c10149844bb81e8ba1b6e289f5d61152  qcae011.pdf
be3655e39efef531cbcbbe902c568a2abe892209  qcae011.pdf
a7ed940a1c37b23d0555c8c1a27619a3e8cced681ef29e1290240ce02cc1a320  qcae011.pdf

Title:           Sex-based analysis of NSTEMI processes of care and outcomes by hospital: a nationwide cohort study
Subject:         DOI: 10.1093/ehjqcco/qcae011 European Heart Journal - Quality of Care and Clinical Outcomes, 10, 8, 06-02-2024. Abstract: Contemporary studies demonstrate that non-ST-segment elevation myocardial infarction (NSTEMI) processes of care vary according to sex. Little is known regarding variation in practice between geographical areas and centres.We identified 305 014 NSTEMI admissions in the United Kingdom (UK) Myocardial Ischaemia National Audit Project (MINAP), 2010–17, including female sex (110 209). Hierarchical, multivariate logistic regression models were fitted, assessing for differences in primary outcomes according to sex. Risk-standardized mortality rates (RSMR) were calculated for individual hospitals to illustrate the correlation with variables of interest. ‘Heat maps’ were plotted to show regional and sex-based variation in the opportunity-based quality indicator score (surrogate for optimal processes of care).Women presented older (77 years vs. 69 years, P < 0.001) and were more often Caucasian (93% vs. 91%, P < 0.001). Women were less frequently managed with an invasive coronary angiogram (58% vs. 75%, P < 0.001) or percutaneous coronary intervention (35% vs. 49%, P < 0.001). In our hospital-clustered analysis, we show a positive correlation between the RSMR and the increasing proportion of women treated for NSTEMI (R2 = 0.17, P < 0.001). There was a clear negative correlation between the proportion of women who had an optimum OBQI score during their admission and RSMR (R2 = 0.22, P < 0.001), with a weaker correlation in men (R2 = 0.08, P < 0.001). Heat maps according to the Clinical Commissioning Group (CCG) demonstrate significant regional variation in the OBQI score, with women receiving poorer quality care throughout the UK.There was a significant variation in the management of patients with NSTEMI according to sex, with widespread geographical variation. Structural changes are required to enable improved care for women.
Keywords:        Sex 0 Quality of care 0 NSTEMI
Author:          Weight Nicholas, Moledina Saadiq, Kontopantelis Evangelos, Van Spall Harriette, Dafaalla Mohammed, Chieffo Alaide, Iannaccone Mario, Chen Denis, Rashid Muhammad, Mauri-Ferre Josepa, Tamis-Holland Jacqueline E., Mamas Mamas A.
Creator:         OUP
Producer:        Acrobat Distiller 10.0.0 (Windows)
CreationDate:    Mon Dec  9 17:33:00 2024 CET
ModDate:         Mon Dec  9 17:33:38 2024 CET
Custom Metadata: yes
Metadata Stream: yes
Tagged:          yes
UserProperties:  no
Suspects:        no
Form:            none
JavaScript:      no
Pages:           13
Encrypted:       no
Page size:       595.276 x 793.701 pts
Page rot:        0
File size:       1751327 bytes
Optimized:       yes
PDF version:     1.3


name                                 type              encoding         emb sub uni object ID
------------------------------------ ----------------- ---------------- --- --- --- ---------
ICIDCC+RMTMI                         Type 1C           Custom           yes yes yes   1533  0
ICIDBB+GillSansNova-BookItalic       Type 1C           WinAnsi          yes yes no    1538  0
ICHLFO+CMBSY10                       Type 1C           Custom           yes yes yes   1541  0
ICICLC+MTSYB                         Type 1C           Custom           yes yes yes   1546  0
ICHKMO+GillSansNova-Book             Type 1C           Custom           yes yes yes   1551  0
ICHKNA+GillSansNova-Bold             Type 1C           Custom           yes yes yes   1556  0
ICIDBC+GillSansNova-Heavy            Type 1C           WinAnsi          yes yes no    1561  0
ICIDED+CMSY10                        Type 1C           Custom           yes yes yes   1564  0
ICIDCD+MTSY                          Type 1C           Custom           yes yes yes   1568  0
ICHKMP+dummy-space                   Type 1C           WinAnsi          yes yes no    1573  0
ICIECP+LCIRCLE10                     Type 1C           Custom           yes yes no      11  0
ICIGCE+GillSansMTStd-Heavy           Type 1C           WinAnsi          yes yes no     144  0
ICIGLB+GillSansNova-BoldItalic       Type 1C           WinAnsi          yes yes no     147  0


Jhove (Rel. 1.28.0, 2023-05-18)
 Date: 2025-07-01 02:42:57 CEST
 RepresentationInformation: qcae011.pdf
  ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16)
  LastModified: 2025-06-30 18:36:19 CEST
  Size: 1751327
  Format: PDF
  Version: 1.3
  Status: Well-Formed and valid
  SignatureMatches:
   PDF-hul
  MIMEtype: application/pdf
  Profile: Linearized PDF, Tagged PDF
  PDFMetadata: 
   Objects: 1653
   FreeObjects: 1
   IncrementalUpdates: 1
   DocumentCatalog: 
    ViewerPreferences: 
     HideToolbar: false
     HideMenubar: false
     HideWindowUI: false
     FitWindow: false
     CenterWindow: false
     DisplayDocTitle: true
     NonFullScreenPageMode: UseNone
     Direction: L2R
     ViewArea: CropBox
     ViewClip: CropBox
     PrintArea: CropBox
     PageClip: CropBox
    PageLayout: OneColumn
    PageMode: UseOutlines
    Language: English
    Outlines: 
     Item: 
      Title: Key learning points
      Destination: section*.2
     Item: 
      Title: Introduction
      Destination: section*.4
     Item: 
      Title: Methods
      Destination: section*.6
     Item: 
      Title: Study design
      Destination: section*.8
     Item: 
      Title: Study population
      Destination: section*.10
     Item: 
      Title: Outcomes
      Destination: section*.12
     Item: 
      Title: Quality indicators
      Destination: section*.18
     Item: 
      Title: Statistical analysis
      Destination: section*.20
     Item: 
      Title: Temporal and geographical changes
      Destination: section*.22
     Item: 
      Title: Results
      Destination: section*.24
     Item: 
      Title: Demographics
      Destination: section*.26
     Item: 
      Title: Management and clinical outcomes
      Destination: section*.28
     Item: 
      Title: ESC ACVC quality indicators
      Destination: section*.30
     Item: 
      Title: Multivariate analysis
      Destination: section*.32
     Item: 
      Title: Hospital-clustered analysis
      Destination: section*.34
     Item: 
      Title: Heat maps
      Destination: section*.36
     Item: 
      Title: Supplementary analysis
      Destination: section*.38
     Item: 
      Title: Discussion
      Destination: section*.40
     Item: 
      Title: Strengths of study
      Destination: section*.42
     Item: 
      Title: Limitations of study
      Destination: section*.44
     Item: 
      Title: Conclusion
      Destination: section*.46
     Item: 
      Title: Supplementary material
      Destination: section*.48
     Item: 
      Title: Acknowledgements
      Destination: section*.50
     Item: 
      Title: Funding
      Destination: section*.52
     Item: 
      Title: Data availability
      Destination: section*.56
     Item: 
      Title: References
      Destination: section*.58
   Info: 
    Title: Sex-based analysis of NSTEMI processes of care and outcomes by hospital: a nationwide cohort study
    Author: Weight Nicholas, Moledina Saadiq, Kontopantelis Evangelos, Van Spall Harriette, Dafaalla Mohammed, Chieffo Alaide, Iannaccone Mario, Chen Denis, Rashid Muhammad, Mauri-Ferre Josepa, Tamis-Holland Jacqueline E., Mamas Mamas A.
    Subject: DOI: 10.1093/ehjqcco/qcae011 European Heart Journal - Quality of Care and Clinical Outcomes, 10, 8, 06-02-2024. Abstract: Contemporary studies demonstrate that non-ST-segment elevation myocardial infarction (NSTEMI) processes of care vary according to sex. Little is known regarding variation in practice between geographical areas and centres.We identified 305 014 NSTEMI admissions in the United Kingdom (UK) Myocardial Ischaemia National Audit Project (MINAP), 2010–17, including female sex (110 209). Hierarchical, multivariate logistic regression models were fitted, assessing for differences in primary outcomes according to sex. Risk-standardized mortality rates (RSMR) were calculated for individual hospitals to illustrate the correlation with variables of interest. ‘Heat maps’ were plotted to show regional and sex-based variation in the opportunity-based quality indicator score (surrogate for optimal processes of care).Women presented older (77 years vs. 69 years, P < 0.001) and were more often Caucasian (93% vs. 91%, P < 0.001). Women were less frequently managed with an invasive coronary angiogram (58% vs. 75%, P < 0.001) or percutaneous coronary intervention (35% vs. 49%, P < 0.001). In our hospital-clustered analysis, we show a positive correlation between the RSMR and the increasing proportion of women treated for NSTEMI (R2 = 0.17, P < 0.001). There was a clear negative correlation between the proportion of women who had an optimum OBQI score during their admission and RSMR (R2 = 0.22, P < 0.001), with a weaker correlation in men (R2 = 0.08, P < 0.001). Heat maps according to the Clinical Commissioning Group (CCG) demonstrate significant regional variation in the OBQI score, with women receiving poorer quality care throughout the UK.There was a significant variation in the management of patients with NSTEMI according to sex, with widespread geographical variation. Structural changes are required to enable improved care for women.
    Keywords: Sex 0 Quality of care 0 NSTEMI
    Creator: OUP
    Producer: Acrobat Distiller 10.0.0 (Windows)
    CreationDate: Mon Dec 09 18:03:00 CET 2024
    ModDate: Mon Dec 09 18:03:38 CET 2024
   ID: 0xade515fa879ffeb49761ad10a3bd7c0d, 0xa5eb0d2ba9e261f0ae3d32ba4f10ce50
   Filters: 
    FilterPipeline: FlateDecode
    FilterPipeline: DCTDecode
   Images: 
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 75
      ImageHeight: 75
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 65
      ImageHeight: 65
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 66
      ImageHeight: 65
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 57
      ImageHeight: 61
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 62
      ImageHeight: 91
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 339
      ImageHeight: 383
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 332
      ImageHeight: 353
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 149
      ImageHeight: 113
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 763
      ImageHeight: 556
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 763
      ImageHeight: 556
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 945
      ImageHeight: 1074
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 1129
      ImageHeight: 1499
      ColorSpace: RGB
      BitsPerSample: 8
      BitsPerSampleUnit: integer
   Fonts: 
    Type1: 
     Font: 
      BaseFont: ICIDCD+MTSY
      FontSubset: true
      FirstChar: 2
      LastChar: 138
      FontDescriptor: 
       FontName: ICIDCD+MTSY
       Flags: Symbolic
       FontBBox: 0, -954, 1043, 796
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: ICIDBB+GillSansNova-BookItalic
      FontSubset: true
      FirstChar: 40
      LastChar: 151
      FontDescriptor: 
       FontName: ICIDBB+GillSansNova-BookItalic
       Flags: Nonsymbolic, Italic
       FontBBox: -316, -235, 1219, 950
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: ICHKMP+dummy-space
      FontSubset: true
      FirstChar: 32
      LastChar: 32
      FontDescriptor: 
       FontName: ICHKMP+dummy-space
       Flags: Nonsymbolic
       FontBBox: 0, 0, 0, 0
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: ICHLFO+CMBSY10
      FontSubset: true
      FirstChar: 129
      LastChar: 129
      FontDescriptor: 
       FontName: ICHLFO+CMBSY10
       Flags: Symbolic, Italic, ForceBold
       FontBBox: -27, -940, 1332, 825
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: ICICLC+MTSYB
      FontSubset: true
      FirstChar: 2
      LastChar: 61
      FontDescriptor: 
       FontName: ICICLC+MTSYB
       Flags: Symbolic, ForceBold
       FontBBox: -16, -935, 1043, 896
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: ICIECP+LCIRCLE10
      FontSubset: true
      FirstChar: 2
      LastChar: 2
      FontDescriptor: 
       FontName: ICIECP+LCIRCLE10
       Flags: Symbolic
       FontBBox: -150, -150, 150, 150
       FontFile3: true
      EncodingDictionary: 
       Differences: true
     Font: 
      BaseFont: ICHKMO+GillSansNova-Book
      FontSubset: true
      FirstChar: 2
      LastChar: 241
      FontDescriptor: 
       FontName: ICHKMO+GillSansNova-Book
       Flags: Symbolic
       FontBBox: -420, -251, 1219, 950
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: ICIGCE+GillSansMTStd-Heavy
      FontSubset: true
      FirstChar: 49
      LastChar: 117
      FontDescriptor: 
       FontName: ICIGCE+GillSansMTStd-Heavy
       Flags: Nonsymbolic
       FontBBox: -231, -240, 1181, 931
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: ICIGLB+GillSansNova-BoldItalic
      FontSubset: true
      FirstChar: 80
      LastChar: 110
      FontDescriptor: 
       FontName: ICIGLB+GillSansNova-BoldItalic
       Flags: Nonsymbolic, Italic, ForceBold
       FontBBox: -404, -250, 1219, 960
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: ICHKNA+GillSansNova-Bold
      FontSubset: true
      FirstChar: 2
      LastChar: 121
      FontDescriptor: 
       FontName: ICHKNA+GillSansNova-Bold
       Flags: Symbolic, ForceBold
       FontBBox: -476, -276, 1276, 961
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: ICIDBC+GillSansNova-Heavy
      FontSubset: true
      FirstChar: 65
      LastChar: 121
      FontDescriptor: 
       FontName: ICIDBC+GillSansNova-Heavy
       Flags: Nonsymbolic, ForceBold
       FontBBox: -504, -287, 1375, 966
       FontFile3: true
      Encoding: WinAnsiEncoding
     Font: 
      BaseFont: ICIDED+CMSY10
      FontSubset: true
      FirstChar: 129
      LastChar: 129
      FontDescriptor: 
       FontName: ICIDED+CMSY10
       Flags: Symbolic, Italic
       FontBBox: -29, -960, 1116, 775
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: ICIDCC+RMTMI
      FontSubset: true
      FirstChar: 2
      LastChar: 62
      FontDescriptor: 
       FontName: ICIDCC+RMTMI
       Flags: Symbolic, Italic
       FontBBox: 0, -213, 987, 680
       FontFile3: true
      EncodingDictionary: 
       Differences: true
      ToUnicode: true
   XMP: <x:xmpmeta xmlns:x="adobe:ns:meta/" x:xmptk="XMP Core 5.1.2">
   <rdf:RDF xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#">
      <rdf:Description rdf:about=""
            xmlns:xmp="http://ns.adobe.com/xap/1.0/">
         <xmp:CreateDate>2024-12-09T22:03+05:30</xmp:CreateDate>
         <xmp:ModifyDate>2024-12-09T22:03:38+05:30</xmp:ModifyDate>
         <xmp:MetadataDate>2024-12-09T22:03:38+05:30</xmp:MetadataDate>
         <xmp:CreatorTool>OUP</xmp:CreatorTool>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:pdf="http://ns.adobe.com/pdf/1.3/">
         <pdf:Producer>Acrobat Distiller 10.0.0 (Windows)</pdf:Producer>
         <pdf:Keywords>Sex 0 Quality of care 0 NSTEMI</pdf:Keywords>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:jav="http://www.niso.org/schemas/jav/1.0/">
         <jav:journal_article_version>VoR</jav:journal_article_version>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:pdfx="http://ns.adobe.com/pdfx/1.3/">
         <pdfx:doi>10.1093/ehjqcco/qcae011</pdfx:doi>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:prism_1_="http://prismstandard.org/namespaces/basic/3.0/">
         <prism_1_:issn>2058-1742</prism_1_:issn>
         <prism_1_:publicationName>European Heart Journal - Quality of Care and Clinical Outcomes</prism_1_:publicationName>
         <prism_1_:aggregationType>journal</prism_1_:aggregationType>
         <prism_1_:volume>10</prism_1_:volume>
         <prism_1_:doi>10.1093/ehjqcco/qcae011</prism_1_:doi>
         <prism_1_:url>https://doi.org/10.1093/ehjqcco/qcae011</prism_1_:url>
         <prism_1_:copyright>© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.</prism_1_:copyright>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:dc="http://purl.org/dc/elements/1.1/">
         <dc:rightsHolder>All Rights Reserved</dc:rightsHolder>
         <dc:format>application/pdf</dc:format>
         <dc:identifier>doi:10.1093/ehjqcco/qcae011</dc:identifier>
         <dc:rights>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.</rdf:li>
            </rdf:Alt>
         </dc:rights>
         <dc:contributor>
            <rdf:Seq>
               <rdf:li>Weight Nicholas</rdf:li>
               <rdf:li>Moledina Saadiq</rdf:li>
               <rdf:li>Kontopantelis Evangelos</rdf:li>
               <rdf:li>Van Spall Harriette</rdf:li>
               <rdf:li>Dafaalla Mohammed</rdf:li>
               <rdf:li>Chieffo Alaide</rdf:li>
               <rdf:li>Iannaccone Mario</rdf:li>
               <rdf:li>Chen Denis</rdf:li>
               <rdf:li>Rashid Muhammad</rdf:li>
               <rdf:li>Mauri-Ferre Josepa</rdf:li>
               <rdf:li>Tamis-Holland Jacqueline E.</rdf:li>
               <rdf:li>Mamas Mamas A.</rdf:li>
            </rdf:Seq>
         </dc:contributor>
         <dc:publisher>
            <rdf:Bag>
               <rdf:li>Oxford University Press</rdf:li>
            </rdf:Bag>
         </dc:publisher>
         <dc:description>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">DOI: 10.1093/ehjqcco/qcae011 European Heart Journal - Quality of Care and Clinical Outcomes, 10, 8, 06-02-2024. Abstract: Contemporary studies demonstrate that non-ST-segment elevation myocardial infarction (NSTEMI) processes of care vary according to sex. Little is known regarding variation in practice between geographical areas and centres.We identified 305&amp;#x2009;014 NSTEMI admissions in the United Kingdom (UK) Myocardial Ischaemia National Audit Project (MINAP), 2010&amp;#x2013;17, including female sex (110&amp;#x2009;209). Hierarchical, multivariate logistic regression models were fitted, assessing for differences in primary outcomes according to sex. Risk-standardized mortality rates (RSMR) were calculated for individual hospitals to illustrate the correlation with variables of interest. &amp;#x2018;Heat maps&amp;#x2019; were plotted to show regional and sex-based variation in the opportunity-based quality indicator score (surrogate for optimal processes of care).Women presented older (77 years vs. 69 years, P&amp;#x00A0;&amp;#x003C;&amp;#x00A0;0.001) and were more often Caucasian (93&amp;#x0025; vs. 91&amp;#x0025;, P&amp;#x00A0;&amp;#x003C;&amp;#x00A0;0.001). Women were less frequently managed with an invasive coronary angiogram (58&amp;#x0025; vs. 75&amp;#x0025;, P&amp;#x00A0;&amp;#x003C;&amp;#x00A0;0.001) or percutaneous coronary intervention (35&amp;#x0025; vs. 49&amp;#x0025;, P&amp;#x00A0;&amp;#x003C;&amp;#x00A0;0.001). In our hospital-clustered analysis, we show a positive correlation between the RSMR and the increasing proportion of women treated for NSTEMI (R2&amp;#x00A0;&amp;#x003D;&amp;#x00A0;0.17, P&amp;#x00A0;&amp;#x003C;&amp;#x00A0;0.001). There was a clear negative correlation between the proportion of women who had an optimum OBQI score during their admission and RSMR (R2&amp;#x00A0;&amp;#x003D;&amp;#x00A0;0.22, P&amp;#x00A0;&amp;#x003C;&amp;#x00A0;0.001), with a weaker correlation in men (R2&amp;#x00A0;&amp;#x003D;&amp;#x00A0;0.08, P&amp;#x00A0;&amp;#x003C;&amp;#x00A0;0.001). Heat maps according to the Clinical Commissioning Group (CCG) demonstrate significant regional variation in the OBQI score, with women receiving poorer quality care throughout the UK.There was a significant variation in the management of patients with NSTEMI according to sex, with widespread geographical variation. Structural changes are required to enable improved care for women.</rdf:li>
            </rdf:Alt>
         </dc:description>
         <dc:subject>
            <rdf:Bag>
               <rdf:li>Sex 0 Quality of care 0 NSTEMI</rdf:li>
            </rdf:Bag>
         </dc:subject>
         <dc:title>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">Sex-based analysis of NSTEMI processes of care and outcomes by hospital: a nationwide cohort study</rdf:li>
            </rdf:Alt>
         </dc:title>
         <dc:creator>
            <rdf:Seq>
               <rdf:li>Weight Nicholas, Moledina Saadiq, Kontopantelis Evangelos, Van Spall Harriette, Dafaalla Mohammed, Chieffo Alaide, Iannaccone Mario, Chen Denis, Rashid Muhammad, Mauri-Ferre Josepa, Tamis-Holland Jacqueline E., Mamas Mamas A.</rdf:li>
            </rdf:Seq>
         </dc:creator>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:xmpMM="http://ns.adobe.com/xap/1.0/mm/">
         <xmpMM:DocumentID>uuid:230d7a4b-f644-33f0-99a0-aefe19f15761</xmpMM:DocumentID>
         <xmpMM:InstanceID>uuid:e9313d87-20d8-420f-a69d-fb47c7d0c1eb</xmpMM:InstanceID>
      </rdf:Description>
      <rdf:Description rdf:about=""
            xmlns:xmpRights="http://ns.adobe.com/xap/1.0/rights/">
         <xmpRights:Marked>True</xmpRights:Marked>
      </rdf:Description>
   </rdf:RDF>
</x:xmpmeta>
   Pages: 
    Page: 
     Label: 750
     Sequence: 1
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 133, 739, 270, 750
      Annotation: 
       Subtype: Link
       Rect: 145, 582, 157, 598
      Annotation: 
       Subtype: Link
       Rect: 155, 588, 163, 600
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 164, 588, 170, 600
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 276, 588, 283, 600
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 284, 588, 291, 600
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 450, 582, 463, 598
      Annotation: 
       Subtype: Link
       Rect: 461, 588, 468, 600
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 160, 572, 168, 584
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 169, 572, 176, 584
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 177, 572, 184, 584
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 319, 567, 331, 583
      Annotation: 
       Subtype: Link
       Rect: 329, 572, 336, 584
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 429, 572, 436, 584
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 153, 551, 165, 567
      Annotation: 
       Subtype: Link
       Rect: 163, 556, 170, 568
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 247, 556, 254, 568
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 379, 551, 391, 567
      Annotation: 
       Subtype: Link
       Rect: 389, 556, 397, 568
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 398, 556, 405, 568
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 406, 556, 413, 568
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 160, 540, 172, 552
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 173, 540, 186, 552
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 363, 540, 375, 552
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 516, 540, 523, 552
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 524, 540, 531, 552
       Destination: 1520
      Annotation: 
       Subtype: Link
       Rect: 261, 79, 345, 89
      Annotation: 
       Subtype: Link
       Rect: 132, 61, 256, 70
     Thumb: true
    Page: 
     Label: 751
     Sequence: 2
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 126, 94, 131, 105
       Destination: 113
      Annotation: 
       Subtype: Link
       Rect: 87, 73, 92, 84
       Destination: 113
      Annotation: 
       Subtype: Link
       Rect: 337, 89, 342, 97
       Destination: 113
      Annotation: 
       Subtype: Link
       Rect: 343, 89, 348, 97
       Destination: 113
     Thumb: true
    Page: 
     Label: 752
     Sequence: 3
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 180, 94, 185, 105
       Destination: 113
      Annotation: 
       Subtype: Link
       Rect: 190, 62, 198, 73
       Destination: 113
      Annotation: 
       Subtype: Link
       Rect: 458, 178, 466, 190
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 396, 62, 404, 73
       Destination: 126
     Thumb: true
    Page: 
     Label: 753
     Sequence: 4
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 252, 156, 279, 167
       Destination: 37
      Annotation: 
       Subtype: Link
       Rect: 414, 143, 422, 154
       Destination: 126
     Thumb: true
    Page: 
     Label: 754
     Sequence: 5
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 184, 125, 192, 136
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 207, 94, 216, 105
       Destination: 126
     Thumb: true
    Page: 
     Label: 755
     Sequence: 6
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 157, 617, 162, 628
       Destination: 55
      Annotation: 
       Subtype: Link
       Rect: 134, 581, 139, 592
       Destination: 55
      Annotation: 
       Subtype: Link
       Rect: 221, 422, 227, 432
       Destination: 55
      Annotation: 
       Subtype: Link
       Rect: 318, 422, 324, 432
       Destination: 55
      Annotation: 
       Subtype: Link
       Rect: 415, 422, 420, 432
       Destination: 55
      Annotation: 
       Subtype: Link
       Rect: 511, 422, 517, 432
       Destination: 55
      Annotation: 
       Subtype: Link
       Rect: 458, 151, 489, 163
       Destination: 37
      Annotation: 
       Subtype: Link
       Rect: 317, 130, 346, 142
       Destination: 47
     Thumb: true
    Page: 
     Label: 756
     Sequence: 7
     Thumb: true
    Page: 
     Label: 757
     Sequence: 8
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 230, 136, 257, 147
       Destination: 51
      Annotation: 
       Subtype: Link
       Rect: 259, 104, 286, 116
       Destination: 51
      Annotation: 
       Subtype: Link
       Rect: 426, 123, 453, 135
       Destination: 55
     Thumb: true
    Page: 
     Label: 758
     Sequence: 9
     Thumb: true
    Page: 
     Label: 759
     Sequence: 10
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 227, 661, 254, 673
       Destination: 55
      Annotation: 
       Subtype: Link
       Rect: 46, 589, 205, 601
      Annotation: 
       Subtype: Link
       Rect: 46, 557, 75, 569
       Destination: 65
      Annotation: 
       Subtype: Link
       Rect: 160, 547, 189, 559
       Destination: 65
      Annotation: 
       Subtype: Link
       Rect: 43, 506, 73, 518
       Destination: 75
      Annotation: 
       Subtype: Link
       Rect: 94, 496, 125, 508
       Destination: 84
      Annotation: 
       Subtype: Link
       Rect: 194, 454, 224, 466
       Destination: 84
      Annotation: 
       Subtype: Link
       Rect: 249, 422, 278, 434
       Destination: 84
      Annotation: 
       Subtype: Link
       Rect: 43, 351, 71, 362
       Destination: 90
      Annotation: 
       Subtype: Link
       Rect: 176, 319, 203, 331
       Destination: 105
      Annotation: 
       Subtype: Link
       Rect: 521, 178, 530, 189
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 381, 125, 390, 137
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 518, 73, 527, 84
       Destination: 126
     Thumb: true
    Page: 
     Label: 760
     Sequence: 11
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 124, 279, 133, 290
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 280, 226, 289, 238
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 218, 184, 227, 196
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 70, 69, 79, 80
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 350, 341, 358, 352
       Destination: 126
      Annotation: 
       Subtype: Link
       Rect: 341, 194, 349, 205
       Destination: 126
     Thumb: true
    Page: 
     Label: 761
     Sequence: 12
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 305, 586, 574, 610
      Annotation: 
       Subtype: Link
       Rect: 309, 302, 316, 311
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 309, 275, 316, 284
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 309, 248, 316, 257
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 309, 212, 316, 221
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 309, 194, 316, 204
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 309, 167, 316, 177
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 309, 140, 316, 150
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 309, 113, 316, 123
       Destination: 1
      Annotation: 
       Subtype: Link
       Rect: 309, 86, 316, 96
       Destination: 37
      Annotation: 
       Subtype: Link
       Rect: 306, 60, 316, 69
       Destination: 37
     Thumb: true
    Page: 
     Label: 762
     Sequence: 13
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 41, 724, 52, 734
       Destination: 37
      Annotation: 
       Subtype: Link
       Rect: 41, 706, 52, 716
       Destination: 37
      Annotation: 
       Subtype: Link
       Rect: 41, 671, 52, 680
       Destination: 47
      Annotation: 
       Subtype: Link
       Rect: 30, 643, 289, 672
      Annotation: 
       Subtype: Link
       Rect: 41, 635, 52, 644
       Destination: 51
      Annotation: 
       Subtype: Link
       Rect: 41, 617, 52, 626
       Destination: 51
      Annotation: 
       Subtype: Link
       Rect: 41, 608, 52, 617
       Destination: 90
      Annotation: 
       Subtype: Link
       Rect: 41, 581, 52, 590
       Destination: 90
      Annotation: 
       Subtype: Link
       Rect: 41, 563, 52, 572
       Destination: 105
      Annotation: 
       Subtype: Link
       Rect: 304, 706, 315, 716
       Destination: 105
      Annotation: 
       Subtype: Link
       Rect: 304, 679, 315, 689
       Destination: 105
      Annotation: 
       Subtype: Link
       Rect: 304, 635, 315, 644
       Destination: 105
      Annotation: 
       Subtype: Link
       Rect: 304, 608, 315, 617
       Destination: 105
      Annotation: 
       Subtype: Link
       Rect: 304, 572, 315, 581
       Destination: 105
      Annotation: 
       Subtype: Link
       Rect: 132, 62, 256, 71
     Thumb: true
  Checksum: 70b2f375
   Type: CRC32
  Checksum: c10149844bb81e8ba1b6e289f5d61152
   Type: MD5
  Checksum: be3655e39efef531cbcbbe902c568a2abe892209
   Type: SHA-1
  Checksum: a7ed940a1c37b23d0555c8c1a27619a3e8cced681ef29e1290240ce02cc1a320
   Type: SHA-256