Door-to-ECG Time and Gender Equity

We have read with interest the article published by Pearlman et al1 regarding the disparities in door-to-ECG time for patients with noncardiac chest pain. They failed to show gender or racial disparities in this time, but they found it was longer for younger patients (aged 18-39 years). Every effort to uncover gender inequities is welcome, especially when it is investigated in patients with a highly prevalent complaint such as chest pain in emergency department.2, 3 Although the authors acknowledge several limitations in their study, we would like to underline two that may significantly influence the results. First, the time of patient inclusion (from noon to 8 pm) may explain the very long times elapsed between patient arrival and the ECG recording (around 30 minutes). In nearly all emergency departments,4, 5 the afternoon is the most overcrowded time of day, and thus this is when objective markers of ED efficacy, such as door-to-ECG time, are predictably the worst. Therefore the prolonged times found by Pearlman et al probably do not mirror what is happening all day in their emergency department. Second, the low number of patients studied did not yield sufficient statistical power to perform multivariate analysis, thereby making it impossible to raise hard conclusions regarding the presence or absence of a gender bias in the door-to-ECG time.

Using a very similar study design, we have recently examined the hypothetical gender bias in 2,111 patients at low risk for acute coronary syndrome who were seen in the chest pain unit of our emergency department.6 Women had a significantly longer door-to-ECG time than men (15 minutes vs 13 minutes, P < .01), although this difference disappeared after consideration of age and Thrombolysis in Myocardial Infarction score in a multivariate analysis. We recognize that improving chest pain care in the emergency department is a true challenge, ranging from an accurate initial assessment to a correct final diagnosis, treatment, and patient disposition.7, 8 Our study findings are in agreement with the conclusions of Pearlman et al,1 but with the additional advantage that it does not have the previously discussed biases. Accordingly, we believe that the emergency department in general and the chest pain unit in particular respect gender equity in the management of urgent patients.