title: Sex bias in cardiovascular testing: the contribution of patient preference.
abstract: OBJECTIVE
  Women with potential acute coronary syndromes are less likely to receive cardiac catheterization or revascularization than men. We hypothesize that this may be due to different diagnostic test preferences of female and male patients.
  
  
  METHODS
  We conducted a cohort study at 4 emergency departments enrolling patients who presented with symptoms of potential acute coronary syndromes. After hearing the potential benefits and harms of each test, subjects completed a 21-item survey assessing their preference for noninvasive testing versus cardiac catheterization. Based on hypothetical test results, similar questions about medical versus interventional management were asked. Subjects were also queried about likelihood of following physician recommendation for each test or intervention. Actual 30-day testing and interventions were recorded. The main outcome was patient preference about each procedure and the likelihood of patient saying they would accept the physician recommendation.
  
  
  RESULTS
  One thousand eighty patients enrolled; 652 (60%) were admitted to the hospital. With regard to diagnostic test preference, both women and men preferred stress test to catheterization (women 58% versus men 52%; difference 6% [95% confidence interval {CI} -0.06% to 12%]), and the proportion of women and men who would accept the physician recommendation for stress tests was similar (85% for both); however, the stated acceptance rate for cardiac catheterization was lower for women (65% versus 75%; difference -10% [95% CI -15% to -4%]). Women were 6% less likely (67% versus 73%; 95% CI for difference 12% to 0.5%) to accept percutaneous coronary intervention over medical therapy and 7% less likely (61% versus 68%; 95% CI for difference -13% to 1%) to desire coronary artery bypass grafting over medical therapy. The survey results are consistent with the patients' clinical course. During the initial hospitalization, women were less likely to receive diagnostic testing of any type (38% versus 45%; difference -7%; 95% CI for the difference -13% to -1.5%) and cardiac catheterization (10% versus 17%; difference -7% [95% CI -11% to -2%]). Revascularization was infrequent in both groups (4% versus 6%; difference -2% [95% CI -5% to 0.6%]).
  
  
  CONCLUSIONS
  Although women and men had similar preferences about cardiac diagnostic tests and treatment options, women were less likely than men to say they would accept the physician recommendation for any intervention. Patient preference may partially explain the disparity in cardiovascular testing between women and men.
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
authors.forename: Bryn E
authors.initials: BE
authors.lastname: Mumma
authors.forename: Brigitte M
authors.initials: BM
authors.lastname: Baumann
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Diercks
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Takakuwa
authors.forename: Caren F
authors.initials: CF
authors.lastname: Campbell
authors.forename: Frances S
authors.initials: FS
authors.lastname: Shofer
authors.forename: Anna Marie
authors.initials: AM
authors.lastname: Chang
authors.forename: Molly K
authors.initials: MK
authors.lastname: Jones
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000188:drug therapy / Q000503:physiopathology / Q000628:therapy; D017225:Atherectomy, Coronary; D006328:Cardiac Catheterization / Q000523:psychology / Q000706:statistics & numerical data*; D001026:Coronary Artery Bypass / Q000523:psychology / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005080:Exercise Test / Q000523:psychology / Q000706:statistics & numerical data*; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology / Q000706:statistics & numerical data; D057240:Patient Preference / Q000706:statistics & numerical data; D012737:Sex Factors; D014481:United States