Gender Disparities in Invasive CVD Procedure Use: the Role of Provider Bias

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PROJECT SUMMARY/ABSTRACT My long-term career goal is to become a nationally recognized independent investigator and expert in cardiovascular disease (CVD) disparities with an emphasis on interventions designed to eliminate disparities. I have laid a strong foundation for reaching this goal by defining a broad mentoring network, obtaining formal training in health services research, and leading several research projects. To date, my research has primarily focused on describing gender disparities in CVD care. For example, I have shown that women with CVD receive fewer invasive procedures than men with CVD. Despite extensive research documenting these disparities, few have investigated their causes. I am committing my career to addressing this gap by conducting research aimed at understanding the mechanisms behind gender disparities to achieve my ultimate goal of instituting evidence-based interventions to reduce gender disparities in CVD care. The Institute of Medicine has identified provider bias as a key contributor to disparities in health care. However, the role of provider bias in gender-based decisions surrounding the use of invasive CVD procedures is poorly characterized. In order to more accurately and fully measure provider attitudes, advanced qualitative and social psychology techniques must be employed; skills I wish to develop. Therefore, I seek a Career Development Award to allow me time and support to pursue mentored research aimed at measuring provider gender attitudes and training in the areas of qualitative research, social psychology and advanced biostatistical techniques. The proposed research and training are a crucial to move my research forward from defining gender disparities towards research aimed at understanding the causes of these disparities. Although studies have implicated provider bias as the cause of gender disparities in CVD care, to our knowledge, no study has directly measured such attitudes using validated instruments. Tools have been developed in other fields that measure implicit (unconscious) gender attitudes such as the Implicit Association Test (IAT). These tools have been widely used to explain gender differences in social outcomes including job promotions and performance evaluations, but they have not been widely applied to the study of health care disparities. Furthermore, these tools may need to be adapted to capture concepts specific to CVD care, such as a provider's belief about women's willingness to undergo invasive procedures or whether a provider views women as fragile and therefore more likely to have a complication from an invasive procedure. This gap in knowledge is a barrier to developing evidence-based interventions to address gender disparities. The research objectives of this Career Development Award are to adapt existing measures of gender attitudes to apply to decisions concerning the use of invasive CVD procedures and to conduct preliminary tests of these adapted measures. The research will occur in three steps. For aim 1, I will conduct semi-structured interviews with cardiologists, using two case scenarios in which an invasive cardiac procedure might be recommended. These interviews will be used to determine providers' gender attitudes specific to invasive cardiac procedures, and the results will then be used to adapt existing measures of gender attitudes. Next, in aim 2, I will test the adapted measures within a second cohort of cardiologists to determine the relationship between measured attitudes and the providers' decision to use an invasive cardiac procedure with women and men in the standard case scenarios. Finally, in aim 3, I will conduct a study to test my ability to link the adapted measures results and the subject cardiologists' actual clinical decisions obtained from retrospective clinical data. As a health services researcher, woman and practicing cardiologist, I am uniquely positioned to make important contributions to the field of gender disparities and CVD. I will bridge the fields of social psychology and health services research in order to gain a better understanding of potential contributors to gender disparities and plan for multimodal interventions aimed at reducing or eliminating disparities in CVD care. My extensive methodological training, research experience and proposed training activities make me ideally positioned to perform the proposed studies. Furthermore, the unique resources available at the University of Colorado Denver and its affiliated campuses will ensure my success towards these goals. Specifically, my mentorship team includes experts in health services and disparities research (Drs. Masoudi, Havranek, and Blair), measurement of explicit and implicit bias using social psychology experimental procedures (Dr. Blair), adaption of survey tools based on qualitative techniques (Dr. Main) and advanced hierarchical modeling (Dr. Dickinson). This qualified group of mentors and the training activities I propose will ensure my successful transition towards independence.