ABSENCE OF SEX BIAS IN THE REFERRAL OF PATIENTS FOR CARDIAC-CATHETERIZATION
ABSENCE OF SEX BIAS IN THE REFERRAL OF PATIENTS FOR CARDIAC-CATHETERIZATION
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DOI：
10.1056/nejm199404213301601
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发表时间：
1994-04-21
影响因子：
158.5
通讯作者：
PRYOR, DB
中科院分区：
文献类型：
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作者：
MARK, DB;SHAW, LK;PRYOR, DB
背景有证据表明，有冠状动脉疾病临床证据的女性比男性更少被转诊进行心导管插入术。为了确定是否有性别相关的偏倚在转介心脏导管术，我们前瞻性研究了一个队列的410例有症状的门诊患者（280名男性和130名女性），他们正在接受运动试验评估可能的冠状动脉疾病。在患者接受运动试验之前，来自一个学术医疗中心的15名心脏病专家被要求预测他们在心脏病诊所看到的患者有任何阻塞性冠状动脉疾病的血管造影证据的概率（狭窄75%或以上）;严重冠状动脉疾病的可能性（三支血管或左主干冠状动脉疾病）;左主干冠状动脉疾病的概率;以及评估后1年、3年和5年的生存概率。通过先前验证的统计模型，使用运动试验前从病史、体格检查和患者静息时12导联心电图中收集的数据，产生类似的预测。总体而言，女性接受心导管插入术的频率明显低于男性（18% vs. 27%，P = 0.03）。与男性相比，女性有一个显着较低的冠心病（由他们的医生估计）和运动试验结果阳性率较低的预检概率。在考虑了这两个因素的差异后，性别不是转诊导管插入术的独立预测因素。将医生对结果的估计与统计模型产生的结果进行比较，没有证据表明医生低估了女性冠心病的风险。此外，医生的预测并没有低估任何阻塞性冠状动脉疾病的可能性，男性和女性谁随后接受导管。学术心脏病专家对可能患有冠状动脉疾病的女性的疾病类别的预测适当低于男性，这些评估，沿着女性运动试验阳性率较低，而不是基于性别的偏见，解释了女性导管插入率较低。
Background. It has been suggested that women with clinical evidence of coronary artery disease are less often referred for cardiac catheterization than are men. To determine whether there is sex-related bias in referral for cardiac catheterization, we prospectively studied a cohort of 410 symptomatic outpatients (280 men and 130 women) who were being evaluated with exercise testing for possible coronary artery disease.Methods. Before the patients underwent exercise testing, 15 cardiologists from an academic medical center were asked to predict the probability that the patients they saw in the cardiology clinic would have angiographic evidence of any obstructive coronary disease (stenosis of 75 percent or more); the probability of severe coronary disease (three-vessel or left main coronary artery disease); the probability of left main coronary artery disease; and the probability of survival one, three, and five years after the evaluation. Similar predictions were generated by previously validated statistical models with use of data collected before exercise testing from the history, physical examination, and 12-lead electrocardiography with the patient at rest.Results. Overall, women were referred for cardiac catheterization significantly less often than men (18 percent vs. 27 percent, P = 0.03). As compared with men, women had a significantly lower pretest probability of coronary disease (as estimated by their physicians) and a lower rate of positive exercise-test results. After accounting for differences in these two factors, sex was not an independent predictor of referral for catheterization. Comparing physicians' estimates of outcome with those generated by the statistical models revealed no evidence that the physicians were underestimating the risk of coronary disease in women. Furthermore, physicians' predictions did not underestimate the probability of any obstructive coronary disease in men and women who subsequently underwent catheterization.Conclusions. Academic cardiologists made appropriately lower pretest predictions of categories of disease in women with possible coronary artery disease than in men, and these assessments, along with women's lower rate of positive exercise tests, rather than bias based on sex, accounted for the lower rate of catheterization among women.