152 | www.critpathcardio.com Critical Pathways in Cardiology •  Volume 13, Number 4, December 2014 ORIGINAL ARTICLE Objective: Physicians’ gender may impact test utilization in the diagnosis of acute cardiovascular disease. We sought to determine if physician gender affected stress test utilization by patient gender in a low-risk chest pain observation unit. Methods: This was a retrospective consecutive cohort study of patients admitted to a chest pain unit in a large volume academic urban emergency department (ED). Inclusion criteria were age >18, American Heart Association low-to-intermediate risk, electrocardiogram nondiagnostic for acute coronary syndrome, and negative initial troponin I. Exclusion criteria were age >75 with a history of coronary artery disease, active comorbid medical problems, or inability to obtain stress testing in the ED for any reason. T-tests were used for univariate comparisons and logistic regression was used to estimate odds ratios (ORs) for receiving testing based on physician gender, controlling for race, insurance, and Thrombolysis In Myocardial Infarction (TIMI) score. Results: Three thousand eight hundred and seventy-three index visits were enrolled during a 2.5-year period. Mean age was 53 ± 20, 55% (95% CI, 53–56%) were female. There was no difference in overall stress utilization based upon physician gender (P = 0.28). However, after controlling for other variables, male physicians had significantly lower odds of stress testing female patients (OR M , 0.82; 95% CI, 0.68–0.99), whereas no difference was found in female physicians (OR F , 0.80; 95% CI, 0.57–1.14). Conclusions: Male physicians appear less likely to utilize stress testing in female patients even after controlling for objective clinical variables, including TIMI score. Although adverse outcomes are uncommon in this patient cohort, further investigation into provider-specific practice patterns based on patient gender is necessary. Key Words: low-risk chest pain, gender, physician gender, stress test utilization (Crit Pathways in Cardiol 2014;13: 152–155) I n 2006, cardiovascular disease represented greater than 25% of all- cause mortality, representing the leading cause of death in both men and women in the United States. 1 Despite advances in therapy and improvements in mortality, treatment disparities between men and women persist in patients with acute coronary syndrome (ACS). 2–7 Studies looking for differences in resource utilization in patients with acute chest pain being evaluated for potential ACS have had mixed results. 4,8 Studies examining provider level differences have also had mixed results. Recent work has indicated that provider gender does not seem to be associated with referral for catheterization by attend- ing physicians 9 or in the workup of patients with potential coronary heart disease by medical students and residents. 10 However, other studies have found an association between female gender of physi- cians and better evidence-based guideline adherence for all of their patients compared with male physicians. 11,12 Chest pain observations units are now a common component of emergency care of the low-risk chest pain patient. Such units potentially offer more objective risk stratification and utilization of stress testing. In 2 single-center studies, we demonstrated that stress test utilization based on physician discretion was safe, efficient, and lowered resource utilization 8 without any evidence of gender bias. 13 The potential effect of provider level bias on the workup of nonspe- cific chest pain, particularly in a chest pain unit (CPU), has not been studied. As a result, we sought to evaluate whether the gender of the physician was associated with disparities in stress utilization of male and female patients in emergency department (ED) CPU patients. MATERIALS AND METHODS Study Design and Setting This was a retrospective consecutive cohort study of patients admitted to a CPU in a large volume academic urban ED with an annual census of 105,000. All clinical, historical, laboratory, stress test, and outcomes information were prospectively entered into a clin- ical registry. The CPU is a 7-bed unit that lies within the ED and is open 7 days a week, 24 hours a day. It is overseen by the Emergency Physician on duty and operated by ED staff. All patients undergo a 6-hour observational protocol including serial electrocardiograms (ECGs), serial biomarkers, and continuous telemetry. After comple- tion of this 6-hour observation period, all patients receive consultation by an attending cardiologist who makes the recommendation as to the necessity and type of stress testing. Exercise stress testing, stress nuclear imaging, stress echocardiography, and computed tomographic (CT) coronary angiography are all available directly from the CPU. The Institutional Review Board of the participating hospital approved this study. Inclusion/Exclusion Criteria All index patients admitted to the CPU were included for analysis. Study inclusion criteria, therefore, were equivalent to criteria for admis- sion to the CPU. These consist of age >18, American Heart Association (AHA) low-to-intermediate risk, ECG nondiagnostic for ACS, and a negative initial troponin I (Bayer ACS: Centaur Troponin I, Tarrytown, NY). 14 Patients >75 years of age with a history of coronary artery dis- ease (CAD), those with active comorbid medical problems, or those unable to obtain stress testing in the ED for any reason were excluded. Study Protocol Demographic, historical, and physical examination features were collected on each patient using a standardized data collection form designed before the study. We defined the primary hypothesis, inclusion and exclusion criteria, and all desired data variables before data abstraction. A trained chart abstractor with extensive experience using the electronic medical record and clinical registry, who was blinded to the hypothesis of the study, extracted the data based on the predefined inclusion and exclusion criteria. We did not assess interra- ter reliability because pertinent data extracted were objective and did not require interpretation. One of the authors of the study (not blinded to the hypothesis) confirmed that the correct filter had been applied before data analysis. The original and serial ECGs were coded as nor- mal, nondiagnostic, dynamic, or ischemic at the time of cardiology Gender Disparities in Stress Test Utilization in Chest Pain Unit  Patients Based Upon the Ordering Physician's Gender Anthony M Napoli, MD, Esther K Choo, MD, Alyson McGregor, MD Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 1003-0117/14/1304-0152 DOI: 10.1097/HPC.0000000000000026 Received for publication June 3, 2014; accepted August 28, 2014. From the Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI. Reprints: Anthony M Napoli, MD, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI. E-mail: anapoli@lifespan.org.