Does Physician Gender and Gender Composition of Clinical Teams Affect Guideline Concordance and Patient Outcomes in Out-of-Hospital Cardiac Arrest?

Abstract

Objective:

Prior literature has shown improved outcomes in morbidity and mortality for admitted patients cared for by female physicians. One theory is that female physicians adhere closely to guideline recommendations. We sought to determine whether patients who have out-of-hospital cardiac arrest (OHCA) experience more guideline-concordant postcardiac arrest care and potentially better outcomes based on the gender of their treating physician and gender distribution of the treatment teams.

Methods:

This study is a retrospective cohort study from the Colorado Cardiac Arrest Registry, local registry of OHCA patients treated at one academic urban tertiary care hospital. We analyzed adult OHCA patients who survived to hospital admission but were comatose. Patient demographic data and arrest characteristics were abstracted for subjects, and the gender of the provider was abstracted from the medical record.

Results:

Patients were admitted by a female attending in 28.5% of the cohort. The difference in guideline-concordant care between male and female providers was not significant. No statistical difference was found between all-male or mixed gender teams in adherence to guideline-concordant care. No patient was cared for by an all-female team. Neither gender of the admitting physician nor gender of the physician who led the family meeting to discuss prognosis was associated with a survival difference.

Conclusions:

Prior literature has described differences in outcome based on gender of the treating physician. Our analysis targeted a similar question in a cohort of OHCA patients with survival to hospital admission. We determined that there was no difference in postcardiac arrest guideline concordance and survival to hospital discharge based on treating physician gender. This finding differs from the prior literature and supports the importance of diverse clinical teams in medicine.

Introduction

In recent years, a growth in the number of women who enter the field of medicine has been observed creating the opportunity to query if men and women vary in their practice patterns. Recent studies have established different practice patterns between male and female physicians, for example, Tsugawa et al. demonstrated that female physicians had better outcomes, measured as lower rates of 30-day mortality and readmission, in patients admitted to the hospital.¹ One explanation for these observed differences has been attributed to gender-based variability in guideline concordance in medical practice, where studies have found that women are more apt to practice guideline-concordant care.^2,3

The management of patients who have experienced out-of-hospital cardiac arrest (OHCA) and achieved return of spontaneous circulation (ROSC) follows internationally derived guidelines. Developed by the International Liaison Committee on Resuscitation and further developed by the American Heart Association (AHA), postcardiac arrest management is described as a bundle of care that includes but is not limited to coronary angiography for presumed cardiac etiology of arrest, targeted temperature management (TTM) in comatose survivors, and multimodal neuroprognostication for patients who have not awakened by 72 hours postnormothermia.⁴

The most recent guideline recommendations deployed in U.S. hospitals for comatose survivors of OHCA are described in detail in the 2020 AHA guidelines update for cardiopulmonary resuscitation (CPR).⁵ These guidelines provide a standardized evidence-based approach to improve survival to hospital discharge and optimize neurological recovery from anoxic injury after cardiac arrest.

In this study, we focus on five postcardiac arrest care guidelines associated with improved recovery from OHCA⁶: coronary angiography within 24 hours of hospital admission, initiation, maintenance, and achievement of TTM, and, if transition to comfort-focused care is chosen, it being initiated >72 hours after admission. Our primary objective was twofold: to determine whether male and female physicians exhibit different rates of guideline concordance and to establish whether physician gender is associated with a difference in patient survival outcomes. As suggested by prior literature,^1
–3 we hypothesized that female physicians will have a higher rate of adherence to guideline-based postcardiac arrest care that will be associated with improved patient outcomes.

Methods

This study is a retrospective cohort study of data from the Colorado Cardiac Arrest Registry (CCAR). CCAR is a single-center quality assurance registry that captures data on all patients who present with an OHCA or who experience arrest within the emergency department at an academic, urban, tertiary care hospital in the United States. Patients included in this registry are adults who by definition have received at least one round of CPR or one defibrillation. Data are captured based on the Utstein template⁷ by trained research assistants. CCAR began enrolling in 2013 and currently includes >1200 cardiac arrest events. This study has been approved by the Colorado Multiple Institutional Review Board.

Study subjects

The patients abstracted from CCAR and enrolled into this study are patients who have suffered OHCA with ROSC and survived to hospital admission. All subjects were 18 years of age or older and were not following verbal commands on admission (Glasgow coma motor score <6). Excluded patients included those who were deceased in the emergency department or had ROSC and were awake (i.e., Glasgow motor score of 6, following verbal commands). We excluded patients who were prisoners or “in custody” for the purpose of this analysis.

Data abstraction

Patient data were abstracted from CCAR including patient gender, age, cardiac arrest characteristics, and outcomes (survival to hospital discharge and cerebral performance category [CPC]). Review of the patients' medical record was used to determine the gender of the admitting attending physician, the attending physician who conducted the primary family meeting where neuroprognosis/goals of care were discussed (for consistency, we evaluated the first family meeting after rewarming from temperature management), and the physicians on the patient care team in the first 72 hours postcardiac arrest.

Patient care teams included the physicians included on the primary team and did not include consultants. Resident and attending physicians were included in this analysis. Given that fellow physicians and medical students do not consistently leave daily progress notes, they were not included in our analysis. All data were stored in a secure research electronic data capture at the University of Colorado.⁸ Physician gender was determined using a local institutional database of employment records that is accessible to the public. This database gives a dichotomous result for gender, either female or male. When physicians could not be found in the institutional employment records, we explored physician gender via national provider identification webpage or local residency webpages.

The guideline measures evaluated were abstracted from existing entries into CCAR and included (1) coronary angiography within 24 hours of hospital arrival; (2) initiation of TTM, achieving the target temperature during TTM, completion of TTM, and defined as maintenance of patient temperature at or below target for at least 24 hours; and (3) if withdrawal of life-sustaining therapy was chosen, it being initiated >72 hours after hospital arrival. Institutional order sets provide clinical support for TTM as well as antishivering.

Patient-specific outcomes abstracted included survival to hospital discharge and neurological recovery at hospital discharge. CPC has been identified as a good measure of neurological recovery,⁹ with CPC 1 or CPC 2 indicating a “good” outcome or return to baseline or near baseline, whereas CPC 3–5 indicate a “poor” outcome.

Statistical analysis

Descriptive statistics were used to report patient demographics and arrest characteristics. Chi-squared tests were used to test the significant difference between physician gender and measured guidelines, with a p-value of 0.05 as significant. Similar methodology was also applied to test the difference between physician gender and patient outcomes, dichotomized into good versus poor CPC, as described previously. All analyses were conducted using STATA statistical software, version 14.1 (State College, TX).

Results

From December 2013 to July 2018, 340 patients who suffered OHCA with ROSC and survival to hospital admission at the University of Colorado were enrolled. Of the total patient cohort, 217 (63.8%) patients were male. The mean age was 59.8 years, 28.2% of patients (96) had an initial shockable rhythm, and 40.5% patients (124) received bystander CPR. Approximately 39.8% of patients (135) survived to hospital discharge, and 29.7% of patients (101) had a favorable cerebral performance score (CPC 1–2) at discharge (Table 1).

Table 1.

Patient Demographics and Arrest Characteristics

Characteristic	% (n), n = 340
Mean age	59.8 ± 15.7 years
Male gender	63.8 (217)
Bystander CPR performed	36.5 (124)
Emergency department arrest	1 (34)
Initial shockable rhythm	28.2 (96)
Survival to hospital discharge	39.7 (135)
CPC at hospital discharge
CPC 5	60.0 (204)
CPC 4	3.8 (13)
CPC 3	6.5 (22)
CPC 2	8.2 (28)
CPC 1	21.5 (73)

CPC, cerebral performance category; CPR, cardiopulmonary resuscitation.

Female physicians, both resident and attending, accounted for 34.6% (450) of the providers caring for the patients included in this study. Of the 309 residents involved in caring for this cohort of postcardiac arrest patients, 40.5% (125) were female.

Of the patient cohort, 97 patients (28.5%) were admitted by a female attending physician. The family meeting was run by female attending physicians 43.8% of the time. A large majority (80%) of the teams were gender diverse (including at least one female attending or resident physician). None of the teams comprised all female physicians.

Overall, no statistical difference was found between male and female admitting attending physicians in the rate of guideline-concordant care after cardiac arrest, including coronary angiography at 24 hours, initiation of TTM, achievement of TTM, and TTM maintenance. In addition, no statistical difference was found in survival to discharge between male and female admitting attending physicians (Table 2).

Table 2.

Guideline Adherence and Outcomes Based on Admitting Physician Gender

Guideline	Male admitting physician, % (n)	Female admitting physician, % (n)	p
TTM initiated	73.7 (179)	76.3 (74)	0.616
TTM goal temperature achieved	69.5 (169)	71.1 (69)	0.773
TTM maintained	44.4 (108)	44.3 (43)	0.985
Angiography (only patients with initial shockable rhythm)	65.9 (50)	66.7 (18)	0.871
Outcome
Poor CPC (3–5)	69.1 (168)	73.2 (71)	0.46
Good CPC (1–2)	30.9 (75)	26.8 (26)	0.46
Survival to hospital discharge	43.2 (105)	39.2 (38)	0.496

TTM, targeted temperature management.

Patient outcomes were also broken down into favorable and not favorable CPC. Female admitting attending physicians had 26 patients (26.8%) with favorable CPC and male admitting attending physicians had 75 patients (30.9%) with favorable CPC. This difference was not statistically significant (Table 2).

When examining TTM, multiple reasons were cited for not initiating or not maintaining TTM. Reasons for not initiating TTM include a glasgow coma scale (GCS) motor score >5 (41 patients), death in the emergency department or catheterization laboratory before arriving in the intensive care unit (11 patients), pre-existing do not resuscitated (7 patients), and etiologies in which TTM has not been shown to be beneficial, most commonly hemorrhagical (14 patients). Reasons for not maintaining TTM included improved GCS before completion of TTM (16 patients), withdrawal of life-sustaining therapy (WLST) before 72 hours (26 patients), death (35), and development of hemodynamic instability or medical complication of TTM (11).

Between male and female attending physicians leading the family meeting, no statistical difference was found in WLST before 72 hours or survival to discharge. WLST occurred in 61.7% of the family meetings led by a male physician and in 55.6% of the family meeting led by a female physician. When looking at an all-male team versus gender-diverse team, no statistical difference was found in any of the variables examined, including cerebral performance score at discharge (Table 3). Survival to discharge was also not found to be statistically significant based on gender of physician leading the family meeting (Table 4).

Table 3.

Guideline Adherence and Outcomes Based on All-Male or Mixed Gender Teams

Guideline	All-male physician team, % (n)	Mixed gender physician team, % (n)	p
TTM initiated	78.6 (55)	69.3 (187)	0.175
TTM goal temperature achieved	74.3 (52)	63.0 (170)	0.106
TTM maintained	40.0 (28)	37.0 (100)	0.710
WLST <72 hours after admit	34.2 (24)	40.7 (110)	0.287
Angiography (only patients with initial shockable rhythm)	65.4 (17)	60 (48)	0.223
Outcome
Poor CPC (3–5)	34.3 (24)	28.9 (78)	0.38
Good CPC (1–2)	34.3 (24)	28.9 (78)	0.38
Survival to hospital discharge	40.0 (28)	40.0 (108)	0.931

WLST, withdrawal of life-sustaining therapy.

Table 4.

Guideline Adherence Based on the Gender of the Physician Leading the Family Meeting

Guideline	Family meeting male physician, % (n)	Family meeting female physician, % (n)	p
WLST <72 hours after admit	61.7 (50)	55.6 (35)	0.455
Survival to hospital discharge	19.8 (16)	23.8 (15)	0.557

Discussion

In this study, we sought to understand whether physician gender affects adherence to postarrest guideline-concordant care as well as patient outcomes. The guidelines examined in this study have been previously identified as being associated with improved outcomes and include angiography for presumed cardiac etiology of arrest with shockable initial rhythm, TTM initiation, achievement, and maintenance, and appropriate delayed neuroprognosticaton.⁶ In this cohort, we found no significant difference in guideline adherence or patient outcomes when comparing the gender of admitting attending or that of the attending conducting the family meeting. There was also no significant difference in guideline concordance when looking at all-male physician teams and those with both male and female members.

The results of this cohort diverge somewhat from that of previous studies.^1
–3 A recent study in the Journal of the American Medical Association looking at national Medicare data found that patients treated by female physicians had lower mortality rates and readmission rates than those treated by male physicians.¹ Although the difference found was statistically significant, the outcomes for each gender were still within 1% of each other. With such a small difference, the clinical significance of this result is unclear.

Past studies, including a 2009 study in the European Journal of Heart Failure, have found that female physicians are more likely to follow guideline-based care.² Although our study found no difference in guideline adherence, we also evaluated the gender diversity of teams, which was not included in prior studies. Around 80% of the teams in our cohort were gender diverse, which may explain the difference in our findings compared with prior studies. As a large academic center, the intensive care units employ multidisciplinary patient care teams, which likely adds to further gender diversity, even with a team of all-male physicians. By having multiple team members including residents, fellows, social workers, and nurses directly involved in the care of a patient, the impact of attending physician gender may become less apparent.

The main limitations of this study are that data were drawn from a single center and looked at a relatively specific patient population (comatose survivors of OHCA) versus a broad cohort of in-patients, leading to smaller numbers when compared with previous studies. By looking at postarrest patients, our study examined a select group of physicians working primarily in the intensive care units of a large tertiary academic institution that has a higher proportion of male attending physicians.

Around 70% of the admitting attending physicians were male and there were no all-female teams, though the gender of the physician running the family meeting was far more evenly split, with 55% of the physicians being male. Given the retrospective nature of our study, we can only describe the clinical team based on who recorded a note within the medical record, therefore, the identity of the multidisciplinary critical care team cannot be clearly defined. For that reason, we were limited to analyzing attending and resident physicians only. Future prospective study with better identification of the entire team would yield important information to better define the role of gender and gender-diverse medical teams in the care of critically ill patients.

Conclusion

Interestingly, the lack of difference in guideline-concordant care for postcardiac arrest patients found between physicians of different genders varies from earlier studies that show increased guideline concordance by female physicians. We propose that care teams for postcardiac arrest patients are diverse in clinical specialty, actively engage a team-based approach in the intensive care unit, and frequently engage in clinical input from other hospital staff such as critical care nursing and respiratory therapy, thus leading to larger teams that are frequently more diverse.

Given the location of our study, in an academic institution, the contribution from students, resident, and fellow trainees also contributes to the diversity of the caregiver team. Given the multidisciplinary nature of postcardiac arrest care, and the frequency for large teams in academic medicine, our observational study does not find an association between physician gender and guideline concordance and survival after OHCA.

Footnotes

Acknowledgment

The authors thank Dr. Ryan Murphy for her contributions to this article.

Authors' Contributions

All authors have made substantial contributions to the conception or design of the study; or the acquisition, analysis, or interpretation of data for the study; and drafting the study or revising it critically for important intellectual content; and final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Author Disclosure Statement

None of the authors report any conflicts of interest pertaining to this study.

Funding Information

Dr. Perman's research time is supported by the NIH/NHLBI through Grant No. 5K23HL138164.

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