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

January 30, 2007

CONCLUSIONS AND RECOMMENDATIONS

In this final portion of the report, we present our conclusions and recommendations. To begin, however, we present a brief summary of our main findings:

• Biology and physiology are primary sources of medical differences between men and women. In addition, the fact of being male or female leads to different socialization, expectations, and lifestyles; thus, gender also influences health.
• Because women have fewer resources in terms of time, money, and insurance coverage in their own names, they face unique access barriers to the healthcare system compared with men. However, women are more likely to seek preventive care than men, perhaps because they have been socialized to seek care before a health crisis occurs.
• Women appear to receive worse quality care than men do. This appears to be especially true for acute conditions. However, women, as more frequent users of preventive care, may actually receive better preventive care than men.
• Despite significant gains in recent decades, women remain relatively understudied as medical research subjects. As a result, medical treatments may not be as appropriate for women as they are for men, and women are more subject to adverse drug reactions than are men.
• There are a variety of approaches being implemented to engage and retain the underserved in systems of healthcare. Data are lacking, however, on the cost-effectiveness of such programs, and on whether there are gender-differences in the effectiveness of these programs.
• Systems-level changes to the U.S. healthcare system likely would result in substantial improvements to quality of care, as well as a reduction in disparities and potentially a reduction in overall costs; implementing gender-based approaches to care seems to require systems-level changes. Other large efforts within the healthcare system (e.g., the effort to create patient-centered care) may be good models or natural allies for such efforts to promote gender-based care.
• Women are financially disadvantaged compared with men and also have greater family responsibilities. This makes healthcare costs, including out-of-pocket costs, a greater burden for women than for men.
• There are very few currently existing gender-based approaches to medicine. There are a substantial number of programs that are designed to serve women, and a smaller (yet growing) number of programs designed to serve men.
• Gender-based healthcare practices-i.e., medical care that effectively addresses differences in men's and women's healthcare needs-are still in their infancy. As such, almost no data exist on the overall effectiveness of such approaches. There also are substantial data collection problems in studying the effectiveness of gender-based care, as there is no historical precedent to collect such data.
• The women's health movement is beginning to produce results concerning effectiveness, and these are quite promising. Women who attend women's clinics rate their overall satisfaction as quite high. In addition, studies are showing that these women are receiving better-quality care, especially better preventive care on traditional women's issues. CoEs clearly are leaders in this kind of woman-specific care, and the CoE model, as a women's healthcare model, has been successful.
• There is anecdotal evidence that increasing the number of women leaders in healthcare improves care for women, and substantial evidence that male and female doctors communicate and interact with patients in different ways.
• Men face some barriers to care that are less common among women, perhaps the most important of which is a general male reluctance to seek preventive or routine care.
• There are several examples of programs that encourage men to receive more preventive care, and many of these use approaches such as creating settings that are more appropriate for male patients and utilizing women as an avenue to reach men (although we note several drawbacks of relying on women as a means to reach men).

In consideration of these main findings, we offer the following conclusions and recommendations.

CoEs have been successful.

We begin by noting that the CoE model implemented by OWH more than a decade ago has been successful. As we have shown in this report, CoEs have helped to raise the profile of women's health issues and have helped to establish this discipline. Women attending CoEs are receiving high-quality care, and the CoEs themselves have been remarkably successful at leveraging funds to build and support this model.

To build on this success, it is time for OWH to move to incorporate a broader sex- and gender-based approach to care that will include men as well as women. In doing this, we do not believe OWH should neglect or abandon the existing CoE or CCOE sites, which, although they have been successful, are unlikely to continue without ongoing Federal leadership and funding. Because of historical and persistent deficits in women's care, it appears that specific interventions for women are still needed.

Although additional research is warranted, studies to date suggest that the CoEs and CCOEs are an excellent base from which OWH can build as it moves toward new models of care. We are not suggesting that such a process should be noncompetitive; rather, that instead of starting anew, OWH might consider a process to competitively leverage existing resources at current or former sites to create new models of care. In addition to using this existing resource base, new sites also could be funded as necessary or appropriate.

Neither men nor women are receiving optimal care from the U.S. healthcare system, with both genders experiencing significant and well-documented disadvantages in healthcare.

While there may sometimes appear to be a tension between the fields of men's and women's health, this is not the case. The U.S. healthcare system does not do an adequate job meeting the needs of either sex, and steps need to be taken to ensure that both sexes receive appropriate care. Both of these fields have undertaken the important job of elevating the needs of each sex. Fortunately, this does not need to be a zero-sum game with men and women competing for optimal care. Instead, improvements in care can benefit both genders.

In the case of women's health, this field continues to draw needed attention to the historical deficit of research on women's health needs. While these deficits are shrinking, women remain understudied. Women also face unique healthcare needs related to their lower income, additional caretaking responsibilities, and role overload. At the same time, the field of men's health has highlighted men's greater reluctance to seek care, especially preventive care, and additional risk factors faced by men (e.g., as derived from their greater propensity to take risks).

Both men and women would benefit from a move toward a gender-based system of care in the United States.

The findings from both women's and men's health studies have shown that both genders would benefit from a gender-based approach to medicine. While the two sexes have much in common, there are enough medical differences between men and women (e.g., regarding how and when diseases occur, optimal treatment approaches, responses to care, and socialization related to seeking health treatment and interacting with doctors), that medical treatment cannot be gender-neutral.

Any gender-based approach to care must continue to have a research emphasis on the needs of women to correct for past deficiencies. Our findings suggest additional benefits of supporting systematic studies of such gender differences, as many findings will have applications to both sexes. Gender-based approaches should consider a broad set of issues related to access to care and quality of care, including factors such as insurance coverage, willingness to seek care, doctor-patient interactions, and optimal medical procedures.

For optimal gains, the movement to gender-based care should be coordinated with efforts underway to reduce racial/ethnic and socioeconomic disparities in care, and those to provide culturally appropriate, patient-centered care. Because the goal of all these efforts is to improve the quality of care to all patients and to reduce disparities in care, coordination of efforts in data collection, setting and evaluation of standards of care, and interventions to improve care and care outcomes will facilitate more rapid gains and make it easier for health plans, clinics, and providers to implement change.

Despite the promise of a gender-based approach, significant research gaps remain.

Even as researchers are increasingly calling for the consideration of gender as an important variable in all health research, the influence of sex and gender on healthcare remains substantially understudied. In our review, we found that many basic issues related to the influence of sex and gender are under-explored. As a result, their influence on men's and women's health and healthcare are unknown at this point.

Thus, we recognize that there is still a considerable need for primary research in this area, even though research to date is promising enough to inform the implementation of some clinical interventions and the development of others. Moreover the CoEs offer excellent opportunities for evaluation work to assess the effectiveness of new and established efforts to improve women's healthcare and outcomes.

All health trends need to be considered from a gender perspective.

In addition to a gender-based approach to medical research and practice, many of the generic trends in healthcare also need to be considered from a gender-based approach. For example, the movement toward consumer-driven healthcare places additional burdens on patients that are not being considered from a gender-perspective. This perspective needs to be kept in mind, however, as there may well be important differences between men and women in how they respond and react to these trends.

Another example is the trend toward increased use of technology in healthcare. This includes personal/portable health records, personal Web portals within healthcare Web sites, and the use of technology to send reminders to improve care. For all of these issues, there may be gender-based differences in access to, comfort with, and use of this technology, and these issues are not currently being considered from a gender perspective.

This type of thinking about possible gender-differences needs to be incorporated throughout the healthcare system to broaden and fully realize the IOM's goal of making sex and gender "a basic human variable" to be considered in all aspects of healthcare (Institute of Medicine, 2001).

Progress toward this goal will require new and continued efforts on multiple fronts.

Multiple areas for effective movement have been identified. Optimal gains can be achieved by pursuing multiple areas to advance and encourage the development and application of gender-based care:

• Scientific evidence is the foundation of gender-based care, and significant knowledge gaps in how men and women access treatment and respond to care will continue to need to be studied.
• Data collection and reporting at all levels of medicine need to include gender as a reporting variable to facilitate sex- and gender-based data analysis.
• Directing educational efforts toward both new and currently practicing healthcare professionals will facilitate more rapid dissemination of findings and advances in gender-based models of care. More diverse medical leadership will help to facilitate this progress.
• Encouraging systems-level changes in the U.S. healthcare system will facilitate the realization of gender-based care and also improve overall care and reduce inefficiencies. A systems approach with a focus on structural changes will make it easier for all people to access routine healthcare.
• A public health education component-so that all people know what kind of care they need, how to access care, and how to get medical advice-is an important part of this effort, as is framing preventive care as neutral and necessary for all people.

Leadership areas for OWH

The gender-based medicine objective fits within a larger effort aimed at creating evidence-based medical care and one aimed at delivering patient-centered care. However, gender differences in healthcare needs extend beyond a simple disparities model. Unlike racial/ethnic and socioeconomic disparities in care, gender differences in healthcare needs, and in quality of care, are related to both social and biological factors that affect men's and women's health, healthcare utilization, and outcomes of care. Therefore, achieving optimal gender-based care will require a multiple-facet effort, and would benefit from working with the many stakeholders pursuing related interests. Possible stakeholders include patients (including subcategories by gender or insurance type or status), clinicians, clinics, healthcare plans, scientists, funders, and others working on issues related to health promotion.

In light of this context, and informed by our systematic review of the literature, we make the following recommendations to OWH to continue in its leadership role:

• The research to date suggests that gender-based medicine is proven enough to warrant a targeted clinical boost. Our recommendation is that OWH consider working with existing CoEs and CCOEs to create a new model of care at these sites that is gender-based for both men and women. Such an approach will maximize resources by building on existing models. Initially, we do not believe such an effort should be overly prescriptive to allow for maximum creativity and innovation in implementing new approaches.
• Another important need that OWH can help to address is that for additional data on the clinical effectiveness and implementation of gender-based medicine. In concert with other Federal agencies working on these issues, OWH should help to establish reporting guidelines and systems that aid in the collection of data. At minimum, OWH should work with others in the healthcare field to emphasize the importance of considering sex as a key variable in all research studies (both in the medical and social sciences), and for data on sex to be broadly collected and available for analysis. Grantees could be encouraged to report on possible sex differences, where appropriate. In addition, OWH could take a leadership role in encouraging other agencies to work with their grantees to report on possible sex or gender differences.
• To advance gender-based models of care, OWH could partner with other Federal agencies to fund and develop instruments and efficacy studies that would document whether new guidelines improve care as anticipated.
• OWH could use its influence to highlight and publicize all aspects of healthcare where gender might be an important variable to be considered. This includes not only research, practice, and data collection, but also larger trends within the healthcare sector that may differentially impact the sexes.
• Quality-of-care improvements will only benefit the segments of the population that access care. Additional efforts would be required to bring the most disadvantaged segments of the population into the healthcare system. The patient-navigator approach appears to be promising in this regard, and significant efforts to study patient-navigators already have been undertaken by other agencies. We recommend that OWH work with these agencies to encourage the study of sex and gender differences in the application of these programs.
• Other nations are engaged in similar efforts to improve gender-based care, and OWH can and should learn from these efforts to the extent possible. Additionally, there may be international cost-savings opportunities to pool data (e.g., related to the effectiveness of gender-based approaches). Moreover, helping to sponsor or host an international conference on gender-based care could bring together key stakeholders and add attention and legitimacy to this work.
• Likewise, it might also be desirable for OWH to bring together various stakeholders promoting gender-based care. Such stakeholders have made substantial investments in promoting such care; coordination of their efforts at intervention and dissemination could facilitate change by bringing additional resources and experience to the table.
• Finally, we recommend continued efforts to educate health professionals and the public about critical sex- and gender-based differences in care. CoE and CCOE sites could be excellent intervention sites to educate practicing health professionals on best practices related to integrated, gender-based medicine. Successful models of how to educate practicing doctors will be critical to ensuring that the findings from this movement toward gender-based medicine benefit the entire population and not just patients who attend a specifically "gender-based" clinic. Ideally, research and practice in all areas of medicine would be evaluated to determine if gender-based care is needed to achieve optimal quality of care and outcomes for both men and women.

Limitations:

Like all studies, ours has limitations, and we briefly discuss them here. First, while we have made substantial efforts to be comprehensive in our searching, it is possible that we have overlooked significant efforts to advance gender-based medicine, and that such work is progressing at a more advanced level in a healthcare setting somewhere. While this is certainly possible (especially on a smaller scale), it is unlikely that significant efforts on a larger scale are ongoing. Not only does the pattern of our findings suggest that this is an emerging trend, but our personal conversations with some of the leaders in this field support this viewpoint (Legato, 2006b). Thus, we remain confident that the study of gender-based medicine, while promising, is still emerging.

Likewise, it is possible that we have failed to uncover significant efforts in terms of either women's or men's healthcare. This is much more likely, and in fact is almost inevitable. Whether the inclusion of any such possible oversights would have changed our conclusions is, of course, an open question. However, the relative consistency of the results we found, especially as regards to the current model of women's healthcare most often found around the world (i.e., a woman-only clinic focused primarily on gynecological care), suggests to us that any such omissions likely would not have impacted our conclusions in a significant way.

Finally, it is possible that we have overlooked significant healthcare trends that will meaningfully impact gender-based care. Again, despite our efforts to be comprehensive both in our search process and in including numerous reviewers, it remains probable that some materials have been overlooked. This is both because of the extensiveness of the healthcare field and the relevance of gender-related questions to almost all aspects of healthcare. In some ways, however, this limitation is illustrative of one of our main conclusions: To be most effective, gender-based care will need to take a broad approach to be well-integrated in all aspects of healthcare.

Thus, despite these limitations, we believe this review provides a sufficient evidence base for OWH to move forward with efforts to create gender-based systems and models of healthcare.

In conclusion, based on our review of the literature, we are calling for additional evidence-based approaches to medicine, including an effort to look at whether and how care should differ for men and women. OWH is well-positioned to take a leadership role in this area.

Current as of March 2007