Gender inequalities in cardiovascular risk factor assessment and management in primary healthcare.

TLDR: For those with, or at high risk of, CVD, the prescription of appropriate preventive medications was more frequent in older women, but less frequent in younger women, compared with their male counterparts.

Abstract: Objectives To quantify contemporary differences in cardiovascular disease (CVD) risk factor assessment and management between women and men in Australian primary healthcare services. Methods Records of routinely attending patients were sampled from 60 Australian primary healthcare services in 2012 for the Treatment of Cardiovascular Risk using Electronic Decision Support study. Multivariable logistic regression models were used to compare the rate of CVD risk factor assessment and recommended medication prescriptions, by gender. Results Of 53 085 patients, 58% were female. Adjusting for demographic and clinical characteristics, women were less likely to have sufficient risk factors measured for CVD risk assessment (OR (95% CI): 0.88 (0.81 to 0.96)). Among 13 294 patients (47% women) in the CVD/high CVD risk subgroup, the adjusted odds of prescription of guideline-recommended medications were greater for women than men: 1.12 (1.01 to 1.23). However, there was heterogeneity by age (p Conclusions Women attending primary healthcare services in Australia were less likely than men to have risk factors measured and recorded such that absolute CVD risk can be assessed. For those with, or at high risk of, CVD, the prescription of appropriate preventive medications was more frequent in older women, but less frequent in younger women, compared with their male counterparts. Trial registration number 12611000478910, Pre-results.

Figures

Table 1. Baseline comparison by gender

Table 2. Assessment of individual risk factors by gender and by age groups

Table 3. Prescription of individual classes of medications to patients in the CVD/high CVD risk subgroup by gender and by age group

Figure 1. Multiple-adjusted female to male odds ratios and 95% confidence intervals for the assessment of cardiovascular risk factors

Figure 3. Multiple-adjusted female to male odds ratios and 95% confidence intervals for the prescription of blood pressure lowering medication, statin, antiplatelet and anticoagulant therapy amongst the patients in the cardiovascular disease/high cardiovascular risk subgroup, by age group

Figure 2. Multiple-adjusted female to male odds ratios and 95% confidence intervals for guidelinerecommended medication prescription amongst the patients in the cardiovascular disease/high cardiovascular risk subgroup

Full text

1
Gender inequalities in cardiovascular risk factor assessment and 1
management in primary healthcare 2
3
Karice Hyun
1
, Julie Redfern
1
, Anushka Patel
1
, David Peiris
1
, David Brieger
2
, David Sullivan
3
, Mark 4
Harris
4
, Tim Usherwood
1,5
, Stephen MacMahon
1,6
, Marilyn Lyford
1,7
, Mark Woodward
1,6
5
6
1
The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, 7
Australia 8
2
Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia 9
3
Department of Chemical Pathology, Royal Prince Alfred Hospital, Sydney, Australia 10
4
Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia 11
5
Sydney Medical School Westmead, University of Sydney, Sydney, Australia 12
6
The George Institute for Global Health, University of Oxford, Oxford, UK 13
7
WA Centre for Rural Health, University of Western Australia, Perth, Australia 14
15
Corresponding author: 16
Karice Hyun 17
Level 10, King George V Building, 83-117 Missenden Rd, Camperdown NSW 2050 Australia 18
E: khyun@georgeinstitute.org.au 19
P: (612) 9993 4569 20
21
Keywords
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Coronary artery disease; Health services; Health care delivery; and Quality and outcomes of care. 23
Word count: 2380 24

2
The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of 1
all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis 2
to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published 3
in HEART editions and any other BMJPGL products to exploit all subsidiary rights.
4

3
ABSTRACT 1
Objectives 2
To quantify contemporary differences in cardiovascular disease (CVD) risk factor assessment and 3
management between women and men in Australian primary healthcare services. 4
Methods 5
Records of routinely attending patients were sampled from 60 Australian primary healthcare 6
services in 2012 for the Treatment of Cardiovascular Risk using Electronic Decision Support 7
(TORPEDO) study. Multivariable logistic regression models were used to compare the rate of CVD 8
risk factor assessment and recommended medication prescriptions, by gender. 9
Results 10
Of 53085 patients, 58% were female. Adjusting for demographic and clinical characteristics, women 11
were less likely to have sufficient risk factors measured for CVD risk assessment (odds ratio (95% 12
confidence interval): 0.88 (0.81, 0.96)). Amongst 13294 patients (47% women) in the CVD/high CVD 13
risk subgroup, the adjusted odds of prescription of guideline-recommended medications were 14
greater for women than men: 1.12 (1.01, 1.23). However, there was heterogeneity by age (p <0.001), 15
women in the CVD/high CVD risk subgroup aged 35-54 years were less likely to be prescribed the 16
medications (0.63 (0.52, 0.77)), and women in the CVD/high CVD risk subgroup aged ≥65 years were 17
more likely to be prescribed the medications (1.34 (1.17, 1.54)) than their male counterparts. 18
Conclusions 19
Women attending primary healthcare services in Australia were less likely than men to have risk 20
factors measured and recorded such that absolute CVD risk can be assessed. For those with, or at 21
high risk of, CVD, the prescription of appropriate preventive medications was more frequent in older 22
women, but less frequent in younger women, compared to their male counterparts. 23
24
25

4
KEY QUESTIONS 1
What is already known about this subject? 2
Risk assessment and medication adherence have a positive impact on preventing and managing 3
cardiovascular disease (CVD), however, differences in CVD assessment and management between 4
women and men have been observed in countries such as the UK. 5
What does this study add? 6
In Australian primary healthcare services, women were less likely to be assessed for CVD risk factors 7
at primary healthcare services. Of those at high risk of CVD, younger women (35-54 years) were less 8
likely to be prescribed guideline-recommended medications than younger men (35-54 years), 9
whereas older women (≥65 years) were more likely to be prescribed guideline-recommended 10
medications than their counterparts. 11
How might this impact on clinical practice? 12
System level strategies are needed to improve the provision of CVD assessment and treatment to 13
minimise the gap between women and men.
14

5
INTRODUCTION 1
Despite decreasing mortality rates due to cardiovascular disease (CVD) in many countries, it remains 2
the leading cause of death worldwide for both women and men. (1, 2) Previously, CVD was assumed 3
to be more prevalent in men and therefore women tended to be less intensively treated. (3) To close 4
the treatment gap between women and men, the improvement of cardiovascular health in women 5
has been promoted through health initiatives and research. (4, 5) Yet, in Australia, as in the United 6
State and the United Kingdom (UK), (6, 7) women have a higher number of cardiovascular deaths per 7
year than men (23,755 vs. 21,867 deaths in 2012), (1) largely because they live longer. Women with 8
diabetes have over 40% greater excess risk of coronary heart disease (CHD) (8) and nearly 30% 9
higher relative risk for stroke compared to men with diabetes. (9) More research is needed to 10
uncover the reasons for these female disadvantages. One possibility is that women are less often 11
recognised as being prone to CVD than men, and are thus less likely to receive a timely diagnosis and 12
to receive appropriate treatment after a positive diagnosis. 13
14
There is evidence that risk assessments and medication adherence have a positive impact on 15
outcomes. (10, 11) Studies from countries outside Australia have found that women with CHD are 16
less likely than men to undergo risk factor assessments in primary healthcare. (12, 13) Some studies 17
have also shown that women with CHD are less likely to receive recommended medications than 18
men, (13, 14) although other studies have shown no gender differences. (15) 19
20
While differences in CVD assessment and management between women and men have been 21
observed in other countries, the extent to which this may be an issue in Australian primary 22
healthcare is unknown. We aimed to determine whether measurement of CVD risk factors and 23
guidelines recommended medication prescriptions varied between women and men in a large 24
Australian primary healthcare cohort. 25
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Frequently asked questions

Q1. How can the authors improve the provision of CVD assessment and treatment?

12 System level strategies are needed to improve the provision of CVD assessment and treatment to 13 minimise the gap between women and men. 

Q2. How many women were more likely to be prescribed guideline-recommended medications than their counterparts?

Of those at high risk of CVD, younger women (35-54 years) were less 8 likely to be prescribed guideline-recommended medications than younger men (35-54 years), 9whereas older women (≥65 years) were more likely to be prescribed guideline-recommended 10 medications than their counterparts. 

Q3. How many women with diabetes are less likely to undergo risk factor assessments in primary healthcare?

11) Studies from countries outside Australia have found that women with CHD are 16 less likely than men to undergo risk factor assessments in primary healthcare. 

Q4. What are the main reasons for the higher risk of stroke in women with diabetes?

Women with 8 diabetes have over 40% greater excess risk of coronary heart disease (CHD) (8) and nearly 30% 9higher relative risk for stroke compared to men with diabetes. 

Q5. How many women were more likely to be prescribed BP medication than men?

Their results show that overall 24 proportion of patients who were assessed and treated were notably low, and women were less likely 25 to have CVD risk factors measured than men. 

Q6. How many women have been disadvantaged in receiving appropriate CVD risk factor assessment?

(22) Further, 15 the misconception of senior physicians may have been passed on to the younger generation of 16 physicians, therefore where there are financial disincentives and time and resource constraints, 17 women have been disadvantaged in receiving appropriate CVD risk factor assessment. 

Q7. Why do women have a higher number of deaths per 7 years than men?

5) Yet, in Australia, as in the United 6 State and the United Kingdom (UK), (6, 7) women have a higher number of cardiovascular deaths per 7 year than men (23,755 vs. 21,867 deaths in 2012), (1) largely because they live longer. 

Q8. What age group was the mean age of the patients in the CVD/high CVD risk?

Of the 13294 patients found to be in the CVD/high CVD risk subgroup, the mean age of women was 14 70 years and of men was 68 years (Table 1). 

Q9. What were the independent predictors of the two outcomes?

For both outcomes, independent predictors included in the 8 models were: gender (women vs. men), age groups (35-54 years, 55-64 years, ≥65 years), 9Aboriginal/Torres Strait Islander status, diabetes status, overweight/obese (BMI ≥25 kg/m2 vs. not), 10 high BP (systolic BP ≥140 mmHg/diastolic BP ≥90 mmHg vs. not), high total cholesterol (total 11 cholesterol ≥5.5 mmol vs. not), low HDL cholesterol (HDL cholesterol ≤1 mmol vs. not) and smoking 12 status (current smokers vs. ex/never smokers). 

Q10. What age group were the ORs for all Aboriginal/Torres Strait Islanders?

For age groups 35-54, 55-64 and 7 65 and older the ORs (95%CIs) for all Aboriginal/Torres Strait Island people were 0.65 (0.53, 0.80), 8 1.30 (1.00, 1.69) and 1.23 (0.93, 1.62) (p interaction=0.01); and the corresponding results for others 9were 0.60 (0.37, 0.96), 0.91 (0.76, 1.09), and 1.36 (1.18, 1.57) (p interaction=0.004), respectively. 

Q11. What were the main variables that were not included in the definition for sufficient assessment of CVD 3?

(17) Although body mass index and fasting glucose are not included in the 2 Framingham risk score, and therefore not included in the definition for sufficient assessment of CVD 3 risk factors, since they are also important risk factors for CVD the authors analysed these variables also. 

Q12. How was the risk of having a smoking test recorded?

Taking the 2 individual risk factors separately, the odds of having smoking status recorded was 22% lower (0.78 3 (0.66-0.91)), SBP recorded was 12% lower (0.88 (0.81-0.96)) and cholesterol (total and/or HDL 4 cholesterol) recorded was 8% lower (0.92 (0.86-0.98)) in women than men. 

Q13. What were the definitions for the assessment of risk factors for CVD?

The definition for sufficient 25 assessment of CVD risk factors were: having recorded smoking status at least once, systolic blood 26pressure in the previous 12 months, total cholesterol and high density lipoprotein cholesterol in the 1 previous 24 months. 

Q14. what is the ad hoc model for cardiovascular risk management in australia?

Sharing risk management: an implementation model for 25 cardiovascular absolute risk assessment and management in Australian general practice. 

Q15. What were the definitions for the assessment of individual risk factors?

Assessment of individual risk factors or 20 prescription of individual medications were defined as having a record; if the value was missing, this 21 was considered as having had no assessment or prescription.