1 11/18/2013

Mapping Quality of Care: 

Assessing Gender Gaps in DM and CVD Care in a 

California Health Care Plan 

Chloe E. Bird, PhD

VA Cyberseminar

November 18, 2013

RAND
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• Review of Gender Differences in CVD and DM

• What Can Mapping Provide?

• Study Design

• What Does Conventional Analysis Tell Us?

• What Does Mapping Add?

• Where Do We Go From Here?

Outline 

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Poll Question #1

• What is your primary role in VA? 

– Student, Trainee, or Fellow

– Clinician 

– Researcher

– Manager or Policy-maker

– Other

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Poll Question #2

• Which best describes your research 

experience? 

– have not done research

– have collaborated on research

– have conducted research myself

– have applied for research funding

– have led a funded research grant

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Gender Differences in CVD 

Prevalence 

• Counted separately, heart disease is the #1 

cause of death among women and vascular 

disease is #3 

• Worldwide, heart disease and stroke kill 8.6 

million women annually – accounting for 1 in 3 

deaths among women 

• Prevalence and age-adjusted CVD death rate 

greater for men 

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Gender Differences in CVD Prevalence 

(continued)

• Yet, women spend more years living with CVD 

than do men 

• Since 1984 more women than men have died of 

CVD

• DM, a major risk factor for CVD, increases 

women’s CVD risk far more than men’s 

• Whereas 1 in 7 women develops breast cancer, 

more than 1 in 3 women has some form of CVD 

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Gender Gap in CVD Mortality Widened in 

the 1980s and 1990s

350

400

450

500

550

1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Deaths in Thousands

Years

Women Men

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CVD in Women is Different

• Women do not tend to have the “TV heart 

attack” 

• their symptoms are often more subtle and less 

specific

• women can present with symptoms like throat 

pain or a sore back

• 64% of women who die suddenly from heart 

disease had no previous symptoms at all

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Impact of Differences in Women’s CVD

• Tests aimed at identifying major coronary artery blockage are less 

informative on cardiac risk in women than in men

• At least half of women’s MIs are caused by coronary microvascular 

disease, leading to narrowing or damage to smaller arteries in the 

heart

• small vessel disease makes diagnosis challenging and poses 

problems for treatment 

• Moreover, 26% of women over age 45 will die within a year of having 

a heart attack, compared with 19% of men.

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Gender Gaps in Quality of Care Contribute to 

Differential Outcomes

• A variety of studies of managed care and care 

within the VA have demonstrated gender 

differences in QoC for CVD and DM

• Large multistate studies of gender differences in 

QoC failed to stimulate efforts to identify and 

address gaps

• However, the VA has demonstrated that identifying 

gaps can open opportunities to improve QoC and 

reduce differences in men’s and women’s care

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Most Disparities Favored Men

N of Plans with ≥ 5 percent 

performance difference n (%)

Measure N of 

Plans 

In Favor of 

Men

In Favor of 

Women

Commercial

 DM LDL < 100 46 25 (54.3) 0 (0.0)

 CVD LDL <100 35 22 (62.9) 0 (0.0)

 HTN BP <140/90 45 9 (20.0) 8 (17.8)

Medicare

 DM LDL < 100 146 89 (61.0) 3 (2.1)

 CVD LDL <100 94 68 (72.3) 3 (3.2)

 HTN BP <140/90 140 54 (38.6) 7 (5.0)

Chou, Wong, Weisman et al. Women’s Health Issues (2007)

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Small Average Differences in Performance Rates May 

Understate Relative Impact Depending on Overall Rate

Measure Men Women Difference RR (95% CI)

DM LDL < 130 41.3 33.4 7.9 .81 (.64 – .99)

CVD LDL < 130 45.5 35.0 10.5 .75 (.54 – 1.03)

BP < 140/90 35.4 30.3 5.1 .64 (.72 – 1.0)

Bird, Fremont, Bierman et al. Women’s Health Issues (2007) 131.138

 Absolute differences of 5 to 11 percentage points translates to rates 

of control that are between 26 and 19% lower for women than men

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• Statistical models typically assess average QoC and 

only control for gender, while those that examine 

gender differences in QoC focus on averages

• Average answers have not engaged health plans or 

other stake holders to take action

• Mapping can identify 

• whether gender differences are uniform or vary 

geographically

• Identify hotspots where women face above average 

disparities and coldspots where women receive better 

care

What Can Mapping Provide?

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• Data are from one of the a large regional California 

managed care plans

• We examined care for two populations of 

individuals. Those who:

• had documented Ischemic Vascular Disease, or 

experienced a cardiovascular event (acute MI, PTCA, or 

CABG) in the prior year (n~30,000) 

• had a diagnosis of diabetes (n~155,000)

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Study Design
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• Measures of CVD and DM quality are part of the 

National Center for Quality Assurance (NCQA) 

Healthcare Effectiveness Data and Information Set 

(HEDIS) 

• Measures report the percentage of eligible 

patients who received the indicated care after 

excluding those with contraindications

• HEDIS measures allow direct comparisons across 

populations

HEDIS Measures

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• Gender

• Age in years

• Insurance Type: Medicare, Commercial HMO, 

Commercial PPO, or Medicaid

• Region: 8 regions used in HEDIS reporting

• County

• Zipcode

• Area Income

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Other Measures
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Quality Scores are Reported for HMO Patients for 8 

Regions of P4P Program*

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• Among adults who had experienced a CVD event, 

77.7% of men and 72.8% of women received the 

indicated LDL screening.

• The gap was smaller among those with DM, with 

76.3% of men and 74.2% of women receiving 

indicated screening. 

• Overall QoC also varied significantly across the 

geographic regions of the state and across 

business lines, with higher quality among HMO 

than PPO patients.

What Does Conventional Analysis Tell Us? 

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LDL Screening for DM Patients Varied by Region

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Gender Gaps in LDL Screening also Vary 

by Age for CVD and DM Patients 

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• Adjusting for age, insurance type, region, and area 

income

• women were 80.5 % as likely as men to receive 

indicated LDL screening

• women with diabetes were 94.3 % as likely as men to 

receive the indicated screening

• Also, HMO patients remained more likely than 

PPO patients to receive LDL screening in both CVD 

and DM populations

Gender Gaps Persist

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Gender Gap Varied by Insurance Type 

– In adjusted models run separately by insurance 

type

• Women in PPOs with CVD were 93% as likely as men to 

receive LDL test, but equally likely in HMOs

• Women in PPOs with DM were 97% as likely as men to 

receive LDL test, but equally likely in HMOs 

– Suggesting that in addition to providing higher 

quality ambulatory care, managed care can 

address the gender gap
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• What Does Mapping Add?

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Gender Gaps in DM:

LDL Screening Rate Varied by Region

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DM: LDL Screening Rate by Region and Ge

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DM: LDL Screening Rate by Region and Gender

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Gender Gap in DM: 

LDL Screening Rate by County

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Assessing Gaps at County Levels or Higher May Mask 

Important Gaps at More Local Level*

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Gender Gaps in DM LDL Screening in LA County by 

Zip Code*

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Gender Gaps in DM LDL Screening in LA County by Zip 

Code and Insurance Type*

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• To make patterns of predictors and disparities 

accessible

• To illustrate where and whether specific 

relationships occur

• do disparities map on to racial/ethnic or socioeconomic 

neighborhood characteristics or the availability of 

specific health services?

• To examine patterns of care 

• are those getting better and worse care treated at the 

same clinics and by the same providers? 

Mapping – Beyond Geography 

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• Gender differences in CVD and DM ambulatory care are typically 

small to moderate

• At the population level, even small average differences can reflect 

large numbers of women not receiving indicated care

• Managed care can produce higher quality care and reduce gender 

gaps

• Maps of gender differences in QoC can inform local and regional 

stakeholders and help to answer questions and precipitate efforts 

to improve women’s QoC

Take Home Points

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Chloe E. Bird, PhD

Chloe@rand.org

Questions? 

RAND
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Acknowledgement

I would like to thank the Barbara Streisand Women’s 

Heart Center at Cedars-Sinai Medical Center for 

supporting this research.