Chronic Illness and Care

Some examples of chronic illnesses affecting women include diabetes, obesity, stroke, heart disease, hypertension, osteoporosis, osteoarthritis, chronic pain, depression, and HIV/AIDS. There are many others, and they usually are long-lasting and affect all aspects of a woman's life. AHRQ researchers are seeking ways to help women understand and manage their chronic conditions and achieve a better quality of life.

Diabetes

• Report describes quality of care and outcomes for women with diabetes.

  This report, prepared by AHRQ and the Centers for Disease Control and Prevention, presents measures for quality of care and outcomes for women with diabetes. It highlights where the American health care system excels with regard to diabetes care and where the greatest opportunities for improvement lie. For example, women with diabetes were less likely than women without diabetes to have their blood pressure controlled or to have had a dental visit in the preceding 12 months. Among younger women (64 or younger), women with diabetes were significantly more likely than women without diabetes to have only public health insurance. On the other hand, women with diabetes were much more likely than women without diabetes to have received an annual flu vaccination and to have ever received a vaccination for pneumonia. Women with Diabetes: Quality of Health Care, 2004-2005 (AHRQ Publication No. 08-0099)* (Intramural). Available online at http://www.ahrq.gov/populations/womendiab/

• Analysis reveals that many women and men with diabetes are not receiving recommended care.

  According to this analysis of 10 quality of care measures—as defined by the National Health Care Quality and Disparities Reports—only 29 percent of women and 34 percent of men with diabetes receive the five care processes recommended for people with diabetes: regular blood sugar measurement, regular eye exams, regular foot exams, flu vaccination each year, and lipid profile every 2 years. Avoidable hospitalizations for diabetes complications decrease as income and education increase among women across all racial and ethnic groups. Correa-de-Araujo, McDermott, and Moy, Women's Health Issues 16(2):56-65, 2006 (AHRQ Publication No. 06-R043)* (Intramural).

• Having a chronic disease like diabetes may be a barrier to receipt of recommended preventive care among women.

  Researchers used data from three nationally representative surveys to examine the quality of care received by women with diabetes and the impact of socioeconomic factors on receipt of clinical preventive services and screening for diabetes-related conditions. They found that use of diabetes-specific preventive care among women is low, and that women aged 45 and younger and those with low educational levels were the least likely to receive recommended services. Also, women with diabetes were less likely than other women to receive a Pap smear, and those who were poor and minority were less likely than more affluent and white women to receive the pneumonia vaccine. Owens, Beckles, Ho, et al., J Women's Health 17(9):1415-23, 2008 (AHRQ Publication No. 09-R018)* (Intramural).

Mental/Behavioral Health

• Nearly half of homeless women are in need of mental health services.

  Researchers conducted face-to-face interviews with 821 homeless women in the Los Angeles area, and found that nearly half of the women had a mental distress score indicating the need for further evaluation and possible clinical intervention. Sixty-seven percent of the women were black, 17 percent were Hispanic, and 16 percent were white. Black women reported the lowest overall mental distress scores; nearly twice as many white women as Hispanic or black women reported childhood or recent physical or sexual assault. Austin, Andersen, and Gelberg, Women's Health Issues 18:26-34, 2008 (AHRQ grant HS08323).

• Dysthymia may be a barrier to use of recommended HIV medications by women.

  Dysthymia—a chronic, low-level daily depression that lasts at least 2 years—is prevalent among women and minorities with HIV and may be a barrier to their use of highly active antiretroviral therapy (HAART). The feelings of hopelessness, indecision, and mental inflexibility that commonly occur in people with dysthymia could reduce the likelihood that they would be offered or accept HAART, according to this study. Researchers analyzed 1997 data on 1,982 adults with HIV; white men were the most likely to receive HAART (69 percent), while Hispanic women (53 percent) and black women (55 percent) were the least likely to receive this life-saving therapy. Turner and Fleishman, J Gen Int Med 21:1235-41, 2006 (AHRQ Publication No. 07-R021)* (Intramural).

• Study reveals differences between male and female providers in behavioral counseling.

  According to this study, female providers are more likely than male providers to counsel depressed patients about anxiety and less likely to provide counseling on alcohol or drug use. Also, female patients are less likely than male patients to be counseled by providers of either sex. Male patients of male providers reported the most counseling, and female patients of female providers reported the least counseling about alcohol or drug use. Rates of depression diagnosis and care were comparable regardless of the provider's sex or whether the provider and patient were of the same sex. Chan, Bird, Weiss, et al., Women's Health Issues 16:122-32, 2006 (AHRQ grant HS08349).

• Longitudinal study identifies patterns of tobacco use among young women
.

Researchers conducted a study of 443 Midwestern women who smoke, beginning in 1980, with followup in 1987, 1993, and 1999. They identified three subgroups among the women who smoked daily: the first group (48 percent) worked full time, were heavy smokers, and were generally happy. The second group (19 percent) started smoking casually in college and exercised regularly. The third group (33 percent) were mothers who smoked because they were addicted and received a psychological boost from smoking. Identifying these groups may help in tailoring smoking cessation interventions and messages appropriate for reaching them. Rose, Chassin, Presson, et al., Addiction 102(8):1310-19, 2007 (AHRQ grant HS14178).

Other

• Osteoporosis and low bone density affect many postmenopausal women.

  Although osteoporosis affects both women and men, it occurs most often in postmenopausal women. It increases bone fragility and susceptibility to fracture; each year in the United States, about 1.5 million people experience a fracture related to osteoporosis. These three documents present information about osteoporosis and low bone density. Comparative Effectiveness of Treatments to Prevent Fractures in Men and Women with Low Bone Density or Osteoporosis presents a review of the evidence comparing the efficacy and safety of agents used to treat low bone density (AHRQ Publication No. 08-EHC008-1). Fracture Prevention Treatments for Postmenopausal Women with Osteoporosis: Clinician's Guide presents information for doctors and other providers on the effectiveness and safety of various treatments for preventing fractures in postmenopausal women (AHRQ Publication No. 08-EHC008-3). Osteoporosis Treatments that Help Prevent Broken Bones: A Guide for Women After Menopause describes the effectiveness, side effects, and costs of the various treatments for low bone density (AHRQ Publication 08-EHC008-2A).* These publications are also available on the AHRQ Web site at http://effectivehealthcare.ahrq.gov/.

• Management of gout differs for women and men.

  About 5 million Americans suffer from gout, a painful inflammation of the joints. According to this study, factors leading to gout, as well as its management, are different in women and men. Researchers examined data on 1.4 million members of seven managed care plans from 1999 to 2003 and identified 6,133 adult members with gout. Women with gout were older than men (mean age of 70 vs. 58), had a greater number of coexisting medical conditions, and received diuretics more often (77 vs. 40 percent), respectively. Harrold, Yood, Mikuls, et al., Ann Rheum Dis 65:1368-72, 2006 (AHRQ grants HS10391, HS10389).

• Young women of low to normal weight with GI complaints should be screened for eating disorders.

  This study found that young men and women (average age of 26) who were hospitalized for an eating disorder were three times as likely as other young people to seek health care for gastrointestinal problems during their illness. Over 90 percent of the individuals studied were women. Thus, the researchers recommend that primary care physicians and gastroenterologists screen young women of low to normal weight who present with GI complaints for possible eating disorders. Simple questionnaires that address issues such as body image, weight loss, and vomiting can be used. Winstead and Willard, J Clin Gastroenterol 40:678-82, 2006 (AHRQ grant HS13852).

• Checklists help women know which medical tests are needed to stay healthy at any age.

  Two checklists from AHRQ show at a glance what the U.S. Preventive Services Task Force recommends for screening tests and preventive services, as well as what constitutes a healthy lifestyle and healthy behaviors. Women: Stay Healthy at Any Age is available in English (AHRQ Publication No. 07-IP005-A) and Spanish (AHRQ Publication No. 07-IP005-B). Women: Stay Healthy at 50+ is also available in English (AHRQ Publication No. 08-IP001-A) and Spanish (AHRQ Publication No. 08-IP001-B).* These publications are also available online at http://www.ahrq.gov/clinic/prevenix.htm (Intramural).

• Weight-loss surgery can lead to dramatic weight loss, but it remains a high-risk procedure.

  In this commentary, AHRQ director Carolyn Clancy, MD, discusses the pros and cons of bariatric surgery for women, including the necessary lifestyle changes that must be made. She also examines the important role of nurses in helping women achieve success with bariatric surgery. Clancy, Women's Health 12(1):21-4, 2008 (AHRQ Publication No. 08R061)* (Intramural).

• Women with HIV receive poorer quality of care than men with HIV.

  Critical health care services for women infected with HIV continue to lag behind services for men with HIV, according to this study. Researchers examined data on care provided to more than 9,000 patients at HIV clinics and found that women were less likely than men to receive highly active antiretroviral therapy (78 vs. 82 percent, respectively) or prophylaxis for pneumonia (65 vs. 75 percent, respectively). They also were less likely than men to have been assessed for their hepatitis C virus status (87 vs. 88 percent, respectively). Hirschhorn, McInnes, Landon, et al., Women's Health Issues 16:104-12, 2006 (AHRQ grants HS10227, HS10408).

Health Impact of Violence Against Women

An estimated 1.3 million women are physically abused by their intimate partners each year, and about one of every four women seeking care in emergency rooms has injuries resulting from domestic violence. There are many consequences of domestic violence, as reflected in the high use of health care services by abused women. In addition to physical injuries, women who are victims of domestic violence experience higher rates of depression, substance abuse, suicidal thoughts, and suicide attempts.

• Women who are victims of abuse have worse health than other women, even years after abuse has stopped.

  Thirty-four percent of women surveyed in a large health plan had suffered from physical and/or sexual intimate partner violence during their adult lifetime, and it took an enormous toll on their health. Their depression and physical symptoms persisted for many years after the abuse had stopped, according to this study. The researchers analyzed survey results from 3,429 women who were asked about their history of abuse and their mental, social, and physical health. Although 34 percent of the women had suffered from sexual and/or physical abuse, only 5 percent reported abuse within the previous year. For the others, it had been a median of 19 years since the last episode of abuse. Bonomi, Anderson, Rivara, and Thompson, J Women's Health 16(7):987-97, 2007. See also Rivara, Anderson, Fishman, et al., Am J Prevent Med 32(2):89-96, 2007 (AHRQ grant HS10909)

• Hispanic women who are abused while pregnant report high levels of stress.

  Researchers surveyed 210 pregnant Latinas in Los Angeles in 2003-2004 to assess intimate partner violence, adverse social behavior, post-traumatic stress disorder (PTSD), depression, and other life situations. Nearly half (44 percent) of the women reported abuse and high levels of social undermining by their partners (criticism, anger, insults) and stress. Women who were abused were more likely to be depressed (41.3 percent) or to have PTSD (16.3 percent) compared with women who were not abused (18.6 percent and 7.6 percent, respectively). Rodriguez, Heilemann, Fielder, et al., Ann Fam Med 6(1):44-52, 2008 (AHRQ grant HS11104).

• Women who were abused as children use more health care than other women.

  Researchers interviewed 3,333 women, grouped the women into one of four categories (no abuse, physical and sexual abuse, physical abuse only, and sexual abuse only), and examined the women's health care use over a 10-year period (1992-2002). Thirty-four percent of women said they were abused as children, and they were more likely to have smoked, used recreational drugs in the past year, have symptoms of depression, and have a higher body mass index than women who were not abused as children. Health care costs for women with a history of physical and sexual abuse were an average $800 higher annually, compared with women who were not abused ($3,203 vs. $2,413, respectively). Bonomi, Anderson, Rivara, et al., J Gen Intern Med 23(3):294-9, 2008 (AHRQ grant HS10909).

• Abused women describe partner interference with health care.

  Researchers examined responses from a survey of 276 women at eight Boston area clinics who had been physically abused during the preceding year. Seventeen percent of the women reported that a partner had interfered with their health care. Women who had less than a high school education were three times as likely as other women to be victimized in this way. Also, women born outside the United States and those who visited the clinic with a man were twice as likely as other women to have a partner that interfered with their health care. Partner interference nearly doubled the odds of women having poor health. McCloskey, Williams, Lichter, et al., J Gen Int Med 22:1067-72, 2007 (AHRQ grant HS11088).

• Location of shelters may increase risk of violence against homeless women.

  Researchers interviewed 974 homeless women who visited 64 shelters and 38 meal programs serving homeless women in eight regions of Los Angeles county and screened them for substance abuse, mental illness, and history of childhood physical and sexual abuse. Results showed that homeless women living in or near skid row (crime ridden and dilapidated neighborhoods) were nearly twice as likely to be physically assaulted as homeless women in other areas of the city. The researchers conclude that seeking safer locations for shelters and other assistance programs could reduce violence against homeless women. Heslin, Robinson, Baker, and Gelberg, J Health Care Poor Underserved 18:203-18, 2007 (AHRQ grant HS08323).

• Intimate partner violence can occur at any age.

  Domestic violence is generally thought to be a problem only in younger women, but this study found that it can happen to women at any age. Researchers surveyed 370 women aged 65 and older; over 2 percent of the women reported abuse within the previous year, and 3.5 percent reported being abused within the previous 5 years. Half of the women were aged 65 to 74, and half were aged 75 or older. Intimate partners included spouses, nonmarital partners, and former marital and nonmarital partners. About 18 percent of the women said they suffered sexual or physical abuse, and 22 percent were victims of nonphysical abuse, including being threatened, called names, or having their behavior controlled by their partner. Bonomi, Anderson, Reid, et al., Gerontologist 47(1):34-41, 2007 (AHRQ grant HS10909).

• Three brief questions can help to identify women who are victims of intimate partner violence.

  A total of 448 urban women who reported intimate partner violence to police or the court system completed surveys at 8 weeks (baseline) and 5 and 10 months after the incident. The researchers compared answers to three questions about physical and psychological abuse and found that the physical abuse question at baseline identified 93 percent of abused women. Two questions about psychological abuse identified 94 percent of victims. The researchers call for testing of these three questions in real-world settings to assess their usefulness as a tool for initiating conversations with women about abuse. Bonomi, Holt, Thompson, and Martin, Am J Prev Med 28(1):55-8, 2005 (AHRQ grant HS10909).

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Health Care Costs and Access to Care

Many changes have taken place over the last 20 years in health care delivery and how we pay for care in the United States. The cost of care has continued its upward climb, which has been particularly steep in the last 5 to 10 years. In 2006, an estimated $1.03 trillion was paid for hospital inpatient and outpatient care, emergency room services, office-based medical provider services, dental services, home health care, prescription medicines, and other medical services and equipment for nearly 3 million individuals in the United States. In 1997, total health care expenditures were $553.2 billion; this number increased to $1 trillion in 2006.

Access to care continues to be a problem for many Americans, including women, and access is a particular challenge for those who lack health insurance, either private insurance or public coverage. For example, in 2006, about 68 million people under age 65—or nearly 27 percent of the population—were uninsured at some point during the year.

Costs

• Women who receive food stamps spend more on health care and are more likely to be overweight or obese.

  Researchers analyzed State-level data on food stamp program (FSP) characteristics and Medical Expenditure Panel Survey data to estimate the link between FSP participation and weight and health care expenditures of nonelderly adults. They found that women who receive food stamps are nearly 6 percent less likely to be normal weight and nearly 7 percent more likely to be obese as women who do not receive food stamps. Also, participation in the FSP leads women to devote $94 extra per year to health care. Meyerhoefer and Pylypchuk, Am J Agric Econ 90(2):287-305, 2008 (AHRQ Publication No. 08-R072)* (Intramural).

• The health costs of being a woman are substantial.

  Based on 3 years of data from the 2000-2002 Medical Expenditure Panel Survey, more than one-fifth of women (21.2 percent) sought care for a female-specific condition over a 1-year period, primarily gynecologic disorders, pregnancy-related conditions, and menopausal symptoms. Women's health care costs were substantial. For example, women spent from a mean of $483 per year for menopausal disorders to $3,896 for female cancers. Overall, women spent an estimated $108 billion a year for health care, of which more than 40 percent was for female-specific conditions. Kjerulff, Frick, Rhoades, and Hollenbeck, Women's Health Issues 17:13-21, 2007 (AHRQ Publication No. 07-R057)* (Intramural).

• Researchers examine women's health care costs and use of services.

  This comprehensive review of U.S. women's health care use and expenditures shows that in 2000, 91 percent of adult women used some form of health care services. Overall, 82 percent of adult women had an outpatient care visit, and 11 percent were hospitalized. The mean expense per woman was more than $3,200 in 2000. Women with private insurance and those on Medicaid were more likely to use health services than uninsured women, and white women used any type of health service more often and used more prescription drugs than minority women and men. Nearly 30 percent of older women in fair or poor health spent 10 percent or more of their income for out-of-pocket medical care in 2000. Taylor, Larson, and Correa-de-Araujo, Women's Health Issues 16(2):66-79, 2006 (AHRQ Publication No. 06-R044)* (Intramural).

Access to Care

• Problems in accessing care are common among women with disabilities.

  About 16 percent of adult women have at least one functional limitation (e.g., difficulty lifting 10 pounds, standing for 20 minutes, using fingers to grasp something, etc.); those with three or more functional limitations are more likely than other women to report being unable to get medical and dental care, according to this study. Women with functional limitations who were age 65 or older were less likely to receive Pap tests or mammograms, compared with women who had no functional limitations. They also were more likely to report being unable to get prescription medicines or eyeglasses, regardless of age group. Researchers compared demographic characteristics, reported health measures, use of clinical preventive services, and other factors. Chevarley, Thierry, Gill, et al., Women's Health Issues 16:297-312, 2006 (AHRQ Publication No. 07-R037)* (Intramural).

• Physician specialty linked to patient satisfaction among younger women.

  Younger women (aged 18 to 34) are more satisfied with their health care when a reproductive health specialist is the primary provider, according to this study of more than 1,100 women who made primary care visits in 2001. The researchers defined reproductive health specialists as obstetrician/gynecologists and nurse midwives. They found increased satisfaction with health care coordination and comprehensiveness of care among younger women seen by these providers. Henderson and Weisman, Med Care 43(8):826-33, 2005 (AHRQ grant HS10237).

• Study finds link between State policies and women's mortality rates for certain diseases.

  Researchers at Oregon Health & Science University examined State policies affecting women's health in four areas: reproductive issues (e.g., State requirements for private insurers to cover cervical cancer screening), economic issues (e.g., child support payments), access to care (e.g., Medicaid eligibility requirements), and ensuring healthy communities (e.g., gun control and aid to victims of domestic violence). They found that Medicaid eligibility policies accounted for 66 percent of the variation in heart disease mortality across States. Policies related to violence against women and gun control, family medical support and efforts to expand Medicaid, and tracking of environmental health accounted for 50 percent of the variance in lung cancer mortality. Wisdom, Berlin, and Lapidus, Soc Sci Med 61:1776-84, 2005 (AHRQ grant T32 HS00069).

• Study characterizes women's preventive health care visits.

  Researchers analyzed data and interview notes on 95 visits with adult females who saw 47 different clinicians at 18 Midwestern family practices. They found that the preventive services delivered in more than half of visits included blood pressure measurement, weight assessment, breast and pelvic exams, identification of smoking status and related counseling, and mammography recommendations. Key issues addressed less often included cholesterol screening, colon cancer screening, alcohol use, and recommended immunizations. Clinicians were inconsistent in obesity counseling. Backer, Gregory, Jaen, and Crabtree, Fam Med 38(5):355-60, 2006 (AHRQ grant HS08776).

• Women living in rural areas receive less preventive care than those residing in urban areas.

  Researchers examined differences in use of preventive health services in four types of counties: large metropolitan counties, small metropolitan counties, counties adjacent to metropolitan areas, and rural counties (not adjacent to metropolitan counties or with fewer than 10,000 residents). They found that rural women were less likely than urban women to have had cholesterol tests, dental exams, and mammograms during the previous 2 years, but they were more likely to have had their blood pressure checked during the previous year. Rural residents, on average, had lower incomes and less education than their urban counterparts, and they were more likely to be uninsured and to face structural barriers to care, such as long travel times, than those living in urban areas. Larson and Correa-de-Araujo, Women's Health Issues 16(2):80-8, 2006 (AHRQ Publication No. 06-R045)* (Intramural).

• Clinic-and community-based strategies can promote use of preventive care by Latinas.

  This study found that using promotoras—lay health advisors recruited from the community—and professional interpreters could increase the use of preventive services among Hispanic women and their children. Other strategies for promoting preventive care among Latinas included tagging the charts of at-risk patients, using videos for in-clinic education, and asking patients for updated contact information at each clinic visit to facilitate recall/reminder interventions. Wasserman, Bender, and Lee, Med Care Res Rev 64(1):4-45, 2007 (AHRQ grant HS13864).

• Certain aspects of medical care are critically important to female Somali refugees newly arrived in the United States.

  In-depth interviews with resettled Somali women in Rochester, NY, revealed differences in spoken language, degree of acculturation, and literacy. They described the elements of U.S. primary care most important to them, including ease of accessing the health care system, availability of interpreters, a trusting relationship with clinicians, and the availability of female clinicians, especially for gynecologic exams. Carroll, Epstein, Fiscella, et al., Patient Educ Counsel 66:337-45, 2007 (AHRQ grant HS14105).

Health Care Quality and Safety

Finding ways to improve health care quality and enhance patient safety has become one of the most significant challenges facing the American health care system. AHRQ researchers are seeking answers and developing tools to improve the quality and safety of health care for all Americans, including women.

• Content of physician visits differs for women and men.

  This study found that the content of women's visits to primary care doctors differs from that of men's visits in several ways. For example, compared with men's visits, women's visits involved more discussion about the results of treatments, more preventive services, less emphasis on physical exams, and less discussion about alcohol, tobacco, and other drug use. Visit length was similar for women and men. These findings are based on previsit interviews and videotaping of actual medical visits for 315 women and 194 men who were cared for by 105 primary care physicians. Bertakis and Azari, J Women's Health 16(6):859-68, 2007 (AHRQ grant HS06167).

• Women have fewer problems after vascular surgery in VA hospitals than in private hospitals.

  Women's mortality rates 1 month after vascular surgery at VA and private-sector hospitals are similar, but they have fewer postoperative problems in VA hospitals, according to this study. Researchers compared postoperative mortality and morbidity for 458 women who had vascular surgery at 128 VA hospitals and 3,535 women who had surgery at 14 private medical centers between 2001 and 2004. After adjusting for severity of illness, 30-day mortality rates were similar; however, there were pronounced differences in postoperative problems between the two groups, with the VA group suffering from 40 percent fewer postoperative complications than the private group. The complications that were more frequent in the private group included deep wound infection, respiratory failure, urinary tract infection, cardiac arrest, and graft failure. Johnson, Wittgen, Hutter, et al., J Am Coll Surg 204(6):1137-46, 2007 (AHRQ grant HS11913).

• Quality of health care varies for older women.

  Women make up more than half (60 percent) of the Medicare population, and they depend on the program for an average of 15 years compared with 7 years for men. This study examined quality of care for older women compared with older men. It shows that older white women tend to receive better quality of care than their Hispanic and black counterparts, and more educated women often receive better quality of care than less-educated women. Also, older women are much less likely than older men to receive a number of preventive tests, have their blood pressured under control, or receive aspirin or a beta-blocker upon hospital admission or discharge for heart attack. Results are mixed for diabetes care and vaccinations for flu and pneumonia. Kosiak, Sangl, and Correa-de-Araujo, Women's Health Issues 16(2):89-99, 2006 (AHRQ Publication No. 06-R046)* (Intramural).

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