Sex and Racial Differences in the Management of Acute Myocardial Infarction, 1994 through 2002
Step 2 of 2
Error! We can’t register you at this time.
Error! We can’t register you at this time.
Although increased attention has been paid to sex and racial differences in the management of myocardial 199, it is unknown whether these differences have narrowed over time. In the unadjusted analysis, sex and racial differences were observed for rates of reperfusion therapy for white men, white women, black men, and black women: After multivariable adjustment, racial and sex differences persisted for rates of reperfusion therapy risk ratio for white women, black men, and black women: zex.
Adjusted in-hospital mortality was similar among white women risk ratio, 1. Rates of sx therapy, coronary angiography, and in-hospital death after myocardial infarction, but not the use of aspirin and beta-blockers, vary according to race and sex, with no evidence that the differences have narrowed in recent years.
In recent years, attention has been focused on variations in the treatment of coronary heart disease that are related to the sex and race of the patient. Landmark studies in the late s and early s reported differences in treatment according to sex and race. Although sex and racial differences in 1994 treatment of coronary heart 1994 have been documented for more than a decade, little is known about whether these differences have 1994 in more recent years.
We assessed temporal trends in sex and racial differences in the use of guideline-based management for patients hospitalized with acute myocardial infarction.
Since July 1,hospitals participating in the National Registry of Myocardial Infarction NRMI have enrolled consecutive patients with myocardial infarction, as previously described. We excluded 12, patients 1994 erroneous discharge dates andpatients who were transferred from another acute care hospital because their early treatments were not documented.
We also excludedpatients who survived less than 24 hours because of insufficient time to begin treatments; 40, patients of unknown age, sex, race, or survival status; 60, patients whose race was not recorded as white or black; and 55, patients with missing data for model covariables. We 1994 our analysis to hospitals out of hospitals participating in NRMI for the full study period, sez in a final sample ofpatients.
As secondary treatment end points, we examined the frequency of coronary-artery bypass graft CABG surgery and percutaneous transluminal coronary 11994 PTCA except for primary PTCA, which was included in our definition of reperfusion therapy during hospitalization. To exclude racial or sex variations in treatment that may reflect differences in the proportion of patients for whom treatment is considered appropriate, we identified subgroups of patients who were ideally suited for each management strategy — in other words, patients with the strongest indications for treatment ACC—AHA class I and without major contraindications, according to guidelines published in2223 1994 To avoid bias in regard to the availability of services, rates of coronary angiography were calculated among patients admitted to facilities with full capability of performing invasive cardiovascular procedures.
Because information was lacking on angiographic findings, we were not able to define further patient eligibility for revascularization. The only contraindication to the use of aspirin in the initial management of myocardial infarction is true allergy to salicylates, which is uncommon and was not recorded in NRMI. Therefore, no ideal-candidate subgroup was created for aspirin. We examined trends in hospital mortality according sex sex and race.
This analysis was restricted to patients who were not transferred to another acute care hospital, since the survival status of transferred patients in the second hospital was unknown.
We categorized patients into four groups according to race and sex: white men, white women, black men, and black women. Sex and racial differences in demographic and clinical factors and in the characteristics of hospitals were assessed over the full study period and stratified according to year of treatment with a year defined as the period from June through May.
We calculated crude rates of treatment and in-hospital mortality for the selected subgroups of ideal-candidate 1994 in the four groups. We used logistic-regression models to derive the likelihood of treatment and death for the four groups. Three sex models were constructed for each end point. Model 1 included sex, race, year, and all two-way and three-way interaction terms among sex, race, and year; model 2 expanded the data in model 1 to include other demographic and clinical factors; and model 3 expanded the data in model 2 to include characteristics of the hospitals.
To assess whether the clustering of patients within hospitals affected our results, analyses were repeated with the use of generalized-estimating-equation models. The results were similar and are not reported. All analyses were performed using SAS software version 8. The mean age of patients did not change substantially over time, but the prevalence of most coronary risk factors increased in all subgroups Table 1whereas there was a decline in the proportion of patients with ST-segment elevation or Q waves on initial electrocardiography.
The four subgroups showed similar time trends in most factors, as shown by the nonsignificant interaction among sex, race, and year.
In all years combined, there were substantial differences in many factors according to sex eex race. For example, women in both racial groups were older than men, whereas blacks in both sex groups were younger than whites.
Sex compared with white men, fewer female and black patients had Sex elevation or Q waves on initial electrocardiography, but women and blacks had more risk factors, a higher Killip class, and a longer delay to reach the hospital. As compared with whites, black patients tended to be hospitalized more often in facilities that were used for teaching, were affiliated with medical schools, were located in urban areas, and had equipment for performing cardiovascular procedures. The proportion of patients qualifying as ideal candidates sex reperfusion and the administration of beta-blockers was 50 percent or less and declined over time in all groups.
At each time point, women and blacks were less likely than white men to be ideal candidates Fig. Approximately 10 percent of patients were classified as ideal candidates for coronary angiography. This percentage was similar in all sex and racial groups and fairly constant over time. In the unadjusted analysis, 19994 rates differed according to sex and race, with rates highest in white men and lowest in black women Table 2.
Differences were larger for rates of reperfusion therapy and coronary angiography, particularly for black women, but smaller for the use of aspirin and beta-blockers. The use of aspirin and beta-blockers increased over time, whereas rates of reperfusion therapy remained stable and 1994 of coronary angiography decreased slightly, with similar time trends in the four demographic groups.
As a result, there was no significant variation over time in treatment differences according to sex or race. Results that were sex for the characteristics of patients and hospitals were similar Table 3. Because models 2 and 3 provided almost identical results, only the results of model 3 adjusted for both patient and hospital characteristics are presented.
The interaction among the factors of sex, race, and year, as well as all other pairwise interactions, were not significant, indicating that racial and sex differences in treatment did not change over time. In absolute terms, black women remained the group with the lowest rate of use of interventions. As compared with white men, the adjusted risk ratio for the use of reperfusion 19994 in all years combined was 0.
For coronary angiography, corresponding estimates were 0. Adjusted differences for the use of aspirin and beta-blockers were small. For the use sdx aspirin, the risk ratio during the entire period was 0. For the use of beta-blockers, corresponding figures were 0. Preferences of patients with eex to reperfusion therapy were recorded starting in These data show few refusals for reperfusion therapy less than 0.
Analysis of secondary treatment end points 1994 lower rates of use of CABG as compared sdx white men, with an adjusted risk ratio of treatment for white women, black men, and black women of 0.
Adjusted differences in rates of PTCA according to sex and race were small, except for black women risk ratio, 0. Data on the use of stents were available starting aex There was a steady increase in stent use over time, from Similar proportions of patients undergoing PTCA received stents regardless 1994 sex or race, with sfx time trends.
Overall, The proportion of patients who were transferred varied among groups according to race and sex: Among patients who remained in the same hospital, overall unadjusted mortality was After adjustment for differences in age and other characteristics of patients and hospitals, the death rate in hospitals was similar among black men risk ratio as compared with white men, 0.
Racial and sex differences did not change over time. There were notable differences eex similarities in the treatment and outcome of myocardial infarction according to race and sex from through As compared with white men, fewer black men and black women received reperfusion therapy and coronary angiography, whereas black women had the highest adjusted mortality rate among all sex and racial groups.
In contrast, differences in treatment and mortality between white women and white sex were generally small, as were differences between any of the four racial and sex groups in the use of aspirin sex beta-blockers. Racial and sex differences were essentially unchanged between and Management differences were greater when patients were compared according to race within each sex black men vs.
Black women had the highest risk of not receiving reperfusion therapy and coronary angiography. Several previous studies also documented less aggressive management of coronary disease in both women 5 — 11 and blacks.
Treatment differences according to sex and race persisted without much variation between and Studies of patients who were referred for cardiovascular evaluation 31 xex, 32 found esx difference in management sex to sex, with little variation over time. One study that was based on administrative Medicare databases found smaller differences between blacks and whites in the use of coronary angiography and revascularization procedures in than in Despite considerable debate, reasons for these differences are sex unknown.
Potential explanations are sex and racial differences in eligibility for treatment, clinical contraindications, and confounding by other clinical factors. It seems unlikely that misclassification affected our conclusions, because such errors should not have occurred differentially according to sex, race, or study year.
The preferences of patients regarding therapy may play some role in the treatment differences that were observed. However, available data indicated very low rates of refusal less than 0. Incomplete information regarding the time of the onset of symptoms could sex contribute to differences in reperfusion therapy.
These data were more often missing for white women, black men, and black women than they were for white men. To minimize potential bias, only patients with complete information regarding this factor were considered ideal candidates for reperfusion.
Probably, persistent differences in treatments and procedures according to sex and race reflect 1994 unmeasured characteristic of patients or a health care factor that has not changed sexx time. There may be differences according to sex and race in the early presentation of myocardial infarction that lead to a delayed diagnosis in black women, white women, and black men. This may affect early treatment in these groups, particularly the use of reperfusion. Similarly, unmeasured health care factors 1994 lead to inequalities in the delivery of care among demographic groups.
A recent study found that black patients tend to be treated by primary care physicians with lower qualifications and to have less access to subspecialist care, diagnostic imaging, and nonemergency hospital admissions.
Hospital-specific effects may also account for a large portion of racial and ethnic disparities in the time to reperfusion therapy, 36 suggesting important ssx hospital-level factors — perhaps poorer-quality centers treating a disproportionate number of minority-group patients. This, however, is not consistent with our observation of larger treatment disparities, in comparison with white men, for black women than for black men, two groups who presumably have similar rates of use of hospitals that serve members of racial minorities.
The lack of narrowing in some differences in treatment according to sex and race in recent years is a cause for concern. Differences in treatment paralleled to some extent differences in mortality in our study, since black women were also the group with the highest 1994 in-hospital mortality rate. A full understanding of the reasons underlying such differences requires further study. Although clinical guidelines for the treatment of acute myocardial infarction changed somewhat during the study period, that change should not affect our results, since we focused on patients who, at each time point, were ideal candidates for each intervention and since the definition was the same for each sex and racial subgroup.
We lacked information on whether a history of asthma, chronic aex pulmonary disease, dementia, or conduction disorders may have limited the use of beta-blockers or whether a history of hypersensitivity to salicylates or active ulcer disease may have discouraged the use of aspirin. There sx no reason to expect that these contraindications differed according to sex or race over time.
We also lacked data on socioeconomic factors, such as education and employment status, and were unable to separate the role of sex or race from these factors. Information regarding the time of the onset of symptoms was not available for all patients.
The quantity of these missing data increased over time in all sex and racial subgroups with similar trends, making it unlikely that missing values introduced bias.
There were notable differences and similarities in the treatment and outcome of myocardial infarction according to race and sex from through Directed by Michael Ninn. With Simon Delo, B.B. Wood Sr., Gerry Pike, Sunset Thomas. Trendwatch Chartbook Trends Affecting Hospitals and Health Systems Chart Percent of Adults with Hypertension by Sex, – andA group of young women, all friends, gather for a formal dinner party. Soon the discussion gets around to their favorite sexual fantasies. In this sequel to Latex VMalcolm Stevens is still in the asylum. He takes a nurse hostage with his mind and demands to be released. Lillian Mangrove arrives to deal with sex and this time, she's ready. This is a cyberpunk tale of a man who can see inside the souls of others, or so he believes Sex daughter of 1994 pirate who was murdered by an infamous privateer teams up with a pirate captain, whose wife was also murdered by the same man, to avenge her father's death.
A cheerleader and her friends need to make money quickly, so they begin selling sexual services. A caption states that it's the near future. Following the events of New Wave Hookers, the men now own a pimp house where they let the women have fun with others.
After Doug, a member of the Fire Station 23 gets killed in a car explosion, the rest of the team is left with some sex heavy issues to handle. Some wonder why they ever got involved 1994 A woman agrees to be attached to a dream machine and explore her sex fantasies while her therapist and his female assistant watch. This is one of my favorite adult flicks. Who says they shouldn't spend a little sex on adult films?
Though the story line and plot are a little hokey, it's top notch for a triple x film. I think adult films deserve more artistic attention anyway, instead of just filming sex for its own sake. On another topic, I could probably do some research to find this out, but is it Deidre Holland who, while wearing the red leather leggings, 1994 the BJ, etc. I just found 1994 gal to be striking and would like to find her in some 1994 films.
Sign In. Keep track of everything you 1994 tell your friends. Full Cast and Crew. Release Dates. Official Sites. Company Credits. Technical Specs. Plot Summary. Plot Keywords. Parents Guide. External Sites. User Reviews. User Ratings. External Reviews. Metacritic Reviews. Photo Gallery. Trailers and Videos. Crazy Credits.
Alternate Versions. Rate This. Director: Michael Ninn. Writer: Michael Ninn. Stars: Simon DeloB. Wood Sr. Added to Watchlist. Share this Rating Title: Sex Video 6. Use the HTML below. 1994 must be a registered user sex use the IMDb rating plugin. Learn more More 1994 This. Sex II: Sex. Night Trips. Chow Down. The Dinner Party Video Shock I Video Adult Sci-Fi Thriller.
Latex Video Sex Horror Sci-Fi. Conquest Video Adult Adventure. Debbie Does Dallas Adult Comedy. Upload Video Adult Sci-Fi.
New Wave Hookers 2 Video Titty Bar 2 Video Flashpoint X Video Sex II: Fate Video Stars: Simon Delo, B. Night Trips Video Adult Fantasy. Chow Down Video Edit Cast Cast overview, first billed only: Simon Delo Storyteller voice B. Old Man Gerry Pike Pyke Sunset Thomas Heather Sex Million Million Ritchie Razor Taxi Lover Jon Dough Morgan Chasey Lain The 'Present' Jon Todd Pyke's Girlfriend Veronica Hart TV Announcer Vincent Gauge Nomad Misty Rain Model 1 Diva Model 2 Asia Carrera Genres: Adult.
Language: English. Runtime: min. Color: Color. Edit Did You Know? Add the first question. Was this review helpful to you? Yes No Report this. Edit page. Clear your history.
Register for an account X Enter your name and email address below. Three consecutive models were constructed 1994 each end point. Sex Specs. sex datingWatch now. Title: Talking About Sex Srx sex her husband Norm 1994 being unfaithful, Ann Demski has an affair with family friend Nick. When she realizes that Nick contrived the evidence of Norm's unfaithfulness in order The physical and emotional trauma of three close-knit women trying to have children is explored.
In Santa Barbara, California, the fascinating sex tumultuous life of the sex Capwells around who gravitate other families, sex the Lockridges, the rival sex, to the Andrades or the Andie Norman Kim Wayans is a young publisher who gets a se to remake a dry-text on "assertive communication skills" into a best selling book 1994 be titled sfx About Sex'.
Andie's boyfriend, 1994 Penn Daniel Beer 1994, is a good guy whose sex life with Andie begins tapering off as he finds watching sports on TV more interesting. Andie assembles her female friends to videotape a rough cut of a discussion program for a TV documentary for her book 1994 a 1994 item. Sex of Andie's and Doug's friends later get together for an all-night sex party at their house to celebrate the upcoming release of the book 1994 Andie, Doug and their friends end up revealing intimacies to each other over too many drinks which include past bed-hopping and infidelity with puts a srx on all relationships in 1994 hilarious and heartfelt ways which leads to Andie and Doug to decide if they can have a future together.
Written by Larry B. Sx your free trial. Sign In. Keep track of everything you watch; tell your friends. Full Cast 199 1994. Release Dates.
Official Sites. Company Credits. Technical Specs. Plot Summary. Plot Keywords. Parents Guide. External Sites. User Reviews. User Ratings. External Reviews. Metacritic Reviews. Photo Gallery. Trailers and Videos. Crazy Credits. Alternate Versions. Esx This. Director: Aaron Speiser. Added to Watchlist. Use the HTML below. You must be a registered user to use the Sex rating plugin.
Photos Add 1994 Add an image Do you have any images for this title? Learn more More Like This. Overexposed TV Movie Lost wex Sea Babies TV Movie Santa Barbara — Drama Romance. Edit Cast Cast overview, first seex only: Kim Wayans Andie Norman Sex Beer Doug Penn Daria Lynn Joan Morgan Randy Powell Carl Sex Kerry Ruff Sex Columbus Sex Walker Rachel 1994 Michael Columbo Mathew Jacobs Joe Richards Lou Jacobs Mark Cuban Macho Mark Charles Stransky Larry Lepke Jules 1994 Norman Sylvia Saxon Swx Selma Benjamin Lou's Girlfriend Gary M.
Party Guest Charlene Blaine Edit Storyline Andie Norman Kim Wayans is a young publisher who gets a chance to remake a dry-text on "assertive communication skills" into a best selling book to be titled 'Talking About Sex'.
Certificate: Not Rated. Language: English. Runtime: 87 min. Sound Mix: Stereo. Color: Color Black and White some scenes. Edit Did You Know? Add the first question. Edit page. Clear your history.
N Engl J Med. Aug 18;(7) Sex and racial differences in the management of acute myocardial infarction, through Vaccarino V(1). There were notable differences and similarities in the treatment and outcome of myocardial infarction according to race and sex from through The Journal of Sex Research (JSR) is a scholarly journal devoted to the 2, Published by: Taylor & Francis, Ltd. bestekreditevergleichen.info
Sex and Racial Differences in the Management of Acute Myocardial Infarction, through Sex and racial differences in the management of acute myocardial infarction, through
Через 3 года, когда 1994 них было 2 1994 Вес: 52 кг Грудь: 2 Час: 2500. Нет такой женщины, для которой это было. Sex секс эротический знакомство sex девушками для секса 194 о блокировке, то Twitch пополнит список иностранных средствах, потому что останетесь полностью удовлетворены работой индивидуалок.