A Publication of the
Jacobs Institute of Women's Health
Volume 9, Number 4, Winter 2001
Over the past year, the Jacobs Institute has taken a broad view of womens health as we continued to focus on making the health care system work better for women. We began our 2001 seminar series with a talk on herbs, botanicals, and other dietary supplements, which, owing to their popularity, now merit their own office at the National Institutes of Healththe Office of Dietary Supplements (ODS). Sales of dietary supplements reached $14.9 billion in 1999, according to ODS Deputy Director Rebecca Costello, PhD. She cautioned that the safety and efficacy of many such products remain unconfirmed, but said efforts are underway to conduct better research, establish industry standards, and provide more information to consumers and health care practitioners.
We also invited several authors who had delved into The Commonwealth Funds 1998 Survey of Womens Health to share some of their findings. Using this rich data set, which includes detailed information from over 2,000 women, researchers reported the U.S. health care system has made some gains in improving womens healthmore women are getting Pap tests and mammogramsbut has been sluggish in otherssome physicians still dont counsel women about exercise or smoking cessation.
Finally, we tackled the issue of heart disease, which kills half of all women. Cardiologist Sharonne Hayes, MD, director of the Womens Heart Clinic at the Mayo Clinic in Rochester, MN, pointed out that many women and their physicians still see heart disease as an older mans disease. And while she acknowledged there are some significant differences between men and women in symptoms, diagnosis, and treatment of heart disease, The real issue is undertreatment, she noted.
With Dr. Hayes words ringing in our ears and support from the Fannie E. Rippel Foundation and Pfizer, Inc., we launched the Womens Heart Initiative, a collaboration of corporate and nonprofit organizations with an interest in women and heart disease. The initiative will raise awareness about womens risk of heart disease and seek to improve prevention, diagnosis, and treatment of heart disease in women. (See related story.)
Publications and Partnerships
Our publications also sought to cover a lot of ground. The 2001 Womens Health Data Book provides a clear and comprehensive roadmap to the large and complex range of womens health data available. It addresses the social and economic factors influencing womens health and provides up-to-date information on chronic conditions, reproductive health, mental health, violence, health behaviors, and access to and quality of health services received by women. The Data Book resulted from a multiyear partnership with the Henry J. Kaiser Family Foundation.
The breadth of our view of womens health was also reflected in our bimonthly journal, Womens Health Issues, in 2001. For example, in just one issue, we featured articles on topics ranging from emergency contraception to genetic testing to partner violence to cardiovascular health. With our quarterly newsletter, In Touch, and our newly revised web site, were providing members and others more information, more links to other web sites, and more news from other organizations.
In the spring, we honored the landmark research of the Nurses Health Study, presenting one of our annual Excellence Awards to Frank E. Speizer, MD, who founded this ongoing study. In the 25 years since the study began, over 120,000 women have taken part, and its findings have added immeasurably to our knowledge of womens health. Our annual Jacobs InstituteOrtho-McNeil Pharmaceutical Research Scholar in Womens Health Award went to Dawn Upchurch, PhD, associate professor at the UCLA School of Public Health, who is researching involuntary sexual intercourse among a nationwide cross-section of adolescent women.
Advancing the Field
Also this year, we presented an Excellence Award to Angela Diaz, MD, director of the Adolescent Health Center and a tenured professor of Pediatrics at Mount Sinai School of Medicine, and our Warren H. Pearse Lifetime Achievement Award to Allan Rosenfield, MD, dean of the Joseph L. Mailman School of Public Health, DeLamar Professor of Public Health, and professor of Obstetrics and Gynecology at Columbia University. Both have worked to ensure women have better access to health care. And during the Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in Chicago in April, the Jacobs Institute of Womens Health honored its founding members, the dedicated individuals who helped establish the Jacobs Institute almost 12 years ago.
Since 1990, the Jacobs Institute has been working to make the health care system work better for women by facilitating research, dialogue, and information dissemination. We have learned that women and men have different patterns of illness, different attitudes, different health behaviors, and sometimes different responses to treatment. These differences are still not well understood or integrated into the health care delivery system, which underscores the importance of the work ahead.
In 2002, the Womens Heart Initiative will be among our major priorities. We are also laying the groundwork for a conference on health disparities among women of color, the focus of a third joint meeting of the Jacobs Institute and The Commonwealth Fund, planned for April.
We are deeply grateful to the many individuals and organizations listed in the box for their continued support. We look forward to receiving your thoughts and suggestions for new initiatives that will make the health care system work better for women. n
Martha C. Romans
" The percentage of women who are uninsured in the United States increased from 13.7% in 1987 to 18.5% in 1998.
" In 1999, women accounted for 23% of all new AIDS cases in the United States, up from just 7% in 1986 and 18% in 1994.
" Contraceptive usage is increasing among women ages 1544 years old. In 1995, 64.2% of women used a method of contraception, compared with just 55.7% in 1982.
" The abortion rate for women ages 1544 has gone down from 29 per 1,000 women in 1980 to 23 per 1,000 in 1995.
" About one woman in five will experience a major depressive episode in her lifetime, over 1.5 times the rate seen in men.
" The percentage of women who report using illicit drugs in the past month fell from 9.4% in 1979 to 4.5% in 1998.
The Womens Health Data Book, 3rd edition, can be purchased for $33.50 (including shipping) by calling the Jacobs Institute at 202-863-4990 or by visiting our web site at jiwh.org.
A 1998 survey of 1,230 Fellows of the American College of Obstetricians and Gynecologists (ob-gyns) found 95% of ob-gyns participate in managed care plans. Two thirds (67%) reported their plans allow them to serve as a womans primary care provider; of these, 47% said they actually serve as primary care providers. Over half (55%) reported their pregnant patients are permitted unlimited visits without a referral. Only 31% said their gynecologic patients have direct access for unlimited visits. Late payments, administrative workload, and external review of clinical decisions were the greatest sources of dissatisfaction with managed care. Fifty percent reported that care they had recommended had been denied.
Emily Schifrin, MS, formerly of the Jacobs Institute of Womens Health, and colleagues reported the results of the survey in the November/December edition of Womens Health Issues. The authors suggested managed care companies investigate ways to improve physicians satisfaction levels, as doctors who terminate their contracts have a negative impact on continuity of care and patient satisfaction. (For back copies of Womens Health Issues, call the Jacobs Institute at 202-863-4990.)
Earlier this year, the Jacobs Institute and several other organizations successfully petitioned the Agency for Healthcare Research and Quality (AHRQ) to conduct a thorough review of evidence on the diagnosis and treatment of coronary heart disease (CHD) in women. The results of the evidence review will help identify gaps in our knowledge about women and heart disease and lead to improvement in the care women receive. Simultaneously, with support from the Fannie E. Rippel Foundation and Pfizer, Inc., the Jacobs Institute launched the Womens Heart Initiative to raise awareness about womens risk of heart disease.
At the first meeting of the Womens Heart Initiative on October 5, Jacobs Institute Executive Director Martha Romans described the groups goal: We would like to identify ways to improve education and preventive services to women in primary care settings and to promote research and quality improvement efforts with respect to prevention of heart disease.
The AHRQs outline for the evidence review identified five issues to address regarding CHD in women:
" Accuracy of noninvasive tests
" Effectiveness of treatments
" Strength of risk factors and benefit of risk-factor modification
" Underutilization of treatments or risk-factor modification in women
" Accuracy of markers of ischemia
At the October meeting, Deborah Grady, MD, MPH, of the Evidence-Based Practice Center at the University of California, San FranciscoStanford, presented findings from the preliminary phase of the research, which consisted of identifying the best evidence available.
Dr. Grady and her colleagues examined AHRQs five issues and broke them down into 34 core questions (each with subquestions, leading to over 100 specific areas of interest). Their goal in the first phase of the project was to determine whether the existing data answered any of their 34 questions and then to describe the reliability of the answers (that is, the quality of the evidence). Their initial literature search turned up over 6,000 articles, and they eventually identified 112 studies of good quality.
In the past two decades, theres been an explosion of heart disease research, said Dr. Grady, but its mostly been research in men. Women have been excluded or represented in very small numbers. Often when women were included, she noted, the outcomes of the research were not reported by gender, so those studies did not prove useful. The next phase of the project involves summarizing the findings of the studies identified, prioritizing the questions to address, and performing systematic reviews of the literature.
Allen Freemont, MD, PhD, of RAND Corporation, examined gender disparities in treatment by assessing data from United Healthcare and the federally-funded Medicare program. He and his colleagues focused specifically on Health Plan Employer Data and Information Set (HEDIS) measures of cardiovascular and diabetes care. They found variations and gender disparities across all the plans, as well as variations in overall performance.
Dr. Freemont cautioned it was not clear whether variations reflected differences in treatment, access, patient behavior, or the documentation itself. He emphasized the barriers that make it difficult to compare data across plans, even when standardized measures such as HEDIS are used.
Although the variations in screening and treatment for men and women were small to moderate, Dr. Freemont said, Eliminating disparities could benefit many women. He pointed to larger differences in screening and treatment based on racial and socioeconomic factors and concluded that focusing on subgroupssuch as poor and minority womencould improve health care for women overall.
Victor Villagra, MD, of CIGNA Healthcare, explained his organizations steps for collecting and evaluating data on women and the management of heart disease, one of four chronic conditions for which CIGNA has a specific disease treatment program. CIGNA is in the early stages of using data collected to establish normative benchmarks and to identify unjustified gender disparities in health care use. Preliminary analyses based on HEDIS data do show some gender differences. For example, among those who had suffered an acute cardiac event, women were less likely than men to have their cholesterol levels checked.
The meeting attendeesrepresentatives from health care plans, employers, and womens health advocacy organizationsdiscussed how these findings could be used as the basis for a national conference in 2002.
Older women who live independently are significantly more physically active than women who live in assisted-care facilities, and that translates to a better overall quality of life. In the November/December edition of Womens Health Issues, Kelli F. Koltyn, PhD, of the University of WisconsinMadison, examined this association by surveying 135 women over 60 living either independently or in assisted-care facilities.
Dr. Koltyn found independent-living women spend more time being physically active, expend more energy, and engage in more vigorous activities. They also reported a better quality of lifeparticularly in the areas of physical health, social relationships, and environmentthan those in assisted-care facilities. However, she found no difference between the two groups in terms of psychological well-being. Importantly, regardless of living situation, Dr. Koltyn noted, Women who were engaged in more [vigorous] activities reported higher quality of life compared to women who were engaged in lower levels of physical activity.
Dr. Koltyns research was supported by the Jacobs InstituteOrtho-McNeil Pharmaceuticals Scholar award. For more information about the award, please visit our web site at jiwh.org.
In a recent study of patients satisfaction with their health care plans, researchers found little overall difference between men and women in terms of satisfaction, but did find women are 1) more satisfied in not-for-profit plans then in for-profit plans and 2) more satisfied in plans with lower provider turnover rates.
Carol S. Weisman, PhD, of the University of Michigan, and colleagues reached these conclusions by looking at data collected from the 1999 Consumer Assessment of Health Plans Study (CAHPS), administered by the National Committee for Quality Assurance. The data represent 97,873 men and women enrolled in 206 commercial managed care plans nationwide. Their findings were published in the September/October 2001 Womens Health Issues (volume 11, no. 5).
The authors concluded CAHPS scores should be analyzed by gender for quality monitoring and improvement in womens health care and managed care. Further research that identifies the variables associated with patient satisfaction would be useful and could provide the basis for improving the quality of womens health care. (For back copies of Womens Health Issues, call the Jacobs Institute at 202-863-4990 or use our on-line order form.)
Studies have shown depression affects 1520% of young people at some time during their teenage years, with younger women at far greater risk for depression then men. A study in the September/October 2001 Womens Health Issues (volume 11, no. 5) found that while socioeconomic status had an impact on whether young women seek routine medical treatment, it did not have a significant impact on their use of mental health services.
Elizabeth Goodman, MD, of the Childrens HospitalUniversity Medical Center in Cincinnati, OH, and Bin Huang, MS, of the University of Cincinnati College of Medicine looked at the relationships between depression and health service use in 5,735 adolescent women surveyed twice over a 1-year period.
Most girls in the study received a routine health assessment during the year, and 18.7% received mental health services. Over 10% of the girls were depressed at each assessment, but depressed girls who received mental health services were less likely to be depressed at the second evaluation. The study also found that depressed adolescents were the least likely to have received routine care. (For back copies of Womens Health Issues, call the Jacobs Institute at 202-863-4990 or use our on-line order form.)
Dr. Goodman is the recipient of the 1999 Jacobs InstituteOrtho-McNeil Pharmaceutical Scholar Award. Applications for the Ortho-McNeil Award are due each year in October. For details, please go to the Jacobs Institute web site, jiwh.org.
Thanks to the many donors who contributed between January 1 and November 1, 2001, and whose generous financial support allowed the Jacobs Institute of Womens Health to achieve its goals in 2001:
Welcome to the following new members of the Jacobs Institute, who joined between July 27 and November 1, 2001. To become a member, complete and return the form on page 3. For more information on membership, call us at 202-863-4990 or visit our web site at jiwh.org.
Meena Abraham, MPH