Title: The impact of patient-physician gender concordance on patient follow-up at time of transition to new primary care provider.

Background: Patient satisfaction with primary care physicians is influenced by multiple factors, including the gender of the provider. Multiple studies have shown patients have a preference for same-sex primary care physicians [1]. Prior research has shown significant differences exist between male and female providers in regards to communication style, visit length, and the likelihood of performing preventive health services [2]. Fang et al. assessed the characteristics of 92,389 visits from the 19952000 National Ambulatory Medical Care Survey. Female PCPs were more likely than male PCPs to see female patients (73% vs. 56%, P <0.01). By 2000, 78% of visits to female PCPs were from women vs. 56% for male PCPs (P <0.01). Female PCPs saw younger patients (mean age, 45 vs. 49 years, P = 0.04), reported longer visits (19 vs. 17 minutes, P <0.01), and ordered more preventive services as compared to male counterparts when seeing female patients ( pap smears - 11% vs. 4.7%, mammograms 9% vs. 4% ). This tendency for gender concordance poses an inherent challenge to residency programs by promoting an imbalanced ambulatory care experience for residents in training. Consequently, male residents are left with less experience with pelvic exams, pap smears, breast exams and womens health issues. Similarly, female residents have fewer male patient encounters which may translate to limited opportunities to perform prostate/testicular exams and practice health maintenance for male patients. In an effort to make resident patient panels less skewed by gender concordance, Healthcare Associates (HCA) intentionally transitioned the majority of outgoing senior resident patient panels to opposite gender incoming interns over the past 3 years. To date, this intervention has been successful in decreasing this gender stratification of the resident experience (more opposite gender primary care patients). This research study is intended to address whether this process has a significant impact on patient satisfaction and follow-up visits. Study Goals: This study is meant to reveal whether changing patients to new, opposite gender providers (from gender of prior provider) leads to reduced follow-up in an outpatient primary care practice. Moreover, when same sex physician-patient dyads are transitioned to gender discordant, or opposite gender physicianpatient dyads, is the rate of patient follow-up significantly impacted? The results of this study may impact how senior resident patient panels are assigned to new PCPs in the future, to try to optimize both resident educational experience and patient likelihood of continuing in HCA after resident PCPs graduate. Preserving continuity of care and patient relationships with the practice is an especially difficult goal within an ambulatory care setting at a teaching hospital, given the inevitable frequent transitions of primary care providers as graduating residents are continually leaving the practice. If the study reveals that there is no significant reduction in patient follow-up after changing the gender of PCP then this supports the continuation of the current panel-switch system. Thus, a positive null hypothesis would still be a meaningful guide for future practice. Additional secondary analyses of patient age and patient gender will be also be performed. Results of these data may outline significant age and gender related behavior patterns which can be referenced in the future to positively impact the design of patient panel distributions.

Research Question: Null Hypothesis: Transferring patient panels to opposite gender primary care physicians does not significantly impact the probability of patient follow-up. Study Description & Design Details: This research study is intended to be a retrospective cohort study that analyzes residency panel transitions along with patient follow-up data at Healthcare Associates (HCA) that has been collected over the past 3 years. Inclusion criteria will be primary care patients from panels of graduating residents from June 2007, June 2008 and June 2009. Patient appointments with newly assigned HCA primary care physicians will be tracked over three 14-month periods (July 2007Sept 2008, July 2008Sept 2009, and July 2009-Sept 2010). Exclusion criteria will be patients who expired during this timeframe. The defined primary exposure for the study is assignment of a new, opposite-gender primary care physician (female PCP to male PCP or male PCP to female PCP) vs. unexposed groups (male PCP to male PCP, female PCP to female PCP). These will be analyzed as categorical variables. The main outcome for the study will be reviewed as a dichotomous variable: patient follow-up vs. no followup. A secondary outcome will be follow-up with any HCA PCP. This secondary outcome and additional sub-analyses of individual patient age and gender will be incorporated to more specifically recognize subgroup behavior tendencies. Additionally, of those patients who did not follow-up with any HCA PCP, this study will attempt to track the patients who continued to follow-up with a nurse practitioner as this represented about ~ 4%-5% of the pilot data statistics. In terms of the data sources, secondary data will be obtained from BIDMC OMR , CCC system , Healthcare Associates disposition reports (i.e., DBPID), and resident panel assignment lists from 20072010. Subjects: Please note that the pilot data reviewed thus far includes only the patient panel data from graduating residents in July 2007 and July 2008. Within this timeframe, there are approximately 3920 patients in the exposed groups or PCP panels which are transferred to an opposite gender PCP. (N= 56 switched gender panels x ~70 patients =3920 patients). This incorporates ~29 patient panels transitioned from a male to female PCP and ~27 patient panels transitioning from a female to male PCP. In terms of the control groups or the unexposed patient panels, N= 32 non-switched panels x ~70 patients =2240. This includes 19 male to male PCP panels and 13 female to female PCP panels.

Preliminary Pilot Data Statistics:

Followed Up with assigned PCP (%) Did Not Follow-Up with assigned PCP (%)

Opposite Gender PCP

F 20% 80%

F M 18% 78%

Same Gender PCP

M M 24% 76%

F F 16% 84%

The above table is a summary of the preliminary pilot data. A sample patient panel was reviewed from each possible PCP switch category (M to F, F to M, M to M, F to F). From this small pilot sampling, the probability of follow-up among switched gender panels and same gender panels was compared. Using statistical software (PS - Power and Sample Size Calculation, version 3.3 for Windows developed Dupont and Plummer), the sample size in this proposed research study should be large enough to detect a 5% statistically significant difference in follow-up rates between groups while maintaining at least 80% power, and using a standard p-value of .05. Moreover, this pilot data does not include the current 20092010 subject figures which, once available, should further increase the power of the study. These sample size calculations are depicted graphically below. Probability of follow-up among switched gender panels and same gender panels

Design and Statistical Analysis: Statistical analysis of the outcomes among the switched gender vs. non-switched groups will be done using a Fischers Exact Test. More detailed analysis of the different categorical exposure groups (F-M, M-F, M-M, F-F) will be done using a logistic regression model. Gender also needs to be accounted for at the level of the individual patient. This would essentially make an 8-way categorical exposure distribution alongside the same dichotomous outcome (follow-up vs. no follow-up). An 8-way analysis will decrease the overall power, but the sample size estimate will also be about ~30% larger than the outlined pilot data once this years resident panel switch data is incorporated (2009-2010 data). A generalized estimated equation (GEE) logistic regression model will be used to search for significant associations that exist between same sex vs. opposite sex patient-physician dyads, as well as patterns of age and gender. Age of patients is a major confounding variable in the study which will need to be adjusted for using this same generalized estimated equation (GEE) model. Using logistical regression, a secondary analysis of the cohort population will be performed to show the proportion of patients who followed up with any HCA PCP. As aforementioned, this will be the secondary outcome for the study. However, a large proportion (~30-32%) of the patients who did not follow-up with assigned PCPs still made appointments with other HCA providers within each 14 month window per pilot data. Other HCA providers included faculty physicians, other residents, and nurse practitioners. In the pilot data, about 5 % of patients that did not follow-up with an HCA assigned PCP continued to see a nurse practitioner. Capturing this data will be useful to assess whether patients have completely left the practice or chosen other interim healthcare providers despite failure to follow-up with specifically assigned new HCA PCPs. Discussion / Potential Challenges: Different methods were used to notify patients of new PCP assignments in 2007 vs. 2008. Patients were sent a letter in 2007 which instructed them to call HCA for newly assigned PCP. The HCA telephone service representatives were given an assignment list to reference when patients called to make these appointments. In 2008, letters were sent to patients by outgoing senior residents. The letters included the name of newly assigned PCP with instructions for patients to call HCA to make new follow-up appointments. This is a major confounding factor in this proposed study which needs to be addressed. The results of initial 14 month period (from July 2007-Sept 2008) will need to be calculated separately and then compared and statistically adjusted in order to account for this confounding issue. Age and clustering effects within individual resident panels will also need to be adjusted for. This will be addressed with a generalized estimated equation (GEE) regression model. Limitations with resident schedules and availability are additional effect modifiers which will also have to be considered in interpretation of data. Lastly, the fact that a large percent of patients (~40-45%) simply do not show up for follow-up in general at HCA primary care practice needs to be taken into account when interpreting results of this proposed research study.

References 1. Fang C.M. Are patients more likely to see physicians of the same sex? Recent national trends in primary care medicine. The American Journal of Medicine, 2004; 117: 575-581 2. Bertakis K.D. Effects of physician gender on patient satisfaction. JAMWA. 2003; 58: 68-75. 3. Blake, R. Gender concordance between family practice residents and their patients in an ambulatory care setting. Academic Medicine. 1990; 65 (11): 702-704 4. PS - Power and Sample Size Calculation (version 3.3 for Windows) developed by William D. Dupont and Walton D. Plummer, Jr.