Literature Review on Effective Sex- and Gender-Based Systems/Models of Care

January 30, 2007

INTRODUCTION

Historically, medical research has failed to adequately assess important differences between men and women, or at times to even distinguish between men and women. Women were excluded from clinical research trials, and the default patient in medical textbooks was an adult (white) male. Women, it was assumed, were essentially "small men" (Legato, 2002). Partly in response to this oversight (but also because of women's desire to have greater control over their own bodies), a women's health movement emerged in the latter part of the 20th century.

Early efforts in women's health ultimately led to shifts in both medical research and in healthcare delivery. While some early women's health centers were mostly a cosmetic exercise (e.g., pink examining rooms for gynecological care), women's health in the 21st century is an established discipline that is uncovering critical differences between the sexes.

This new research focus has led to the discovery of vast differences between the sexes on numerous biological and physiological processes. Differences have been found in virtually every body system, from the heart to the brain (Legato, 2002). As the Institute of Medicine (2001) noted in its paradigm-shifting report on sex differences in health and illness:

Sex matters. Sex, that is, being male or female, is an important basic human variable that should be considered when designing and analyzing studies in all areas and at all levels of biomedical and health-related research. Differences in health and illness are influenced by individual genetic and physiological constitutions, as well as by an individual's interaction with environmental and experiential factors. ... Although in many cases these sex differences can be traced to the direct or indirect effects of hormones associated with reproduction, differences cannot be solely attributed to hormones.

Not only does sex matter, but sex differences must now shift to the forefront of medical research:

There is now sufficient knowledge of the biological basis of sex differences to validate the scientific study of sex differences and to allow the generation of hypotheses. The next step is to move from the descriptive to the experimental and to establish the conditions that must be in place to facilitate and encourage the scientific study of the mechanisms and origins of sex differences. ... Barriers to the advancement of knowledge about sex differences in health and illness exist and must be eliminated (Institute of Medicine, 2001).

Important differences between men and women regarding healthcare relate not only to sex-differences, but to gender-differences as well. The fact of being male or female leads to different socialization, expectations, and lifestyles, and these gender roles affect and interact with health in complex ways. For example, some factors make women more likely to seek treatment, while others make them less likely to seek treatment. Thus, gender is also an important component of healthcare.

In the wake of this ever-expanding knowledge, many women's health researchers increasingly are realizing that women are not the only ones who need to be studied. The previous one-sex research focus (first on men, then on women) meant that scientists missed an entire pattern of differences. Now, "the new knowledge about women is forcing a correction and expansion of male models of normal human function and the workings of illness and how to repair and destroy it" (Legato, 2002).

The result is that medical research is moving toward becoming gender-based (that is, considering gender as a potentially important variable in all aspects of research and care). For diseases affecting both genders, single-sex studies cannot indicate whether a specific type of care or intervention is better suited to one gender. Just as we cannot generalize from all male studies to women, we cannot assume that the findings from all male studies do not apply to women. The reverse is also true; for instance, if researchers found that a particular form of doctor-patient interaction works well for women in a single sex study, this would not provide the basis for knowing whether the benefits of the intervention are unique to women.

This new research focus will be helpful to clinicians in their efforts to effectively respond to patient needs. To date, this medical literature has not been comprehensive as it relates to sex- and gender-differences, but ongoing research will continue to address these issues:

Unfortunately, the published scientific and medical literature too often fails to aid clinicians who seek to understand potential sex differences in disease presentation. In the absence of research that includes sufficient numbers of women to support a separate analysis ... clinicians are often left to apply findings from studies on men to the care of women. Increasingly, we are shown that this is not the ideal way to deliver quality care. Indeed, new sex-specific clinical evidence often invalidates previously accepted conventional wisdom regarding the best choices for patient care and replaces it with more accurate, effective, or safer alternatives (Washington & Bird, 2002).

In many ways, the success of the women's health movement has rapidly pushed the frontiers of medicine to first include women and then to have a new and better understanding of men. This poses a new challenge for the field of women's health, however: How can the discipline of women's health continue to study the unique ways women differ from men (a necessary process because of the accumulated knowledge deficit from past oversights), while simultaneously embracing a new movement that includes gender-specific treatment for both sexes?

One organization currently facing this challenge is the Department of Health and Human Service's Office on Women's Health (OWH). OWH has developed several programs to model and promote excellent care for women. For example, in 1996 OWH established and promoted several Centers for Excellence in Women's Health. Although not created to do research, these CoEs

have served as leaders and change agents in the area of women's health. Their pioneering efforts have led to changes in the way that women's health services are delivered, changes in women's health curricula, acceptance of community health workers and allied health professionals as key members of the care delivery team, development of leadership and empowerment programs for women, and much more (US Department of Health and Human Services Office on Women's Health, 2006).

OWH is currently in the process of revisiting this model. Building on the success of the CoEs (and other similar programs), OWH now is ready "to move to incorporate women's health into an evidenced-based, sex and gender-based approach to care that includes medical, dental, and mental health services" (US Department of Health and Human Services Office on Women's Health, 2006). To provide an up-to-date research frame in which to move toward this kind of model, OWH commissioned this literature review "on comprehensive, integrated models of care, especially sex and gender-based systems/models of care" (US Department of Health and Human Services Office on Women's Health, 2006). This literature review will thus serve as a foundation as OWH moves forward in its efforts to improve healthcare for both genders.

OWH contracted with Uncommon Insights, LLC, to conduct this review. We have investigated seven main research questions, which will be discussed in more detail in this report:

1. What key sex and gender differences exist in the current healthcare system structure, including reimbursement mechanisms, content of and access to appropriate care, quality of care, and patient safety?
2. What models or approaches have been successful in engaging and retaining people in systems of healthcare, especially the underserved, the "difficult to reach," or low literacy populations? Are there sex/gender differences in the effectiveness of these approaches?
3. What are the trends in demographics, service delivery, costs, insurance, or other sectors that could be addressed via a systems approach? To what extent are patients reimbursed for care for specific services (i.e., prevention, mental health, etc.)? Are there gender or sex differences in out of pocket patient costs?
4. How does a service delivery site successfully integrate a model program into its current infrastructure of delivering care?
5. How effective are sex- and gender-based healthcare practices? (Comment on whether this research is far enough along to warrant a targeted boost via clinical practice models.) What measures have been used to determine the effectiveness of these practices? What barriers exist to translating/adapting these approaches into clinical practice?
6. How effective is a focus on clinical care at improving women's healthcare? How effective are systemic improvements (i.e. more women in professorships/research positions or emphasis on women's health in medical school curriculum) at improving women's healthcare? Are there other factors (e.g. continuity of care) that may be more important to women than to men or to women's outcomes vs. men's outcomes?
7. How can programs targeting boys and men be created to recruit and retain them in the healthcare system? Are programs such as patient advocate or patient navigator more needed or more effective for men at getting them into the system and to needed care?

The remainder of this report will describe our findings as they pertain to these seven research questions. We also describe our methodology to conduct this literature review, provide a brief overview of some recent findings related to sex-specific medical differences to help set the context of this report, offer our conclusions and recommendations (including a brief discussion of limitations), and include a complete bibliography.

Because of gender's potential implications for many aspects of healthcare, and the broad scope of OWH's initial research questions, our review covers a diverse set of topics such as quality improvement, systems level changes, the role of provider behavior, insurance patterns, and many others. In these discussions, we highlight gender-specific findings and research where available. Where gender is not discussed, we did not find any gender-specific analysis.

One of the primary reasons to include such broad-ranging information in our review is that, as will be discussed later on, while gender-based approaches to healthcare are not yet well-developed, there is a growing body of evidence and experience from related movements (e.g., toward culturally sensitive or patient-centered care) that can be drawn on. These movements not only provide important lessons-learned in thinking about how to implement gender-based care, but they also provide important opportunities for synergy.

Current as of March 2007