Q&A: Dependent care, lapsing insurance impact CV health in women amid pandemic - Healio

February 03, 2022

6 min read

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Bairey Merz reports consulting for iRhythm Technologies.

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Disruptions in daily living arising from the COVID-19 pandemic have affected population health, productivity and chronic disease management for all, but in many ways, may have more acutely afflicted women.

Lapses in insurance coverage caused by unemployment, delayed health care born from COVID-19 anxiety or the demand of dependent care, and distinct voids in women’s CVD research may have contributed sex-based disparities observed amid the pandemic.

C. Noel Bairey Merz, MD, FACC, FAHA, professor of cardiology and director of the Barbra Streisand Women’s Heart Center at the Smidt Heart Institute, Cedars-Sinai.

In recognition of Wear Read Day, Healio spoke with Cardiology Today Editorial Board Member, C. Noel Bairey Merz, MD, FACC, FAHA, professor of cardiology and director of the Barbra Streisand Women’s Heart Center at the Smidt Heart Institute, Cedars-Sinai, about the ways in which COVID-19 has disparately affected the heart health of women and affected the pipeline of women’s CVD research.

Healio: What disparities have COVID-19 brought to the forefront of concern?

Bairey Merz: We have seen a disproportionate burden of COVID-19 on women, predominantly because of child care and elder care responsibilities, but mostly child care. This has resulted in women dropping out of the workforce, so now they’re uninsured, gaining weight because they stayed home with children, and skipping health care. The Kaiser Family Foundation said women are more likely to skip health care than men during the pandemic, for obvious reasons. Nobody wanted to get exposed to COVID-19. But again, because of all these dependent responsibilities, women have been disproportionately impacted by finances and environments that are not good for their heart health.

We’re projecting there’s going to be a tsunami of women’s heart disease. COVID-19 has killed many Americans, and we now have a second wave that we’re catching up on of deferred care. There are valves that are being replaced that should have been replaced a year ago. There are people who are having heart attacks because the first one wasn’t taken care of because they couldn’t get into the hospital. We’ll have a third tsunami wave of worsened CVD because of the absence of chronic disease management, something that women suffer disproportionately from because of dependent care issues.

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Healio: Were there any preexisting disparities from before the COVID-19 pandemic that were only made worse by the pandemic?

Bairey Merz: Absolutely. We and others have published repetitively that women, particularly those younger than 65 years and premenopausal women younger than 50 years, are less likely to see a health care provider. They often are waiting to go and see the doctor after they’ve lost some weight. There’s a lot of weight shaming. They are less likely to be treated with effective therapy. For example, if a woman with diabetes and a man with diabetes, both 50 years old, go to see the doctor, the diabetic man will receive diabetic medications, while the woman will be told to lose weight, even though the man is typically more overweight than the woman. Women are less likely to get any kind of cardiac testing. They’re less likely to be evaluated if they have symptoms of heart disease. These are longstanding disparities that are being exacerbated by the pandemic.

Healio: How has the pandemic affected the dependent care dynamic?

Bairey Merz: It has exacerbated it, similar to those Kaiser Family Foundation data. This is old news that women put themselves last. They take care of the kids first, then the husband or partner, followed by the family dog, and then, finally, their own health. The burden of dependent caretaking, combined with women dropping out of the workforce, which for most Americans means you don’t have that employer-related health insurance, means it’s hard to get health care, especially if they can’t pay for it.

Healio: How has the pandemic impacted the diagnosis of ischemia with nonobstructive coronary arteries (INOCA), which disproportionately affects women?

Bairey Merz: I’m not aware of any data that speaks to this, but I would expect because of the deferred, delayed or just abandoned chronic disease management of high BP, high cholesterol and high blood sugar, which are all risk factors for INOCA, I would predict that we will see more INOCA.

Healio: Do you think that the recent advances in telehealth could help to reduce some of these disparities? Or is there a potential for more harm?

Bairey Merz: Those are two good possibilities. Different people may or may not benefit. Telehealth will clearly facilitate care when delivered appropriately in a consumer who can actively participate. They have to have a Zoom; they have to have an ability to check their BP at home; they have to have the wherewithal to pay attention, dial in when appropriate and submit appropriate records, maybe from a local lab.

This is going to enhance care in our rural areas. For example, California is a big state and there are many patients for whom we now are able to provide center of excellence care, which prior to telemedicine we could not do. It will also potentially benefit the elderly and frail if it’s a simple chronic disease management visit that can be done over the phone.

The way that it could potentially harm women and other patients would be if, for example, the women who dropped out of the workforce and now have no health insurance. Telehealth is not free. If you don’t have health insurance, it’s hard to get health care.

There is also a concern in the business community that men who are more readily returning to work in-person would be men who are more readily returning to in-person visits for their health care and get more attention. Could women more likely opt for telemedicine because of these dependent care reasons? Could they have inferior care? Would it be small, cumulative, erosions of quality of care? We’ll have to be vigilant to this and be evaluating it. We don’t know that that those things could happen, but hypothetically, they could.

Healio: The pandemic made enrollment in large clinical trials problematic. Do you think this will have a lasting impact on women’s CVD research?

Bairey Merz: That is very true. Many clinical trials halted or just closed. However, many trials we do annually, and I have no idea what number that is, but let’s just say we launch 100 per year and let’s say 75% of them were closed, altered or terminated, we’re going to be lacking 2 years’ worth of what would’ve been appropriate clinical trials conducted to discover how we can improve human health.

The percentage of clinical trial participation of women tends to be lower. CV clinical trials still typically have 25% to 30% women represented in a disease, CVD, that very clearly affects women and men 50/50. Any kind of erosion of clinical trials and studies will further reduce that sample size of women and make the results even less relevant to the 50% of patients with CVD who are women.

Healio: Moving forward, what are the immediate needs that should be addressed in women’s CV research?

Bairey Merz: We have a tremendous number of phenotypes of CVD that have not yet been adequately studied in women. Despite women being one of two heart disease patients, we spend relatively less money on women than men.

We also have studies that are very much needed. For example, in Takotsubo syndrome, which majorly impacts women, very little research has been done; INOCA and MINOCA, a little more, but still relatively slim compared with traditional HF with preserved ejection fraction; and very little compared with the male pattern of HF with reduced ejection fraction. We need to do better.

Healio: Are there any particular disparities that you would like to draw attention to?

Bairey Merz: In COVID-19, women are more likely to fall into the 10% group of long-haulers, meaning they’ve recovered from COVID-19, but have persistent symptoms, including brain fogginess, muscle aches, throat swelling, rashes and chronic fatigue. That is a disparity in the sense that we really need to know more about it. We’re putting a tremendous amount of research into antivirals, how many boosters we need, a master vaccine, but funding for research looking at long-haulers, who are predominantly women, will not be a priority.

‘Oh, she’s just tired.’

Well, of course she’s tired. She’s taking care of three children.