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OBJECTIVE: Previous research measuring differences in the care between men and women with myocardial infarction has focused on differences in procedure use and mortality. However, little is known about differences in processes and outcomes that are reported by patients, such as interpersonal processes of care and health status. Our goal was to measure differences in patient-reported measures for men and women who recently were hospitalized with myocardial infarction.
PARTICIPANTS AND SETTING: We surveyed by mail patients with myocardial infarction discharged to home from one of 27 Cleveland area hospitals 3 months following discharge; 502 (64%) of 783 patients responded. The mean age of subjects was 65 years and 40% were women.
MEASUREMENTS: Process measures included the quality of communication during the hospitalization and at time of discharge and reports of health education discussions during hospitalization. Outcome measures included physical and mental health component scores of the Medical Outcomes Study 36-Item Short-Form Health Survey, change in work status, and days spent in bed because of ill health. We compared processes and outcomes in men and women using multivariate analyses that adjusted for age, other demographic characteristics, comorbid conditions, severity of the myocardial infarction, and premorbid global health status.
MAIN RESULTS: In multivariate analyses, women were as likely as men to report at least one problem with communication during the hospitalization (odds ratio [OR] 0.86; 95% confidence interval [95% CI] 0.56 to 1.33) or at time of discharge (OR 1.24; 95% CI, 0.82 to 1.89) and to report that they were given dietary advice before discharge (OR 0.60; 95% CI, 0.36 to 1.01), were told what to do if they developed chest pain (OR 1.21; 95% CI, 0.66 to 2.23), or, if they smoked cigarettes, given advice about how to stop smoking (OR 0.64; 95% CI, 0.26 to 1.58). However, 3 months after discharge, women reported worse physical health (P < .05) and mental health (P < .05), were more likely to report spending time in bed because of ill health (OR 1.80; 95% CI, 1.06, 3.05), and were more likely to report working less than before their myocardial infarction (OR 4.02; 95% CI, 1.58 to 10.20).
CONCLUSIONS: In terms of processes of care measured with patient reports, women with myocardial infarction reported their quality of care to be similar to that of men. However, 3 months following myocardial infarction, women reported worse health status and were less likely to return to work than men.
Differences in treatment and survival have been consistently demonstrated for men and women with myocardial infarction. 1–15 Women hospitalized with myocardial infarctions are less likely to be treated with thrombolytics or revascularization. 1–6 Women also have a higher mortality rate following myocardial infarction, which may be partially explained by higher ages and increased comorbidity. 4–15
Despite this extensive literature comparing procedures and mortality in men and women with myocardial infarction, there is little information about patients' perceptions of processes and outcomes. For example, little is known about processes of care that require patient reports to measure, such as the quality of communication during the hospitalization or at the time of discharge, or health education discussions with providers. In terms of outcomes, gender differences have seldom been examined in outcomes important to the quality of life of patients such as health status or employment status.
Our goal was to measure differences in the processes and outcomes of care for men and women hospitalized for myocardial infarction, focusing on processes and outcomes that require patient reports. We surveyed patients in a community-based cohort 3 months after their myocardial infarction. We focused on 3 domains of process of care: quality of communication during the hospitalization, quality of communication at the time of discharge, and health education discussions. In addition, we measured several health care outcomes: physical and psychological health, bed days because of ill health, and employment status.
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Previous studies have documented gender differences between men and women in procedure use and mortality among patients hospitalized with myocardial infarction, 1–15 but few studies have assessed whether there are differences in processes and outcomes that require patient perceptions to measure. We found that women had worse health status outcomes than men, as indicated by worse physical and mental health, a greater likelihood of spending time in bed due to ill health, and a lower likelihood of returning to work 3 months after discharge; however, we found no differences in the quality of interpersonal communication or health behavior counseling for men and women. Thus, it is unlikely that previously described differences in outcomes between men and women can be explained by differences in the quality of physician-patient communication, or health behavior counseling.
The communication processes we assessed in our survey address discrete aspects of quality of care that can be measured only with patient reports. The items in our survey have previously been described by patients as components of hospital care that were most important to them. 17 Although our data do not allow us to assess the technical quality of care, our results do demonstrate that for one key component of the quality of care, women and men received similar care.
We are not aware of other studies of gender differences in patient reports of process and outcome measures shortly after hospitalization for myocardial infarction. However, our results are consistent with those reporting similar measures in other groups of patients with cardiovascular disease. Schwartz et al., for example, reported that among patients with coronary artery disease and a prior history of myocardial infarction, physical health deteriorated more over 1 year in women than in men. 25 Similarly, Chin and Goldman reported that in patients hospitalized with congestive heart failure, women were not more likely than men to report problems with their hospital care, but did report worse physical health than men 1 year following discharge. 26
Although the adjusted differences between men and women on the SF-36 scales are modest, we believe they are clinically significant and important on a population level. For example, the 3.8-point difference on the physical function scale we documented in the bivariate analysis is approximately equivalent to the effect of a diagnosis of type 2 diabetes or chronic obstructive pulmonary disease. The 2.1-point difference in the multivariate analysis is similar to the effect of depression. 20 Although our data do not identify the reasons for these differences, we believe there are several potential explanations. First, women may have worse baseline health than men. We believe this is unlikely to fully explain differences in health outcomes given the consistency of results across multiple health measures, and the persistence of differences when adjusting for comorbidity and a baseline global measure of self-assessed health. Second, gender differences in outcomes may be related to differences between men and women in aspects of the quality of care other than those we measured, or that occur after discharge. Third, different health status outcomes could reflect differences in the biologic or sociologic responses to myocardial infarction in men and women. Finally, differences in employment status following myocardial infarction could be partially the result of role differences and different societal expectations in men and women.
Our results demonstrated that patients who reported no communication problems or problems with the discharge process had better SF-36 physical and mental component scores than patients who did report problems. It would be premature, however, to conclude there is a causal link between these processes and physical and mental health outcomes. In fact, we think it is unlikely that the interpersonal processes we measured in this study would have such a dramatic effect on the outcomes we studied over a short 3-month time span. Rather, we think the association between the quality of interpersonal processes and outcomes is, in part, the result of a tendency of patients with worse health status to report less satisfaction with their care than patients with better health status. 27 For example, we previously reported in this journal that among hospitalized older patients, changes in health status during a hospitalization are not associated with satisfaction with the hospitalization after controlling for discharge health status. 27 These previous data suggested that the tendency of patients with better health status to report greater satisfaction with their care was better explained by an intrinsic tendency for patients with better health to be more satisfied with their health care, rather than by a tendency for patients whose health improves after an encounter with the health system to be more satisfied. Thus, the association we observed between better communication and discharge processes and outcomes may have been the result of patients with better health outcomes being more satisfied with their hospital care. Nonetheless, the finding of an association between interpersonal processes and outcomes, along with the lack of gender differences between these processes, strengthens the conclusion that gender differences in outcomes are not explained by differences in the interpersonal processes measured in this study.
Although some of the specific aspects of communication and behavior counseling we measured might not by themselves be expected to influence outcomes 3 months after myocardial infarction, we believe that in aggregate these measures describe a process of care that may have strong influences on long-term outcomes. For example, the quality of the physician-patient relationship, especially the quality of physician-patient communication, has been demonstrated to have significant effects on the outcomes for several chronic conditions. 28,29 Likewise, the belief that counseling patients about health behaviors will improve outcomes is supported by research demonstrating a strong relation between physician counseling about adverse health behavior and the subsequent cessation of that health behavior. 19,30
A strength of our study was the use of a representative community-based sample. Several limitations of our study should also be considered. First, we had only limited data on baseline health status, and only partial data on comorbid conditions and the severity of the myocardial infarction. Nonetheless, as most previous studies of gender differences in outcomes following myocardial infarction have used administrative databases, our ability to adjust for potential confounders exceeds that of most published studies. Second, we have no data about use of invasive procedures or thrombolytic therapy in our patients. Third, nonresponse bias may have affected our results. Nonetheless, our response rates exceed those of many community-based surveys, and were similar for men and women. Finally, it is possible that women may systematically report lower scores on health status measures such as the SF-36. We think this is unlikely to explain our results, for several reasons. First, normative data suggest that among older patients, median scores among men on the SF-36 summary scales are no more than 1 point higher than among women. 20 Second, adjustment for baseline health status most likely controlled for this possible reporting bias. Third, the consistency across multiple measures of health status, including more objective measures such as bed days and changes in employment, supports the conclusion that women had worse health status outcomes.
In conclusion, we found that among patients hospitalized for myocardial infarction, women were not more likely than men to report problems with the quality of communication in the hospital or at discharge. However, women reported poorer health outcomes than men 3 months following myocardial infarction. Although it is reassuring that the care provided to men and women was similar for this one area of quality, the reasons for outcome differences in men and women with myocardial infarction remain undetermined.