2014-02-13

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When Gender Equality is Close to Heart

Women have to wait longer at the emergency ward before getting transferred to the intensive heart care unit while men with heart symptoms are more often transferred directly. Men receive more expensive treatment than women but are less satisfied with their care at the intensive heart care unit.

‘We are pretty certain that once patients arrive at the intensive heart care unit, we treat woman and men equally. But something happens before they get to us,’ says Lars Ekström at the Division of Cardiology, Sahlgrenska University Hospital.

Cardiology specialist Peter Währborg is rumoured to recently have said: ‘In the last decade, cardiology research has made great progress. Two major discoveries stand out in particular – patients have a gender and you can talk to them.’

His remark is humorous but in fact reflects reality and some of the developments in cardiac care in recent years.

It has now been established that focusing research solely on men has not been such a great idea, since women’s symptoms of for example a heart attack often differ from those of men. Women’s symptoms are often more vague. Non-existent chest pain but significant fatigue may be a sign of heart problems.

In addition, it turns out that although women and men have similar needs, they have different priorities. In rehabilitation, men tend to value physical performance whereas women see it as more important to be able to manage everyday life. At the Division of Cardiology, Sahlgrenska University Hospital in Gothenburg, the total cost of care is higher for men than for women. This is true for both in- and outpatient care. Women have to wait longer at the emergency ward before they are transferred to the intensive heart care unit – if they are transferred there at all, that is. Many female patients instead end up at general medicine without the cardiology expertise they may need.

Men with heart symptoms more often than women are transferred directly from the ambulance to the intensive heart care unit.

Fewer surgical procedures are performed on women than men, but there are no differences in long-term survival. Male heart patients are less satisfied than their female counterparts with the care they receive.

These are all results of a complex reality where simple explanations to seemingly strange observations are hard to find.

Easier Said than Done

Lars Ekström, head of the Division of Cardiology at Sahlgrenska University Hospital in Gothenburg, is a bit new at the whole thing.

And he does not deny it. One year ago, gender equality was not even discussed at the management meetings.

‘But that stuff is easier said than done if you don’t know how to do it.’

‘I had headed the division for 2-3 years and thought it was getting embarrassing to write in the operational plan every year that we were going to work on the gender equality issue, since we really weren’t.’

Lars Ekström had completed a two-day course on gender equality and knew about gender mainstreaming and that statistics should be separated by gender.

‘But that stuff is easier said than done if you don’t know how to do it.’

So he turned to an expert. Helena Norlinder, personnel secretary and member of the Division’s gender equality group, has extensive experience with gender equality issues. When her boss asked her for advice, she was ready with an answer.

‘In the gender equality group we had decided that we wanted to look at the service users with a gender equality focus. We chose to explore gender differences in waiting times for coronary angiography,’ says Norlinder.

Ekström was disappointed. He had expected efforts targeting the staff, which was an area he was more familiar with, but nevertheless gave his go-ahead.

‘Then we were invited to participate in the gender equality programme Gör det Jämnt, and that made me interested. I was in the programme’s steering group and heard about what was going on in for example dental care, and that made me wonder about our patients.’

Different Symptoms

The management group for the Division of Cardiology attended a one-day course on gender and gender equality hosted by Gör det Jämnt. Around the same time, the study on waiting times for coronary angiography concluded that there wasn’t much of a gender difference. It turned out that men on average have to wait a little longer, but the difference was insignificant. Yet there were some other discoveries that raised many eyebrows. Among women who had completed a coronary angiography, the most common result was ‘no significant stenoses that led to intervention: balloon dilation and ACB procedure’.

Men were more likely to be diagnosed with significant stenoses that led to intervention: balloon dilation and ACB procedure.

‘Are women more difficult to diagnose? Are the established criteria for coronary angiography less suitable for women than for men? We don’t know and should look further into it,’ says Nordlinder.

The Entire Chain

By the time the results reached the management group, the ball had started rolling.

‘When we saw that our waiting times for coronary angiography were the same for women and men, we decided to look at the entire care chain,’ says Ekström.

The objective was to ensure gender equality throughout the whole care process – from going in an ambulance and medical treatment to rehabilitation.

Since 2007 the ambulance care sorts under the Division of Cardiology. They had come a long way in their gender mainstreaming work, so all we needed to do was ask them about it.’

‘We separated all interventions by gender, for example ACB procedures, and that’s when we found some differences’, says Lars Ekström.

To analyse the reasons behind the findings, the group tried to utilise the available research and medical expertise within the group.

Smaller Blood Vessels

They noticed that women were recommended bypass surgery to a less extent than men. The reason for this is that women have smaller blood vessels, making it more difficult to connect their vessels to increase the blood flow. Since the procedure is based on connecting blood vessels, it is not as suitable for women. Instead, women are more likely to be recommended balloon dilation, which is cheaper and hence one reason men receive more costly care.

‘Women and men often have different heart problems. The problems that men have require more expensive equipment, such as pacemakers,’ says Ekström.

So what about the observation that women are more likely to be transferred to general medicine instead of intensive heart care? And that women have to wait longer at the emergency ward before they are moved to the intensive heart care unit?

‘Women and men often have different heart problems. The problems that men have require more expensive equipment, such as pacemakers’

‘Their symptoms were rated lower at the emergency ward,’ Ekström explains.

The solution to this problem was to expand the criteria for when a patient should be transferred to cardiac care. Women’s sometimes more diffuse symptoms must fit within the framework of the evaluation made, which increases the risk for congestion at the cardiac unit.

‘But that’s something we just need to handle.’

Age-related Discrimination

The analysis identified another important factor as well: age.

‘Three-quarters of all heart attack victims are men. Women don’t catch up in the statistics until age 75. Age is an aspect that deserves attention. Maybe the same treatments shouldn’t be used in two different age categories.’

Lars Ekström is certain there is age discrimination in cardiac care.

‘Too few heart attack patients older than 75 are treated with balloon dilation, regardless of gender.’

When it comes to other differences unveiled so far, not all results have been analysed in detail yet.

Ekström believes that the finding that men are less satisfied than women with the way they are treated in cardiac care is due to men generally being more picky and demanding than women when it comes to healthcare.

‘They indicate more intense pain than women, which makes them seem more acutely ill.’

The fact that men with heart symptoms more often than women are sent directly to intensive heart care – implying higher priority – is largely due to men generally having more obvious symptoms, according to Ekström.

‘They indicate more intense pain than women, which makes them seem more acutely ill.’

Gender Equal Budget

All parts of Region Västra Götaland are to gender mainstream their budgets. In practice, however, few do.

‘There is more to it than just medical priorities. The budget can be adjusted so that more women can benefit from intensive cardiac care. We can see that women as a group are undertreated,’ says Lars Ekström.

This can be compensated for through redistributions of resources to make different patient groups more even.

‘Another effect of the work is that gendered statistics are now required. We are the first ones to do this, together with orthopaedics.’

Yet there is a technical problem – only 75 per cent of the hospital-wide systems can separate statistics according to gender.

‘But that’s about to change. We are modifying the systems as we speak.’

Standardised Care

Lars Ekström is convinced that the gender equality work must be made a natural part of all quality assurance work aiming to ensure fair care.

‘This is not some kind of side track. This is service development.’

Concretely, the development may imply increased standardisation of healthcare in order to reduce the differences and in so doing achieve more gender-equal care.

He mentions their assessment of care time differences between women and men as an example.

‘Women are treated five days longer at Sahlgrenska’s general medicine units, but not if they were admitted to intensive heart care right away – there was no difference there. And why is that? It’s because the care at the intensive heart care unit is standardised. It’s a perfect example,’ says Ekström.

Lena Gunnarsson
Source: Region Västra Götaland
Edited: 25 Oct 2016
Published: 13 Feb 2014
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