Tailoring Cardiac Care for Women

Developing heart centers that specialize in women's cardiology care is of growing importance, not only for women's health, but for hospitals seeking improved economic returns.

This article appears in the December issue of HealthLeaders magazine.

Confusion and uncertainty cloud the issue of women's heart disease, and perhaps surprisingly that lack of clarity is even evident among physicians—or at least among those who aren't cardiologists.

Heart disease is the leading cause of death in females, but this fact is not understood universally by the general population. Many people also fail to realize that the symptoms of heart disease in women can be dramatically different than those for the same ailment in men.

Many hospitals are deciding the time is right to focus on women's cardiac health. While women's health programs have been part of hospital service lines for years and are showing steady growth, some healthcare providers are creating special centers that address women's cardiac health specifically. They tailor care for patients to focus on heart disease risk factors, with education a key component in delivering preventive strategies. That education is beginning to pay off.

"We're seeing an increase in recognition by women that heart disease is something that is much more likely to occur than any other form of disease, such as cancer," says Gretchen L. Wells, MD, PhD, who is director of the women's heart center at 885-licensed-bed Wake Forest Baptist Medical Center in Winston-Salem, N.C. "It's nice to see awareness increasing, but there are definitely gaps in knowledge among age groups and ethnicity of patients."

The lack of awareness includes patients and physicians, points out Kimberly A. Skelding, MD, director of women's heart and vascular health for Geisinger Health System in Danville, Pa. "After I spoke to a group of women on the topic, one woman came up to me and said, 'Oh my goodness, I have these complications you spoke of.' Light bulbs went off," recalls Skelding.

The Geisinger system includes the 545-bed Geisinger Medical Center campus in Danville, 547 beds at two other acute hospitals, and a rehab and nursing facility. "Women's cardiac problems present differently than [they do in] men, and it's not even known extensively in the cardiology community," Skelding says. "I'm only 15 years out of my general cardiology training, and I didn't have women's cardiac care as part of my training. This is something everyone needs to know about."

The most common heart attack symptom in women is chest pain or discomfort similar to what men experience, but women can have other symptoms, such as nausea, shortness of breath, and back or jaw pain, according to the American Heart Association.

The AHA has been pivotal in trying to change the conversation around women's heart health. Although much progress has been made in the "awareness, treatment, and prevention" of cardiovascular disease in women since the organization published its first clinical guidelines in 1999, the AHA states that "considerable challenges remain." Heart disease remains a major killer of women and, reversing a trend of the past four decades, death rates of women 35–54 years of age in the United States appear to be increasing, likely because of the impact of the obesity epidemic.

"Among our priorities is to provide comprehensive cardiovascular care and early identification of cardiac disease," says Indu Poornima, MD, director of the women's heart center at the 661-licensed-bed Allegheny General Hospital in Pittsburgh, part of the 1,200-bed West Penn Allegheny Health System, which includes five western Pennsylvania–based acute care hospitals. "Comprehensive care for women is offered at the center before an event occurs because the heart conditions of women present differently, and specialty care in cases such as hypertension can manage symptoms."

Over time, physicians and academics have continually found differences in what men and women need in cardiac care. Some reports are contradictory, puzzling, and still being sorted out. For instance, women's risk of heart disease appears to increase as their estrogen levels decrease during menopause, but the link is not clear.

In addition, postmenopausal women undergoing hormonal modulation may have greater risks of heart disease, and pregnant women with certain conditions may be susceptible to more cardiology ailments. Most baffling of all, nearly two-thirds of the deaths from heart attacks in women occur among those who have no history of chest pain. Other studies also have raised growing concerns about atrial fibrillation among women.

Developing a heart center that specializes in women's cardiology care is of growing importance for institutions, not only for improving care for women but also for hospital ROI, says David X. Zhao, MD, FSCAI, FACC, chief of cardiology and director of the heart and vascular center for excellence at Wake Forest Baptist Medical Center.

Within months of his arrival in July, Zhao restructured the hospital's cardiology team to also ensure a focus on women's cardiac issues and appointed Wells to head the women's heart program. Previously, "we didn't have a lot of interaction" with women cardiac patients, says Zhao. The new program is part of an evolving "cohesive service line," including a physician champion for women's health and prevention programs to address patient weight management, risk stratification, and hypertension.

Developing such a women's heart program was "critical from an institutional standpoint and for patients," Zhao adds. The program "creates a specific health structure using a platform to educate the public" and a streamlined approach for primary care physicians who refer cardiac patients to the hospital, he says.

Having a specific heart center that focuses on women's cardiac issues also opens the door for improved economic returns for the hospital, says Zhao.

"You capture those referral volumes from physicians by having a heart center for women," says Zhao. "From a business standpoint, you are increasing patient visits from women. It's the woman who makes a lot of the healthcare decisions in a family. If you provide good service, they tell their husband or father, and we triple, quadruple the service from the hospital's standpoint if the entire family comes in."

The Center for Women's Heart Care at the 957-licensed-bed Duke University Medical Center is not located in a separate facility, but within the cardiac division on the main Durham, N.C., campus. It's what L. Kristin Newby, MD, MHS, a cardiologist at DUMC calls a "virtual" program.

It works this way, she says: "We have our physicians declare their interest or special interest in heart disease in women, and our communications center aligns patients when they call in—asking for specific services—with those physicians."

That, Newby says, helps patients feel more comfortable: knowing they have a women's cardiac program to address their needs.

Success key No. 1: Specialized centers

Cardiac care centers for women often target subspecialties of need. For instance, Allegheny General Hospital is putting a concentrated effort on pulmonary hypertension and follow-up care for patients. The 664-bed Rush University Medical Center's Rush Heart Center for Women in Chicago is examining atrial fibrillation and its impact on women.

While these centers have a different focus, they incorporate a multidisciplinary team to ensure a coordinated framework with primary care and other specialists.

At Rush Medical Center, the multi-disciplinary teams include psychologists because many women who have had heart attacks experience stress and anxiety as they fear having another cardiac episode, says Annabelle Volgman, MD, FACC, medical director of the Rush Heart Center for Women. The center includes mostly women cardiologists and nutritionists in its programs. Female patients often feel more comfortable with physicians of the same sex, although not exclusively, Volgman says. One reason is that for too long, women were not treated in care as aggressively as men, she says.

Rush Heart Center's conce tration on atrial fibrillation issues reflects increasing concerns among women about the most common type of arrhythmia, an abnormal heart rhythm. An estimated 2.6 million people had atrial fibrillation in 2010, and about 12 million may have the condition by 2050.

Volgman says the Rush Heart Center is exploring not only a host of therapeutic procedures to prevent atrial fibrillation but also ways to ensure safe management of the disease once it is diagnosed.

Among the therapies being used: adding blood thinners for women, sometimes as often as men receive them, and consistently monitoring anticoagulation therapy to avoid excessive bleeding, Volgman explains. Prescribing a blood thinner also has been effective in stroke care, she says. The hospital determined that while older women were twice as likely to receive aspirin as the blood thinner warfarin in treatment, warfarin reduced stroke risk by 84% in women and 60% in men, she adds. They adjusted treatment accordingly.

Those continued evaluations of medications are important as the heart center assesses women's cardiac care, Volgman says.

Today, Volgman reports seeing more female cardiac patients coming through the hospital's doors. "A decade ago, I was only seeing patients one half day a week, and now I have to limit my time to see patients to three full days a week," Volgman says of her clinical practice. "I also now have two other female cardiologists helping to see women patients interested in being seen in the center."

In Pittsburgh, Allegheny General Hospital is focusing on a different aspect of women's cardiac care: pulmonary hypertension, or high blood pressure in the arteries that affect the lungs or the right side of the heart. The condition can be easily missed in women, who may not understand why they have shortness of breath, says Poornima, director of the women's heart center.

Pulmonary hypertension "specifically impacts more women than men and can present itself quite differently," Poornima says. "Sometimes, it is not diagnosed until it becomes quite severe. You definitely need a full spectrum of experts to treat and monitor the condition."

Moreover, the prevalence of a related disease, pulmonary arterial hypertension, is twice as common in women than in men, according to Allegheny Health Network's Srinivas Murali, MD, FACC, director of the division of cardiovascular medicine and medical director of the Cardiovascular Institute. "Pulmonary hypertension" describes high blood pressure in the arteries of the lungs. Pulmonary arterial hypertension is one form of pulmonary hypertension.

The Allegheny Health Network's program features a multidisciplinary team that includes pulmonary, rheumatology, and imaging specialists who conduct a comprehensive review of each patient with pulmonary hypertension. Once a patient is diagnosed, the team evaluates the severity of the condition, prescribes treatment, offers educational programs, and coordinates care with referring physicians, Poornima says.

"Our goal is preventive treatment, and we see patients early—before they develop their heart attacks, strokes, symptoms of congestive heart failure, and other cardiovascular risk," she says. "We're seeing increased awareness—not only in referrals from other physicians but also in self-referrals from patients who would like to know more about their disease."

Success key No 2: Using electronic records

While women of child-bearing age may gravitate toward their OB-GYNs for care, they sometimes neglect checkups with primary care physicians after giving birth and may miss some nonobstetrical health issues, says Geisinger's Skelding. Studies have shown a link between certain pregnancy-related complications for women in their 20s through 40s and "having a higher risk of cardiovascular events later in life," she says.

Yet new mothers may not think of the potential problems ahead. "After her delivery, a patient's pregnancy-related issues vanish and she goes on her way, not realizing that she's at risk in the next 20 years for heart disease," says Skelding. "A woman may not see an internist for primary care until
middle age," she adds.

Through electronic health records and community involvement programs, Geisinger is focusing on improving cardiovascular care for women who have complications during pregnancy and may have a greater risk for cardiovascular disease, Skelding says.

"We and other centers around the country are attempting to engage these women early on, after their pregnancy and get them engaged in their health for life," Skelding says. "We try to work with them, to keep their risk factors in check, and have a basic awareness of the risks."

Geisinger has begun using its ProvenCare program, supported by the electronic medical records, to treat pregnant women. This will allow Geisinger to identify women with pregnancy-related complications and direct them to healthcare providers to lower their risk of cardiovascular disease later in life. Geisinger has used the program for perinatal care and surgical procedures such as coronary artery bypass grafts.

Overall, the program has shown steady improvements in clinical and financial areas, according to Geisinger officials. In 2012, the hospital reported an 80% improvement in reduced inhospital mortality rates and a 29% decrease in pulmonary complications, through the use of coronary artery bypass grafts since ProvenCare was initiated. The hospital's data was the result of reviews of 132 patients before the use of the ProvenCare and 321 afterward. An earlier Geisinger report showed ProvenCare reduced the length of patient stays from 6.2 to 5.7 days, with a 30-day readmission rate that fell 44%, from 6.9% to 3.8% between 2005 and 2009

The total inpatient profit per coronary artery bypass graft case increased by $1,946, according to the 2012 report.

Using the ProvenCare program, "we have a link between the OB-GYN navigator and the cardiology navigator, and we have ready access—in real time—to these pregnancy-related complications that are known to increase cardiovascular problems," Skelding adds. "This continually identifies these women and brings them to our attention."

The idea is to develop educational materials targeting women who might not have picked up a packet in the OB-GYN clinic or hadn't read about it on the Internet, she says. "We can focus our educational efforts toward them … offering them screening programs, as well as further educational material, to help keep them healthy for years to come."

Coordination is important with specialties and evaluation by primary care providers, Skelding says. There are OB-GYN partners "who are also very interested and motivated to identify these women and get them to us for screening, prevention, and treatment if needed," she adds.

Success key No. 3: Facing care discrepancies

While healthcare leaders are working to improve treatment equity for cardiovascular disease that impacts women, they are also looking at the demographics of subgroups of women, especially among African-American and Hispanic populations.

A 2012 study by the American Heart Association noted that education campaigns helped white women become more aware of heart disease risks, but those efforts did not have an apparent impact in minority communities.

The study of trends among racial and ethnic groups showed that from 1997 to 2010, the rate of awareness among whites of cardiovascular disease as a leading cause of death increased from 30% to 56%. Yet awareness in 2012 was only 36% among black women and 34% among Hispanics—at levels similar to those of white women in 1997.

The AHA report noted, "Awareness of cardiovascular disease among women has improved in the past 15 years, but a significant racial/ethnic minority gap persists." It added, "Continued effort is needed to reach at-risk populations."

Findings like that have prompted officials of Baltimore's 372-licensed-bed St. Agnes Hospital's women's heart center to initiate a community outreach program to improve awareness.

African-Americans and Hispanics have "some of the highest rates of cardiovascular disease in the city, and the gap is even greater among women," says Shannon Winakur, MD, medical director of the St. Agnes Hospital women's heart center.

Heart disease and stroke are the leading cause of death in Baltimore. African-American men die 6.7 years earlier than white men, and African-American women die 4.2 years earlier than white women there, according to a 2011 report from the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities.

To overcome the challenges, St. Agnes Hospital has initiated a Heart to Heart initiative that includes partnerships with churches in the region to screen African-American women for cardiovascular disease.

If patients are found to have risk factors such as diabetes, hypertension, high blood pressure, or other symptoms of heart disease, they can receive follow-up screenings. As of October 29, 222 women have been screened, with 160 of them qualifying for the intervention, which included participating in St. Agnes' well4life program with four months of exercise and educational classes, plus access to a lifestyle coach and support groups, she says.

St. Agnes has conducted screenings at four churches so far. "For the first three screenings, we are in the process of conducting the follow-up visits for postintervention after four months," she says.

The follow-up visits repeat first-round biometrics, such as weight, blood pressure, and waist circumference, as well as blood work for cholesterol and blood glucose, to follow the women's progress after the intervention.

The hospital also conducts a heart health assessment in an hour-long program that costs patients $60 each. Patients complete a comprehensive risk assessment and can receive a personalized education program based on the results.

St. Agnes wants to keep up the drumbeat for women's cardiac care. The hospital sponsors seminars, meetings, and educational events. While there is often great interest among women in the topic around Valentine's Day—with American Heart month and AHA Go Red for Women activities—sometimes interest drops off afterward. That shouldn't happen, Winakur says. It's a year-round, day-to-day effort, and women "need to be aware of the risk factors."

Reprint HLR1213-6

This article appears in the December issue of HealthLeaders magazine.