Category Archives: Disparities in Care

Going Up In Smoke: The Falling Lifespans of Women in the US Today

As I have stated many times in the past, women are undertreated and underserved when it comes to cardiovascular disease and stroke.  Now, more than ever, this may even be more important due to several recent studies that have been published in the last few weeks.  Several investigations have demonstrated two troublesome facts:  In certain areas of the country, life expectancy for women is decreasing AND women who smoke are much more likely to have lung cancer than men who smoke.  These facts argue for more aggressive treatment of women and more targeted gender specific prevention efforts–no longer can women’s risk for disease be discounted. Although awareness efforts are continuing, we continue to fall short in identifying and treating women with cardiovascular disease.

In a study published last week in the journal Health Affairs, researchers compared mortality rates from 1992-96 with those from 2002-06 in 3,140 counties in the United States.  In the study, female mortality rates increased in 42% of counties while rates in men only increased by 3.4%.  Factors associated with lower mortality rates in women included higher education, location not in the south or west and non use of tobacco.  These findings are incredibly troubling in that over the same time period, mortality rates in men have fallen in these same counties.

In a related article published this year in the New England Journal of Medicine, it was found that smoking in women is associated with a higher risk for lung cancer, cardiovascular disease and death as compared to smoking in men.  Among men, the risks of death from smoking have plateaued since the 1980s.  In the 1980s women who smoked were 13 times more likely to die from lung cancer –in contrast, women are now found to be 26 times more likely to die as compared to those who do not smoke.  However, there are data that show that smokers who quit by age 40 are able to reduce their risk for death significantly and in fact add 10 additional years to their life span.

So, altogether, it seems that smoking for women is a significant public health issue.  Women are smoking in greater numbers and those that began smoking in the 1960s are now seeing the long term effects–this cohort of women is truly the first group of long term female smokers that have been studied.  The results are truly sobering.  As healthcare providers we must do our best to prevent chronic disease.  Certainly in this era of cost containment and the new Affordable Care Act, we must strive to modify risk.  Smoking cessation is something that all providers, regardless of specialty, must work to encourage.  In fact, I believe that individual cost and  access to insurance coverage should be based on one’s smoking habits.  Those who choose to smoke should pay significantly higher premiums as they will be using more resources down the line.  Physicians will be held accountable for documenting smoking status and smoking cessation counselling–why then can’t patients and consumers of healthcare be held accountable for their own reckless behaviors (such as smoking).

But, back to the issue at hand.  Once again, we find that women are under treated and underserved.  According to recent studies, women are less likely to be referred or counseled for smoking cessation. In addition, data from the NCBI indicates that women have more difficulty quitting.  According to NCBI researchers, unique factors affecting a woman’s ability to successfully stop smoking include concerns over weight gain,  mood variability and withdrawal symptoms associated with hormonal changes during the menstrual cycle.

Ultimately, we must do a better job helping women with smoking cessation.  Mortality statistics such as the those recently presented serve as a failing report card when it comes to prevention activities in women.  We must identify female patients at risk and push for smoking cessation.  Once again, we must empower women to take an active role in their healthcare and engage them in healthy lifestyle modification activities.

Black Smoke and Fire Rises


Things Aren’t Always As They May Seem: The Challenge of Diagnosing and Treating Cardiovascular Disease in Women

Recently, television personality Rosie O’Donnell was in the headlines after suffering a heart attack.  Her presentation with an acute coronary syndrome (ACS) was atypical; her symptoms were different from the traditional symptoms seen in men having a heart attack.  Earlier in the day  of her event, Ms O’Donnell had helped  a woman from her car.  That evening she blogged that “a few hours later my body hurt, and that  i had an ache in my chest. both my arms were sore. everything felt bruised.”  Ms O’Donnell’s symptoms were persistent and she began to wonder if her symptoms might represent a heart attack.  She decided to take an aspirin (a particularly good idea in her case) but continued to deny the symptoms until she consulted her physician the next day.  She immediately underwent a cardiac catheterization and was found to have a 99% blockage of her left anterior descending artery (LAD).  She had a stent (small metal tube to open the blocked artery) placed and is likely to recover completely.
Her case highlights one of the biggest challenges in caring for women with cardiovascular disease–lack of recognition by clinicians and denial and delay by patients experiencing the symptoms.  Women in the US today account for a large number of the nearly half million deaths from CV disease and Sudden Cardiac death.  Yet, as I have discussed in previous blogs, women remain underdiagnosed and undertreated.  The best way to impact disparities in care is through education and awareness.
Recognizing the signs:
Traditionally, male heart attack victims present with crushing sub-sternal chest pain, shortness of breath, diaphoresis (sweating) and nausea.  Sometimes the pain may radiate into the neck or jaw.  Women and men are biologically quite different as we all know.  There are distinct differences in the way cardiovascular disease develops, progresses and ultimately presents clinically.  Certainly, women can present with classic symptoms.  However, often women present quite atypically.  Moreover, some diagnostic tests are less accurate in women as compared to me.  Diagnosing both acute and indolent cardiovascular disease in women can be quite challenging.Women tend to take care of their children and spouse first, often ignoring their own healthcare needs for long periods of time.  This may dismiss symptoms and carry on with their daily routines in order to avoid disrupting the family.  Coronary artery disease in women tends to be more diffuse (more widespread) and involves more small vessel disease.   Women also tend to present later than their male counterparts and often with more advanced disease.  Some of this may be explained by hormonal and biologic differences.  Symptoms in women may be quite vague and may include feelings of dread or anxiety, fatigue, or flu-like illness.  These vague symptoms can make prompt diagnosis much more difficult.   Women can also present with classic chest pain just as we described in men but often women deny the symptoms could be related to heart disease.
Making a Difference in Outcomes:  
1. Educate women and providers of healthcare to women about the risk factors for cardiovascular disease.  Make sure that every woman understands the signs and symptoms of heart attacks and how they may be different in female patients.
2. Actively screen at risk women for cardiovascular disease.  Ask about risk factors such as hypertension, smoking, high cholesterol, diabetes and family history of CAD.  Aggressively evaluate women with multiple risk factors even in the absence of classic symptoms.  Make sure that female patients understand what the risk factors are  how they can modify those risks.
3. Empower women to take control of their own healthcare.  Actively engage women in the prevention of disease.  Make sure women understand that they must act quickly when symptoms occur.  Denial of symptoms and delay in treatment most often results in much poorer outcomes.
The Upshot:
Rosie O’Donnell was fortunate.  She had symptoms consistent with a heart attack (although somewhat atypical).  For a little while she denied the symptoms but ultimately took an aspirin and sought care.  Luckily, she was able to get to a hospital and have a procedure done to open a blocked coronary artery before significant heart damage was done.  We must all learn from this case and educate our friends, families and colleagues on the risks of cardiovascular disease in women.  Through education, awareness and advocacy we can make a difference and reduce cardiovascular deaths in women.
Rosie O'Donnell in July 2011.

Women and Cardiovascular Disease: Addressing Disparities in Care

Over the last 6 years, I have developed an educational symposium for healthcare providers to address women and cardiovascular disease, particularly prevention of sudden cardiac death. This symposium has been well received and I have produced it all over the country. The focus of the event has been to specifically address disparities in care–men are much more likely to receive more advanced, more aggressive and more cutting edge therapy than women in identical circumstances. Many hypotheses have been put forward to explain and address these disparities. Some include access to care, patient concerns and education about CV disease, social stereotypes and patient denial of symptoms or risk. During the development of the symposium, I realized that many women in the US today regularly see OB/GYN physicians as their only healthcare provider. OB/GYN physicians are not always well equipped to provide comprehensive primary care and may have little time to devote to screening for cardiovascular disease–these are highly trained women’s health experts. Most women who see an OB/GYN are more concerned with dying of breast, uterine or ovarian cancer than with CV disease or sudden cardiac death. WIth the OB/GYN, I saw an opportunity to really impact disparity in care. I began to target OB/GYN physicians and developed a quick and easy office screening tool that can be used to pre screen patients for CV disease. A simple waiting room questionnaire is filled out by the patient and handed to the nurse at intake. This questionnaire would then prompt a busy OB/GYN provider to more aggressively screen at risk women. I also produced educational events specifically for OB/GYN physicians and invited cardiologists to attend in the hopes of facilitating interactions between very dichotomous specialties. In some cases this worked well and OB/GYNs and cardiologists began to develop referral relationships following the event.

However, gender disparities in care continue to exist. Despite my best efforts (and the efforts of countless others) over the last 6 years, women with cardiovascular disease continue to be undertreated and underserved. Although we are making significant progress there is still much work to be done. A review article published in July 2012 in Women’s Health by McSweeny et al examined disparities in congestive heart failure (CHF) and other CV diseases in women. In this review, the authors identify reasons why outcomes in women with CHF are poorer as compared to men. Lack of aggressive treatment of the underlying causes of CHF such as coronary artery disease as well as a lack of adherence to medical therapy, late presentation and multiple comorbidities are identified as significant contributors to these poor outcomes. A complete lack of social support is also labelled as a major factor in the outcome of women with CHF.

In 2012, the Minnesota Women’s Heart Summit was held to address issues surrounding disparities in care. Four major points of emphasis were identified:
1. Community Awareness and Prevention. Women’s knowledge of risk of CV disease is improving but is still inadequate. Local events to raise awareness among the general public is an important part of reducing CV deaths in women. We must engage clinicians, healthcare consumers as well as government policy-makers in order to make a difference
2. Symptom recognition and delays in seeking treatment. Often women present atypically with CV disease and we must work to educate women. Public service informational campaigns are needed to promote symptom recognition in women as well as the importance of seeking timely treatment. A parallel campaign to educate primary care physicians and ER providers about the atypical nature of symptoms in women with a focus on avoiding therapy delays should be conducted.
3. Closing the Survival Gap. Women are less likely to receive evidence based therapies such as beta blockers and ACE inhibitors that have been proven to decrease mortality. Women are less likely to have coronary artery bypass surgery, cardiac catheterizations and revascularization. Goal should be to impact this fact through advocacy, better training of physicians and inclusion of more women in research and clinical trials.
4. Patient-Provider Connections. Physicians must strive to develop better relationships and have better communication with patients. Often depression, socioeconomic status and other issues become barriers to care. By seeing the whole patient and addressing some of these issues, a physician may be able to better partner with female patients and improve care.

Disparities in care for women continue to exist. It is a significant public health problem today. More women than men die from cardiovascular disease each year. Although many have worked very hard to reduce these disparities, there is much work yet to be done. We must continue to communicate, advocate and educate in order to improve outcomes in the future.