The Institute of Medicine’s landmark publication Unequal Treatment1  describes gender bias as unequal access or treatment that is not justified on the basis of an underlying health condition. In a health care setting, bias against women may be manifested when women are diagnosed, counseled, treated, or otherwise managed not just differently, but to a lesser degree of adherence to established standards of care than men with comparable health status. Potential effects of this bias include worse health outcomes for women, marked by higher complication, morbidity, and mortality rates.2  This expression of prejudice is believed to be implicit, operating at an unconscious level on the basis of situational cues.3  When a nearly invisible impediment to equitable quality health care can potentially undermine roughly half of the world’s population, it should warrant our attention. In the United States, our 309 million residents comprise 50.8% or 156.5 million females4  who may receive substandard health care.

My personal interest in the topic was piqued after returning home from my granddaughter’s funeral following an automobile crash and reading study findings that female trauma victims with life-threatening injuries comparable to males were less often triaged by emergency medical service personnel to trauma facilities and less often transferred by nontrauma physicians to trauma centers.5  Because both initial transport6  and secondary transfer to a trauma center7  correlate with more favorable clinical outcomes, whereas initial triage to a nontrauma facility is associated with a 30% higher mortality rate,8  the potentially lethal implications of both of those findings hit home immediately and personally.

I found it hard to reconcile that a practice arena heavily accustomed to following protocols and procedures based on valid research delivered a lower standard of care to women. In pursuit of answers and facts, I examined the literature surrounding this issue, hoping to locate evidence that my concern was unfounded. What I found was that this detriment to women’s health does not exist as a rare, isolated occurrence limited to third world countries, but has flourished as a pervasive, largely unrecognized phenomenon in the United States and throughout the world.9  I shared my findings in a 2012 editorial titled “Is there gender bias in critical care?”10 

In the 5 years since that report, research continues to describe and affirm the nature, extent, and effects of gender bias with some awakening of awareness to its existence and potential for harm. The Table provides a sampling of the literature findings related to gender bias, with an emphasis on studies relevant to critical care. Please refer to it to become acquainted with or to refresh your own recognition of this problem and, I hope, to ignite your interest in contributing to its eradication. To support you in this effort, we can consider some of the approaches suggested for reducing or managing gender bias and then highlight a possibly promising breakthrough discovered serendipitously.

Strategies to Mitigate Gender Bias in Health Care

A number of approaches have been employed to help prevent or reduce implicit bias in health care. A frequent starting place is to help health care professionals gain some awareness of their own vulnerability to this form of prejudice. This step is often accomplished using the Implicit Association Test (IAT)—software that measures automatic associations evoked by rapid reactions in response to specific visually presented features representing various races, genders, ages, and sexual orientations. As different features are presented, the computer-based program tracks changes in response latency that reveal implicit bias. The IAT has been used in hundreds of studies across many disciplines and can be previewed at Harvard’s Project Implicit website.137 

Merely exposing health care workers to the IAT may not alter attitudes or beliefs, however, so multiple strategies are often used, including combinations of education about implicit bias, prejudice, and stereotyping; peer discussions and focus groups; self-reflection; reading about implicit bias; and practicing skills aimed at countering stereotypical responses. To date, none of these has produced any blockbuster success. According to Zestcott et al,138  more research is needed to determine which of these interventions are effective, to understand how provider bias affects care, and how to motivate providers to control implicit bias.

One window into understanding these dynamics may have opened recently and surreptitiously, while shining a plausible and promising path to success.

An Unanticipated Breakthrough in Helping to Eliminate Gender Bias in Health Care

In 2005, after a random chart audit in a few high risk patient areas revealed that only 33% of vulnerable patients had received appropriate venous thromboembolism (VTE) prophylaxis, patient safety staff at Johns Hopkins Hospital launched a collaborative program to maximize adherence to VTE prophylaxis guidelines by means of a checklist.139  Further examination of these findings revealed that whereas 31% of male trauma patients did not receive VTE prophylaxis, for female trauma patients, that failure rate was 45%, making women nearly 50% more vulnerable to thrombi/emboli.140  Checklists were used as clinical decision support devices based on their effectiveness in improving compliance with other guidelines related to infection control141  and reducing postoperative complications.142  Among the lessons learned with this project was that while many interventions to foster staff buy-in for this effort may have contributed to substantial improvements in VTE prophylaxis compliance observed in successive project reports,143145  2 other aspects were requisite for success: (1) The checklist order sets must be evidence based, user friendly, efficient, smoothly integrated into normal work-flow, and enable real-time performance monitoring, and (2) physician participation in completing all checklist requirements needs to be mandatory to achieve consistent compliance.139  In addition to the checklists, a “culture of safety” should include instruction in safety science, recognition of possible safety problems, design of evidence-based solutions, monitoring for improvements, and empowerment of all caregivers to halt procedures when safety appears to be compromised.146 

Continued work with these computer-based mandatory checklists as clinical decision support tools has not only expanded their application as effective means for maximizing staff compliance with best practices, but has also afforded an apparent breakthrough into achieving desired clinical practice results while erasing disparities ascribed to race and gender bias. Lau et al145  describe attainment of significantly improved VTE prophylaxis compliance for hospitalized medical and trauma patients with concurrent elimination of preexisting racial and gender disparities. For medical patients, compliance with prescribed risk-appropriate VTE prophylaxis improved from 70% for black patients and 62%, for white patients (P = .015) before protocol implementation to 92% for black patients and 88% for white patients with no differences in compliance between the races (P = .082). Similarly, for trauma patients, the proportion of males prescribed VTE prophylaxis before the protocol was significantly higher than for female trauma patients (70% vs 55%, P = .045), whereas after protocol implementation, compliance increased for both male (86%) and female (81%) trauma patients (P = .078).145  Although other reports have highlighted the strong association between strict adherence to established guidelines and improved patient outcomes,147149  Lau et al rightly underscore their unique findings of mutual and simultaneous benefits in both optimal and equitable patient care: “These findings highlight the potential of health information technology approaches to improve the quality of care for all patients and eradicate health-care disparities.”145(p6)

How Critical Care Nurses Can Contribute to Eliminating Gender Bias

Some of the cumulative lessons that critical care nurses can take away from these studies:

  • Evidence of gender bias against women in delivery of health care services is pervasive and persistent.

  • Acknowledging the existence of gender bias against women is a necessary first step in eliminating it.

  • Gaining insight into one’s own biases via the IAT can be a valuable personal enlightenment.

  • Critical care staff who would like to eliminate gender bias at their facility can learn from the experiences of multidisciplinary teams at Johns Hopkins Hospital as they refined their checklists141,150  designed the culture of safety,146  and implemented the VTE prevention program.139,143 

  • Monitoring for gender bias includes observing for errors, omissions, or deviations from established protocols, standing orders, and national guidelines in our own setting as well as upon receipt of patients from emergency medical services or other facilities.

  • Just as with security concerns, the culture of safety demands that when you see something in a health professional’s practice that deviates from expectations, you say something so the practice is not permitted to continue or repeat.

If gender bias against women can be reduced by ensuring that all health care providers follow established protocols for practice in their clinical area, then we may not have a panacea but surely a promising means to eradicate a significant proportion of the gender bias that surrounds us. Critical care nurses can make their contributions via their insights and participation as integral members of the collaborative teams tasked with eliminating gender bias while maximizing compliance with best practices. Critical Care Nurse looks forward to hearing about your progress against gender bias, so please keep us informed.

References

References
1
Institute of Medicine
.
Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare
.
Washington, DC
:
The National Academies Press
;
2002
.
2
Risberg
G
,
Johansson
EE
,
Hamberg
K
.
A theoretical model for analysing gender bias in medicine
.
Int J Equity Health
.
2009
;
8
:
28
.
3
Blair
IV
,
Steiner
JF
,
Havranek
EP
.
Unconscious (implicit) bias and health disparities: where do we go from here?
The Permanente Journal
.
2011
;
15
(
2
):
71
78
.
4
United States Census Bureau
.
Age and Sex Composition: 2010
.
2010 Census Briefs
. . Accessed February 1, 2017.
5
Gomez
D
,
Haas
B
,
de Mestral
C
, et al
.
Gender-associated differences in access to trauma center care: a population-based analysis
.
Surgery
.
2012
;
152
:
179
185
.
6
MacKenzie
EJ
,
Rivara
FP
,
Jurkovich
GJ
, et al
.
A national evaluation of the effect of trauma-center care on mortality
.
N Engl J Med
.
2006
;
354
:
366
378
.
7
Garwe
T
,
Cowan
LD
,
Neas
B
,
Cathey
T
,
Danford
BC
,
Greenawalt
P
.
Survival benefit of transfer to tertiary trauma centers for major trauma patients initially presenting to nontertiary trauma centers
.
Acad Emerg Med
.
2010
;
17
:
1223
1232
.
8
Haas
B
,
Stukel
TA
,
Gomez
D
, et al
.
The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis
.
J Trauma Acute Care Surg
.
2012
;
72
:
1510
1517
.
9
Kent
JA
,
Patel
V
,
Varela
NA
.
Gender disparities in health care
.
Mt Sinai J Med
.
2012
;
79
(
5
):
555
559
.
10
Alspach
JG
.
Is there gender bias in critical care?
Crit Care Nurse
.
2012
;
32
(
6
):
8
14
.
11
Yourstone
J
,
Lindholm
T
,
Grann
M
,
Svenson
O
.
Evidence of gender bias in legal insanity evaluations: a case vignette study of clinicians, judges and students
.
Nord J Psychiatry
.
2008
;
62
(
4
):
273
278
.
12
Diaz-Granados
N
,
McDermott
S
,
Wang
F
, et al
.
Monitoring gender equity in mental health in a low-, middle-, and high-income country in the Americas
.
Psychiatr Serv
.
2011
;
62
(
5
):
516
524
.
13
Centers for Disease Control and Prevention
.
CDC QuickStats
. . Accessed February 3, 2017.
14
Osika
I
,
Evengard
B
,
Waernulf
L
,
Nyberg
F
.
The laundry-basket project—gender differences to the very skin. Different treatment of some common diseases in men and women
.
Läkartidningen
.
2005
;
102
(
40
):
2846
2848
.
15
Brännström
J
,
Hamberg
K
,
Molander
L
,
Lövheim
H
,
Gustafson
Y
.
Gender disparities in the pharmacological treatment of cardiovascular disease and diabetes mellitus in the very old: an epidemiological, cross-sectional survey
.
Drugs Aging
.
2011
;
28
(
12
):
993
1005
.
16
National Institute for Health and Clinical Excellence (NICE)
.
Referral for suspected cancer: a clinical practice guideline
.
London
.
2005
.
Clinical guideline 27. http://www.nice.org.uk/CG027
. Accessed February 6, 2017.
17
Rachet
B
,
Maringe
C
,
Nur
U
, et al
.
Population-based cancer survival trends in England and Wales up to 2007: an assessment of the NHS cancer plan for England
.
Lancet Oncol
.
2009
;
10
:
351
369
.
18
Scosyrev
E
,
Noyes
K
,
Feng
C
,
Messing
E
.
Sex and racial differences in bladder cancer presentation and mortality in the US
.
Cancer
.
2009
;
115
:
68
74
.
19
Lyratzopoulos
G
,
Abel
GA
,
McPhail
S
,
Neal
RD
,
Rubin
GP
.
Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey
.
BMJ Open
.
2013
;
3
:
e002861
.
20
Borkhoff
CM
,
Hawker
GA
,
Kreder
HJ
,
Glazier
RH
,
Mohamed
NN
,
Wright
JG
.
The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty
.
CMAJ
.
2008
;
178
:
681
687
.
21
Juni
P
,
Low
N
,
Reichenbach
S
,
Villiger
PM
,
Williams
S
,
Dieppe
PA
.
Gender inequity in the provision of care for hip disease: population-based cross-sectional study
.
Osteoarthrit Cartilage
.
2010
;
18
(
5
):
640
645
.
22
Hame
Sharon L
,
Alexander
Reginald A
.
Knee osteoarthritis in women
.
Curr Rev Musculoskelet Med
.
2013
;
6
(
2
):
182
187
.
23
Thamer
M
,
Hwang
W
,
Fink
NE
, et al
.
CHOICE Study. Choices for Healthy Outcomes in Caring for ESRD. U.S. nephrologists’ attitudes towards renal transplantation: results from a national survey
.
Transplantation
.
2001
;
71
(
2
):
281
288
.
24
Klassen
AC
,
Hall
AG
,
Saksvig
B
,
Curbow
B
,
Klassen
DK
.
Relationship between patients’ perceptions of disadvantage and discrimination and listing for kidney transplantation
.
Am J Pubc Health
.
2002
;
92
(
5
):
811
817
.
25
Couchoud
C
,
Bayat
S
,
Villar
E
,
Jacquelinet
C
,
Ecochard
R
.
A new approach for measuring gender disparity in access to renal transplantation waiting lists
.
Transplantation
.
2012
;
94
(
5
):
513
519
.
26
Mathur
AK
,
Schaubel
DE
,
Gong
Q
,
Guidinger
MK
,
Merion
RM
.
Sex-based disparities in liver transplant rates in the United States
.
Am J Transplant
.
2011
;
11
(
7
):
1435
1443
.
27
Lack
DZ
.
Women and Pain: Another Feminist Issue
.
Women and Therapy
.
1982
;
1
(
1
):
55
64
.
28
Faherty
BS
,
Grier
MR
.
Analgesic medication for elderly people post-surgery
.
Nurs Res
.
1984
;
33
(
6
):
369
372
.
29
Calderone
KL
.
The influence of gender on the frequency of pain and sedative medication administered to postoperative patients
.
Sex Roles
.
1990
;
23
(
12
):
713
725
.
30
Unruh
AM
.
Gender variations in clinical pain experience
.
Pain
.
1996
;
65
:
123
167
.
31
Wandner
LD
,
Heft
MW
,
Lok
BC
, et al
.
The impact of patients’ gender, race, and age on health care professionals’ pain management decisions
.
Int J Nurs Stud
.
2014
;
51
(
5
):
726
733
.
32
Enriquez
JR
,
Pratap
P
,
Zbilut
JP
,
Calvin
JE
,
Volgman
AS
.
Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, beta-blockers, or statins
.
Gend Med
.
2008
;
5
(
1
):
53
61
.
33
Hernandez-Vila
EA
.
Peripheral arterial disease in women: the effect of gender on diagnosis and treatment
.
Tex Heart Inst J
.
2011
;
38
(
2
):
154
156
.
34
Poisson
SN
,
Johnston
SC
,
Sidney
S
,
Klingman
JG
,
Nguyen-Huynh
MN
.
Gender differences in treatment of severe carotid stenosis after transient ischemic attack
.
Stroke
.
2010
;
41
(
9
):
1891
1895
.
35
Vouyouka
AG
,
Egorova
NN
,
Salloum
A
, et al
.
Lessons learned from the analysis of gender effect on risk factors and procedural outcomes of lower extremity arterial disease
.
J Vasc Surg
.
2010
;
52
(
5
):
1196
1202
.
36
Hirsch
AT
,
Allison
MA
,
Gomes
AS
, et al
.
A call to action: women and peripheral artery disease: a scientific statement from the American Heart Association
.
Circulation
.
2012
;
125
:
1449
1472
.
37
McDermott
MM
,
Ferrucci
L
,
Liu
K
, et al
.
Women with peripheral arterial disease experience faster functional decline than men with peripheral arterial disease
.
J Am Coll Cardiol
.
2011
;
57
:
707
714
.
38
Fowler
RA
,
Sabur
N
,
Li
P
, et al
.
Sex-and age-based differences in the delivery and outcomes of critical care
.
CMAJ
.
2007
;
177
(
12
):
1513
1519
.
39
Meisel
ZF
,
Armstrong
K
,
Mechem
CC
, et al
.
Influence of sex on the out-of-hospital management of chest pain
.
Acad Emerg Med
.
2010
;
17
(
1
):
80
87
.
40
Zègre-Hemsey
J
,
Sommargren
CE
,
Drew
BJ
.
Initial ECG acquisition within 10 minutes of arrival at the emergency department in persons with chest pain: time and gender differences
.
J Emerg Nurs
.
2011
;
37
(
1
):
109
112
.
41
Pelletier
R
,
Humphries
KH
,
Shimony
A
, et al
.
Sex-related differences in access to care among patients with premature acute coronary syndrome
.
CMAJ
.
2014
;
186
(
7
):
497
504
.
42
Valentin
A
,
Jordan
B
,
Lang
T
,
Hiesmayr
M
,
Metnitz
PG
.
Gender-related differences in intensive care: a multiple-center cohort study of therapeutic interventions and outcome in critically ill patients
.
Crit Care Med
.
2003
;
31
:
1901
1907
.
43
Mahmood
K
,
Eldeirawi
K
,
Wahidi
MM
.
Association of gender with outcomes in critically ill patients
.
Critical Care
.
2012
;
16
:
R92
. . Accessed February 6, 2017.
44
Abuful
A
,
Gidron
Y
,
Henkin
Y
.
Physicians’ attitudes toward preventive therapy for coronary artery disease: is there a gender bias?
Clin Cardiol
.
2005
;
28
(
8
):
389
393
.
45
Jarvie
JL
,
Foody
JM
.
Recognizing and improving health care disparities in the prevention of cardiovascular disease in women
.
Curr Cardiol Rep
.
2010
;
12
:
488
496
.
46
Huxley
R
,
Barzi
F
,
Woodward
M
.
Group excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies
.
BMJ
.
2006
;
332
:
73
76
.
47
Franzini
L
,
Ardigo
D
,
Cavalot
F
, et al
.
Women show worse control of type 2 diabetes and cardiovascular disease risk factors than men: results from the MIND.IT Study Group of the Italian Society of Diabetology
.
Nutr Metab Cardiovasc Dis
.
2013
;
23
(
3
):
235
241
.
48
Chou
AF
,
Scholle
SH
,
Weisman
CS
, et al
.
Gender disparities in the quality of cardiovascular disease care in private managed care plans
.
Womens Health Issues
.
2007
;
17
:
120
130
.
49
Vimalananda
VG
,
Miller
DR
,
Palnati
M
, et al
.
Gender disparities in lipid-lowering therapy among veterans with diabetes
.
Womens Health Issues
.
2011
;
21
(
4 suppl
):
S176
S181
.
50
Virani
SS
,
Woodard
LD
,
Ramsey
DJ
, et al
.
Gender disparities in evidence-based statin therapy in patients with cardiovascular disease
.
Am J Cardiol
.
2015
;
115
:
21
26
.
51
Lehmann
JB
,
Wehner
PS
,
Lehmann
CU
, et al
.
Gender bias in the evaluation of chest pain in the emergency department
.
Am J Cardiol
.
1996
;
77
:
641
644
.
52
Rothrock
SG
,
Brandt
P
,
Godfrey
B
,
Sal Silvestri
S
,
Pagan
J
.
Is there gender bias in the prehospital management of patients with acute chest pain?
Prehospital Emerg Care
.
2001
;
5
(
4
):
331
334
.
53
Bösner
S
,
Haasenritter
J
,
Hani
MA
, et al
.
Gender bias revisited: new insights on the differential management of chest pain
.
BMC Fam Pract
.
2011
;
12
:
45
.
54
Schulman
KA
,
Berlin
JA
,
Harless
W
, et al
.
The effect of race and sex on physicians’ recommendations for cardiac catheterization
.
N Engl J Med
.
1999
;
340
:
618
626
.
55
Chandra
NC
,
Ziegelstein
RC
,
Rogers
WJ
, et al
.
Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I
.
Arch Intern Med
.
1998
;
158
:
981
988
.
56
Rathore
SS
,
Wang
Y
,
Radford
MJ
,
Ordin
DL
,
Krumholz
HM
.
Sex differences in cardiac catheterization after acute myocardial infarction: the role of procedure appropriateness
.
Ann Intern Med
.
2002
;
137
:
487
493
.
57
Blomkalns
AL
,
Chen
AY
,
Hochman
JS
, et al
.
Gender disparities in the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: large scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative
.
J Am Coll Cardiol
.
2005
;
45
:
832
837
.
58
Vaccarino
V
,
Rathore
SS
,
Wenger
NK
, et al
.
Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002
.
N Engl J Med
.
2005
;
353
(
7
):
671
682
.
59
Peterson
ED
,
Shah
BR
,
Parsons
L
, et al
.
Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006
.
Am Heart J
.
2008
;
156
:
1045
1055
.
60
Chang
AM
,
Mumma
B
,
Sease
KL
,
Robey
JL
,
Shofer
FS
,
Hollander
JE
.
Gender bias in cardiovascular testing persists after adjustment for presenting characteristics and cardiac risk
.
Acad Emerg Med
.
2007
;
14
:
599
605
.
61
Mumma
BE
,
Baumann
BM
,
Diercks
DB
, et al
.
Sex bias in cardiovascular testing: the contribution of patient preference
.
Ann Emerg Med
.
2011
;
57
(
6
):
551
560.e4
62
Takakuwa
KM
,
Shofer
FS
,
Hollander
JE
.
The influence of race and gender on time to initial electrocardiogram for patients with chest pain
.
Acad Emerg Med
.
2006
;
13
:
867
872
.
63
Arnold
AL
,
Milner
KA
,
Vaccarino
V
.
Sex and race differences in electrocardiogram use (the National Hospital Ambulatory Medical Care Survey)
.
Am J Cardiol
.
2001
;
88
:
1037
1040
.
64
Diercks
DB
,
Miller
CD
.
Disparities in the care of chest pain
.
Can Med Assoc J
.
2008
;
179
:
631
633
.
65
Nguyen
HL
,
Saczynski
JS
,
Gore
JM
,
Goldberg
RJ
.
Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction: a systematic review
.
Circ Cardiovasc Qual Outcomes
.
2010
;
3
:
82
92
.
66
Golden
KE
,
Chang
AM
,
Hollander
JE
.
Sex preferences in cardiovascular testing: the contribution of the patient-physician discussion
.
Acad Emerg Med
.
2013
;
20
:
680
688
.
67
Shaw
LJ
,
Miller
DD
,
Romeis
JC
, et al
.
Gender differences in the noninvasive evaluation and management of patients with suspected coronary artery disease
.
Ann Intern Med
.
1994
;
120
:
559
566
.
68
Kaul
P
,
Chang
WC
,
Westerhout
CM
,
Graham
MM
,
Armstrong
PW
.
Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes
.
CMAJ
.
2007
;
177
(
10
):
1193
1199
.
69
Krämer
HU
,
Raum
E
,
Rüter
G
, et al
.
Gender disparities in diabetes and coronary heart disease medication among patients with type 2 diabetes: results from the DIANA study
.
Cardiovasc Diabetol
.
2012
;
11
:
88
.
70
Bugiardini
R
,
Estrada
JL
,
Nikus
K
,
Hall
AS
,
Manfrini
O
.
Gender bias in acute coronary syndromes
.
Curr Vasc Pharmacol
.
2010
;
8
(
2
):
276
284
.
71
Poon
S
,
Goodman
SG
,
Yan
RT
, et al
.
Bridging the gender gap: insights from a contemporary analysis of sexrelated differences in the treatment and outcomes of patients with acute coronary syndromes
.
Am Heart J
.
2012
;
163
(
1
):
66
73
.
72
Shehab
A
,
Al-Dabbagh
B
,
AlHabib
KF
, et al
.
Gender disparities in the presentation, management and outcomes of acute coronary syndrome patients: data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2)
.
PLoS One
.
2013
;
8
(
2
):
e55508
73
Hammoudeh
AJ
,
Shobaki
N
,
Hamdan
H
, et al
, and
the Jordan Collaborating Cardiology (JCC) Group
.
Gender disparities in medical care and early death after acute coronary syndrome in the Middle East: a study of >4000 cases [abstract 0186]. Circulation
. . Accessed Feburary 6, 2017.
74
Wang
N
,
Zhao
D
,
Jing
L
, et al
.
Quality of in-hospital management in women with acute coronary syndrome in China: results from the bridging the gap on CHD secondary prevention in China (BRIG) project
.
Poster presentation P681 from World Congress of Cardiology Scientific Sessions
,
Dubai, United Arab Emirates
;
April 18–21, 2012
. . Accessed February 6, 2017.
75
Steingart
RM
,
Packer
M
,
Hamm
P
, et al
.
Sex differences in the management of coronary artery disease. Survival and Ventricular Enlargement Investigators
.
N Engl J Med
.
1991
;
325
(
4
):
226
230
.
76
Maserejian
NN
,
Link
CL
,
Lutfey
KL
,
Marceau
LD
,
McKinlay
JB
.
Disparities in physicians’ interpretations of heart disease symptoms by patient gender: results of a video vignette factorial experiment
.
J Women Health
.
2009
;
18
(
10
):
1661
1667
.
77
Cook
NL
,
Ayanian
JZ
,
Orav
EJ
,
Hicks
LRS
.
Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care
.
Circulation
.
2009
;
12
;
119
(
18
):
2463
2470
.
78
Worrall-Carter
L
,
McEvedy
S
,
Wilson
A
,
Rahman
MA
.
Gender differences in presentation, coronary intervention, and outcomes of 28,985 acute coronary syndrome patients in Victoria, Australia
.
Womens Health Iss
.
2016
;
26
(
1
):
14
20
.
79
Pais
P
,
Xavier
D
,
Gupta
R
, et al
.
Characteristics, treatments and outcomes in young as compared with elderly acute coronary syndrome patients in India (CREATE registry)
.
Poster presentation P178 from World Congress of Cardiology Scientific Sessions
,
Dubai, United Arab Emirates
;
April 18–21, 2012
. . Accessed February 6, 2017.
80
Worrall-Carter
L
,
McEvedy
S
,
Wilson
A
,
Rahman
MA
.
Impact of comorbidities and gender on the use of coronary interventions in patients with high-risk non-ST-segment elevation acute coronary syndrome
.
Catheter Cardiovasc Interv
.
2016
;
87
(
4
):
E128
136
.
81
Ayanian
JZ
,
Epstein
AM
.
Differences in the use of procedures between women and men hospitalized for coronary heart disease
.
N Engl J Med
.
1991
;
325
:
221
225
.
82
Roe
MT
,
Harrington
RA
,
Prosper
DM
, et al
.
Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease: the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators
.
Circulation
.
2000
;
102
:
1101
1106
.
83
Patel
MR
,
Chen
AY
,
Peterson
ED
, et al
.
Prevalence, predictors, and outcomes of patients with non-ST-segment elevation myocardial infarction and insignificant coronary artery disease: results from the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) initiative
.
Am Heart J
.
2006
;
152
:
641
647
.
84
Maddox
TM
,
Ho
PM
,
Roe
M
,
Dai
D
,
Tsai
TT
,
Rumsfeld
JS
.
Utilization of secondary prevention therapies in patients with nonobstructive coronary artery disease identified during cardiac catheterization: insights from the National Cardiovascular Data Registry Cath-PCI Registry
.
Circ Cardiovasc Qual Outcomes
.
2010
;
3
:
632
641
.
85
Gauri
AJ
,
Davis
A
,
Hong
T
, et al
.
Disparities in the use of primary prevention and defibrillator therapy among blacks and women
.
Am J Med
.
2006
;
119
:
167
,
e17
e21
.
86
Curtis
LH
,
Al Khatib
SM
,
Shea
AM
, et al
.
Sex differences in the use implantable defibrillators for primary and secondary prevention of sudden cardiac death
.
JAMA
.
2007
;
298
:
1517
1524
.
87
Hernandez
AF
,
Fonarow
GC
,
Liang
L
, et al
.
Sex and racial differences in the use of implantable cardioverter-defibrillators among patients hospitalized with heart failure
.
JAMA
.
2007
;
298
:
1525
1532
.
88
Crilly
MA
,
Bundred
PE
,
Leckey
LC
,
Johnstone
FC
.
Gender bias in the clinical management of women with angina: another look at the Yentl syndrome
.
J Womens Health (Larchmt)
.
2008
;
17
(
3
):
331
342
.
89
MacFadden
DR
,
Tu
JV
,
Chong
A
, et al
.
Evaluating sex differences in population-based utilization of implantable cardioverter-defibrillators: role of conditions and non-cardiac co-morbidities
.
Heart Rhythm
.
2009
;
6
:
1289Y1296
.
90
European Institute of Women’s Health
.
Gender bias continues in heart health
.
2012
; Accessed 10/05/2012. . Accessed October 5, 2012.
91
El-Menyar
AA
,
Suwaidi
JA
.
Impact of gender in patients with acute coronary syndrome
.
Expert Rev Cardiovasc Ther
.
2009
;
7
(
4
):
411
421
.
92
Drozda
J
Jr
,
Messer
JV
,
Spertus
J
, et al
.
ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement
.
Circulation
.
2011
;
124
:
248
270
.
93
Thomas
RJ
,
King
M
,
Lui
K
,
Oldridge
N
,
Pina
IL
,
Spertus
J
.
AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures
.
Circulation
.
2010
;
122
:
1342
1350
.
94
Mosca
L
,
Benjamin
EJ
,
Berra
K
, et al
.
Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association
.
Circulation
.
2011
;
123
:
1243
1262
.
95
Smith
SC
Jr
,
Benjamin
EJ
,
Bonow
RO
, et al
.
AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation
.
Circulation
.
2011
;
124
:
2458
2473
.
96
Balady
GJ
,
Williams
MA
,
Ades
PA
, et al
.
Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation
.
Circulation
.
2007
;
115
:
2675
2682
.
97
Balady
GJ
,
Ades
PA
,
Bittner
VA
, et al
.
Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association
.
Circulation
.
2011
;
124
:
2951
2960
.
98
Fihn
SD
,
Gardin
JM
,
Abrams
J
, et al
.
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
.
Circulation
.
2012
;
126
:
e354
e471
.
99
Grace
SL
,
Gravely-Witte
S
,
Kayaniyil
S
, et al
.
A multisite examination of sex differences in cardiac rehabilitation barriers by participation status
.
J Womens Health (Larchmt)
.
2009
;
18
:
209
216
.
100
McCarthy
MM
,
Vaughan Dickson
V
,
Chyun
D
.
Barriers to cardiac rehabilitation in women with cardiovascular disease: an integrative review
.
J Cardiovasc Nurs
.
2011
;
26
:
E1
E10
.
101
Bangalore
S
,
Fonarow
GC
,
Peterson
ED
, et al
.
Age and gender differences in quality of care and outcomes for patients with ST-segment elevation myocardial infarction
.
Am J Med
.
2012
;
125
:
1000
1009
.
102
Aguilar
SA
,
Patel
M
,
Castillo
E
, et al
.
Gender differences in scene time, transport time, and total scene to hospital arrival time determined by the use of a prehospital electrocardiogram in patients with complaint of chest pain
.
J Emerg Med
.
2012
;
43
(
2
):
291
297
.
103
Dreyer
RP
,
Beltrame
JF
,
Tavella
R
, et al
.
Evaluation of gender differences in Door-to-Balloon time in ST-elevation myocardial infarction
.
Heart Lung Circ
.
2013
;
22
:
861
869
.
104
Singh
JA
,
Lu
X
,
Ibrahim
S
,
Cram
P
.
Trends in and disparities for acute myocardial infarction: an analysis of Medicare claims data from 1992 to 2010
.
BMC Med
.
2014
;
12
:
190
.
105
Kaul
P
,
Federspiel
JJ
,
Dai
X
, et al
.
Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes
.
JAMA
.
2014
;
312
:
1999
2007
106
Lauffenburger
JC
,
Robinson
JG
,
Oramasionwu
C
,
Fang
G
.
Racial/Ethnic and gender gaps in the use of and adherence to evidence-based preventive therapies among elderly Medicare Part D beneficiaries after acute myocardial infarction
.
Circulation
.
2014
;
129
:
754
763
.
107
Gnavi
R
,
Rusciani
R
,
Dalmasso
M
, et al
.
Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI
.
Differences or inequities? Int J Cardiol
.
2014
;
176
:
724
730
.
108
Yu
J
,
Mehran
R
,
Grinfeld
L
, et al
.
Sex-based differences in bleeding and long term adverse events after percutaneous coronary intervention for acute myocardial infarction: three year results from the HORIZONS-AMI trial
.
Catheter Cardiovasc Interv
.
2015
;
85
:
359
368
.
109
Mehta
LS
,
Beckie
TM
,
DeVon
HA
, et al
,
for the American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research
.
Acute myocardial infarction in women: a scientific statement from the American Heart Association
.
Circulation
.
2016
;
133
:
916
947
.
110
Koopman
C
,
Vaartjes
I
,
Heintjes
EM
, et al
.
Persisting gender differences and attenuating age differences in cardiovascular drug use for prevention and treatment of coronary heart disease, 1998–2010
.
Eur Heart J
.
2013
;
34
:
3198
3205
.
111
Kim
LK
,
Looser
P
,
Swaminathan
RV
, et al
.
Sex-based disparities in incidence, treatment, and outcomes of cardiac arrest in the United States, 2003–2012
.
J Am Heart Assoc
.
2016
;
5
:
e003704
.
112
Govindarajan
P
,
Friedman
BT
,
Delgadillo
JQ
, et al
.
Race and sex disparities in prehospital recognition of acute stroke
.
Acad Emerg Med
.
2015
;
22
(
3
):
264
272
.
113
Menon
SC
,
Pandey
DK
,
Morgenstern
LB
.
Critical factors determining access to acute stroke care
.
Neurology
.
1998
;
51
(
2
):
427
432
.
114
Cheung
RT
.
Hong Kong patients’ knowledge of stroke does not influence time-to-hospital presentation
.
J Clin Neurosci
.
2001
;
8
(
4
):
311
314
.
115
Barr
J
,
McKinley
S
,
O’Brien
E
,
Herkes
G
.
Patient recognition of and response to symptoms of TIA or stroke
.
Neuroepidemiology
.
2006
;
26
(
3
):
168
175
.
116
Mandelzweig
L
,
Goldbourt
U
,
Boyko
V
,
Tanne
D
.
Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke
.
Stroke
.
2006
;
37
(
5
):
1248
1253
.
117
Foerch
C
,
Misselwitz
B
,
Humpich
M
, et al
.
Sex disparity in the access of elderly patients to acute stroke care
.
Stroke
.
2007
;
38
(
7
):
2123
2126
.
118
McInnes
C
,
McAlpine
C
,
Walter
M
.
Effect of gender on stroke management in Glasgow
.
Age Ageing
.
2008
;
37
(
2
):
220
222
.
119
Gargano
JW
,
Wehner
S
,
Reeves
MJ
.
Do presenting symptoms explain sex differences in emergency department delays among patients with acute stroke?
Stroke
.
2009
;
40
:
1114
1120
.
120
Engelstein
E
,
Margulies
J
,
Jeret
JS
.
Lack of t-PA use for acute ischemic stroke in a community hospital: high incidence of exclusion criteria
.
Am J Emerg Med
.
2000
;
18
:
257
260
.
121
Yu
RF
,
San Jose
MC
,
Manzanilla
BM
,
Oris
MY
,
Gan
R
.
Sources and reasons for delays in the care of acute stroke patients
.
J Neurol Sci
.
2002
;
199
:
49
54
.
122
Frankel
M
,
Hinchey
J
,
Schwamm
L
, et al
.
Prehospital and hospital delays after stroke onset—United States, 2005–2006
.
MMWR Morb Mortal Wkly Rep
.
2007
;
56
:
474
478
.
123
Jungehulsing
GJ
,
Rossnagel
K
,
Nolte
CH
, et al
.
Emergency department delays in acute stroke: analysis of time between ED arrival and imaging
.
Eur J Neurol
.
2006
;
13
:
225
232
.
124
Reed
SD
,
Cramer
SC
,
Blough
DK
,
Meyer
K
,
Jarvik
JG
.
Treatment with tissue plasminogen activator and inpatient mortality rates for patients with ischemic stroke treated in community hospitals
.
Stroke
.
2001
;
32
:
1832
1839
.
125
Brown
DL
,
Lisabeth
LD
,
Garcia
NM
,
Smith
MA
,
Morgenstern
LB
.
Emergency department evaluation of ischemic stroke and TIA: the BASIC Project
.
Neurology
.
2004
;
63
:
2250
2254
.
126
Schumacher
HC
,
Bateman
BT
,
Boden-Albala
B
, et al
.
Use of thrombolysis in acute ischemic stroke: analysis of the Nationwide Inpatient Sample 1999 to 2004
.
Ann Emerg Med
.
2007
;
50
:
99
107
.
127
Deng
YZ
,
Reeves
MJ
,
Jacobs
BS
, et al
.
Paul Coverdell National Acute Stroke Registry Michigan Prototype Investigators. IV tissue plasminogen activator use in acute stroke: experience from a statewide registry
.
Neurology
.
2006
;
14
;
66
(
3
):
306
312
.
128
Gargano
JW
,
Reeves
MJ
.
Sex differences in stroke recovery and stroke-specific quality of life: results from a statewide stroke registry
.
Stroke
.
2007
;
38
:
2541
2548
.
129
Reid
JM
,
Dai
D
,
Gubitz
GJ
,
Kapral
MK
,
Christian
C
,
Phillips
SJ
.
Gender differences in stroke examined in a 10-year cohort of patients admitted to a Canadian teaching hospital
.
Stroke
.
2008
;
39
:
1090
1095
.
130
Reeves
MJ
,
Fonarow
GC
,
Zhao
X
, et al
.
Quality of care in women with ischemic stroke in the GWTG program
.
Stroke
.
2009
;
40
:
1127
1133
.
131
Chang
DC
,
Bass
RR
,
Cornwell
EE
,
Mackenzie
EJ
.
Undertriage of elderly trauma patients to state-designated trauma centers
.
Arch Surg
.
2008
;
143
(
8
):
776
781
.
132
Hsia
RY
,
Wang
E
,
Saynina
O
,
Wise
P
,
Perez-Stable
EJ
,
Auerbach
A
.
Factors associated with trauma center use for elderly patients with trauma: a statewide analysis, 1999–2008
.
Arch Surg
.
2011
;
146
(
5
):
585
592
.
133
Rubenson Wahlin
R
,
Ponzer
S
,
Lövbrand
H
,
Skrivfars
M
,
Lossius
HM
,
Castrén
M
.
Do male and female trauma patients receive the same prehospital care? An observational follow-up study
.
BMC Emerg Med
.
2016
;
16
:
6
.
134
Michael
GE
,
Sporer
KA
,
Youngblood
GM
.
Women are less likely than men to receive prehospital analgesia for isolated extremity injuries
.
Am J Emerg Med
.
2007
;
25
(
8
):
901
906
.
135
Lord
B
,
Cui
J
,
Kelly
AM
.
The impact of patient sex on paramedic pain management in the prehospital setting
.
Am J Emerg Med
.
2009
;
27
(
5
):
525
529
.
136
Lord
B
,
Bendall
J
,
Reinten
T
.
The influence of paramedic and patient gender on the administration of analgesics in the out-of-hospital setting
.
Prehosp Emerg Care
.
2014
;
18
(
2
):
195
200
.
137
Harvard University
.
Project Implicit
. . Accessed February 6, 2017.
138
Zestcott
CA
,
Blair
IV
,
Stone
J
.
Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review
.
Group Process Intergroup Relat
.
2016
;
19
(
4
):
528
542
.
139
Streiff
MB
,
Carolan
H
,
Hobson
DB
, et al
.
Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention Collaborative
.
BMJ
.
2012
;
344
:
e3935
140
Nordell
J
.
A fix for gender bias in health care? Check
.
The New York Times
. . Accessed February 3, 2017.
141
Pronovost
P
,
Needham
D
,
Berenholtz
S
, et al
.
An intervention to decrease catheter-related bloodstream infections in the ICU
.
N Engl J Med
.
2006
;
355
:
2725
2732
.
142
Haynes
AB
,
Weiser
TG
,
Berry
WR
, et al
;
Safe Surgery Saves Lives Study Group
.
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention
.
BMJ Qual Saf
.
2011
;
20
:
102
107
.
143
Haut
ER
,
Lau
BD
,
Kraenzlin
FS
, et al
.
Improved prophylaxis and decreased preventable harm with a mandatory computerized clinical decision support tool for venous thromboembolism (VTE) prophylaxis in trauma patients
.
Arch Surg
.
2012
;
147
(
10
):
901
907
.
144
Zeidan
AM
,
Streiff
MB
,
Lau
BD
, et al
.
Impact of a venous thromboembolism prophylaxis “smart order set”: Improved compliance, fewer events
.
Am J Hematol
.
2013
;
88
:
545
549
.
145
Lau
BD
,
Haider
AH
,
Streiff
MB
, et al
.
Eliminating Healthcare Disparities Via Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example
.
Med Care
.
2015
;
53
(
1
):
18
24
.
146
Johns Hopkins Medicine
.
News release: Safety Checklist Use Yields 10 Percent Drop in Hospital Deaths
.
January
31
,
2011
. . Accessed February 3, 2017.
147
Napolitano
LM
.
Guideline compliance in trauma: evidence-based protocols to improve trauma outcomes?
Crit Care Med
.
2012
;
40
:
990
992
.
148
Rice
TW
,
Morris
S
,
Tortella
BJ
,
Wheeler
AP
,
Christensen
MC
.
Deviations from evidence-based clinical management guidelines increase mortality in critically injured trauma patients
.
Crit Care Med
.
2012
;
40
:
778
786
.
149
Graham
G
,
Xiao
Y-YK
,
Rappoport
D
,
Siddiqi
S
.
Population-level differences in revascularization treatment and outcomes among various United States subpopulations
.
World J Cardiol
.
2016
;
8
(
1
):
24
40
.
150
Pronovost
PJ
,
Berenholtz
SM
,
Needham
DM
.
Translating evidence into practice: a model for large scale knowledge translation
.
BMJ
.
2008
;
337
:
963
965
.