Is there a clinically significant gender bias in post-myocardial infarction pharmacological management in the older (>60) population of a primary care practice?

Is There a Gender Self-Advocacy Gap? An Empiric Investigation Into the Gender Pain Gap

There are documented differences in the efficacy of medical treatment for pain for men and women. Women are less likely to have their pain controlled and receive less treatment than men. We are investigating one possible explanation for this gender pain gap: that there is a difference in how women and men report their pain to physicians, and so there is a difference in how physicians understand their pain. This paper describes an exploratory study into gendered attitudes towards reporting uncontrolled pain to a physician. This exploratory study provided subjects with a vignette describing a situation in which their pain is not being treated adequately and asked them questions about their attitudes towards self-advocacy and the strategies they would likely use to express themselves. We found that women scored higher than men on measures of patient likelihood to self-advocate. Women also reported intending to use more varied self-advocacy strategies than men. This suggests it is unlikely that patient's communication styles are to blame for the gender pain gap.

Gender differences in the surgical management of lumbar degenerative disease: a scoping review

OBJECTIVE

Despite efforts toward achieving gender equality in clinical trial enrollment, females are often underrepresented, and gender-specific data analysis is often unavailable. Identifying and reducing gender bias in medical decision-making and outcome reporting may facilitate equitable healthcare delivery. Gender disparity in the utilization of surgical therapy has been exemplified in the orthopedic literature through studies of total joint arthroplasty. A paucity of literature is available to guide the management of lumbar degenerative disease, which stratifies on the basis of demographic factors. The objective of this study was to systematically map and synthesize the adult surgical literature regarding gender differences in pre- and postoperative patient-reported clinical assessment scores for patients with lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis).

METHODS

A systematic scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. MEDLINE, Embase, and the Cochrane Registry of Controlled Trials were searched from inception to September 2018. Study characteristics including patient demographics, diagnoses, procedures, and pre- and postoperative clinical assessment scores (pain, disability, and health-related quality of life [HRQoL]) were collected.

RESULTS

Thirty articles were identified, accounting for 32,951 patients. Six studies accounted for 84% of patients; 5 of the 6 studies were published by European groups. The most common lumbar degenerative conditions were disc herniation (59.0%), disc degeneration (20.3%), and spinal canal stenosis (15.9%). The majority of studies reported worse preoperative pain (93.3%), disability (81.3%), and HRQoL (75%) among females. The remainder reported equivalent preoperative scores between males and females. The majority of studies (63.3%) did not report preoperative duration of symptoms, and this represents a limitation of the data. Eighty percent of studies found that females had worse absolute postoperative scores in at least one outcome category (pain, disability, or HRQoL). The remainder reported equivalent absolute postoperative scores between males and females. Seventy-three percent of studies reported either an equivalent or greater interval change for females.

CONCLUSIONS

Female patients undergoing surgery for lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis) have worse absolute preoperative pain, disability, and HRQoL. Following surgery, females have worse absolute pain, disability, and HRQoL, but demonstrate an equal or greater interval change compared to males. Further studies should examine gender differences in preoperative workup and clinical course.

Diagnosis and management of acromegaly: the patient's perspective

PURPOSE

Early diagnosis is a success factor for the prevention of long-term comorbidity and premature death in patients with acromegaly, but large-scale data on the diagnostic process and disease management are scarce. Therefore, we aimed to evaluate the diagnostic process, implementation of treatment and changes in life situation in patients with acromegaly, focusing on sex-specific differences.

METHODS

Non-interventional patient-reported outcome study. 165 patients with clinically and biochemically proven acromegaly were questioned about the diagnostic process and utilization of health care by means of a self-developed standardized postal survey including questions on acromegaly symptoms experienced before diagnosis, number and specialty of consulted doctors, time to diagnosis and aftercare.

RESULTS

The diagnostic process took 2.9 (SD 4.53) years, during which 3.4 (SD 2.99) physicians were consulted. Women waited longer [4.1 (SD 5.53) years] than men [1.6 (SD 2.69) years; p = 0.001] for the correct diagnosis, and consulted more doctors in the process [4.0 (SD 2.99) vs. 2.7 (SD 2.84) doctors, p < 0.001, respectively]. In 48.5 % of patients, acromegaly was diagnosed by an endocrinologist (men: 45.1 %; women: 52.4 %). Overall disease duration from symptom onset until last surgery was 5.5 (SD 6.85) years, with no sex differences. A change in employment status was the most commonly reported event after diagnosis and a quarter of the patients stated that the illness had changed their lives.

CONCLUSIONS

Our findings confirm the urgent need to increase awareness of the clinical manifestation of acromegaly to facilitate an earlier diagnosis of the disease and to provide diagnostic equality across the sexes.

Sex differences in predictors of longitudinal changes in carotid artery stiffness: the Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

To identify sex differences in predictors of longitudinal changes in carotid arterial stiffness in a multiethnic cohort.

APPROACH AND RESULTS

Carotid artery distensibility coefficient (DC) and Young's elastic modulus (YEM) were measured in 2650 Multi-Ethnic Study of Atherosclerosis participants (45-84 years old and free of cardiovascular disease) at baseline and after a mean of 9.4 years. Predictors of changes in DC and YEM for each sex were evaluated using multivariable linear regression models. The 1236 men (46.6%) were 60.0 (SD, 9.3) years: 40% were white, 22% black, 16% Chinese, and 22% Hispanic. The 1414 (53.4%) women were 59.8 (9.4) years old with a similar race distribution. Despite similar rates of change in DC and YEM, predictors of changes in distensibility markers differed by sex. In men, Chinese (P=0.002) and black (P=0.003) race/ethnicity, systolic blood pressure (P=0.012), and diabetes mellitus (P=0.05) were associated with more rapidly decreasing DC (accelerated stiffening). Starting antihypertensive medication was associated with improved DC (P=0.03); stopping antihypertensives was associated with more rapid stiffening (increased YEM, P=0.05). In women, higher education was associated with slower stiffening (DC, P=0.041; YEM, P<0.001) as was use of lipid-lowering medication (P=0.03), whereas baseline use of antihypertensive medications (YEM, P=0.01) and systolic blood pressure (DC, P=0.02; P=0.04) predicted increasing stiffening in women.

CONCLUSIONS

Longitudinal changes in carotid artery stiffness are associated with systolic blood pressure and antihypertensive therapy in both sexes; however, race/ethnicity (in men) and level of education (in women) may have different contributions between the sexes.

Inequality in analgesic prescription in Spain. A gender development issue

OBJECTIVES

It is well known that sex differences in analgesic prescription are not merely the logical result of greater prevalence of pain in women, since this therapeutic variability is related to factors such as educational level or social class. This study aims to analyse the relationship between analgesic prescription and gender development in different regions of Spain.

METHODS

Cross-sectional study of sex-differences in analgesic prescription according to the gender development of the regions studied. Analgesic prescription, pain and demographic variables were obtained from the Spanish Health Interview Survey in 2006. Gender development was measured with the Gender Development Index (GDI). A logistic regression analysis was conducted to compare analgesic prescription by sex in regions with a GDI above or below the Spanish average.

RESULTS

Once adjusted by pain, age and social class, women were more likely to be prescribed analgesics than men, odds ratio (OR) = 1.74 (1.59-1.91), as residents in regions with a lower GDI compared with those in region with a higher GDI: ORWomen = 1.26 (1.12-1.42), ORMen = 1.30 (1.13-1.50). Women experiencing pain in regions with a lower GDI were more likely than men to be treated by a general practitioner rather than by a specialist, OR = 1.32 (1.04-1.67), irrespective of age and social class.

CONCLUSIONS

Gender bias may be one of the pathways by which inequalities in analgesic treatment adversely affect women's health. Moreover, research into the adequacy of analgesic treatment and the possible medicalisation of women should consider contextual factors, such as gender development.

The quality of primary care in a country with universal health care coverage

BACKGROUND

Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage.

OBJECTIVE

To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage.

DESIGN AND PARTICIPANTS

Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings.

MAIN MEASURES

We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator.

KEY RESULTS

Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥ 65 years, p = 0.047).

CONCLUSIONS

Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

Reaching those most in need: a scoping review of interventions to improve health care quality for disadvantaged populations with osteoarthritis

OBJECTIVE

To conduct a systematic review to identify and describe the scope and nature of the research evidence on the effectiveness of interventions to improve health care quality or reduce disparities in the care of disadvantaged populations with osteoarthritis (OA) as an example of a common chronic disease.

METHODS

We searched electronic databases from 1950 through February 2010 and grey literature for relevant articles using any study design. Studies with interventions designed explicitly to improve health care quality or reduce disparities in the care of disadvantaged adult populations with OA and including an evaluation were eligible. We used the PROGRESS-Plus framework to identify disadvantaged population subgroups.

RESULTS

Of 4,701 citations identified, 10 met the inclusion criteria. Eight were community based and 6 targeted race/ethnicity/culture. All 10 studies evaluated interventions aimed at people with OA; 2 studies also targeted the health care system. No studies targeted health care providers. Nine of 10 studies evaluated arthritis self-management interventions; all showed some benefit. Only 1 study compared the difference in effect between the PROGRESS-Plus disadvantaged population and the relevant comparator group.

CONCLUSION

There are few studies evaluating the effectiveness of interventions to improve health care quality in disadvantaged populations with OA. Further research is needed to evaluate interventions aimed at health care providers and the health care system, as well as other patient-level interventions. Gap intervention research is also needed to evaluate whether interventions are effective in reducing documented health care inequities.

Disparity in management of diabetes and coronary heart disease risk factors by sex in DCCT/EDIC

AIMS

Coronary heart disease (CHD) is a major cause of morbidity and mortality in patients with diabetes. Sex disparity in the treatment of modifiable CHD risk factors in patients with Type 2 diabetes has been reported previously; however, there is little comparable information in Type 1 diabetes.

METHODS

We performed a cross-sectional analysis of 1153 subjects with Type 1 diabetes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) cohort to compare achievement of metabolic and CHD risk factor goals and use of recommended risk factor interventions between the sexes.

RESULTS

Women were less likely than men to achieve glycated haemoglobin (HbA1c)<7.0% [adjusted odds ratio (AOR) 0.76, 95% confidence interval (CI) 0.57-0.995] or<8.0% (AOR 0.74, 95% CI 0.58-0.95). Achievement of target lipid levels was not significantly different between the sexes. As in the non-diabetic population, men had higher blood pressure. Women were significantly less likely than men to report using aspirin (AOR 0.77, 0.60-0.99) and angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (AOR 0.62, 0.49-0.80) and statins (AOR 0.56, 0.43-0.73), even after adjusting for blood pressure and lipid levels, respectively. Reported use of statins was also lower in women than men in the subset that developed a low-density lipoprotein (LDL) cholesterol level>3.4 mmol/l (39% vs. 60%, P<0.05).

CONCLUSIONS

In Type 1 diabetes, women report lower frequency than men in the use of interventions that decrease CHD risk. These findings are consistent with reports in the Type 2 diabetic population, showing that risk-reducing measures are underused in women with diabetes.

Patients' gender affected physicians' clinical decisions when presented with standardized patients but not for matching paper patients

OBJECTIVE

To compare physicians' treatment and referral decisions for total knee arthroplasty (TKA) for standardized patients with matching paper patients.

STUDY DESIGN AND SETTING

Sixty-seven physicians (38 family physicians and 29 orthopedic surgeons) performed blinded assessments of two standardized patients (one man and one woman) with moderate knee osteoarthritis and otherwise identical clinical scenarios differing only in gender, and consented to including their data. Standardized patients recorded physicians' recommendations (yes/no) to refer for, or perform, TKA. Sixty physicians provided their treatment recommendations to matching paper patients.

RESULTS

Recommendation rates for both the male and the female standardized patients (67% and 32%, respectively) were lower compared with the matching paper patients (80% and 67%, respectively). Physicians were more likely to recommend TKA to a man than to a woman when presented with standardized patients (odds ratio, 4.2; 95% confidence interval [CI]=2.4-7.3; P<0.001). In contrast, patients' gender did not affect the same physicians' recommendations regarding referral for, or performing, TKA for the matching paper patients (odds ratio, 2.0; 95% CI=0.9-4.6; P=0.101).

CONCLUSION

Unlike their treatment recommendations for standardized patients, the same physicians' treatment and referral decisions for paper patients were not influenced by patients' gender, suggesting that paper patients are not a sensitive method of assessing physician bias.

Evaluating sex differences in population-based utilization of implantable cardioverter-defibrillators: role of cardiac conditions and noncardiac comorbidities

BACKGROUND

The influence of age and comorbidities on sex-specific implantable cardioverter-defibrillator (ICD) use for primary or secondary prevention is undefined.

OBJECTIVE

The purpose of this study was to investigate the influence of age and comorbidities on sex-specific ICD use.

METHODS

Sex disparities and sex-specific trends in ICD implantation according to indication in patients with cardiac arrest (1998-2007) in Ontario, Canada, were examined. Use of ICDs for primary prevention in patients with myocardial infarction (2002-2007) or heart failure (2005-2007) also was examined.

RESULTS

Among 9,246 eligible secondary prevention patients (age 66.3 +/- 14.3 years; 3,577 women [39%]) with cardiac arrest, men were more likely to undergo ICD implantation, with an age-, comorbidity-, and arrhythmia-adjusted hazard ratio (HR) of 1.92 (95% confidence interval [CI]: 1.66-2.23). Among 105,516 patients with myocardial infarction (age 68.3 +/- 12.7 years; 42,987 women [41%]), men were threefold more likely to undergo ICD implantation, with an adjusted HR of 3.00 (95% CI: 2.53-3.55). Among 61,160 patients with heart failure (age 76.2 +/- 12.0 years; 31,575 women [52%]), ICD implantation was more likely in men, with an adjusted HR of 3.01 (95% CI: 2.59-3.50). The odds of ICD implant for secondary prevention increased over time by 21% (95% CI: 13%-30%) in women and by 6% (95% CI: 2%-11%) in men, but rates of ICD use in men for primary prevention indications were persistently higher.

CONCLUSION

Men were more likely to undergo defibrillator implant than were women for primary and secondary prevention. Age and comorbidities did not account for the observed sex differences. Although sex differences in secondary prevention are declining over time, disparities in primary prevention persist.

Changing lifestyle habits as secondary prophylaxis after coronary artery bypass grafting

BACKGROUND

Many studies have investigated the effect on mortality and morbidity of modified risk factors after coronary artery bypass grafting (CABG). We performed a retrospective survey to evaluate changing lifestyle habits after CABG during 1990-2003, focusing on the correlation between lifestyle habits and freedom from symptoms and regained exercise tolerances.

METHODS

We reviewed data from 2269 patients who had undergone CABG in the year 1990, 1993, 1998, 2000, 2001, 2002, or 2003. Data were collected with a questionnaire that addressed lifestyle modifications and their outcomes with regard to quality of life for up to 5 years after surgery.

RESULTS

We observed significant decreases in changing dietary habits after surgery in patients who had surgery in 2000-2003 compared with patients who had surgery in 1990-1998 (15.9% +/- 1.6% vs 24.7% +/- 2.6%; P < .001). In addition, the desire for nutritional counselling decreased steadily over time (35.1% +/- 7.9% vs 26.6% +/- 1.4%; P <.0001). Notably, among patients 50-59 years old, fewer men than women followed a strict diet (males 20.0% vs females 41.5%; P = .001). Patients suffering from recurrent angina consulted nutritionists more often than patients without angina (36.6% vs 29.8%; P = .016). The more the patients were restricted in terms of physical fitness, as determined by the New York Heart Association (NYHA) class, the more likely they were to adhere to a healthy diet (NYHA III 22.2% vs NYHA II 14.6% vs NYHA I 10.2%; P <.001). Among patients 60-79 years old, men exercised more often than women (72.4% +/- 2.4% vs 51.1% +/- 4.9%; P <.001) and suffered less frequently from recurrent angina (13.4% +/- 4.0% vs 28.8% +/- 10.8%; P = .002).

CONCLUSIONS

Despite knowledge of hypercholesterolemia or obesity as agents contributing to advancing coronary heart disease, attention to nutrition tends to significantly decrease over time in patients who have undergone CABG. Thus patients who have undergone CABG, especially male patients older than 50, years would benefit from dietary education. Similarly, female patients older than 60 years would benefit from increased physical activity. Patients obviously tend to delay lifestyle modification until symptoms occur. Hence they must be reminded of the importance of healthy nutrition and adequate physical activity.

The effect of patients' sex on physicians' recommendations for total knee arthroplasty

BACKGROUND

The underuse of total joint arthroplasty in appropriate candidates is more than 3 times greater among women than among men. When surveyed, physicians report that the patient's sex has no effect on their decision-making; however, what occurs in clinical practice may be different. The purpose of our study was to determine whether patients' sex affects physicians' decisions to refer a patient for, or to perform, total knee arthroplasty.

METHODS

Seventy-one physicians (38 family physicians and 33 orthopedic surgeons) in Ontario performed blinded assessments of 2 standardized patients (1 man and 1 woman) with moderate knee osteoarthritis who differed only by sex. The standardized patients recorded the physicians' final recommendations about total knee arthroplasty. Four surgeons did not consent to the inclusion of their data. After detecting an overall main effect, we tested for an interaction with physician type (family physician v. orthopedic surgeon). We used a binary logistic regression analysis with a generalized estimating equation approach to assess the effect of patients' sex on physicians' recommendations for total knee arthroplasty.

RESULTS

In total, 42% of physicians recommended total knee arthroplasty to the male but not the female standardized patient, and 8% of physicians recommended total knee arthroplasty to the female but not the male standardized patient (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.4-7.3, p < 0.001; risk ratio [RR] 2.1, 95% CI 1.5-2.8, p < 0.001). The odds of an orthopedic surgeon recommending total knee arthroplasty to a male patient was 22 times (95% CI 6.4-76.0, p < 0.001) that for a female patient. The odds of a family physician recommending total knee arthroplasty to a male patient was 2 times (95% CI 1.04-4.71, p = 0.04) that for a female patient.

INTERPRETATION

Physicians were more likely to recommend total knee arthroplasty to a male patient than to a female patient, suggesting that gender bias may contribute to the sex-based disparity in the rates of use of total knee arthroplasty.

Hyperlipidemia guideline adherence and association with patient gender

BACKGROUND

Gender disparities in cardiovascular disease (CVD) management have become increasingly apparent in recent years. Previous research has focused on inpatient disparities, but little is known about how patient gender affects assessment, treatment, and management of patients for hyperlipidemia and cardiovascular risk in primary care settings. Patients with coronary artery disease (CAD) and hyperlipidemia are at high risk for cardiovascular and cerebrovascular morbidity. We sought to examine the effect of patient gender on assessment, treatment, and target maintenance of hyperlipidemia among patients with CAD in a primary care setting.

METHODS

Chart abstraction was done for 715 patients with CAD in 55 family practices in New Jersey and eastern Pennsylvania as part of the Using Learning Teams for Reflective Adaptation (ULTRA) project. Hyperlipidemia assessment, treatment, and target adherence scores were determined for those at-risk patients based on National Heart, Lung, and Blood Institute (NHLBI) recommended National Cholesterol Education Program (NCEP) ATP III guidelines. Generalized linear models were used to determine the association of hyperlipidemia guideline adherence with patient gender, using comorbidities and age as confounders.

RESULTS

After controlling for comorbidities and age, women were less likely to be assessed for lipids (p = 0.0462). There was no difference in treatment (p = 0.1074) or target laboratory values (p = 0.3949).

CONCLUSIONS

Women with CAD are less often assessed for lipids than men in primary care practices. More intensive efforts may be necessary to educate physicians and patients about cardiovascular risk for women.

Clinical and nonclinical correlates of adherence to prescribing guidelines for hypertension in a large managed care organization

To examine correlates of guideline adherence in a population with access to health care and prescription drug benefits, the authors conducted a cross-sectional analysis among 5789 patients undergoing hypertension treatment with a single medication in a large New England managed care organization. Logistic regression was used to determine correlates of adherence, defined as use of diuretics or beta blocker as antihypertensive monotherapy during the 1-year study period. Women were more likely than men to receive guideline-adherent therapy (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.45-1.85). Compared with patients covered by health maintenance organization plans, Medicare coverage was positively associated with guideline adherence (OR, 1.38; 95% CI, 1.13-1.69), but fee-for-service coverage was negatively associated (OR, 0.66; 95% CI, 0.48-0.91). Patient age was not a significant correlate of adherence to guidelines (OR, 1.01; 95% CI, 0.94-1.09). Understanding these observations may lead to strategies to improve guideline adherence and reduce health care disparities.

Retrospective review of sex differences in the management of dyslipidemia in coronary heart disease: an analysis of patient data from a Maryland-based health maintenance organization

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death in men and women in the United States, with a higher mortality in women, despite a lower prevalence. Statins effectively treat dyslipidemia and reduce the risk of CHD mortality.

OBJECTIVE

The objective of this study was to evaluate the treatment of dyslipidemia in patients with CHD and determine if sex differences exist.

METHODS

This was a retrospective chart review performed within a multioffice staff model health maintenance organization of approximately 70,000 members. An administrative database, containing inpatient and out-patient medical claims, was used to identify patients with CHD based on diagnostic codes. Charts were randomly selected and the following information was obtained from chart review: age; sex; risk factors for CHD; diagnosis and/or prescription for depression; blood low-density lipoprotein cholesterol (LDL-C) level; and drug, dosage, and duration of prescribed lipid-lowering therapy. Exclusion criteria included missing charts and unavailable LDL-C values. LDL-C values were classified as at target if LDL-C<2.59 mmol/L (<100 mg/dL). Patients receiving statin monotherapy were categorized into 3 potency groups, based on efficacy to lower LDL-C values: high (atorvastatin 20-80 mg, lovastatin 80 mg), medium (atorvastatin 10 mg, pravastatin 40 mg, simvastatin 200 mg), and low (fluvastatin 10-40 mg, lovastatin 10-40 mg, pravastatin 10-20 mg, simvastatin 5-10 mg).

RESULTS

A total of 1487 adult patients (64.4% male with a mean (SD) age of 65.7 (11.8) years were identified, based on diagnostic codes for CHD. Three hundred twenty charts were selected for review. After exclusion, the final study cohort was 290 patients. The cohort was 66.2% male (192/290) with no significant difference in mean (SD) age between men (65.2 [9.2] years) and women (66.9 [10.5] years). Weight of women ranged from 85 to 305 lbs; 134 to 288 lbs for men. Among the study cohort, 46.2% (134/290) of the patients achieved the target LDL-C of <2.59 mmol/L (<100 mg/dL), with significantly more men (51.0% [98/192]) than women (36.7% [36/98]) reaching target (P=0.021). Lipid-lowering therapy was prescribed to 68.6% (199/290) of the patients, with no significant sex differences (men, 71.4% [137/192]; women, 63.3% [62/98]). Of the patients prescribed lipid-lowering therapy (primarily statins), 53.8% (107/199) achieved target LDL-C. There was no significant sex difference in the potency groups prescribed, and the rate of LDL-C target attainment was similar across potency groups. Overall, 70.3% of patients who did not receive lipid-lowering therapy had inadequately controlled LDL-C (women, 31/36 [86.1%]; men, 33/55 [60.0%] [P=0.008]).

CONCLUSIONS

The majority of CHD patients from a Maryland-based health maintenance organization had elevated LDL-C values, despite a lipid-lowering prescription rate of 68.6%. A significant gap in dyslipidemia treatment in these CHD patients remained, particularly for women.

Physicians' attitudes toward preventive therapy for coronary artery disease: is there a gender bias?

BACKGROUND

While much of the gender difference in the treatment of coronary artery disease (CAD) results from the fact that the women being treated are older and have more comorbidities, it remains to be established whether a true gender bias exists. We compared physicians' attitudes and practice toward preventive therapy in men and women with CAD.

HYPOTHESIS

Physicians perceive the prevention of CAD in men as more important than in women.

METHODS

In the "attitude study," we obtained data on the attitudes of 172 physicians toward treatment, using hypothetical case histories of 58-year-old male and postmenopausal female patients with identical clinical and laboratory data and mild coronary atherosclerosis on angiography. In the "actual practice study," we evaluated the lipoprotein levels and prescription of lipid-lowering medications from medical records of 344 male and female patients with angiographic evidence of CAD.

RESULTS

In the hypothetical case histories, physicians in general considered the male patient to be at higher risk and prescribed aspirin (91 vs. 77%, p < 0.01) and lipid-lowering medications (67 vs. 54%, p < 0.07) more often for the male patient. Evaluation of medical charts of patients with CAD revealed that in patients with baseline low-density lipoprotein cholesterol > 110 mg/dl, 77% of the males received a lipid-lowering medication, compared with only 47% of the female patients (p < 0.001).

CONCLUSIONS

We found evidence for a gender bias in the attitude as well as in actual practice of secondary prevention toward patients with CAD. While the proportion of male patients receiving lipid-lowering medications appears appropriate, the proportion of women receiving such treatment remains undesirable.

Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes

OBJECTIVE

Diabetes eliminates the protective effect of female sex on the risk of coronary heart disease (CHD). We assessed sex differences in the treatment of CHD risk factors among patients with diabetes.

RESEARCH DESIGN AND METHODS

A cross-sectional analysis included 3,849 patients with diabetes treated in five academic internal medicine practices from 2000 to 2003. Outcomes were stratified by the presence of CHD and included adjusted odds ratios (AORs) that women (relative to men) were treated with hypoglycemic, antihypertensive, lipid-lowering medications or aspirin (if indicated) and AORs of reaching target HbA(1c), blood pressure, or lipid levels.

RESULTS

Women were less likely than men to have HbA(1c) <7% (without CHD: AOR 0.84 [95% CI 0.75-0.95], P = 0.005; with CHD: 0.63 [0.53-0.75], P < 0.0001). Women without CHD were less likely than men to be treated with lipid-lowering medication (0.82 [0.71-0.96], P = 0.01) or, when treated, to have LDL cholesterol levels <100 mg/dl (0.75 [0.62-0.93], P = 0.004) and were less likely than men to be prescribed aspirin (0.63 [0.55-0.72], P < 0.0001). Women with diabetes and CHD were less likely than men to be prescribed aspirin (0.70 [0.60-0.83], P < 0.0001) or, when treated for hypertension or hyperlipidemia, were less likely to have blood pressure levels <130/80 mmHg (0.75 [0.69-0.82], P < 0.0001) or LDL cholesterol levels <100 mg/dl (0.80 [0.68-0.94], P = 0.006).

CONCLUSIONS

Women with diabetes received less treatment for many modifiable CHD risk factors than diabetic men. More aggressive treatment of CHD risk factors in this population offers a specific target for improvement in diabetes care.

Evidence-based cardiovascular care in the community: a population-based cross-sectional study

Background

Ischaemic heart disease and congestive heart failure are common and important conditions in family practice. Effective treatments may be underutilized, particularly in women and the elderly. The objective of the study was to determine the rate of prescribing of evidence-based cardiovascular medications and determine if these differed by patient age or sex.

Methods

We conducted a two-year cross-sectional study involving all hospitals in the province of Nova Scotia, Canada. Subjects were all patients admitted with ischaemic heart disease with or without congestive heart failure between 15 October 1997 and 14 October 1999. The main measure was the previous outpatient use of recommended medications. Chi-square analyses followed by multivariate logistic regression analyses were used to examine age-sex differences.

Results

Usage of recommended medications varied from approximately 60% for beta-blockers and angiotensin converting enzyme (ACE) inhibitors to 90% for antihypertensive agents. Patients aged 75 and over were significantly less likely than younger patients to be taking any of the medication classes. Following adjustment for age, there were no significant differences in medication use by sex except among women aged 75 and older who were more likely to be taking beta-blockers than men in the same age group.

Conclusions

The use of evidence-based cardiovascular medications is rising and perhaps approaching reasonable levels for some drug classes. Family physicians should ensure that all eligible patients (prior myocardial infarction, congestive failure) are offered beta-blockers or ACE inhibitors.

Review of evidence and explanations for suboptimal screening and treatment of dyslipidemia in women. A conceptual model

Screening and treatment rates for dyslipidemia in populations at high risk for cardiovascular disease (CVD) are inappropriately low and rates among women may be lower than among men. We conducted a review of the literature for possible explanations of these observed gender differences and categorized the evidence in terms of a conceptual model that we describe. Factors related to physicians' attitudes and knowledge, the patient's priorities and characteristics, and the health care systems in which they interact are all likely to play important roles in determining screening rates, but are not well understood. Research and interventions that simultaneously consider the influence of patient, clinician, and health system factors, and particularly research that focuses on modifiable mechanisms, will help us understand the causes of the observed gender differences and lead to improvements in cholesterol screening and management in high-risk women. For example, patient and physician preferences for lipid and other CVD risk factor management have not been well studied, particularly in relation to other gender-specific screening issues, costs of therapy, and by degree of CVD risk; better understanding of how available health plan benefits interact with these preferences could lead to structural changes in benefits that might improve screening and treatment.