By Erik Skinner | Vol . 28, No. 44 | December 2020
A QUICK LOOK INTO IMPORTANT ISSUES OF THE DAY
Cardiovascular disease is the leading cause of death for women in the United States, with nearly 48 million women living with or at risk of heart disease. Cardiovascular disease is an umbrella term that includes conditions of the heart and vascular system, such as coronary artery disease, heart rhythm conditions (arrhythmias), blood vessel diseases and heart diseases present from birth (congenital heart defects). In the United States, 1 in 5 women will die of heart disease. There are also racial disparities in cardiovascular disease rates, with Black women dying at higher rates than white women. While overall mortality has decreased over the last five decades, the racial disparities remain.
Women also experience longer wait times than men in the critical minutes after suffering a heart attack or cardiac event. Upon arriving at the emergency department, women wait an average of three minutes longer for an electrocardiogram. Clinical data also shows it takes seven minutes longer to activate the heart attack treatment protocol for women than for men. Additionally, women’s pain is sometimes dismissed or not factored into their care. Research suggests physicians prescribe women pain medication for coronary bypass surgery at half the rate they do for men.
In addition to disparities in clinical outcomes between men and women, bias in medical research and clinical trials can contribute to differences in cardiovascular health outcomes for women. Women do not reap the same benefits of cardiovascular research as men because of lack of accounting for sex differences in heart structure and function and low female trial enrollment.
Heart disease and other chronic conditions increase the risk of death and severe illness from COVID-19. Maintaining preventive and primary care services for people with cardiovascular disease is a key strategy to minimize risk. These efforts address challenges of decreasing hospitalizations for heart attacks and increasing mortality rates brought on by the pandemic.
While the pandemic exacerbated existing health care disparities, scientists are also analyzing new data and gaining knowledge about COVID-19 and its effect on health care delivery and outcomes for women with cardiovascular disease. To address the disparities and decrease their morbidity and mortality rates, states, the federal government and health systems employ a range of prevention, treatment and coverage strategies.
Efforts to improve women’s cardiovascular health may include public health approaches such as screening, education and counseling, as well as clinical treatment and coverage of cardiovascular disease services. For example, the Alabama Legislature created the Office of Women’s Health within the state department of health to consider and address women’s health and clinical care. Through data collection and analysis, the office assists the state health officer with identifying priority areas and developing strategies to improve women’s health. Key women’s health indicators that address cardiovascular health include tobacco cessation, regular exercise and blood pressure screenings.
In Illinois, the executive branch reorganized its Office of Women’s Health to include maternal and child health programs as well as prevention and treatment efforts for heart disease and cancer. The office’s mission statement references disparities in research and clinical outcomes for chronic conditions between men and women.
In addition to specific programs and offices to address women’s cardiovascular health, all 50 states have a point of contact or office to address health equity or health disparities based on sex, race and other demographics.
Alabama, Arizona, California, Georgia, Kansas, Michigan, Mississippi, Oklahoma, Pennsylvania, Tennessee and Wisconsin adopted resolutions in 2019 to recognize efforts to improve women’s cardiovascular health.
States also play a role in insurance coverage, which is associated with fewer cardiovascular deaths. Women make up a majority of Medicaid enrollees and over half of all Medicaid enrollees have a history of heart disease, making the program a significant source of coverage for screening and treatment for women with cardiovascular disease.
To reach people with chronic illnesses and others requiring medical care, all 50 states and the District of Columbia have made some revision to their telehealth policies during the pandemic to increase access to health care services and minimize potential exposure to the coronavirus. To enhance the effectiveness and reach of telehealth, state policymakers are bolstering Medicaid and private insurance coverage, expanding access to different telehealth modalities, and enhancing the number of services delivered via telehealth. For example, Kentucky waived in-person exam requirements to initiate telehealth services and Maryland ordered the reimbursement of synchronous and asynchronous telehealth services covered by Medicaid or authorized by a provider’s scope of practice.
In the clinical environment, efforts to ensure patient-centered health care decisions can mitigate the effects of health care system bias and reduce disparities in outcomes between men and women. The University of Florida’s UF Health Women’s Center is a cardiovascular care clinic designed specifically for women. The clinic creates a plan for each patient that accounts for female-specific cardiovascular risk factors. Florida appropriated money to hospitals that provide over $10 million in charity care through the Florida Medicaid Low Income Pool Program. The hospitals must also provide tertiary care services, including comprehensive stroke and other specialized services to address adult cardiovascular disease.
Virginia required the state Medicaid director to develop a bundled payment program for congestive heart failure, maternity care and asthma in order to improve the quality of care for enrollees and reduce costs.
Long-standing chronic disease prevention priorities include supporting the adoption of protective behaviors such as avoiding tobacco use, increasing physical activity and encouraging healthy nutrition. To support these priorities among women, the U.S. Department of Health and Human Services operates the national Office on Women’s Health. The office provides information on risk factors and signs of heart attacks and strokes, as well as resources and links related to healthy eating, stress reduction and other behavioral risk factors for cardiovascular disease.
To reach women at high risk of cardiovascular disease, the Centers for Disease Control and Prevention’s (CDC’s) Division for Heart Disease and Stroke Prevention developed the WISEWOMAN screening program. The program provides health screening, counseling and referral to services for women at risk for cardiovascular disease. Between 2008 and 2013, the program served 150,000 women, 91% of whom had at least one risk factor for heart disease and stroke. The Centers for Medicare and Medicaid Services and CDC lead the Million Hearts 2022 initiative to reduce heart attack, stroke and related conditions with a goal to prevent 1 million heart attacks or strokes in five years.