Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study
Introduction
Coronary artery disease (CAD) is the leading cause of death amongst women in the UK and the US (Wenger, Speroff, & Packard, 1993), accounting for 1 in 5 deaths. Angina is the most common symptom of CAD and, based on primary care consultations, has been increasing in prevalence in recent years; the prevalence in women now equals that in men (McCormick, Fleming, & Charlton, 1995). For women, angina is the commonest initial presentation of CAD (Murabito, Evans, Larson, & Levy, 1993; Orencia, Bailey, Yawn, & Kottke, 1993). Despite this, women with angina are less likely than men to be referred for coronary angiography (Ayanian, Udvarhelyi, Gatsonis, Pashos, & Epstein, 1993; Shaw et al., 1994; Majeed & Cook, 1996), the definitive investigation to determine the presence and severity of CAD, and less likely to be subsequently referred for revascularisation (Ayanian & Epstein, 1991; Johnstone et al., 1992; Petticrew, McKee, & Jones, 1993; Dong, Ben Shlomo, Colhoun, & Chaturvedi, 1998). Women who do undergo invasive management (coronary angiography and revascularisation) differ clinically from men, tending to be older (Murabito et al., 1993; Orencia et al., 1993), more functionally impaired (Naylor & Levinton, 1993) and with greater co-morbidity. Taken together, these observations raise the possibility of health care inequality or referral bias.
A diagnosis of angina is made on the basis of a patient's verbal account of their symptoms elicited by a doctor as part of the clinical history. It is plausible therefore that gender differences in language use might influence gender differences in the management of angina. Women and men use language differently in everyday settings (Giles & Coupland, 1991; Coates, 1993) and during medical consultations (Stewart, 1984) with male patients being more ‘factual’ and female patients expressing more feelings. Doctors’ decisions seem to be influenced by the manner in which symptoms are presented to them. For example one study (Birdwell, Herbers & Kroenke, 1993) found that a female actress portraying a patient describing specific cardiac symptoms in a ‘business like’ way was more likely to be diagnosed as having CAD than when the same symptoms were described ‘histrionically’. Another study found that doctors tend to ignore emotional issues preferring to focus on facts during the consultation (Suchman, Markarkis, Beckman, & Frankel, 1997). Therefore, if women do describe their symptoms and health problems in a more emotional way, then this might influence not only diagnosis but also subsequent treatment decisions.
Gender differences in language used to describe angina symptoms may also be explained by lay beliefs about CAD, patterns of co-morbidity and by reporting behaviour. Many women still believe that CAD is a male disease and that they are more likely to die from cancer than CAD (Penque et al., 1998). This belief may lead women to describe their symptoms in a way that attributes their health problem to other causes. Compared with men, women tend to have more co-morbidity, report a greater number and variety of symptoms and have a greater use of medication and health service consultations (Verbrugge & Steiner, 1981; Wingard, 1984; Wingard, Cohn, Kaplan, Cirillo, & Cohen, 1989). One study found that patients with co-morbidity often had difficulty in highlighting their angina symptoms (Gardner & Chapple, 1999). Such factors may serve to mask cardiac symptoms in women, making diagnosis difficult.
Although gender differences in describing angina are both plausible and may have consequences for patient management, the authors are unaware of any previous studies investigating this question. We sought as an ‘a priori’ hypothesis of the Appropriateness of Coronary Revascularisation (ACRE) study, to investigate whether gender differences exist in the language used to describe angina symptoms and perceived health problems immediately prior to angiography, which might contribute to differences in subsequent revascularisation rates. We further examined whether any differences were independent of age, functional status and the presence of CAD, as determined by angiography. Content analysis of 200 free text written responses were used in order to obtain accounts representative of the parent ACRE study.
Section snippets
Participants of ACRE study
Between April 1996 and April 1997, all consecutive patients (from five contiguous Health Authorities) admitted to the Royal Hospitals Trust, London, for coronary angiography, were invited to participate in the ACRE study (Hemingway et al., 1999). There were no exclusion criteria and 4121 patients (1201 women) were identified. The resident population of the health authorities was 2.833 million (procedure rate 1700 per million) and 89% of the angiographies performed on their residents were done
Results
Patient characteristics are described in Table 1. There were no gender differences in age (due to sample selection based on age strata) or age at leaving full time education, highest attained educational qualification or social class based on occupation (data not shown). There were no differences in the severity of angina symptoms using the CCS classification, but women were less likely to have angina using the Rose angina criteria (19% vs. 32%, p=0.07). Women were less likely to have had a
Discussion
In a content analysis of 200 written accounts of symptoms and health problems leading up to angiography among participants investigated for chronic stable angina, we found gender differences in the description of symptoms which may influence subsequent management. Women described more throat, neck or jaw pain than men in the presence of coronary artery disease and in those who were not subsequently revascularised. This gender difference was also seen among those appropriate for
Conclusions
This study set out to investigate whether there were gender differences in use of language when describing symptoms and health problems prior to coronary angiography that could contribute to subsequent management decisions. Although there were no differences in discourses used, women and men reported pain in different locations and women reported more symptoms. This was particularly evident among participants with CAD who were not revascularised. The widespread use of the term ‘atypical’ in
Acknowledgements
The ACRE study was established with a grant from East London and the City Health Authority, and subsequently funded by a consortium of health authorities (North Essex, Barking and Havering, Redbridge and Waltham Forest), the North Thames NHS Research and Development program (RFG 258), the British Heart Foundation (PG/97216), Guidant and Boston Scientific Corporation. We gratefully acknowledge the comments of others working on the ACRE study (particularly Angela Crook and Julie Sanders) as well
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