A FRAMEWORK FOR THE CONSIDERATION OF CHRONIC DEBILITATING CONDITIONS IN WOMEN

背景/概述： 随着我国人口老龄化和预期寿命比男子更长，慢性衰弱性疾病对妇女的健康造成越来越大的负担。慢性病包括一生中发生的各种疾病和紊乱，其中许多是性别特异性的。1虽然妇女现在经常被纳入临床研究，但研究很少旨在获得关于妇女的数据。入选标准和研究终点通常不以女性的需求为中心。2慢性疾病的患病率和临床表现存在性别差异。CMS数据（按服务收费的受益人，不包括医疗保险优惠计划的参加者），按性别分列，注意到妇女更经常发生的六种情况：高血压、关节炎、抑郁症、痴呆症、哮喘和糖尿病。3较低的社会经济地位和较低的教育程度是多发病的额外风险因素，多发病定义为同时发生两种或多种疾病，可能有或可能没有因果联系，这进一步使妇女处于不利地位，并对那些历来代表性不足的妇女的健康产生额外的不利影响。 我们对女性慢性衰弱性疾病的理解存在一些证据差距，这是由于历史上临床研究过度依赖男性造成的。妇女所经历的慢性病症状往往与男子不同;妇女对许多一线治疗的反应率较低;激素转换，如更年期，对慢性病自然史的影响尚未得到很好的描述。此外，妇女健康与生殖健康不可分割地联系在一起的广泛假设限制了对痛经、子宫内膜异位症和多囊卵巢综合征等女性特有慢性病的研究。青春期后先天和适应性免疫系统的性别差异可能会影响疾病的风险（例如，哮喘）、自身免疫以及对疫苗接种和癌症治疗的反应。6慢性疾病风险-包括冠心病、癌症、肌肉骨骼疾病、慢性疼痛、肥胖、糖尿病和认知障碍-随着年龄的增长而积累，并且通常在绝经后增加，此时生殖激素产生下降。虚弱和骨质流失影响或受妇女慢性病的影响。衰老相关的骨骼肌功能缺陷（SMFD）或骨骼肌功能障碍-包括肌肉质量（少肌症）、肌肉力量和肌肉功能的丧失-可能对女性慢性疾病或慢性衰弱性疾病产生负面影响或受到其影响。 女性比男性更常患有多病。9女性的发病率“网络”不同，与男性相比，多病更可能跨越多个器官系统。10此外，发病率累积的模式，即诊断出的初始慢性疾病以及疾病如何叠加，因性别和性别而异。11在患有多病的女性中，人们对各种条件之间的相互作用了解甚少，而且往往处理不当。 美国卫生与公众服务部（HHS）于2010年将慢性衰弱性疾病定义为“持续一年或更长时间并需要持续医疗护理和/或限制日常生活活动的疾病”。12然而，这一定义和其他现有的慢性衰弱性疾病定义没有纳入性或性别方面的考虑。性和性别影响健康;然而，在预防、诊断和治疗妇女慢性衰弱性疾病的证据基础方面存在着重大的知识差距。 任务说明： · 回顾现有的文献慢性疾病的具体妇女。 O 具体回顾文献，了解女性慢性疾病的发展和积累如何受到绝经、衰老相关的骨骼肌功能障碍（肌肉质量、肌肉力量和肌肉功能丧失）和虚弱等因素的影响，包括流行病学和社会经济影响。 O 应考虑临床表现和结局的性别、种族和民族差异。 O 预防，诊断和治疗女性特有的妇科疾病应审查和考虑 · 召开确定的专家研讨会。 · 收集关于妇女慢性衰弱状况的循证调查结果。 O 调查结果应纳入健康的社会决定因素的影响，包括但不限于性别、种族和/或族裔、社会经济地位、性和性别少数群体以及得不到充分服务的农村人口 编写一份研讨会报告，说明目前证据方面的差距，并为未来的研究议程提出建议。

Background/Overview: With the aging of our population and longer life expectancies compared to men, chronic debilitating conditions pose an increasingly significant burden on the health of women. Chronic conditions include a wide array of diseases and disorders that occur across the lifespan, many of which are sex-specific.1 Although women are now routinely included in clinical research, research is infrequently designed to obtain data on women. Inclusion criteria and study end points are not often centered around the needs of women.2 Sex and gender differences in the prevalence and clinical presentation of chronic conditions have been documented. CMS data (fee-for-service beneficiaries, excluding Medicare Advantage enrollees), disaggregated by sex, notes six conditions that occur more frequently in women: hypertension, arthritis, depression, dementia, asthma, and osteoporosis.3 Lower socioeconomic status and lower educational attainment are additional risk factors for multimorbidity, defined as the simultaneous occurrence of two or more diseases that may or may not share a causal link, that further disadvantage women, with additional disadvantage impacting the health of women who identify with historically underrepresented populations.4, 5 Several evidence gaps in our understanding of chronic debilitating conditions in women have arisen from a historical over-reliance on men in clinical research. Symptoms of chronic conditions experienced by women are often different from men; women have lower response rates to many first-line treatments; and the effects of hormonal transitions, such as menopause, on the natural history of chronic diseases have not been well-described. Further, the broad assumption that women’s health is inexorably linked to reproductive health has limited research on female-specific chronic conditions such as dysmenorrhea, endometriosis, and polycystic ovarian syndrome. Sex differences in the innate and adaptive immune system after puberty may influence the risk for disease (e.g., asthma), autoimmunity, and response to vaccination and cancer therapies.6 Chronic disease risk—including for coronary heart disease, cancers, musculoskeletal conditions, chronic pain, obesity, diabetes, and cognitive impairment—accumulate with age and generally increase after menopause, when reproductive hormone production declines.7, 8 There is a pressing need to understand how aging-related skeletal muscle dysfunction, frailty and bone loss impact or is impacted by chronic conditions in women. Aging-related skeletal muscle function deficit (SMFD) or skeletal muscle dysfunction—including loss of muscle mass (sarcopenia), muscle strength, and muscle function—may negatively impact or be impacted by chronic conditions or chronic debilitating conditions in women. Women more commonly than men have multimorbidity.9 The “networks” of morbidity are different in women, with multimorbidity more likely to cross multiple organ systems compared to men.10 Additionally, the pattern of accumulation of morbidity, meaning what initial chronic conditions are diagnosed and how conditions are additive, differs by sex and gender.11 In women with multimorbidity, the interactions among conditions are poorly understood and often inadequately treated.4 Chronic debilitating conditions were last defined by the US Department of Health and Human Services (HHS) in 2010 as “conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living.”12 However, this and other existing definitions of chronic debilitating conditions do not incorporate sex or gender considerations. Sex and gender influence health; and yet, significant knowledge gaps exist in the evidence base for prevention, diagnosis, and treatment of chronic debilitating diseases amongst women. Task Description: • Review existing literature on chronic conditions specific to women. o Specifically review literature on how the development and accumulation of chronic conditions in women are influenced by factors such as menopause, aging-related skeletal muscle dysfunction (loss of muscle mass, muscle strength, and muscle function), and frailty including the epidemiology and social and economic impact. o Gender, racial, and ethnic differences in clinical presentation and outcomes should be considered. o Prevention, diagnosis, and treatment of female-specific gynecologic conditions should be reviewed and considered • Convene workshop[s] of identified experts. • Assemble evidence-based findings on chronic debilitating conditions in women. o The findings should incorporate the influence of social determinants of health, including but not limited to gender, race and/or ethnicity, socioeconomic status, sexual and gender minorities and underserved rural populations Produce a workshop report that describes current gaps in evidence and provides a suggested research agenda for the future.