Socioeconomic Factors and their Impact on Access and Use of Coronary and Structural Interventions.

In the past few decades, the accelerated improvement in technology has allowed the development of new and effective coronary and structural heart disease interventions. There has been inequitable patient access to these advanced therapies and significant disparities have affected patients from low socioeconomic positions. In the US, these disparities mostly affect women, black and hispanic communities who are overrepresented in low socioeconomic. Other adverse social determinants of health influenced by structural racism have also contributed to these disparities. In this article, we review the literature on disparities in access and use of coronary and structural interventions; delineate the possible reasons underlying these disparities; and highlight potential solutions at the government, healthcare system, community and individual levels.

Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients With Suspected Coronary Artery Disease: Insights From the PROMISE Trial.

OBJECTIVES: The aim of this study was to determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD). BACKGROUND: Although established CAD presentations differ by sex, little is known about stable, suspected CAD. METHODS: The characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial were compared using chi-square and Wilcoxon rank-sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression. RESULTS: Women were older (62.4 years of age vs. 59.0 years of age) and were more likely to be hypertensive (66.6% vs. 63.2%), dyslipidemic (68.9% vs. 66.3%), and to have a family history of premature CAD (34.6% vs. 29.3) (all p values <0.005). Women were less likely to smoke (45.6% vs. 57.0%; p < 0.001), although their prevalence of diabetes was similar to that in men (21.8% vs. 21.0%; p = 0.30). Chest pain was the primary symptom in 73.2% of women versus 72.3% of men (p = 0.30), and was characterized as "crushing/pressure/squeezing/tightness" in 52.5% of women versus 46.2% of men (p < 0.001). Compared with men, all risk scores characterized women as being at lower risk, and providers were more likely to characterize women as having a low (<30%) pre-test probability of CAD (40.7% vs. 34.1%; p < 0.001). Compared with men, women were more often referred to imaging tests (adjusted odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44) than nonimaging tests. Women were less likely to have a positive test (9.7% vs. 15.1%; p < 0.001). Although univariate predictors of test positivity were similar, in multivariable models, age, body mass index, and Framingham risk score were predictive of a positive test in women, whereas Framingham and Diamond and Forrester risk scores were predictive in men. CONCLUSIONS: Patient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches for the evaluation of CAD.

Innovative approaches to increase deep vein thrombosis prophylaxis rate resulting in a decrease in hospital-acquired deep vein thrombosis at a tertiary-care teaching hospital.

BACKGROUND AND OBJECTIVE: Hospital-acquired venous thromboembolic events (VTEs) in medically ill patients account for a significant percentage of in-hospital mortality. Unfractionated heparin and low-molecular-weight heparin have been shown to be effective in the prevention of VTEs. However, use of these medications for thromboprophylaxis remains suboptimal. The objective of this article is to report the impact of a continuous quality improvement project on adherence with DVT prophylaxis guidelines and on the subsequent incidence of hospital-acquired DVT in medical patients at a teaching hospital between 2002 and 2005. METHODS: In November 2002, Kings County Hospital Center Department of Medicine embarked on a project to increase the rate of thromboprophylaxis use. Quality improvement strategies included an active, multifaceted, layered combination of provider education, provider reminders with decision support, and audit with feedback. RESULTS: The DVT prophylaxis rate on the general medicine house-staff service increased from a baseline of 63% in 2002 to 96% in 2005. The number of hospital-acquired DVTs decreased from a baseline of 14 in 2002 to 1 in 2005. The hospital-acquired DVT rate fell significantly, from 2.6 per 1000 discharges in 2002 (95% CI 1.5-4.4) to 0.2 per 1000 discharges in 2005 (95% CI 0.0-1.1), P = .007. CONCLUSIONS: A layered combination of provider education, provider reminders with decision support, and audit with feedback increased the DVT prophylaxis rate and decreased the rate of hospital-acquired DVTs in the medicine department at a tertiary-care hospital center.