Physician Knowledge Levels and Barriers to Coronary Risk Prevention in Women: Survey Results from the Women and Heart Disease Physician Education Initiative

doi:10.1016/j.whi.2006.11.003

Women's Health Issues

Volume 17, Issue 2, March–April 2007, Pages 93-100

Presented in part at the 27th Annual Meeting of the Society of General Internal Medicine, Chicago Illinois (May 2004).

https://doi.org/10.1016/j.whi.2006.11.003 Get rights and content

Background

Few studies have examined whether physician knowledge, attitudes, or practice patterns might contribute to gender disparities in the primary prevention of coronary heart disease (CHD), including among physicians caring for the largest number of reproductive-age women, obstetricians and gynecologists (OB/GYNs). We sought to identify barriers affecting the provision of recommended coronary risk factor therapies in women.

Methods

We surveyed internists and OB/GYNs who attended Grand Rounds presentations developed for the New York State Women and Heart Disease Physician Education Initiative. This program was designed to improve screening and management of coronary risk factors in women. Attendees were asked to complete a 7-minute questionnaire.

Results

The mean age of the 529 respondents was 40.3 years (standard deviation = 12.3), 75.1% were internists (n = 378), and 42.7% (n = 226) were women. Physicians correctly responded to 71.5% of the 13 questions assessing knowledge of coronary risk prevention (range, 4–13). Almost one third of internists and half of the OB/GYNs did not know that tobacco use was the leading cause of myocardial infarction in young women. For patients who smoked tobacco, only two thirds of internists and 55.4% of OB/GYNs reported suggesting a quit date (p = .007). After controlling for covariates, physicians who did not perceive time as a barrier were more likely to discuss smoking cessation (odds ratio = 1.7 [1.1–2.7]).

Conclusions

Among the internists and OB/GYNs surveyed, time was perceived as a barrier to implementing risk prevention. These physicians also underestimated the impact of tobacco use as a risk factor for CHD in young women. To lessen gender disparities in CHD prevention, both specialties need time-efficient educational programs that reflect specialty differences.

Section snippets

Survey Instrument

The Physician Education Initiative Survey was designed to capture the most salient features of clinical practice guidelines in preventive cardiovascular care available at the time of our educational program (Executive summary of the clinical guidelines on the identification 1867, Expert Panel on Detection 2001, The sixth report of the Joint National Committee on prevention 1997). The surveys were distributed before each presentation began and efforts were made to collect them within 5 minutes

Results

The 529 internists and OB/GYNs completing the survey had a mean age of 40.3 years (standard deviation [SD] = 12.3). The majority of physicians who specialized in internal medicine (71.4%) practiced in the New York City metropolitan area (73.7%). Respondents preferred patient handouts or pamphlets as a method for enhancing heart disease prevention knowledge among their women patients (79%). There were significant demographic differences between the specialties: OB/GYNs were older, more likely to

Discussion

Based on these survey results, many internists and OB/GYNs in New York state who attended our CHD prevention program had limited knowledge of practice guidelines for optimal lipid levels, underestimated the impact of tobacco use as a risk factor for CHD in young women, and needed to improve their counseling and referral services for tobacco cessation. Furthermore, up to one third of these physicians did not know that nicotine replacement therapy for tobacco cessation may be used during

Acknowledgments

The authors thank Governor George E. Pataki and the New York State Department of Health, Commissioner, Antonia C. Novello, MD, MPH, DrPH, for funding the Women and Heart Disease: Physician Education Initiative and the staff from New York State Chapters of the American College of Obstetrics and Gynecology (Donna Williams, Deborah Elliott, and Christine Rutan) and American College of Physicians (Linda Lambert and Meg McCarthy) who worked tirelessly to implement this project. We would also like to

Dr. Barnhart is an Assistant Professor of Medicine and Epidemiology and Population Health at the Albert Einstein College of Medicine. Her research interests includes health disparities and cardiovascular disease as well as the risk perception of heart disease among women and minorities.

References (53)

J.W. Anderson et al.
Long-term weight-loss maintenance: A meta-analysis of US studies
American Journal of Clinical Nutrition74
(2001)
J.O. Andrews et al.
Provider feedback improves adherence with AHCPR Smoking Cessation Guideline
Preventive Medicine33
(2001)
A.G. Bertoni et al.
Sex disparities in procedure use for acute myocardial infarction in the United States, 1995 to 2001
American Heart Journal147
(2004)
M.S. Biswas et al.
Are women worrying about heart disease?
Womens Health Issues12
(2002)
M.D. Cabana et al.
Physician adherence to preventive cardiology guidelines for women
Womens Health Issues13
(2003)
S.J. Dempsey et al.
Women’s decision to seek care for symptoms of acute myocardial infarction
Heart & Lung24
(1995)
G.B. Ewing et al.
Self-report of delivery of clinical preventive services by U.S. physiciansComparing specialty, gender, age, setting of practice, and area of practice
American Journal of Preventive Medicine
(1999)
L.R. Simkin-Silverman et al.
Predictors of weight control advice in primary care practices: Patient health and psychosocial characteristics
Preventive Medicine
(2005)
R.S. Stafford et al.
Specialty differences in cardiovascular disease prevention practices
Journal of the American College of Cardiology
(1998)
M.M. Ward et al.
Effectiveness of a nationally implemented smoking cessation guideline on provider and patient practices
Preventive Medicine
(2003)

ACOG committee opinionSmoking cessation during pregnancy

Obstetrics and Gynecology106

(2005)

A. Anastasi et al.

Psychological testing

(1997)

J. Barnhart et al.

Is coronary angiography underused in an inner-city population?

Ethnicity and Disease16

(2006)

J. Barnhart et al.

Differential use of coronary revascularization and hospital mortality following acute myocardial infarction

Archives of Internal Medicine163

(2003)

J. Barnhart et al.

Clinical and nonclinical correlates of racial and ethnic differences in recommendation patterns for coronary revascularization

Clinical Cardiology23

(2000)

A.G. Bertoni et al.

Racial and ethnic disparities in cardiac catheterization for acute myocardial infarction in the United States, 1995–2001

Journal of the National Medical Association97

(2005)

Missed opportunities for preventive counseling for cardiovascular disease

MMWR Morbidity and Mortality Weekly Report

(1998)

P. Charney

Coronary artery disease in women

Hurst’s The Heart

(2004)

A.V. Chobanian et al.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report

Journal of the American Medical Association289

(2003)

J.D. DePue et al.

Dissemination of the AHCPR clinical practice guideline in community health centres

Tobacco Control

(2002)

S.H. Ebrahim et al.

Trends in pregnancy-related smoking rates in the United States, 1987–1996

Journal of the American Medical Association

(2000)

Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults

Archives of Internal Medicine

(1998)

Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III)

Journal of the American Medical Association

(2001)

M.C. Fiore

US public health service clinical practice guideline: treating tobacco use and dependence

Respiratory Care

(2000)

M.C. Fiore et al.

Smoking cessation: Principles and practice based upon the AHCPR Guideline, 1996Agency for Health Care Policy and Research

Annals of Behavioral Medicine

(1997)

D.A. Galuska et al.

Are health care professionals advising obese patients to lose weight?

Journal of the American Medical Association

(1999)

Cited by (43)

Managing Cardiac Patients: Dentists’ Knowledge, Perceptions, and Practices
2022, International Dental Journal
Citation Excerpt :
Our results show that the participants knowledge of CVD in women and its risk factors, including smoking and diabetes mellitus, is deficient. Similar to observations from studies involving physicians,57 many dentists underestimated the impact of tobacco use as a risk factor for coronary artery disease on women's health. We found that an increased perception of complications risk among women was the only significant predictor of higher knowledge scores of this topic, as opposed to the knowledge scores of general cardiology issues.
Dental patients may require invasive treatment, and awareness of their medical conditions is essential for optimal care. We assessed the knowledge, perceptions, and attitudes of dentists practicing in Saudi Arabia (SA) and their associations with managing patients with common cardiac conditions.
A national survey of knowledge and attitudes of practicing dentists towards patients with common cardiac conditions was conducted from May 2019 to July 2020 in SA. The survey comprised a newly developed, validated, electronic, self-administered English questionnaire.
Overall, 282 dentists completed the survey, of whom 45.5% perceived cardiac patients as difficult to manage, while 64.5% stated that they refer these patients to cardiologists before dental intervention. Regarding knowledge about cardiac conditions, 72% achieved an overall knowledge score <55%; however, their infective endocarditis scores were better. Consultants and specialists (P < .001), those with a PhD/board certification (P = .013), dentists with prior education on cardiac patient management (P = .002), and those working with a cardiologist (P = .016) scored higher on knowledge. Conversely, private dentists (P = .003) and those referring patients to cardiologists before treatment (P = .003) scored lower. Dentists’ knowledge of cardiovascular diseases in women was low; only those who believed women experience a greater risk of cardiac complications achieved a higher score. Approximately 90.1% wished to receive education regarding cardiac patient management.
Knowledge of cardiac patient management was suboptimal in this study. Dentists perceived cardiac patients as difficult to manage, but wished to learn more regarding optimal management. Thus, postgraduate education programmes that promote optimal dental management strategies for cardiac patients are necessary.
The Magnitude and Potential Causes of Sex Disparities in Statin Therapy in Veterans with Type 2 Diabetes: A 10-year Nationwide Longitudinal Cohort Study
2022, Women's Health Issues
Past research has shown that women eligible for statin therapy are less likely than their male counterparts to receive any statin therapy or be prescribed a statin at the guideline-recommended intensity. We compared statin treatment in men and women veterans from a national cohort of older veterans with type 2 diabetes.
The Veterans Health Administration Corporate Data Warehouse and Centers for Medicare and Medicaid Services data were used to create a unique dataset and perform a longitudinal study of veterans with type 2 diabetes from 2007 to 2016. Mixed-effects logistic regression was used to model the association between the primary exposure (sex) and statin use.
The study included 714,212 veterans with diabetes, including 9,608 women, with an overall mean age of 75.9 years. In the unadjusted model for any statin use, women veterans had a 14% significantly lower odds of having any statin use compared with men. After adjusting for all covariates, including markers of Veterans Administration care use (service-connected disability rating, Veterans Administration use, and primary care visits) that serve as proxies for access and mental health comorbidities (depression and psychiatric disorder), this disparity narrowed from 14% to 3% and was no longer statistically significant. In the model for high-intensity statin therapy (high-intensity vs. low or none), women were 10% less likely than men to use high-intensity statins in the base model that included only time and sex. After adjusting for all measured covariates, the direction of the association changed and women had 16% higher odds of high-intensity statin use compared with men (odds ratio, 1.16; 95% confidence interval, 1.03–1.31).
Consistent with prior research, in the unadjusted analysis a significant sex disparity was observed in statin use, with lower rates observed in women. For the outcome of any statin use, after adjustment for covariates that included variables that are proxies for access as well as psychiatric and depression comorbidities, this disparity lost statistical significance and narrowed. In the high-intensity statin versus low or none model, the direction of the association changed after controlling for measured covariates and women had a 16% higher odds of high-intensity statin use compared with men. This study highlights a persistent health disparity in lipid-lowering therapy for women veterans. Additional research is needed to further elucidate the reasons for and develop interventions to mitigate this persistent sex disparity in cholesterol management for veterans with diabetes.
Epidemiology and Prevalence
2021, Sex Differences in Cardiac Diseases: Pathophysiology, Presentation, Diagnosis and Management
Cardiovascular disease (CVD) is the leading cause of death in both men and women in the United States and most other developed countries. In 2016, CVD claimed the lives of 412,244 women in the United States. Growing knowledge of sex differences in symptoms/clinical presentation, pathophysiology of CVD, reliability of diagnostic tests, and responses to treatments, as well as an improved recognition of nontraditional risk factors specific to women, have resulted in improved clinical outcomes in women. However, despite these advances, CVD continues to be the leading cause of morbidity and mortality in both women and men in the United States. Women face disparities in diagnosis, treatment, and research related to heart disease. Persistent differences in risk factor prevalence, healthcare access, low levels of awareness by both the public and medical communities leading to underdiagnosis, delayed adoption of evidence-based guidelines in women, and major knowledge gaps are some of the factors contributing to CVD disparities. The objective of this chapter is to address the known sex differences in CVD based on epidemiologic and clinical data, characterize current sex-specific health disparities, discuss challenges, and identify strategic pathways to improve the cardiovascular health of women.
Young Women's Perceptions of Heart Disease Risk
2020, Journal of Adolescent Health
Heart disease is the number one cause of death in women. Little is known about how adolescent and young adult women perceive their risk of heart disease.
We conducted eight online, semistructured focus groups with 35 young women aged 15–24 years recruited from two primary care practices in Boston, MA. Focus group discussion topics built upon data from a larger sample of women who completed the American Heart Association Women's Health Study survey. Topics included health concerns salient to young women, perceived susceptibility to heart disease, and barriers to heart-healthy behaviors. We used qualitative coding and thematic analyses to synthesize data.
Participants were surprised to learn that heart disease is the leading cause of death in women. Young women discussed age (“I feel like those are things I associate with older people like 40”), gender (“I usually hear more about men suffering from heart problems than women”), and social norms (“we're so pressured just to grow up and [be] more focused on pregnancies or depression or our weight”) as reasons for their low perceived risk for heart disease. Participants noted several barriers to adopting heart-healthy behaviors including stress, lack of time, and low perceived risk. “We just don’t have time to worry about hearts. Especially if our hearts aren’t bothering us to begin with and we can't see it.”
Perceptions of age, gender, and social norms contribute to low heart disease awareness among young women, which in turn may limit heart-healthy behaviors.
Poor awareness among health care professionals about gender differences in the relationship between type 2 diabetes mellitus and cardiovascular disease
2020, Semergen
Varios estudios han identificado un peor control de los factores de riesgo cardiovascular en el sexo femenino en pacientes con diabetes tipo 2. Una de sus causas podría ser el desconocimiento sobre el perfil de riesgo cardiovascular de la mujer con diabetes tipo 2 por parte de los profesionales.
Conocer la percepción y el conocimiento de los profesionales de la salud involucrados en el manejo de los pacientes con diabetes tipo 2, del impacto que las diferencias de género tienen en el control de los factores de riesgo cardiovascular en estos pacientes.
Se envió una encuesta de 24 preguntas relacionadas con el conocimiento y percepción (agrupadas por temas) a profesionales interesados e involucrados en el cuidado de pacientes con diabetes tipo 2. Se analizaron 998 encuestas. Construimos un modelo de ANOVA para comparar los resultados por especialidad y años de experiencia ajustados por el resto de las variables de confusión y regresión logística para estudiar los factores que podían influir en tener más de 12 respuestas adecuadas (resultado favorable).
La media de respuestas correctas fue 10,3, discretamente mayor para especialistas (rango 10,7-11,8) y aumentaba con la experiencia (p = 0,001). Se encontró el género femenino y los años de experiencia como predictores de tener 12 o más respuestas correctas.
El nivel de conocimientos sobre el tema es bajo, pero similar a los resultados de otros estudios sobre la relación del género con determinadas patologías.
Several studies have found poorer control of the cardiovascular risk factors among women with type 2 diabetes. This could be explained by the lack of awareness of their cardiovascular risk among professionals.
To determine the perception and knowledge of health care professionals involved in diabetes management on the impact of gender difference on the control of cardiovascular risk factors in patients with type 2 diabetes mellitus.
A 24-question survey related to knowledge and perceptions (grouped by topics) was sent to professionals who were interested and involved in diabetes care. A total of 998 surveys were analysed. An ANOVA model was constructed to compare the results by specialty and years of experience, as well as adjusting for the rest of the confounding factors. On having more than 12 correct answers (favourable result), a logistic regression was also performed in order to study the factors that could have an influence.
The mean number of correct answers was 10.3, and was slightly better for specialists (range 10.7-11.8), and associated with years of experience (P = .001). Female gender and years of experience were identified as predictors of having more than 12 correct answers.
The level of knowledge was low, but similar to the results of the other studies.
Risk of vascular disease in premenopausal women with diabetes mellitus
2014, Clinical Therapeutics
Citation Excerpt :
However, for women, up to 20% of all coronary events occur in the absence of these major risk factors,15 whereas many women with traditional risk factors do not experience coronary events, indicating that the algorithm used is not sensitive enough to prevent most of the cardiovascular events. In addition, physicians and other health care practitioners continue to underestimate cardiovascular risk in women, with consequent underuse of preventive therapies.16,17 Furthermore, women present with more advanced disease, owing to lack of early recognition and management.2
The aims of this study were (1) to estimate the prevalence of cardiovascular disease risk factors among premenopausal and menopausal Argentinean women with and without type 2 diabetes mellitus and (2) to assess the contribution of total plaque area (TPA) to risk stratification when added to Framingham risk scores.
A descriptive cross-sectional study in primary prevention in 1257 women (ages 19-84 years) from Argentina. TPA was measured by ultrasonography. Framingham sex-specific risk equations were used to predict the risk of developing cardiovascular disease, coronary heart disease, and stroke during the next 10 years. Patients were divided into diabetic (n = 293) and control groups (n = 964), and then each group was divided according to age (>40, 40–49, 50–59, and ≥60 years).
No difference was observed between diabetic and control groups in the incidence of smoking or the presence of early family cardiovascular event. Overall, diabetic patients had higher body mass index, blood pressure, and TPA versus the control group. The Framingham risk score was higher in the diabetic group in all age groups. The mean (SD) coronary heart disease scores for the diabetic group at <40, 40 to 49, 50 to 59, and ≥60 were 6% (1.7%), 19% (2.5%), 38% (2.0%), and 60% (1.5%), respectively, whereas the scores in the control group 3% (0.8%), 7% (0.9%), 17% (0.9%), and 40% (0.9%), respectively. The stroke score was also enhanced in diabetic women, independent of their age. These data indicate that diabetic women in the premenopausal age or the early years of menopause age (40-50 years) are at intermediate or higher risk of developing a cardiovascular event.
Premenopausal diabetic women should be considered at possibly high risk of cardiovascular events compared with nondiabetic women. Direct assessment of atherosclerotic burden, such as TPA, should be used early in this population instead of relying on traditional risk scores.

View all citing articles on Scopus

Dr. Lewis is the Associate Dean for Faculty Development for Women and Diversity at the University of Rochester School of Medicine. She has a longstanding interest in the treatment of postmenopausal women from the perspectives of a clinician as well as researcher.

Dr. Houghton is a Professor of Medicine and Academic Director of Interventional Cardiology at Albany Medical College. She is the Director of Women’s Healthy Heart Initiative (WHHIN) at Albany Medical College.

Dr. Charney is a the Internal Medicine Residency Program Director at Norwalk Hospital. Her interests include the impact of sex, age, and ethnicity on cardiovascular disease and its management.

: Funded by the New York State (NYS) Department of Health, Albany, New York.

View full text

ArticlePhysician Knowledge Levels and Barriers to Coronary Risk Prevention in Women: Survey Results from the Women and Heart Disease Physician Education Initiative

Background

Methods

Results

Conclusions

Section snippets

Survey Instrument

Results

Discussion

Acknowledgments

American Journal of Clinical Nutrition74

Preventive Medicine33

American Heart Journal147

Womens Health Issues12

Womens Health Issues13

Heart & Lung24

American Journal of Preventive Medicine

Preventive Medicine

Journal of the American College of Cardiology

Preventive Medicine

ACOG committee opinionSmoking cessation during pregnancy

Obstetrics and Gynecology106

Psychological testing

Is coronary angiography underused in an inner-city population?

Ethnicity and Disease16

Differential use of coronary revascularization and hospital mortality following acute myocardial infarction

Archives of Internal Medicine163

Clinical and nonclinical correlates of racial and ethnic differences in recommendation patterns for coronary revascularization

Clinical Cardiology23

Racial and ethnic disparities in cardiac catheterization for acute myocardial infarction in the United States, 1995–2001

Journal of the National Medical Association97

Missed opportunities for preventive counseling for cardiovascular disease

MMWR Morbidity and Mortality Weekly Report

Coronary artery disease in women

Hurst’s The Heart

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report

Journal of the American Medical Association289

Dissemination of the AHCPR clinical practice guideline in community health centres

Tobacco Control

Trends in pregnancy-related smoking rates in the United States, 1987–1996

Journal of the American Medical Association

Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults

Archives of Internal Medicine

Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III)

Journal of the American Medical Association

US public health service clinical practice guideline: treating tobacco use and dependence

Respiratory Care

Smoking cessation: Principles and practice based upon the AHCPR Guideline, 1996Agency for Health Care Policy and Research

Annals of Behavioral Medicine

Are health care professionals advising obese patients to lose weight?

Journal of the American Medical Association

Article
Physician Knowledge Levels and Barriers to Coronary Risk Prevention in Women: Survey Results from the Women and Heart Disease Physician Education Initiative