A NSW Legislative Council "Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales" has been underway since August 2020, but curiously its terms of reference do not mention gender bias

 

Gender bias takes many forms and the media perhaps more frequently reports on gendered income bias. Such as the longstanding pay gap between the average weekly full-time earnings of males and females, which predominately favours men. Currently Australia's national gender pay gap stands at 13.4 per cent. Or the end of working life disparity between the superannuation outcomes of men and women.

However, it has been apparent for many years now that the health professions, hospitals and governments carry a general societal bias against women into the healthcare sector and that bias barely rates a mention when governments establish terms of reference for parliamentary inquiries into aspects of health service delivery and outcomes.

The NSW Legislative Council Portfolio Committee No.2 - Health’s Terms of Reference for its current Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales is no exception to this lack of consideration of gender bias.

A bias which has the potential to disproportionally affect the health outcomes for females from low income families, those women who identify as Aboriginal or Torres Strait Islander and women living in regional, rural and remote areas.

So these articles below are a timely reminder that the existence of gender bias is indicated in Australia and also of the global scale of such bias.

Australian Institute of Health and Welfare, “Cardiovascular disease in women”, report excerpt, July 2019:

1.1 A focus on women

Much of our knowledge of heart disease is based on research conducted primarily among men (McDonnell et al. 2018), which shapes our view of how cardiovascular disease impacts the Australian population. However, it is known that there are important differences between women and men in risk factors for CVD, in symptoms, and in treatment and outcomes.

Need for greater awareness

Many women are unaware of the risk that CVD presents to their health. Their knowledge about heart attack symptoms and CVD as a cause of death is less than optimal—in 2018, for example, only one-fifth (21%) of Australian women correctly perceived heart-related causes to be the leading cause of death (Bairey Merz et al. 2017; Flink et al. 2013; Heart Foundation 2018; Hoare et al. 2017).

2 Cardiovascular disease in women

Women presenting with CVD often have different symptoms than men. These symptoms may not be recognised as CVD, thus increasing the likelihood of a missed diagnosis.

Although men with heart attack typically describe chest pain or discomfort, women are more likely to have non-chest pain symptoms such as shortness of breath, weakness, fatigue and indigestion (Mehta et al. 2016; Wenger 2013), and frequently with worse consequences (Maas et al. 2011; McDonnell et al. 2018; Pagidipati & Peterson 2016).

Women generally present with CVD later in life than do men. Older women are also more likely to have other health conditions, making their CVD more complex to diagnose and treat, which in turn can lead to worse health outcomes (Bennett et al. 2017; Saeed et al. 2017).

Physicians are more likely to underestimate CVD risk in women, and this can influence their diagnosis and treatment (Wenger 2013). Research finds that younger women aged under 55 with acute coronary syndrome are more likely to be misdiagnosed and discharged from emergency departments than men (Bairey Merz et al. 2017; Saw et al. 2014).

Differences in treatment

A number of studies have identified disparities between women and men in CVD treatment and in outcomes. Women with acute coronary syndrome tend to receive fewer medications, are less likely to have their condition treated aggressively and have fewer invasive interventions (Kuhn et al. 2014, 2015, 2017; Pagidipati & Peterson 2016; Saeed et al. 2017).

Similarly, women with ST segment elevation myocardial infarction (STEMI: a type of heart attack) are less likely to receive invasive management, revascularisation or preventive medication at discharge (Khan et al. 2018). Women with stroke are more likely to have a delay in care than men, and are less likely to receive aspirin, statins or thrombolytics (Raeisi-Giglou et al. 2017).

Healthier women

An increased recognition of gender differences in risk factors, presentation, treatment and outcomes will contribute to improving women’s cardiovascular health in Australia.

The Australian Government, the Heart Foundation, the Stroke Foundation and other key stakeholders contribute by building awareness among the public and health-care providers about the risks of CVD to women’s health.

Chronic conditions, including CVD, and preventative health are a priority for action in the National Women’s Health Strategy 2020–2030 (Department of Health 2018). The development and delivery of a national campaign to promote awareness of the different risks for and symptoms of CVD in women is a key action in the current strategy. The ongoing monitoring of the impact of CVD is an important component of policy and programme initiatives that focus on women’s health.

Australian Institute of Health and Welfare, Cardiovascular disease in Australian women — a snapshot of national statistics, June 2019:

”Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.” [THE LANCET COMMISSIONS, The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030, 16 May 2021]

 

The Lancet, 19 June 2021:

Ana Olga Mocumbi (May 2021) “Women's cardiovascular health: shifting towards equity and justice”

Cardiovascular disease in women is understudied, under-recognised, underdiagnosed, and undertreated globally, despite being the leading cause of death in women worldwide, as highlighted by a new Lancet Commission.¹ Several misperceptions contribute to this neglect, notably, the persistent view that cardiovascular disease primarily affects men or only women in high-income countries and results from poor lifestyle choices. The Lancet women and cardiovascular disease Commission¹ identifies disparities in prevalence and outcomes of cardiovascular disease in women worldwide, delineates the substantial impact of socioeconomic deprivation in determining these differences, and proposes strategies to address these inequities, increase sex-related research, and support integration of care and strengthening of health systems.¹

From 1990 to 2019 there have been large declines in cardiovascular disease age-standardised rates of death, disability-adjusted life-years, and years of life lost.² There have been declines in age-standardised prevalence of coronary heart disease and stroke mortality rates in men and women in most parts of the world, with greater age-specific reductions in coronary heart disease in men than in women.³

Between 2010 and 2019, the age-standardised cardiovascular disease death rate increased or stagnated in many other parts of the world, including eastern Europe and countries in central, south, and east Asia.² In a Canadian setting, the 30-day acute myocardial infarction mortality rates declined similarly for women and men from 2000 to 2009, but women younger than 55 years had an excess mortality risk compared with men of the same age.⁴ Under-representation of young people in clinical studies on cardiovascular disease, as well as worse risk profile due to comorbidities, might contribute to these slow improvements. Importantly, because of women's longer life expectancy, overall deaths from cardiovascular disease are higher in women than in men, and this excess number of cardiovascular disease deaths in women is likely to increase with population ageing. Moreover, the success in declining age-standardised cardiovascular disease mortality over the past decades has been limited to countries with a high Socio-demographic Index (SDI); some countries with a low SDI had the highest cardiovascular disease mortality rate shift from men to women.²

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Poverty continues to affect a considerable proportion of the world's population, determining unique patterns of non-communicable diseases, including cardiovascular disease in young women.⁵ In countries with a low SDI, where premature cardiovascular disease mortality is largely driven by poverty, poor access to care, and underuse of interventions of proven efficacy, women face the coexistence of an increased prevalence of cardiovascular disease, a rise in metabolic risk factors, and endemic infectious diseases such as tuberculosis, HIV/AIDS, and schistosomiasis. Furthermore, specific risk factors and conditions affect women in countries with a low SDI. Chronic exposure to biomass fuel is common in rural Africa and Asia and contributes to the burden of acute coronary events and stroke,⁶ affecting predominantly women; this exposure could partly explain the high occurrence of and sex differences in isolated right heart failure in non-smokers in these places.^{6, 7} Similarly, in poor countries women younger than 40 years are increasingly affected by neglected or poverty-related conditions, such as rheumatic heart disease and endomyocardial fibrosis.⁸,⁹ Moreover, maternal mortality remains unacceptably high. About 295 000 women died during and after pregnancy and childbirth in 2017.10 94% of these deaths occurred in low-resource settings, where the maternal mortality ratio was 462 per 100 000 livebirths versus 11 per 100 000 livebirths in high-income countries.¹⁰ Since cardiovascular disease is the leading non-obstetric cause of maternal mortality worldwide,¹¹ one should consider the role of disparity in fertility rates, incidence of peripartum cardiomyopathy, and pre-existing uncontrolled arterial hypertension8 as potential determinants of maternal mortality. Indeed, there are a considerable number of maternal deaths due to cardiovascular disease in low-income and middle-income countries.¹² Unfortunately, even in the USA, where the maternal mortality ratio was 17·4 maternal deaths per 100 000 livebirths in 2018, the maternal mortality ratio was more than double among non-Hispanic Black women (37·1 per 100 000 livebirths), with more than half of these deaths and near deaths being preventable, and cardiovascular disease being the leading cause.¹³ Inadequate access to quality and affordable health care along with long-standing health disparities plays a role in this disparity; additionally, social determinants of health can increase the risk of gestational diabetes, peripartum cardiomyopathy, caesarean deliveries, and future cardiovascular disease in neglected communities.

To address the gaps highlighted by this Commission, current knowledge must be used to achieve health equity so that no one is disadvantaged from attaining their full health potential because of their social position or other socially determined circumstance. Reduction of disparities in clinical outcomes requires the prioritisation of high-impact solutions in under-resourced areas, involving tailored strategies for decentralised and integrated care, and support from global and regional partners to improve the availability of interventions for cardiovascular disease prevention and management. Front-line health workers with shared competences for cardio–obstetric care, digital health, and portable ultrasound should be used to deliver decentralised care, improve referral systems, and support surveillance of sex-related outcomes. Digital health provides opportunities to enhance the quality, efficiency, and safety of primary health care, as well as help address racial and ethnic disparities,¹⁴ but insufficient digital health competencies among front-line health workers are among the factors that hamper the adoption of digital tools and technologies.¹⁵ Finally, as emphasised in the Commission, peer-to-peer supporters and educators in local communities should be used to empower women in improving their ability to access, understand, appraise, and apply health information to promote good cardiovascular health.

In the midst of the COVID-19 pandemic, values of human dignity, solidarity, altruism, and social justice should guide our communities to ensure equitable share of wealth and leveraging of efforts towards the reduction of cardiovascular disease burden in women worldwide. The Commission's recommendations on additional funding for women's cardiovascular health programmes, prioritisation of integrated care programmes, including combined cardiac and obstetric care, and strengthening of the health systems accords with efforts to bridge the gap for the world's worst off.⁵ Such a shift in women's cardiovascular care would be a major step towards equity, social justice, and sustainable development.

I declare no competing interests.

References

1.Vogel B Acevedo M Appelman Y et al.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.

Lancet. 2021; (published online May 16.)

https://doi.org/10.1016/S0140-6736(21)00684-X

2.Roth GA Johnson C Abajobir A et al.

Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015.

J Am Coll Cardiol. 2017; 70: 1-25

3.Bots SH Peters SAE Woodward M

Sex differences in coronary heart disease and stroke mortality: a global assessment of the effect of ageing between 1980 and 2010.

BMJ Global Health. 2017; 2e000298

4.Izadnegahdar M Singer J Lee MK et al.

Do younger women fare worse? Sex differences in acute myocardial infarction hospitalization and early mortality rates over ten years.

J Womens Health. 2014; 23: 10-17

5.Bukhman G Mocumbi AO Atun R et al.

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion.

Lancet. 2020; 396: 991-1044

6.Bassig BA Dean Hosgood H Shu XO et al.

Ischaemic heart disease and stroke mortality by specific coal type among non-smoking women with substantial indoor air pollution exposure in China.

Int J Epidemiol. 2020; 49: 56-68

7.Stewart S Mocumbi AO Carrington MJ Pretorius S Burton R Sliwa K

A not-so-rare form of heart failure in urban black Africans: pathways to right heart failure in the Heart of Soweto Study cohort.

Eur J Heart Fail. 2011; 13: 1070-1077

8.Mocumbi AO Sliwa K

Women's cardiovascular health in Africa.

Heart. 2012; 98: 450-455

9.Zühlke L Engel ME Karthikeyan G et al.

Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study).

Eur Heart J. 2015; 36 (122a): 1115

10.WHO

Maternal mortality, key facts.

https://www.who.int/news-room/fact-sheets/detail/maternal-mortality

Date: 2019

11.Kassebaum NJ Barber RM Bhutta ZA et al.

Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.

Lancet. 2016; 388: 1775-1812

12.Heemelaar S Petrus A Knight M van den Akker T

Maternal mortality due to cardiac disease in low- and middle-income countries.

Trop Med Int Health. 2020; 25: 673-686

13.Bond RM Gaither K Nasser SA et al.

Working agenda for Black mothers: a position paper from the Association of Black Cardiologists on solutions to Improving Black maternal health.

Circ Cardiovasc Qual Outcomes. 2021; 14e007643

14.López L Green AR Tan-McGrory A et al.

Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities.

Jt Comm J Qual Patient Saf. 2011; 37: 437-445

15.Jimenez G Spinazze P Matchar D et al.

Digital health competencies for primary healthcare professionals: a scoping review.

Int J Med Inform. 2020; 143104260

https://doi.org/10.1016/S0140-6736(21)01017-5

Copyright

© 2021 Elsevier Ltd. All rights reserved.

Labor MLA for Lismore: Rural Health Inquiry’s Lismore hearing to be live webcast on Thursday 17 June 2021

 

Office of NSW Labor MLA for Lismore, Janelle Saffin, media release, 17 May 2021:

Rural Health Inquiry’s Lismore hearing to be webcast

NSW Labor has ensured that the NSW Parliamentary Inquiry into health and hospital services in rural, regional and remote NSW’s Lismore hearing on Thursday June 17 will be webcast, according to State Member for Lismore Janelle Saffin.

“This is a good win because all locals, together with all residents of rural and regional NSW need to have access to their Parliament and its processes,” Ms Saffin said yesterday.

“I lobbied for this Inquiry to sit in our Electorate of Lismore and it is important that as many people as possible get to hear testimony from individuals and organisations who made submissions about their experience of the health system.

“The Inquiry has already held hearings in Deniliquin and Cobar, both of which were not webcast. I understand that the transcripts then took over a week to be released publicly.

“This was unacceptable to many country people and media outlets, so my colleague, NSW Shadow Minister for Health Ryan Park raised these concerns directly with the Chief Executive of the Department of Parliamentary Services.

“In light of the high level of public interest in the Inquiry’s work, the Committee, chaired by Labor MLC Greg Donnelly, now will be trialling the live webcasting of its hearings in Wellington tomorrow (Tuesday, 18 May) and in Dubbo on Wednesday (19 May).”

The Inquiry was established on 16 September 2020 to inquire into and report on health outcomes and access to health and hospital services in rural, regional and remote New South Wales. It has received more than 700 submissions from people across NSW.

Live stream details:

https://www.parliament.nsw.gov.au/Pages/webcasts.aspx

NSW Parliamentary Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales public hearings begin on 19 March in Sydney, with one hearing scheduled for the NSW North Coast at Lismore on 16 June 2021

 

A NSW Parliamentary Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales was established in September 2020.

Public hearings begin on 19 March in Sydney, with one hearing scheduled for the NSW North Coast at Lismore on 16 June 2021.

Submission excerpts as examples of what the Inquiry has heard thus far

“Increase in work load adding pressure to perform unreasonable duties on your shift, resulting in working past your finishing time to complete patient notes and not getting paid to stay back, missed morning teas and lunch breaks due to patient work loads, overtime due to staff calling in sick and staff leaving the service due to burn out and not getting replaced, bullying from senior management is rife, medication errors due to over worked and high stress levels all caused by management, staff are being put on performance management programs due to, not being able to perform duties on shift, due to patient work loads, morale is at its lowest, nurses victimised for complaining or putting in an imms, lack of recruitment and the process being very complex and sometimes taking over 3 months to recruit a single nurse, our patients deserve much better from the health system which is broken and putting nurses registration at risk, with no support from management” [Name Suppressed, Submission No.2 out of 703 submissions received by Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales]

“In November 2016 my mum had a fall and broke her pelvis. She was taken to Maitland Public hospital . She had suffered brain surgery and radiation treatment earlier in the year. She was 84. On the first day of her admission to hospital a resident doctor shocked both my father and myself telling us she would probably die not from the broken pelvis but from being in hospital. My dad and myself visited her every day for the next 8 weeks. She was sent to a neighbouring hospital at Kurri Kurri 3 times and returned twice with infections and delirious and we were never actually told why she was deteriorating so much. She would be very agitated saying she was not attended to when she wanted to go to the toilet. Then she was told she needed to try to walk and was using a walker, then all of a sudden that was taken away and a nurse said she was never supposed to start rehab yet. So much confusion and no one still explained to us exactly what would happen to her. No communications or accurate ones anyway.

And then it was Christmas we were going to try to get her home just for a couple of hours but on Christmas Eve she apparently had a stroke and was transferred close to a nurses station for observation her confusion level was beyond belief. On the day after Boxing Day I got a call from my dad very upset saying they were transferring mum back to Kurri hospital for rehab. I was very angry with this decision and went straight to Maitland hospital mum was screaming pleading not to be taken back there as she had already been there twice and sent back very sick both times. I argued with the nurse that it should not happen but she said there was no choice as it was about numbers. we were allowed to go in the ambulance with mum and she was crying all the way, even the ambulance drivers seemed upset. When we arrived at Kurri hospital we were met by a nurse who made a comment that surely someone else could have been transferred today.

Mum died two days later she was broken by this stage and made a comment to me that when you get to a certain age they don’t care about you any more. I said it wasn’t true at the time but ponder that question every day. Mum was a wonderful Wife, Mother, grandmother , great grandmother, sister and friend to many I miss her every day. My daughter sent a letter to Maitland Hospital and we did receive an apology for her treatment after an investigation.

Too late.”

[Name Supplied, Submission No.7 out of 703 submissions received by Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales]

“The Tweed Hospital is a Peer Group B hospital that currently has 255 beds and Level 5 emergency department.

Currently at Tweed Hospital, Nursing Hours Per Patient Day wards (Medical and Surgical) are funded at 5.5 hrs instead of the 6.0 hrs that Peer Group A hospitals receive.

At Tweed the Surgical and Medical Wards are no different to any other wards of a city hospitals. The same type of patients with the same level of acuity, but at Tweed Heads every patient receives 0.5 hrs less care due to their postcode.

Our Hospital routinely has between 95%-104% occupancy and 5.5 NHPPD has a huge impact on delivering safe patient care and nursing workload.

Staffing retention is also an issue here at Tweed Heads due to our proximity to the Queensland Border, nurses no longer must put up with the horrendous workload, risks to their registration or their ability to deliver safe patient care. Many nurses have left the NSW system preferring to work in Queensland at the University Hospital 20 minutes up the highway:

They have Ratios 1:4

Education Allowance of $1800 per year

100% Salary Sacrifice

Higher pay rate by $3,000 per year

Higher penalty rates on Night Duty”

[Name Supplied, Submission No. 178 out of 703 submissions received by Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales]

“In March 2012 the LHD announced it would develop a Clinical Services Plan for Coraki and surrounds to assess the health needs of the area and make recommendations on how those needs could best be met. That Plan was completed, with community input, in August 2012. It recommended the adoption of a 'HealthOne Model of Care' - bringing together Commonwealth- funded general practice and state-funded primary and community health services in the one facility. After considerable lobbying by the Reference Group the NSW Government allocated $4 million for the construction of the HealthOne in 2016 and the facility was opened in May 2017.

According to various publications by NSW Health the key features of the HealthOne model that distinguishes it from other primary and community health services are integrated care provided by co-located general practice and community health services; organised multidisciplinary team care; care across a spectrum of needs from prevention to continuing care; and client and community involvement. In Coraki we now have an impressive new HealthOne which has consulting rooms for two GPs and houses a variety of community health practitioners. Regrettably, since its opening it has not been possible to attract a single GP to the purpose-built facilities. We feel we have a HealthOne without a heart.

We are aware the lack of a GP is not unique to Coraki and that it is shared by many rural and regional communities across NSW. We are hoping this inquiry will shine a light on this problem and spur governments, both State and Commonwealth, to come up with solutions.

In Coraki's case a possible solution might be to expand the HealthOne into a Multi-Purpose Service. There is a 49-bed aged care facility adjacent to the HealthOne (operated by Baptist Care) and the future expansion of the HealthOne was allowed for in its planning and design. The Reference Group notes that a recent Commonwealth Government Report (Review of the Multi-Purpose Services Program - 2019), which was done in consultation with state and territory governments, found that the MPS is a sound model for delivering integrated health and aged care services in rural and remote communities and made recommendations, which have in large part been accepted by the Commonwealth Government, to strengthen and expand the MPS program. An MPS in Coraki, with its expanded range of health services and clients, would enhance the attractiveness of Coraki for prospective GPs.

Finally, we wish to draw the Committee's attention to the lack of an ambulance in Coraki. While ambulances are available from Casino, Evans Head and Lismore, the extra half hour they take to reach Coraki can be critical….” [Name Supplied, Submission No. 179 out of 703 submissions received by Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales]

 

“To support our submission we would like to highlight anecdotal evidence of an issue that is raised time and time again – The need for increased funding for public health professionals working across the cancer care coordination/ social work areas to be more available to patients.

We have heard of many case studies from patients across the Northern Rivers and Far North Coast, ranging from private and public treatment centres about such barriers to better health outcomes.

One case study – a gentleman with Basal Cell Carcinoma of the outer nose, lost most of the features of his nose after surgery. This patient continued about his daily life with social anxiety, unable to go back to a normal daily life. Until one day, quite simply he was asked by a fellow patient to the reasons why he had not considered a prosthetic nose free of charge through a charitable support scheme. His heartbreaking response “I never had knowledge of such option, or service available to someone like me with limited financial means”. Please conceive, if only this patient had been linked to an appropriate cancer care coordinator or social worker, his burden could have been lifted much sooner and thus contributing to better outcomes. How many more patients are currently in the same position?

Another case study we would like to highlight is of a female who had undergone lumpectomy just over the border in Queensland. A breast cancer nurse who happened to be on shift advised - as this patient was living in New South Wales and not Queensland, she was not eligible to any support services. Therefore she was advised to go home to Byron Hospital and request community social work support. Once at Byron Bay Hospital, she was told that the hospital was only issued with two community social worker services per week, and that as it was now Thursday, they had already been handed out for the week. This patient was left alone at home, without support and in pain, not even able to slice a tomato for a salad. She was not even given a phone number to contact. With so many questions and with no one to turn to, she was left overwhelmed, scared and unsupported.

Had there been a dedicated cancer care coordinator available to both patients as highlighted in our case studies, they would have received the appropriate care deserved and thus better health outcomes.

We passionately could continue highlighting similar case studies as of the two above, however we hope these testimonies clearly demonstrate the priority need for increased funding for socio/emotional support during and after treatment.” [Name Supplied, Submission No. 184 out of 703 submissions received by Inquiry Into Health Outcomes And Access To Health And Hospital Services In Rural, Regional And Remote New South Wales]

All written submission made to the Inquiry can be found at 

https://www.parliament.nsw.gov.au/committees/inquiries/Pages/inquiry-details.aspx?pk=2615#tab-submissions