Differences in Cardiovascular Disease Risk Factor Management in Primary Care by Sex of Physician and Patient

Hava Tabenkin; Charles B. Eaton; Mary B. Roberts; Donna R. Parker; Jerome H. McMurray; Jeffrey Borkan

doi:10.1370/afm.1071

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Author's response
Charles B. Eaton

Published on: 20 January 2010
Evidence for differences between female and male physicians in the quality of health care delivered
Heiner K. Berthold

Published on: 20 January 2010
Quality of Health Care for Cardiovascular Disease Risk Reduction
Brian V. Reamy

Published on: 15 January 2010

Published on: (20 January 2010)
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Author's response
Charles B. Eaton, Pawtucket , RI USA
We appreciate the comments Drs. Berthod and Ioanna Gouni-Berthold regarding their findings in Germany of differences by physician gender on CVD risk factor control in diabetics. Certainly the differences in geography, training of providers and sample size may explain the discrepant results. We did however perform hierarchical cluster analysis adjusting for patient, provider and practice level clustering and varying samp...
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We appreciate the comments Drs. Berthod and Ioanna Gouni-Berthold regarding their findings in Germany of differences by physician gender on CVD risk factor control in diabetics. Certainly the differences in geography, training of providers and sample size may explain the discrepant results. We did however perform hierarchical cluster analysis adjusting for patient, provider and practice level clustering and varying sampling frames (20-120 pts/provider) for each provider, thus this factor is an unlikely explanation of the differences found.
We also agree with Dr. Reamy that our providers and the patients charts that were audited might be a slightly biased sample since the providers had to agree to be in a clinical trial regardinig cholesterol management, and the patients had to agree to have there records reviewed. Thus the absolute rates of control of cardiovascular risk factors in our study should viewed with some caution as being representative. To assess this potential bias, we compared our study physicians to the state registry of primary care physicians and found few differences. In a separate pilot study using the same sampling strategy, We compared our patients (that had given informed consent) to a random de-identified chart audit and found that our patients were more likely to have higher Framingham Risk Scores and a greater percentage had documented lipid disorders compared to the random chart audits, making it less likely to be controlled. However, these biases should not have effected the gender X gender comparisons discussed in the article.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (20 January 2010)
Page navigation anchor for Evidence for differences between female and male physicians in the quality of health care delivered
Evidence for differences between female and male physicians in the quality of health care delivered
Heiner K. Berthold, Berlin, Germany
Other Contributors:
To the Editor: The study of Tabenkin et al. is the latest in a recent series of studies focusing on the effect of physician and/or patient gender on the quality of care provided. This particular work examines cardiovascular risk factor management and is of interest, since it addresses a subject of high clinical relevance. The authors find differences in the management of patients with diabetes, depending on the sex of th...
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To the Editor: The study of Tabenkin et al. is the latest in a recent series of studies focusing on the effect of physician and/or patient gender on the quality of care provided. This particular work examines cardiovascular risk factor management and is of interest, since it addresses a subject of high clinical relevance. The authors find differences in the management of patients with diabetes, depending on the sex of the patient, with women receiving less aspirin and less ACE inhibitor therapy compared to men. In patients with diabetes, the fact that patient gender affects the quality of care provided, with female patients receiving consistently worse care than men, has been pretty much established beyond reasonable doubt, based on the results of multiple studies on the subject (1-3).
Tabenkin et al. found no differences in cardiovascular risk factor management depending on the sex of the physician. This is not in agreement with our recent findings (4), which showed that in a diabetic population patients of female physicians more often reached HbA1c, LDL cholesterol and systolic blood pressure target values compared to patients of male physicians. The discordant results may be due to (i) the much larger population of our study (3096 physicians treating 51,052 patients vs. 55 physicians treating 4195 patients), (ii) the different geographical areas assessed (all areas of Germany vs. southeast New England), and (iii) the fact that in our study additional effects (beyond case-mix bias) of physician level clustering on significance testing were addressed using generalized estimating equations.
Considering that in the present study one physician could be reporting data from a minimum of 20 up to 120 patients, corrections for clustering might have altered the results. Another recent study also showed that patients with chronic heart failure treated by female physicians were treated better than patients of male physicians regarding guideline-recommended drug use and achieving target doses (5).
The general message on gender issues is that gender plays a role in quality of care, both provided and received. The reasons behind this phenomenon remain to be elucidated and seem to be one of the most interesting research areas in health services research.
Heiner K. Berthold, MD, PhD, Professor of Clinical Pharmacology, Dept. of Geriatrics, Charité University Medicine Berlin (Germany)
Ioanna Gouni-Berthold, MD, Professor of Internal Medicine and Endocrinology, Dept. of Internal Medicine II, University of Cologne (Germany)
References
1. Wexler DJ, Grant RW, Meigs JB, Nathan DM, Cagliero E. Sex disparities in treatment of cardiac risk factors in patients with type 2 diabetes. Diabetes Care 2005 Mar;28(3):514-20.
2. Gouni-Berthold I, Berthold HK, Mantzoros CS, Bohm M, Krone W. Sex disparities in the treatment and control of cardiovascular risk factors in type 2 diabetes. Diabetes Care 2008 Jul;31(7):1389-91.
3. Ferrara A, Williamson DF, Karter AJ, Thompson TJ, Kim C. Sex differences in quality of health care related to ischemic heart disease prevention in patients with diabetes: the translating research into action for Diabetes (TRIAD) study, 2000-2001. Diabetes Care 2004 Dec;27(12):2974- 6.
4. Berthold HK, Gouni-Berthold I, Bestehorn KP, Bohm M, Krone W. Physician gender is associated with the quality of type 2 diabetes care. J Intern Med 2008 Oct;264(4):340-50.
5. Baumhakel M, Muller U, Bohm M. Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. Eur J Heart Fail 2009 Mar;11(3):299-303.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (15 January 2010)
Page navigation anchor for Quality of Health Care for Cardiovascular Disease Risk Reduction
Quality of Health Care for Cardiovascular Disease Risk Reduction
Brian V. Reamy, Bethesda, USA
To the Editor, I greatly appreciated the scope, complexity and thoroughness with which Tabenkin et al approached the topic of potential differences in cardiovascular disease risk management.1 While style differences among male and female physicians were noted, it was encouraging to see that patients met cardiovascular disease treatment goals similarly regardless of the gender of the patient or physician. This study of 3...
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To the Editor, I greatly appreciated the scope, complexity and thoroughness with which Tabenkin et al approached the topic of potential differences in cardiovascular disease risk management.1 While style differences among male and female physicians were noted, it was encouraging to see that patients met cardiovascular disease treatment goals similarly regardless of the gender of the patient or physician. This study of 30 practices in southeastern New England also gave a “report card” of how well a group of primary care practices were doing in managing key cardiovascular risk factors. Approximately, 59 percent of patients were at LDL cholesterol goal, 80 percent of patients were at blood pressure goals, and 67 percent were meeting diabetes management goals.1
Is this good or bad? Is there a point of reference? The best point of reference is the large RAND corporation study on the quality of healthcare delivered to adults in the United States.2 It examined 6712 participants living in 12 metropolitan areas for 30 acute and chronic conditions from 1998 to 2000. Taking methodological differences into account, one can still make some interesting comparisons.
In the RAND study only 49 percent of patients met LDL cholesterol goals, 65 percent met blood pressure goals and only 45 percent met diabetes management goals.2 What could account for the relative improvements? Are the patients more compliant? Are the physicians better trained and versed in prevention standards or has our “system” of health care delivery actually improved. These are all interesting questions meriting further research.
Brian V. Reamy, M.D., Professor of Family Medicine & Associate Dean for Faculty, Uniformed Services University School of Medicine, Bethesda, Maryland
1. Tabenkin H, Eaton CB, Roberts MB, et al. Differences in Cardiovascular Disease Risk Factor Management in Primary Care by Sex of Physician and Patient. Ann Fam Med 2010;8:25-32.
2. McGlynn EA, Asch SM, Adams J, et al. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med 2003;348:2635-2645.
Competing interests: None declared
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Competing Interests: None declared.