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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Figure 1.
Lipid management: percentage of patients given diet and weight loss advice.
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Figure 2.
Diabetes management: percentage of patients on angiotensin-converting enzyme therapy.
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Figure 3.
Diabetes management: percentage of patients with blood pressure under control.

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Table 1.

Characteristics of Male and Female Patients

Characteristic	All Participants	Male	Female	PValue^a
^a Comparison by sex.
Number participating, No. (%)	4,195 (100)	1,671 (40)	2,524 (60)
Age, mean (SD), y	52.53 (13.3)	53.14 (12.9)	52.1 (13.5)	.13
Body mass index, mean (SD)	28.34 (6.03)	29.09 (4.88)	27.96 (6.59)	<.001
Race, white, %	95.1	94.67	95.40	.77
Marital status, partnered, %	71.78	79.29	66.80	<.001
Education level, %
High school or less	29.05	29.86	28.52
Some college	16.24	13.67	17.94	<.001
College degree or higher	54.71	56.47	53.54
Income, %
Less than $35,000	15.38	10.60	18.87
$35,000 – $74,999	38.38	36.42	39.81	<.001
$75,000 or greater	46.24	52.98	41.32
Insurance, %
Ensured overall	98.59	98.86	98.42
Private insurance	80.43	81.51	79.71	.02
Cardiovascular disease %	8.61	13.4	5.4	<.001
Stroke, %	1.48	2.21	0.99	.002
Congestive heart failure, %	1.62	1.92	1.43	.28
Lipid disorder, %	52.3	62.8	45.3	<.001
Hypertension, %	40.3	45.4	36.9	<.001
Diabetes mellitus, %	9.7	11.7	8.3	<.001
Current smokers, %	14.3	13.9	14.5	.27
Physically inactive, %	23.2	22.5.	23.7	.22
Body mass index class, %				<.001
<25	30.9	18.7	38.9
25–29.9	36.4	45.9	30.1
>30	32.7	35.3	31.0
Cardiovascular disease risk, %				<.001
Coronary heart disease equivalent	19.1	26.1	14.5
High	9.5	20.2	2.5
Moderate	20.3	18.7	21.3
Low	51.1	35.0	61.7

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Table 2.

Characteristics of 55 Participating Physicians

Characteristic	Overall No. (%)	Male No. (%)	Female No. (%)	PValue
CHC = coronary heart disease; CVD = cardiovascular disease; NP = nurse practitioner; PA = physician assistant.
Physician sex
Male	39 (70.9)	39 (70.9)
Female	16 (29.1)		16 (29.1)
Practice size
Small	18 (32.7)	14 (35.9)	4 (25.0)	.63
Large	37 (67.3)	25 (64.1)	12 (75.0)
In practices with NP/PA	16 (29.1)	14 (35.9)	2 (12.5)	.10
Specialty
Family practice	28 (50.9)	21 (55.3)	7 (43.8)	.44
Internal medicine	27 (49.1)	17 (44.7)	9 (56.3)
US graduates	41 (74.5)	29 (74.4)	12 (75.0)	.96
Family history CHD	23 (41.8)	17 (43.6)	6 (37.5)	.90
CVD history	3 (5.5)	3 (8.1)	0 (0.0)	.24
Physical activity	49 (89.1)	35 (92.1)	14 (87.5)	.59
Patient sex				<.001
Male	1,671 (39.8)	1,490 (50.4)	1,81 (14.6)
Female	2,523 (60.2)	1,467 (49.6)	1,056 (85.4)
	Mean (SD)	Mean (SD)	Mean (SD)
Physicians age, y	46 (7.37)	47 (7.09)	46 (8.2)	.65
Patients age, y	52.5 (13.3)	53.9 (8.9)	51.2 (9.2)	<.001
Years in practice, No.	15.1 (8.04)	16 (7.99)	13 (7.93)	.18
Patients seen per day, No.	19.7 (7.47)	21.5 (7.24)	15.2 (6.2)	.005
Patient care hours per week, No.	43.3 (13.4)	45.3 (12.36)	38.7 (15.01)	.10
Body mass index	25.2 (3.38)	25.7 (3.43)	23.9 (3.01)	.07
Time lag (minutes behind), min	20 (17.8)	18 (18.1)	28 (14.6)	.095

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Table 3.

Cardiovascular Risk Factors Management by Sex of Patient and Physician

Management Characteristic	Male Patient % (No.)	Female Patient % (No.)	PValue^a	Male Physician % (No.)	Female Physician % (No.)	PValue^b
ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BP = blood pressure; HgA_1c=glycated hemoglobin; LDL=low-density lipoprotein.
^a For patient comparison by sex.
^b For physician comparison by sex.
Lipid management
LDL at goal	59.14 (621)	58.48 (668)	.865	58.36 (949)	59.50 (340)	.693
Received advice for diet and weight loss	72.10 (757)	72.59 (829)	.982	67.62 (1,135)	78.61 (451)	<.001
Received physical activity advice	49.52 (520)	53.94 (616)	.977	45.94 (752)	62.94 (384)	<.001
Suggested medication for treatment	66.10 (694)	60.33 (689)	.039	64.10 (1,056)	58.03 (327)	.049
On lipid-lowering medication	57.81 (607)	53.59 (612)	.179	57.14 (937)	50.27 (282)	.020
Blood pressure management
Under control (<140/90 mg Hg)	82.45 (625)	79.27 (738)	.028	80.38 (1,021)	85.36 (342)	.088
Under optimal control (<120/80)	17.68 (134)	19.98 (186)	.408	18.41 (229)	23.28 (91)	.063
Received advice for diet and weight loss	72.16 (547)	68.74 (640)	.116	65.53 (864)	77.13 (323)	<.001
Received physical activity advice	50.26 (381)	52.09 (485)	.877	43.12 (575)	68.29 (291)	<.001
On medication to control hypertension	77.57 (588)	80.02 (745)	.270	76.42 (985)	83.18 (348)	.013
Weight management
Documented weight problems	32.30 (335)	42.46 (504)	<.001	39.27 (648)	33.28 (191)	.113
Received advice for diet and weight loss	72.23 (749)	71.27 (846)	.432	69.52 (1,147)	78.05 (448)	<.001
Received physical activity advice	52.46 (544)	55.94 (664)	.705	49.39 (815)	68.47 (393)	<.001
Diabetes management
Under control (HgA_1c <7%)	68.37 (134)	66.99 (140)	.756	65.44 (195)	73.83 (79)	.113
On medication	69.39 (136)	58.37 (122)	.020	66.33 (200)	54.79 (58)	.063
On aspirin therapy	55.61 (109)	35.41 (74)	<.001	47.81 (143)	36.59 (40)	.078
On ACE medication	51.53 (101)	41.06 (85)	.038	48.82 (145)	38.68 (41)	.084
On ARB medication	24.49 (48)	20.77 (43)	.347	25.25 (75)	15.09 (16)	.040
BP under control (<130/85 mm Hg)	62.76 (123)	56.94 (119)	.227	59.04 (176)	61.45 (66)	.681
LDL at goal	48.47 (95)	42.58 (89)	.196	48.16 (140)	38.58 (44)	.142
Received advice for diet and weight loss	80.10 (157)	86.60 (181)	.033	79.24 (242)	83.17 (96)	.329
Received physical activity advice	52.04 (102)	63.64 (133)	.019	48.55 (152)	74.25 (83)	<.001

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Table 4.

Patient and Physician Sex Differences in Cardiovascular Risk Factor Management Using Multiple Level Regression Models

Management	Female vs Male Patient OR (95% CI)	Female vs Male Physician OR (95% CI)
ACE=angiotensin-converting enzyme; CI=confidence interval; OR = odds ratio.
Note: Adjusted for patients’ variables: age (<55 vs 55+ years), body mass index, education, marital status, type of medical insurance, on medication for the condition (lipid disorder, hypertension, diabetes mellitus), cerebrovascular disease risk.
Physicians’ variables: sex, specialty (family medicine vs internal medicine), medical school graduation (US vs other), number of patients per day, (1–20/d vs >20/d), number of hours per week in patient care (more or less than 40 h/wk), number of years in the practice (more or fewer than 16 years).
Practice variables: practice size (small vs large), practices with or without physicians’ assistants.
Intracluster coefficients: lipid management, lipid-lowering medication, 0.10; hypertension management, blood pressure control, 0.08; dietary advice, 0.24; blood pressure medication, 0.04; weight loss-diet advice, 0.18; physical activity advice, 0.28; diabetes mellitus management, dietary advice, 0.21, glucose-lowering medication, 0.04, physical activity advice, 0.36, aspirin therapy, 0.10.
Lipid management
Suggest medication	0.75 (0.56–1.02)	1.03 (0.69– 1.52)
Hypertension management
Blood pressure <140/90 mm Hg	0.61 (0.36–1.03)	1.61 (0.90– 2.89)
Advice for diet and weight loss	1.05 ( 0.65–1.71)	2.22 (1.12–4.40)
On blood pressure medication	0.84 ( 0.55–1.27)	1.98 (1.19–3.29)
Weight management
Advice for diet and weight loss	0.93 (0.66–1.31)	2.14 (1.30–3.51)
Physical activity advice	1.00 (0.74–1.34)	2.03 (1.3–3.18)
Diabetes management
Advice for diet and weight loss	2.58 ( 0.90–7.39)	2.25 (0.50–10.22)
Physical activity advice	1.16 ( 0.55–2.48)	6.55 (2.01–21.33)
Diabetes medication	0.49 (0.25–0.94)	0.76 ( 0.35–1.67)
Aspirin therapy	0.30 (0.15–0.58)	0.69 (0.30–1.57)
ACE inhibitor therapy	0.39 (0.22–0.72)	0.82 (0.41–1.64)

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Supplemental Appendixes

Supplemental Appendix 1. Chart Audits and Data Collection; Supplemental Appendix 2. ATP III Guideline Coronary Heart Disease (CHD) Risk Categorization Definitions; Supplemental Appendix 3. Definitions of Cardiovascular Risk Factor Management

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Supplemental data: Appendix 1-3 - PDF file, 3 pages, 175 KB
The Article in Brief

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

Charles B. Eaton , and colleagues

Background Previous research suggests that there may be disparities by sex in the ways that doctors manage cardiovascular disease and its risk factors. This study looks at the role that the sex of the doctor and patient play in the management of cardiovascular disease risk factors.

What This Study Found This study finds that women doctors provide more preventive counseling for cardiovascular risk factors, including diet, weight loss, and physical activity. Women patients, regardless of the sex of their doctor, are less likely to receive drug therapy for diabetes management, including glucose-lowering medications, ACE inhibitor therapy and aspirin therapy. Quality of care (measured by whether patients meet treatment goals for cardiovascular disease risk factors), however, is similar regardless of the sex of the patient or physician.

Implications

Future research is needed to explore whether stylistic differences in cardiovascular disease risk factor management have a long-term impact on clinical outcomes, such as heart attacks, strokes, heart failure, and death.