The POWER of equity

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Publication Date: 
Wed, 2010-03-31

By Naushaba Degani and Arlene S. Bierman

The POWER (Project for an Ontario Women’s Health Evidence-Based Report) Study is producing a women’s health equity report that measures the health of Ontarians, the performance of the health care system, gender differences in access to, quality and outcomes of care for the leading causes of morbidity and mortality. By measuring health inequities associated with sex and socioeconomic status, we can inform interventions to improve health and reduce health inequities.
Monitoring these inequities in health and health care over time can be used to assess whether or not progress is being made. So far, the POWER Study has released six chapters: Introduction to the POWER Study, The POWER Study Framework, Burden of Illness, Cancer, Depression, and Cardiovascular Disease (CVD), which is the focus of this article. The chapter on Access to Health Care Services will be released in March 2010.

Cardiovascular disease is a leading cause of death and disability among Canadian women and men, accounting for 32 percent of deaths in 2004. Though CVD-related mortality in Canada has declined since the 1950’s, the proportion of CVD deaths that occur in women has increased, and now just over half of all CVD deaths occur in women. There is a significant body of evidence that shows that chronic disease prevention and management and patient self-management interventions can reduce CVD-related morbidity and mortality.         

The implementation of guidelines for the clinical management of patients with heart disease can improve outcomes of care and specific adherence to guidelines for female patients will narrow gender disparities in care and outcomes. Community engagement and empowerment and social policies aimed at addressing the social determinants of health – an important factor in heart disease risk — can reduce the burden of illness due to heart disease.

The POWER Study CVD chapter includes four sections: the health and functional status of adults with CVD, heart failure, ischemic heart disease, and stroke. In the first, we report on self-rated health, activity limitations and CVD risk factors. In the last three, we examine the acute and longer-term clinical care of patients (the types of physicians providing care, medication management, diagnostic testing and interventions) and health outcomes including hospital admissions, emergency department visits and death.

We identified a number of areas where care received by women and men is comparable, particularly management of the majority of indicators of stroke care in the acute setting and medication management among those age 65 and older, with the exception of statins. Nevertheless, gender gaps persist and we found multiple areas for improvement. First, we found large differences in health and functional status among individuals who reported having heart disease or a stroke associated with gender and socioeconomic status. Women with CVD were more likely than men to report activity limitations, mobility problems, chronic pain and disability days and low income women were more likely to report these problems than those with higher incomes. These findings draw attention to the need for gender sensitive approaches to reducing CVD burden as well as the need to address the social determinants of health in efforts to reduce the burden of CVD. Second, we found a high prevalence of modifiable risk factors among individuals with heart disease, underscoring the need for increased emphasis on secondary prevention. Third, there were high rates of potentially avoidable emergency department visits and hospital readmissions among individuals with HF, emphasizing the need for the widespread implementation of effective chronic disease management programs integrated across settings of care. Fourth, gender disparities in care remain — particularly in acute myocardial infarction (AMI) care — calling attention to the need to close this gap by explicitly addressing the needs of women in quality improvement efforts and by stratifying indicators by sex to track progress. Finally, performance on many measures varied across the province, highlighting the need for innovative interventions to standardize care, taking into account regional needs and differences.

Key messages

While we have made progress in improving the quality and outcomes of care for CVD and narrowing gender gaps, much work remains to be done. Sex and socioeconomic inequities in the health and functional status of individuals were much greater than inequities in the provision of acute care services. This suggests that by addressing the social determinants of health, we may also reduce the burden of CVD. The following actions are suggested as ways to reduce the burden of CVD, improve health outcomes among women and men with CVD and reduce health inequities related to CVD. But to be successful, gender and socioeconomic differences in the prevalence of CVD and experiences with care will need to be addressed.

Reduce health inequities associated with CVD by focusing upstream.

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