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Randomized Controlled Trial
. 2017 Nov 29;6(12):e006872.
doi: 10.1161/JAHA.117.006872.

Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists

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Free PMC article
Randomized Controlled Trial

Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists

Stacie L Daugherty et al. J Am Heart Assoc. .
Free PMC article

Abstract

Background: Physicians' gender bias may contribute to gender disparities in cardiovascular testing. We used the Implicit Association Test to examine the association of implicit gender biases with decisions to use cardiovascular tests.

Methods and results: In 2014, cardiologists completed Implicit Association Tests and a clinical vignette with patient gender randomly assigned. The Implicit Association Tests measured implicit gender bias for the characteristics of strength and risk taking. The vignette represented an intermediate likelihood of coronary artery disease regardless of patient gender: chest pain (part 1) followed by an abnormal exercise treadmill test (part 2). Cardiologists rated the likelihood of coronary artery disease and the usefulness of stress testing and angiography for the assigned patient. Of the 503 respondents (9.3% of eligible; 87% male, median age of 45 years, 58% in private practice), the majority associated strength or risk taking implicitly with male more than female patients. The estimated likelihood of coronary artery disease for both parts of the vignette was similar by patient gender. The utility of secondary stress testing after an abnormal exercise treadmill test was rated as "high" more often for female than male patients (32.8% versus 24.3%, P=0.04); this difference did not vary with implicit bias. Angiography was more consistently rated as having "high" utility for male versus female patients (part 1: 19.7% versus 9.8%; part 2: 73.7% versus 64.3%; P<0.05 for both); this difference was larger for cardiologists with higher implicit gender bias on risk taking (P=0.01).

Conclusions: Cardiologists have varying degrees of implicit gender bias. This bias explained some, but not all, of the gender variability in simulated clinical decision-making for suspected coronary artery disease.

Keywords: angiography; gender disparities; implicit bias; stress testing.

Figures

Figure 1
Figure 1
Flowchart of the study population. IAT indicates Implicit Association Test.
Figure 2
Figure 2
Cardiology physicians' gender bias regarding risk taking and strength. IAT indicates Implicit Association Test.
Figure 3
Figure 3
The strength of angiography rating varied according to case patient gender and physician implicit gender bias. The x‐axis represents physician gender bias based on Implicit Association Test scores, and the y‐axis represents the extent to which angiography was rated as useful for the case vignette by the physician. The relationship between gender bias and angiography rating is indicated when the case patient was male (blue line) and female (red line). In unadjusted analysis, significant interactions were seen between gender bias and case gender; those with higher implicit gender bias on risk taking (A) or strength (B) rated angiography as less useful in women than men (unadjusted P<0.05 for interaction for both). After adjustment for perceived likelihood of coronary artery disease and physician specialty, the interaction between risk‐taking bias and patient gender on angiography usefulness remained significant (adjusted P=0.01 for interaction in panel A); however, the interaction with strength bias was no longer significant (adjusted P=0.12 in panel B).

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References

    1. Tobin JN, Wasserthiel‐Smoller S, Wexler JP, Steingart RM, Budner N, Lense L. Sex bias in considering coronary bypass surgery. Ann Intern Med. 1987;107:19–25. - PubMed
    1. Steingart R, Packer M, Hamm P, Coglianese M, Gersh B, Geltman E, Sollano J, Katz S, Moye L, Basta L, Lewis S, Gottlieb S, Bernstein V, McEwan P, Jacobson K, Brown E, Kukin M, Kantrowitz N, Pfeffer MA. Sex differences in the management of coronary artery disease. Survival and Ventricular Enlargement Investigators. N Engl J Med. 1991;325:226–230. - PubMed
    1. 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. - PubMed
    1. Shaw LJ, Miller DD, Romeis JC, Kargl D, Younis LT, Chaitman BR. Gender differences in the noninvasive evaluation and management of patients with suspected coronary artery disease. Ann Intern Med. 1994;120:559–566. - PubMed
    1. Blomkalns AL, Chen AY, Hochman JS, Peterson ED, Trynosky K, Diercks DB, Brogan JGX, Boden WE, Roe MT. 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. - PubMed

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