Cardiac rehab programs face task of attracting women for treatment
Cardiac rehab programs face task of attracting women for treatment
New approaches urgently needed to get women involved
The studies continue to pile up that show women aren’t participating in cardiac rehab nearly as much as men. Maybe it’s because heart disease is still considered a man’s problem, even though it’s actually the No. 1 killer of women. Maybe it’s because women heart patients tend to be older and sicker than men. Maybe it’s because not as many women are referred to cardiac rehab or not as many stick with it.
But whatever the reasons, now is the time for rehab programs to take action, experts say.
"It’s time to intervene," says Veronique Roger, MD, professor of medicine and consultant in the division of cardiovascular diseases at the Mayo Clinic in Rochester, MN. "Yes, we do need to understand what the barriers are, but we need to intervene and find different ways to approach women with heart attacks, either at the time of the hospital stay or shortly thereafter. You can’t approach the burden of heart disease for a 70-year-old man in the same way as for a 50-year-old woman. The implications in terms of life-cycle issues are completely different, and we need to rethink it."
Roger, an observational epidemiologist, has been studying utilization of cardiac rehab in Olmsted County, MN, where the Mayo Clinic is located. Her preliminary data in a recent study of patients after a first heart attack showed that cardiac rehab was used less among women and older people than among men and younger patients. The study ruled out lack of insurance and the presence of comorbidities as a determining factor. Roger also found that women were less likely to receive primary prevention counseling after stress testing.
"Rehab is the vehicle for secondary prevention. With shorter hospital stays, we need to address this," Roger says. "Women typically experience heart attack at an older age than men, and they sometimes have transportation issues and social isolation issues. Over the last 20 years, heart attacks have been increasing among women and the elderly. There’s a sense of urgency to exploring these issues."
Other researchers have found similar results in recent years. A North Carolina study showed that although 46% of coronary heart disease deaths in the state occurred in women, between 60% and 70% of participants in cardiac rehab programs across the state were men.1 Another study of 3,841 patients enrolled in the Minnesota Heart Survey Registry found that 22% of women used cardiac rehab, compared to 41% of men.2 In a 2002 study published in Circulation, researchers found a 47% participation rate for women vs. 63% for men.3 Half of the studies cited in the 1995 Cardiac Rehabilitation Clinical Practice Guidelines issued by the Agency for Healthcare Policy and Research dealt only with male patients, and studies that included women had less than 20% female patients.4 The panel that wrote the guideline cited the need to encourage women to participate in cardiac rehab programs.
Physicians lead the way
Sharonne Hayes, MD, director of the Mayo Clinic Women’s Heart Clinic, says while more clinicians are becoming aware of this issue, she still is surprised by the number of women who don’t participate in rehab programs. Hayes co-wrote an article earlier this year based on a national survey of women heart patients funded by WomenHeart: The National Coalition for Women with Heart Disease. Less than 60% of the women in the study who had a diagnosis of coronary artery disease had received cardiac rehab services.5
"My feeling as a cardiologist is if you have coronary disease and have had an intervention, you should participate in a rehab program at some point. What was striking in our study was the number that had not," Hayes says. "Women who participate in cardiac rehab are less likely to have a heart attack and are more likely to live at five years. Women tend to have a higher risk burden after heart attack or bypass than men. If anything, we should be sending more women to rehab than men."
In the WomenHeart survey, 31% of women with coronary artery disease were not referred to rehab. Of those who were referred, 16% did not attend, citing such barriers as lack of insurance, inconvenient location, and no transportation. Fifty percent of those who went to cardiac rehab rated the experience as very positive, while 34% said it was helpful but lacking in selected areas such as support systems.
"The No. 1 predictor of a woman going to cardiac rehab is the strength of the physician’s recommendation," Hayes says. "If the physician says she can go or not, she’s not going to go. Physicians can discourage rehab by not encouraging it. Physicians need to realize they personally have a pretty big effect on how a woman might get her health care."
Many of the women in the survey indicated they were brushed aside or their worries were minimized. "Some of them were relieved at first, because nobody wants to have heart problems, but they were angry later when they were found to have real disease," Hayes says. "We didn’t survey men, but there certainly was a perception among women that they might have been treated differently if they were men."
Both physicians and women patients need to think "heart" when they encounter symptoms, Hayes says, especially if the women are over 65 and past menopause. "They may be able to quickly eliminate heart disease as a diagnosis, but if you never think it, that’s a problem," she says. "For women over 75, the risk of heart attack approaches that of a man’s. Premenopausal women have a low rate of heart disease, but it’s still their No. 1 killer. You’re never immune from heart disease."
Why women won’t go
But even when heart disease is correctly diagnosed, women still may avoid cardiac rehab. In the WomenHeart survey, women who didn’t go to rehab or who dropped out before finishing the program cited barriers including the following:
- For young women, it’s a sea of gray hair. "There aren’t very many young women, but they have particular needs that are not being met in the rehab environment as it currently stands across the country," Hayes says. "They go to rehab and it’s predominantly older men or women. Nobody else is worrying about carpools and child care." Younger women also tend to be reasonably fit and need more psychosocial support than exercise training. Some of Hayes’ patients have joined breast cancer support groups because they couldn’t find a heart-related group.
- Rural women cite location and transportation issues. And there could be a cultural issue as well: "If you’re a farm wife, you may need permission from your husband to go to rehab," Hayes says.
- Older women may lack social support to encourage their participation. "You’ll often see a man who had a heart attack, and his wife drives him in and sits there and knits while he goes on the treadmill," Hayes says. "Many of the women are widowed and have a lower income level. There’s no one driving them in."
- Older women also tend to have more comorbidities such as arthritis or hip replacement that make an exercise-based program difficult.
But perhaps the most striking piece of information to come out of the WomenHeart survey was the incidence of mental health issues, Hayes says. Fifty-seven percent of the women reported some type of mental illness, such as anxiety or clinical depression, associated with their heart disease. "Depression appears to be more common in women after a heart attack, and that increases their risk of further heart problems," Hayes says. "If the emotional issues are not treated, it defeats the purpose of rehab. If you’re depressed, you’re not going to want to exercise. The mental health aspect for rehab is critically important to deal with."
Mayo has begun to address the problems women heart patients face. For starters, the hospital offers a monthly outpatient support group, says Kathy Zarling, RN, MS, cardiac rehab coordinator for the Mayo Medical Center. "Patients come back and discuss their anxieties and stumbling blocks," she says. "We have a whole gamut of patients across medical, interventional, and surgical cardiac. We want to make sure we’re dealing with the psychosocial aspects because that’s an important part of recovery."
The Mayo Clinic also has stepped up its efforts to make sure all heart patients get cardiac rehab referrals. With ever-decreasing lengths of stay, it’s easy to miss a patient who comes in for a stint and goes home the next day. The hospital has put procedures in place to identify all patients who come in for interventional procedures, bypass surgery, heart attacks, or coronary artery disease. The goal is to have a rehab nurse visit those patients before they leave the hospital, but if patients are missed, the nurse calls them at home.
"We try to have an outpatient appointment in their hands before they leave the hospital," Zarling says. "If they’re outside our area, we find the most convenient location for them. We send a letter to that cardiac rehab program, we call the program, and that provider calls the patient at home."
References
1. Evenson K, Rosamond W. Outpatient cardiac rehabilitation in North Carolina. North Carolina Medical Journal 2000; 61:75-79.
2. Evenson K, Rosamond W, Luepker R. Predictors of outpatient cardiac rehabilitation utilization: The Minnesota Heart Survey Registry. JCR 1998; 18:192-198.
3. Vaccarino V, et al. Sex differences in use of cardiac rehabilitation programs after CABG. Circulation 2002; 106:II-713. Abstract 3515.
4. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation Clinical Practice Guidelines No. 17. AHCPR Publication No. 96-0672; 1995.
5. Marcuccio E, Loving N, Bennett SK, et al. A survey of attitudes and experiences of women with heart disease. Women’s Health Issues 2003; 13:23-31.
The studies continue to pile up that show women arent participating in cardiac rehab nearly as much as men. Maybe its because heart disease is still considered a mans problem, even though its actually the No. 1 killer of women. Maybe its because women heart patients tend to be older and sicker than men. Maybe its because not as many women are referred to cardiac rehab or not as many stick with it.Subscribe Now for Access
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