risk (60.5% versus 52.4%; odds ratio [OR] 1.39; 95% confidence interval [CI] 1.33 to 1.45). Women were hospitalized or received stress testing less frequently than men for low HEART scores (18.8% versus 22.8%; OR 0.79; 95% CI 0.73 to 0.84) and intermediate ones (46.7% versus 49.7%; OR 0.88; 95% CI 0.83 to 0.95), but similarly for high-risk ones (74.1% versus 74.4%; OR 0.99; 95% CI 0.77 to 1.28). Women had 18% lower odds of hospitalization or noninvasive cardiac testing (OR 0.82; 95% CI 0.78 to 0.86), even after adjusting for HEART score and comorbidities. Men had higher risks of major adverse cardiac events than women for all HEART score categories but the risk for men was significantly higher among low-risk HEART scores (0.4% versus 0.1%). CONCLUSION Women with low-risk HEART scores are hospitalized or stress tested less than men, which is likely appropriate, and women have better outcomes than men. Use of the HEART score has the potential to reduce sex disparities in acute coronary syndrome care.
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Affiliation(s)
- Salena M Preciado
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Benjamin C Sun
- Department of Emergency Medicine, University of Pennsylvania, Leonard Davis Institute, Philadelphia, PA
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA
| | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Shaw Natsui
- New York City Health + Hospitals, New York, NY
| | - Aniket A Kawatkar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Stacy J Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Rita F Redberg
- Division of Cardiology, University of California-San Francisco, San Francisco, CA.
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Azap RA, Hyer JM, Diaz A, Tsilimigras DI, Mirdad RS, Pawlik TM. Sex-based differences in time to surgical care among pancreatic cancer patients: A national study of Medicare beneficiaries. J Surg Oncol 2020; 123:236-244. [PMID: 33084065 DOI: 10.1002/jso.26266] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The objective of this study was to characterize time from cancer symptoms to diagnosis and time from diagnosis to surgical treatment among patients undergoing pancreatectomy for cancer. METHODS Medicare beneficiaries who underwent pancreatectomy for cancer between 2013 and 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Mixed effects negative binomial regression models were utilized to determine which factors were associated with the number of weeks to diagnosis and pancreatic resection. RESULTS Among 7647 Medicare beneficiaries, two-thirds (n = 5127, 67%) had symptoms associated with a pancreatic cancer diagnosis before surgery. Median time from the first symptom to diagnosis was 6 weeks (IQR: 1-25) and the median time from diagnosis to surgery was 4 weeks (IQR: 2-15). In risk-adjusted models, female patients had 13% longer waiting times from identification of a related symptom to pancreatic cancer diagnosis (OR = 1.13, 95% CI: 1.05-1.21) and 12% longer waiting times from diagnosis to surgery (OR = 1.12, 95% CI: 1.07-1.18). Older age was associated with 10% longer waiting times from symptom identification to diagnosis (p < .0001). CONCLUSIONS Female and older patients had longer wait times between symptom presentation and pancreatic cancer diagnosis. Sex-based disparities in cancer care need to be recognized and addressed by policymakers and health care institutions.
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Affiliation(s)
- Rosevine A Azap
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - James M Hyer
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Adrian Diaz
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Rayyan S Mirdad
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, James Comprehensive Cancer Center, Columbus, Ohio, USA
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Frequency, Risk Factors, Causes, and Consequences of Diagnostic Errors in Critically Ill Medical Patients: A Retrospective Cohort Study. Crit Care Med 2020; 47:e902-e910. [PMID: 31524644 DOI: 10.1097/ccm.0000000000003976] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Diagnostic errors are a source of significant morbidity and mortality but understudied in the critically ill. We sought to characterize the frequency, causes, consequences, and risk factors of diagnostic errors among unplanned ICU admissions. DESIGN We conducted a retrospective cohort study of randomly selected nonsurgical ICU admissions between July 2015 and June 2016. SETTING Medical ICU at a tertiary academic medical center. SUBJECTS Critically ill adults with unplanned admission to the medical ICU. MEASUREMENTS AND MAIN RESULTS The primary investigator reviewed patient records using a modified version of the Safer Dx instrument, a validated instrument for detecting diagnostic error. Two intensivists performed secondary reviews of possible errors, and reviewers met periodically to adjudicate errors by consensus. For each confirmed error, we judged harm on a 1-6 rating scale. We also collected detailed demographic and clinical data for each patient. We analyzed 256 unplanned ICU admissions and identified 18 diagnostic errors (7% of admissions). All errors were associated with harm, and only six errors (33%) were recognized by the ICU team within the first 24 hours. More women than men experienced a diagnostic error (11.7% vs 2.7%; p = 0.015, χ test). On multivariable logistic regression analysis, female sex remained independently associated with risk of diagnostic error both at admission (odds ratio, 5.18; 95% CI, 1.34-20.08) and at 24 hours (odds ratio, 11.6; 95% CI, 1.37-98.6). Similarly, Quick Sequential Organ Failure Assessment score greater than or equal to 2 at admission was independently associated with diagnostic error (odds ratio, 5.73; 95% CI, 1.72-19.01). CONCLUSIONS Diagnostic errors may be an underappreciated source of ICU-related harm. Women and higher acuity patients appear to be at increased risk for such errors. Further research is merited to define the scope of error-associated harm and to clarify risk factors for diagnostic errors among the critically ill.
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Heraty E, Griffin BL, Vest KM. Faculty insights regarding incorporation of gender- and sex-related differences in the PharmD curriculum: Phase 2. CURRENTS IN PHARMACY TEACHING & LEARNING 2019; 11:1167-1171. [PMID: 31783964 DOI: 10.1016/j.cptl.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 05/03/2019] [Accepted: 07/24/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND While pharmacists should be aware of gender and sex-related differences in treatment related decisions, this is not a required doctor of pharmacy curricular component. A regional pilot study demonstrated that approximately half of pharmacy practice faculty discussed these differences in their content area. The aim of this study was to evaluate the extent of inclusion of gender and sex-related differences on a national level in doctor of pharmacy curricula and to determine if faculty are comfortable teaching the topic. METHODS An electronic message with a link to an online survey was distributed to 7250 faculty members at 139 colleges of pharmacy. The survey remained open for three weeks and potential participants received weekly email reminders. The survey was voluntary, and responses were de-identified. RESULTS Overall, 641 faculty participated in the survey (8.8% response rate). Most respondents indicated that they do not teach about gender or sex-related differences (54.9%). Of those faculty reporting teaching gender and/or sex-related differences, 28% indicated that it was addressed in one clinical topic, while some (7.7%) indicated that the content was included in up to five topics. Half of faculty (53.6%) indicated that they believe this topic is somewhat important. CONCLUSIONS Results of this study suggest that gender and sex-related differences are not adequately addressed in current pharmacy curricula.
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Affiliation(s)
- Erin Heraty
- Midwestern University Chicago College of Pharmacy, 555 31st Street, Downers Grove, IL 60515, United States.
| | - Brooke L Griffin
- Midwestern University Chicago College of Pharmacy, 555 31st Street, Downers Grove, IL 60515, United States.
| | - Kathleen M Vest
- Midwestern University Chicago College of Pharmacy, 555 31st Street, Downers Grove, IL 60515, United States.
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Mackey C, Diercks DB. Gender Bias in the Management of Patients Still Exists. Acad Emerg Med 2018; 25:467-469. [PMID: 29479769 DOI: 10.1111/acem.13394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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