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ACC committee: Sex disparities evident in heart health care
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“Struggles to achieve high-quality and equitable CV health care persist today for many women, and evidence abounds that the quality of care received by women of diverse race and ethnicity is pervasively suboptimal, affecting as many as 60 million adult U.S. women,” Leslee J. Shaw, PhD, FACC, FASNC, FAHA, professor of medicine in the division of cardiology at Emory University, co-director of Emory Clinical Cardiovascular Research Institute and a member of the Cardiology Today Editorial Board, and colleagues wrote.
Underestimated risk
Although clinical risk prediction models consider risk factors and other conditions in both male and female populations, the risk in women is typically underestimated due to nonclinical factors including environmental and economic factors. A recent WHO report found that factors in women such as less education, higher rates of poverty, lower-paying jobs and more familial responsibilities may affect health outcomes.
“Access and use of health care resources affect racially and ethnically diverse women in complex ways, such as cultural norms, health beliefs and trust of the health care system; language; and living in an urban vs. a rural setting,” Shaw and colleagues wrote. “These factors are important determinants of health, quality of life, patient compliance and/or adherence, and contribute to premature death and disability.”
Other factors such as income, health insurance status and Social Security and Medicare benefits may affect a woman’s utilization of health care services. Race and ethnic minority groups, especially black and Native American women, experience worse health outcomes related to CVD. Half of the uninsured population in the United States are members of ethnic and racial minority groups.
Equity should not be described as sameness, according to the review. Factors such as biological differences, outcomes and influences of cultural, social and financial challenges should be considered when caring for women.
Women often delay receiving care due to these factors, which may affect the outcome, regardless of the condition.
“The result is that the paradigm of early detection and prevention will offset high cost, as well as hospital and end-stage care, while improving societal productivity similarly for women and men, but the inputs and parameters for risk detection and guided treatment are likely to differ by sex,” Shaw and colleagues wrote.
Suggestions for improved care
The committee suggested a few approaches that may ensure that health care needs are met for women. Algorithms can help standardize care while recognizing the differences of care among men and women. Individualized care can be provided with shared decision-making, which can take into account a woman’s lifestyle, values and priorities. Including more women in clinical trials can help identify the difference in care and to apply them accordingly.
Other recommendations include the development of a more accurate global risk score, utilization of electronic health records, female-centered health care models and improvements in health care and coverage policies to focus on women’s needs.
The Affordable Care Act has helped with some of these recommendations, such as tax credits to help women purchase health insurance and expansion of funding for community health centers.
Improvements can also stem back to education by implementing disease-based management and sex-specific pathophysiology into the curriculum. This may lead to effective clinical care and critical thinking.
“For health care, the principle of sameness in equitable care between women and men is a near-term target, but we cannot achieve optimal population health without consideration of the gendered structural determinants of health and the development of unique care pathways optimized for women,” Shaw and colleagues wrote. “We propose radical changes to our health care system, including redesign, locality of services and payment reform, aimed to improve equity of CV care for women.” – by Darlene Dobkowski
Disclosures: Shaw reports no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures.
Perspective
Back to TopChristine Jellis, MD, PhD
This is a well-written article in which the authors have put together a summary of health care in women, gender disparities and other associated issues. It certainly suggests that we still have a long way to go in terms of providing equitable health care, and the authors suggest ways to achieve this during an era of change in the health care system, particularly focusing on how patients are receiving insurance.
The article has implications for clinical practice for physicians. It’s a timely reminder that we need to make sure that all of our patients receive evidence-based care according to current guideline recommendations. Women make up 50% of our general population, but they are often underrepresented in clinical trials. Even despite the available evidence, women don’t seem to be getting that recommended care. As physicians, we need to make sure that all women are able to access appropriate health care services and receive recommended prescription medications and treatments. It’s also a reminder for clinicians that sometimes we overlook simple things that may preclude minority groups and women from being able to access health care. These factors may include remote location, limited transport, work and family commitments, financial constraints and educational factors including literacy.
The suggestions outlined by the manuscript are a good platform on which to base our ongoing clinical practices.
Education is vitally important. The authors discuss education of medical students and different case-based practices that we can use for our young trainees to educate them on the importance of women’s health. Additionally, it remains important to educate young girls and women about the importance of their own health and optimizing cardiac risk factors, by not smoking and making sure that other factors such as BP, cholesterol, weight and diabetes are well controlled. Education of women has been shown to benefit society as a whole and typically places individual women in a better position financially, which can translate into them having more secure incomes, better health insurance and then more access to health care.
This paper raises a lot of good points. If we can not only address the issues they raise, but also build upon them, we will be at least part of the way there. It may be still some time before we can achieve complete equilibrium between the genders for a variety of reasons, but it’s commendable that a journal such as JACC is publishing this manuscript to highlight these important issues and hopefully correct some of these disparities.
While the recommendations in this paper are realistic, sometimes we overlook simple solutions. For example, I recently saw a patient who was felt to be noncompliant with her medications. When we talked to her, we learned that she had been too embarrassed to tell us that she couldn’t read. Therefore, she couldn’t read the labels on her medications or follow her recommended medication regimen. With tools like photos, we were able to put together a medication schedule that she was able to follow. It is always important to step back and think, ‘In this particular person, what is the obstacle that they are facing to achieve their optimal health care?’ It might be financial, it might be educational, it might be that they are caring for many children or elderly relatives and they are using their own money to pay for medicines for those people, to the detriment of their own health.
A large number of women work part-time or are dependent on their partners for insurance. As circumstances change, they may be at risk of losing their insurance or paying high copays and deductibles. In this time of uncertainty about future plans with insurance, this can be increasingly stressful. We physicians need to ensure that people are able to receive care now, but are also able to access quality health care going forward.
There is certainly a concern that minority groups may be disadvantaged by changes in health care. Although women are not a minority group, often they’re a disadvantaged group and therefore, it will be important that any changes made to current health care systems are mindful of the implications of amendments on women and other minority groups.
Women can have nontraditional presentations for CVD, and therefore often present late or have more comorbidities when they do present. There have been numerous trials to show that they are not receiving the care that guidelines would suggest that they should receive. We need to educate women to present earlier and seek medical assistance when required. Physicians also need to ensure that we provide optimum guideline-based care for everyone regardless of gender.
Women are often great multitaskers, sometimes to the detriment of their own health. Particularly now, women are often caring for children and elderly parents, which can leave them very time-poor. To be able to look after others, we need to remind women that their own health care needs must also be prioritized.
This manuscript in JACC goes a long way to summarizing the gender-related issues in CV healthcare, and if we can build upon their recommendations, it will certainly put us on a good road going forward.
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