title: Gender disparities in cardiovascular care access and delivery in India: Insights from the American College of Cardiology's PINNACLE India Quality Improvement Program (PIQIP).
abstract: BACKGROUND
  Limited data are available to assess whether access to and quality of cardiovascular disease (CVD) care are comparable among men and women in India. We analyzed data from the American College of Cardiology's PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP) to evaluate gender disparities in CVD care delivery.
  
  
  RESULTS
  Between 2011 and 2015, we collected data on performance measures for patients with coronary artery disease (CAD) (n=14,010), heart failure (HF) (n=11,965) and atrial fibrillation (AF) (n=496) in PIQIP, among 17 participating practices. The total number of women was 31,796 (32.0%). Women had fewer total encounters compared to men during the study interval (mean number of encounters=2.59 vs. 2.82 for women and men, respectively, p≤0.001). Women were significantly younger (48.9years vs. 51.5years, p≤0.01), but had a higher co-morbidity burden compared to men - hypertension (62.0% vs. 45.6%, p≤0.01), diabetes (39.4% vs. 35%, p≤0.01), and hyperlipidemia (3.7% vs. 3.1%, p=0.19). On the contrary, the guideline-directed medication prescriptions were strikingly lower in women with CAD compared to men - aspirin (38% vs. 50.4%, p≤0.001), aspirin or thienopyridine combination (46.9% vs. 57.2%, p≤0.001), and beta-blockers (36.8% vs. 47.8%, p≤0.001). Similarly, among women with ejection fraction ≤40%, the use of guideline-directed medical therapy was significantly lower compared to men for beta-blockers (30.8% vs. 37.0%, p≤0.001), angiotensin-converting enzyme inhibitors (ACE-i) or angiotensin receptor blockers (ARBs) (29.3% vs. 34.9%, p≤0.001), and beta-blockers/ACE-i or ARBs (24.6% vs. 31.0%, p≤0.001). Among patients with atrial fibrillation and CHADS2 score≥2, more women were on oral anticoagulation (19.6% vs. 14.6%, p=0.34), although this was not significantly different, and the overall number of patients with atrial fibrillation was low.
  
  
  CONCLUSIONS
  Despite a significantly higher co-morbidity burden in women, we found fewer women receiving guideline-directed medical therapy for CVD compared with men. If such disparities are confirmed in the larger Indian population, it is important to find potential causes for, and seek solutions to narrow this gap.
authors.affiliation: Division of Cardiology, Department of Medicine, Kalra Hospital SRCNC (Sri Ram Cardio-thoracic and Neurosciences Centre) Pvt. Ltd., New Delhi, India; Division of Interventional Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Safety, Quality, Informatics and Leadership Program, 2016-17, Harvard Medical School, Boston, MA, United States.
authors.forename: Ankur
authors.initials: A
authors.lastname: Kalra
authors.affiliation: Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City, Department of Cardiovascular Research, Kansas City, MO, United States.
authors.forename: Yashashwi
authors.initials: Y
authors.lastname: Pokharel
authors.affiliation: American College of Cardiology Foundation, Washington, DC, United States.
authors.forename: Nathan
authors.initials: N
authors.lastname: Glusenkamp
authors.affiliation: American College of Cardiology Foundation, Washington, DC, United States.
authors.forename: Jessica
authors.initials: J
authors.lastname: Wei
authors.affiliation: King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai, India.
authors.forename: Prafulla G
authors.initials: PG
authors.lastname: Kerkar
authors.affiliation: American College of Cardiology Foundation, Washington, DC, United States.
authors.forename: William J
authors.initials: WJ
authors.lastname: Oetgen
authors.affiliation: Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, and Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States. Electronic address: virani@bcm.edu.
authors.forename: Salim S
authors.initials: SS
authors.lastname: Virani
mesh_terms: D000367:Age Factors; D001281:Atrial Fibrillation / Q000188:drug therapy*; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000188:drug therapy*; D011307:Drug Prescriptions / Q000145:classification / Q000706:statistics & numerical data*; D019317:Evidence-Based Medicine; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D007194:India; D008297:Male; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D063507:Sexism
keywords: American College of Cardiology; Cardiovascular care; Gender disparity; India; Quality improvement