A FRAMEWORK FOR THE CONSIDERATION OF CHRONIC DEBILITATING CONDITIONS IN WOMEN

背景/概述： 随着我们人口的老龄化和比男性更长的预期寿命，慢性衰弱疾病对妇女的健康构成了越来越大的负担。慢性病包括在一生中发生的各种疾病和障碍，其中许多是针对性别的。1虽然妇女现在经常被纳入临床研究，但研究很少是为了获得关于妇女的数据。纳入标准和研究终点通常不以妇女的需要为中心。2慢性病患病率和临床表现方面的性别和性别差异已有记录。CMS数据(按性别分类的服务费用受益人，不包括联邦医疗保险优势参保人)指出，在妇女中更常见的六种疾病：高血压、关节炎、抑郁症、痴呆症、哮喘和骨质疏松症。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，其定义为同时发生两种或两种以上的疾病，这些疾病可能具有或不具有相同的因果联系，从而进一步使妇女处于不利地位，另外的不利因素会影响那些认为历史上代表性不足的人口的妇女的健康。 在我们对女性慢性衰弱疾病的理解中，有几个证据差距是由于在临床研究中历史上对男性的过度依赖造成的。妇女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应答率较低；荷尔蒙转换，如更年期，对慢性病自然病史的影响尚未得到很好的描述。此外，女性健康与生殖健康有着不可阻挡的联系的广泛假设，对女性特有的慢性疾病，如痛经、子宫内膜异位症和多囊卵巢综合征的研究有限。6慢性疾病风险--包括冠心病、癌症、肌肉骨骼疾病、慢性疼痛、肥胖症、糖尿病和认知障碍--随着年龄的增加而积累，在绝经后生殖激素产生下降的情况下通常会增加。与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(肌萎缩症)、肌肉力量和肌肉功能丧失--可能会对女性产生负面影响，或受到慢性病或慢性衰弱疾病的影响。 妇女比男子更常见地患有多发性疾病。9妇女的发病率“网络”不同，与男子相比，多发性疾病更有可能跨越多个器官系统。10此外，发病率的累积模式，即最初诊断的慢性病以及病情是如何加重的，因性别和性别而异。11在患有多发性疾病的妇女中，病情之间的相互作用知之甚少，往往得不到适当的治疗。 美国卫生与公众服务部(HHS)上一次将慢性衰弱疾病定义为“持续一年或更长时间，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疾病定义没有包括性别或性别因素。性别和性别影响健康；然而，在妇女中预防、诊断和治疗慢性衰弱疾病的证据基础上存在着重大的知识差距。 任务说明： ·回顾有关女性慢性病的现有文献。 O具体回顾有关妇女慢性疾病的发展和积累如何受到更年期、与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(包括流行病学和社会和经济影响)等因素影响的文献。 O应考虑临床表现和结果的性别、种族和民族差异。 O应审查和考虑女性特有妇科疾病的预防、诊断和治疗 ·召开已确定专家的研讨会[S]。 ·收集关于女性慢性衰弱状况的循证发现。 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、性少数群体和性别少数群体以及服务不足的农村人口。 编写一份研讨会报告，描述当前证据方面的差距，并为未来提供建议的研究议程。

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.