heart attack

Valentine’s Day is not the only reason to think about hearts in February, a.k.a. American Heart Month.  This guest-post on women’s heart health by Chloe E. Bird, Ph.D. — senior sociologist at the nonprofit, nonpartisan RAND Corporation and professor at the Pardee RAND Graduate School — discusses findings from a recent RAND pilot study.*  In our email exchange, Chloe emphasized, “…please don’t assume that you, or the women in your life, are too young to be concerned.”

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High-quality routine care for both cardiovascular disease (CVD) and diabetes is at least as relevant to women’s health and survival as it is to men’s.  Yet evidence suggests that women continue to face gaps in even low-cost, routine aspects of care.

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CVD is the leading cause of death for women, as well as for men. More than one in three adult women has some form of CVD.  In fact, since 1984, more U.S. women than men have died of CVD, and 26 percent of women over age 45 die within a year of having a recognized heart attack, compared with 19 percent of men. Diabetes is a major cardiovascular risk factor, and it increases risk of CVD more so in women than in men.

Despite improvements over recent decades in care for CVD and diabetes, evidence suggests that the care women receive—and their health outcomes—continue to lag behind those of men, even for routine care such as monitoring and control of cholesterol. Although the American Heart Association’s “Go Red for Women” campaign and efforts by Sister-to-Sister and WomenHeart have done much to raise awareness among both women and their clinicians about CVD, there is still too little attention devoted to preventing heart disease in women.

Part of the problem is that quality of care is not routinely measured and reported by gender. Conventional methods of measuring quality of care focus on average “quality performance scores” across the overall population. Separate assessments and reporting by gender are rare, so the care received by women is generally assumed to be equal to that received by men, despite evidence to the contrary. As a result, the quality gap in care remains largely invisible to individual women, providers, payers and policymakers, even among those seeking to improve women’s health and health care. In cases where gender gaps in care have been monitored and targeted, such as in recent initiatives by the Veterans Health Administration, marked reductions in gender disparities in CVD and other types of care have been achieved; though some gaps persist.

In an examination of gender gaps in cholesterol screening among adults in one large California health plan who had been diagnosed with CVD or with diabetes, we found larger gender differences on average in care for CVD (5 percentage points) than for diabetes (2 percentage points). Although the gaps may appear small among the 30,000 CVD patients and 155,000 diabetes patients whose care we examined, they translate into a significant number of women who were not screened, but who might have been had they been men.

We focused on screening because clinicians agree that CVD and diabetes patients should receive annual screenings for high LDL cholesterol.  Such screening is also the first step in assessing quality of care.  Moreover, research on disparities in care often finds that gaps in screening are associated with larger gaps in treatment and poorer intermediate outcomes.

In our study, gender gaps in cholesterol screening varied geographically and favored men far more often than women. Among CVD patients, there were gaps favoring men in 79 percent of counties. In 35 percent of counties, those gaps were moderate (from 5 to less than 10 percentage points) or large (at least 10 percentage points). In 12 percent of the counties there were small gaps (from 1 to less than 5 percentage points) favoring women. Among patients with diabetes, which has not traditionally been viewed as a man’s disease, there were moderate gaps favoring men in 17 percent of counties and small gaps favoring men in another 40 percent of counties. In contrast, there were large gaps favoring women in 4 percent of counties, moderate gaps in 2 percent, and small gaps in another 12 percent.

Lessons from areas with the highest quality of care and from areas with the fewest gender disparities can motivate efforts to improve care and reduce disparities. Mapping quality of care at specific geographic levels and focusing on the areas of interest to specific stakeholders may prove to be essential to efforts to tackle disparities efficiently and meaningfully.

Without gender-stratified reporting of quality of care, gender gaps are invisible and intractable. Such reporting is essential if health plans, health care organizations, and policymakers are to ensure that overall improvements in care narrow gender gaps.

Health plans should use gender-based analysis and mapping to address gender gaps and to motivate improvements in care, treatment and outcome measures. Similarly, analyses of pooled data from multiple health plans could be used to assess gender disparities in care for CVD and diabetes for managed care patients and determine whether the size and patterns of disparities differ across plans.

Closing the gender gap is crucial if women are to benefit equally from improvements in care for CVD and diabetes.  At the same time, focusing on gender gaps can inform a broader discussion of the prevalence and burden of CVD in women and the need for improvements in prevention, diagnosis and treatment.

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*For more information, check out the online report and videos of her presentation and other researchers’ talks from RAND and UCLA’s recent women’s heart health event.

This month’s column features one of our past guest authors: Chloe E. Bird, Ph.D. is a senior sociologist at the nonprofit, nonpartisan RAND Corporation and co-author of Gender and Health: The Effects of Constrained Choices and Social Policies (Cambridge University Press).

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In the past two months, two of my friends–both seemingly healthy women–became unlikely victims of cardiovascular disease. One, a woman who by any textbook definition would be considered at low risk for heart problems, nonetheless suffered a heart attack. Thankfully, she is recovering. The other, a longtime friend and a mentor of mine, tragically passed away after suffering a stroke. These experiences left me wondering how we can accelerate efforts to reduce cardiovascular disease risk and mortality in women.

As a women’s health researcher, I am concerned about how long it is taking to bring attention and resources to this problem. After all, it has been decades since we’ve learned that cardiovascular disease affects women every bit as much–or even more–than it does men. Indeed, since 1984, cardiovascular disease has killed more women than men in the United States. When it comes to women’s health, cancer gets a good deal of the attention; somehow, it hasn’t fully registered that so many of our mothers, sisters, friends and daughters are being affected by another, often silent killer.

Commonly referred to as heart disease, cardiovascular disease includes both heart disease and other vascular diseases. When tallied separately, stroke is the third leading cause of death among women. Both strokes and cardiac events are all too common in women over 40 and, sadly, so are deaths.

Consider a few statistics:

  • In the U.S., women account for 60 percent of stroke deaths, and 55,000 more women than men suffer a stroke each year.
  • Worldwide, heart disease and stroke kill 8.6 million women annually–accounting for one in three deaths among women.
  • Whereas one in seven women develops breast cancer, more than one in three women has some form of cardiovascular disease.

Although the American Heart Association’s Go Red for Women campaign has done much to raise awareness, there is still too little attention devoted to preventing heart disease in women and improving the quality and outcomes of their care.

While we should celebrate the significant improvements in the care and survival of men with cardiovascular disease, those gains began decades ago, and the death rate among men has fallen more quickly than it has for women. Unfortunately, women continue to face lower rates of diagnosis, treatment and survival. The new Million Hearts campaign aimed at preventing a million heart attacks and strokes by 2017 has partnered with WomenHeart, a national coalition for women with heart disease. This effort is essential and represents progress, but prevention is not the only challenge.

Why are outcomes worse for women? Even if biomedical research on cardiovascular disease had not traditionally focused almost exclusively on men, these conditions would likely still be harder to recognize and treat in women. Women don’t tend to have the “TV heart attack”–the familiar image of a man clutching his left arm or his chest in pain. Rather, for women, the symptoms of a heart attack are often more subtle and less specific. Women can present with symptoms like throat pain or a sore back. In fact, 64 percent of women who die suddenly from heart disease had no previous symptoms at all.

Furthermore, tests that are mostly reliable in assessing men’s cardiac risk are not as accurate in women, largely because they are aimed at identifying major coronary artery blockage. At least half of heart attacks in women are caused by coronary microvascular disease, which involves narrowing or damage to smaller arteries in the heart. This not only makes the diagnosis challenging, but it poses problems for treatment as well. Women often go undiagnosed or incorrectly untreated after major blockages have been ruled out, and optimal treatment of microvascular disease remains unclear. Consequently, 26 percent of women over age 45 will die within a year of having a heart attack, compared with 19 percent of men. The deficits in women’s cardiovascular care may have developed unintentionally, but our efforts to address them need to be both intentional and focused.

Fortunately, we know what it will take to close the gap and get women better diagnosis and treatment for cardiovascular disease. We can start by looking to the fight against breast cancer. Our first task is to call for increased public and private funding for public-health, biomedical and health-services research to reduce women’s risk and improve their outcomes. Second, on the private side, there are many foundations dedicated to addressing cardiovascular risk in women. But they and the women they serve would benefit from more collaboration and better coordination of effort. Finally, doctors and medical clinics need to do more to improve assessment and the quality of women’s cardiovascular care. Otherwise, women’s care and outcomes will continue to lag behind men’s.

Our bodies are complex systems. So, if we want to take on women’s health in a way that truly moves the needle on outcomes, we need a comprehensive approach. Women’s health care in general needs to become a primary focus for research and practice. And improving women’s health and longevity will require us to expand our focus beyond sex-specific reproductive cancers and predominantly female diseases, such as breast cancer. This doesn’t mean that we should divert resources from other areas of study, of course. But we need to recognize that woman-specific health care should not be confined to conditions that don’t (or don’t often) affect men.

The stakes for women are high, but we can and must bring greater attention to women’s cardiovascular health. Personally, I am not willing to let go of another friend, colleague or relative to a condition that could have been caught and treated if women routinely received appropriate preventive care, diagnostic testing and treatment.  It’s time for feminists to take on heart disease as a women’s issue.

— Crossposted with permission from the Ms. Blog