The POWER of Equity

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Examining gender and heart health in Ontario

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.

Poverty, low educational attainment, access to healthy foods, and neighbourhood and work place characteristics are underlying factors that increase the risk of heart disease among individuals, increase the rates of heart disease in the population and contribute to continued CVD-related health inequities among those with heart disease. Focusing efforts upstream through community and cross sectoral collaboration can help address the root causes of these health inequities and reduce the burden of heart disease in the population. Because women are more likely to live in low-income households than men, to be most effective, these efforts will need to address the factors that lead to increased rates of poverty among women.


Prevention (primary and secondary) is key to reducing the burden of illness due to CVD.

The prevalence of behavioural risk factors for heart disease remain high in Ontario — smoking, physical inactivity, obesity, and poor diets — in the general population and among people with heart disease. Primary prevention, or reducing risk among those who do not yet have CVD, is key to reducing illness burden. Secondary prevention will reduce CVD-related illness and death among women and men with heart disease. Prevention interventions need to address the social determinants of health, be gender sensitive and target those who are socioeconomically disadvantaged and therefore at greatest risk. Increased emphasis on prevention and integrated approaches at the population, community and clinical levels are essential to reduce the burden of illness due to CVD in Ontario.


Close the gender gap in care for CVD.

Gender gaps in CVD care have narrowed because of an increased awareness of the importance of heart disease to women and a recognition of the gender disparities in care that exist, combined with activities to close these gaps including gender-specific guidelines. While we did find some gender gaps in clinical care, there were a number of indicators where care for women and men was similar and where there were disparities, many of these were modest. Nevertheless women were still less likely to receive care from a cardiologist, undergo diagnostic testing and they were more likely to be readmitted to hospital after an admission for a heart attack. Of greater concern, women with heart disease consistently reported worse functional status and higher rates of disability than men. Women were more likely to report activity limitations, mobility problems, activities prevented by pain, and disability. Gender sensitive models of care focussed on disability prevention and improved functional status can improve the quality of life of women with heart disease.


Comprehensive patient-centred chronic disease management can improve quality and outcomes of care for CVD.

CVD is a chronic disease requiring coordination across settings of care, including physician care and hospital care. Individuals with CVD often have other chronic conditions such as diabetes and hypertension, because of similar risk factors for these conditions and because CVD and other chronic diseases are more prevalent with increasing age. We found high rates of emergency department use and hospital readmission in women and men with heart failure. Effective interventions that prevent both emergency department use and hospital readmissions would reduce the burden on hospitals and free much needed resources. The implementation of a coordinated, comprehensive, patient-centred, chronic disease prevention and management strategy — one that addresses the needs of at-risk populations — may be the key to improving quality and outcomes of care for CVD.


Province-wide, integrated, organized models of care delivery can improve health outcomes and reduce inequities in care.

We found sizable regional variations in care probably due to differences in human resources, capacity and practice patterns. Province-wide, integrated, organized models of care delivery can improve health outcomes and reduce inequities in care. The Ontario Stroke System—which targets activities across the continuum of stroke care from prevention, prehospital care, acute care and rehabilitation and community reintegration—provides an example for such a model that could be applied to other types of CVD.


Improve quality, availability and timeliness of data to assess CVD and CVD care in the province.

While data quality and availability to assess CVD care in the province has improved, there is still much to be done to improve the quality, availability and timeliness of data. Specifically, medication data on those under age 65, data on management of CVD in ambulatory care settings, and datasets that capture clinical factors are needed. Additionally, data on ethnicity would allow us to assess disease burden as well as access, quality, and outcomes of care to Ontario’s diverse communities.


Naushaba Degani is Project Director of the POWER Study.

Arlene S. Bierman, a general internist, geriatrician, and health services researacher is Principal Investigator for the POWER study.

To download the entire CVD chapter or the Chapter Highlights go to