Orthopedics

Feature Article Supplemental Data

The Importance of Concordance Between Patients and Their Subspecialists

Romil F. Shah, MD; Kevin Mertz, BS; Joseph A. Gil, MD; Sara L. Eppler, MPH; Derek Amanatullah, MD, PhD; Jeffrey Yao, MD; Loretta Chou, MD; Robert Steffner, MD; Marc Safran, MD; Serena S. Hu, MD; Robin N. Kamal, MD

Abstract

Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired t tests with a Bonferroni correction. A total of 118 patients were recruited in clinic, and a total of 982 volunteers were recruited online. In the clinic cohort, the level of importance for patient–physician concordance of age, ethnicity, language, and religion was not significantly different between PCPs and specialists. In the volunteer cohort, the level of importance for concordance of age, sex, national origin, language, and religion was not significantly different between PCPs and specialists. The volunteers recruited online had significantly higher concordance scores than the patients recruited in clinic for most variables. Patients find patient–physician concordance as important in specialty care as they do in primary care. This may have similar effects on patient outcomes in specialty care. [Orthopedics. 2020;43(5):315–319.]

Abstract

Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired t tests with a Bonferroni correction. A total of 118 patients were recruited in clinic, and a total of 982 volunteers were recruited online. In the clinic cohort, the level of importance for patient–physician concordance of age, ethnicity, language, and religion was not significantly different between PCPs and specialists. In the volunteer cohort, the level of importance for concordance of age, sex, national origin, language, and religion was not significantly different between PCPs and specialists. The volunteers recruited online had significantly higher concordance scores than the patients recruited in clinic for most variables. Patients find patient–physician concordance as important in specialty care as they do in primary care. This may have similar effects on patient outcomes in specialty care. [Orthopedics. 2020;43(5):315–319.]

The concept of concordance, defined as shared demographic characteristics between the physician and the patient,1 has been introduced as an important concept in health care that can improve patient-centered care and the physician–patient relationship. The importance of concordance in health care has been well studied in a few areas of medicine. When care is provided in concordant pairs, patients are more likely to use care,2 have improved communication,3,4 have improved quality metrics like higher rates of preventive screenings,5 and, in some cases, have improved outcomes.6

Several studies in primary care have examined the effects of physician–patient concordant pairs. These studies found that patients value shared race, sex, and language with physicians when establishing care7–10 and that concordant pairs lead to improved patient satisfaction. Some analyses have been conducted to demonstrate the importance of concordant pairs in specialty medicine. In cardiology, for example, improved medication adherence was demonstrated in ethnic-concordant pairs,11 and improved mortality after myocardial infarctions was demonstrated in sex-concordant pairs.6 Further research is needed to evaluate the importance of concordance in other specialties, such as orthopedic surgery, where physician sex and racial diversity have remained poor.12,13 Encouraging concordant care in these specialties may improve the patient experience and therefore impact communication, satisfaction, and outcomes.

The objective of this study was to evaluate whether participants value concordance in care with their subspecialty physician as much as they do with their primary care physician (PCP).

Materials and Methods

Cohort Selection

This prospective cross-sectional study was conducted at a suburban academic outpatient multispecialty orthopedic clinic after receiving institutional review board approval. Data were collected between January and March 2018. Patients were considered eligible for enrollment if they were a new patient presenting to 1 of the 7 participating physicians, were 18 years or older, spoke English, were literate, and were able to give informed consent. The participating physicians included hand, spine, sports, total joint, tumor, and foot and ankle specialties. Two of the physicians were women and 4 were ethnic minorities. Eligible patients were asked to complete a survey on patient–physician concordance.

In addition, the authors conducted recruitment using the Mechanical Turk (MTurk) platform (Amazon, Seattle, Washington). MTurk is a platform for completion of human intelligence tasks where volunteers online complete surveys.14 This methodology has been used successfully in several past medical15,16 and orthopedic investigations.17,18 An advertisement was placed on the MTurk platform from March to May 2018 for “workers” to complete a survey. The workers, herein referred to as volunteers, were told the survey would take 5 to 10 minutes and were paid per survey. Volunteers who clicked on the link were taken to a brief description of the study and were asked to complete a survey, which is described below. This study was approved by the ethics committee board at the host institution.

Questionnaire

Participants were given a survey that collected demographic information and were administered a questionnaire (Figure A, available in the online version of the article). The following demographic and socioeconomic elements were collected in all participants: age, sex, income, race, employment status, education level, relationship status, and insurance type. The questionnaire asked them to rate the importance of having the following characteristics in common with a PCP on an ordinal scale from 1 to 10 of “not at all important” to “very important”: age, sex, ethnicity, national origin, sexual orientation, primary language spoken, marital status, parental status, religion, and personality. The same set of questions was asked regarding a specialty care provider like an orthopedic surgeon. These attributes were selected after a review of the literature on concordance to determine the aspects of concordance that are most studied, as well as attributes that are less frequently studied.5,9,19–21

SurveySurveySurveySurvey

Figure A -:

Survey

Patients in clinic were also asked if they consider the following characteristics important when seeking a PCP or specialty physician: years in practice, communication style, location of training, and practice location.

Statistical Analysis

General information, including demographic data, was reported for participants in both the clinic and on MTurk. These cohorts were compared with each other with chi-square analysis when comparing categorical variables such as educational status, and unpaired t tests when comparing numerical values such as age.

The difference in the way participants value concordance in their PCP and in their specialists were then compared with paired t tests. An a priori sample size estimate based on recognizing a difference between provider types was performed. To detect a 3-point difference on the ordinal scale with an alpha of 0.05 and 90% power, a total sample size of 94 was calculated. This analysis was done independently in each cohort, both of which met the minimal sample size criteria. Because each cohort had 10 comparisons, the authors used a Bonferroni correction that adjusted their alpha value to 0.005 from 0.05.

The authors additionally analyzed differences in scores between the MTurk and clinical cohorts for each concordant variable with unpaired t tests with a Bonferroni correction. Because 10 comparisons were made in this analysis as well, the authors used a Bonferroni correction, which adjusted their alpha value to 0.005 from 0.05.

Finally, the authors analyzed differences in whether patients find years in practice, communication style, location of training, and location of practice important in PCPs and specialty physicians with paired t tests.

Results

A total of 118 total patients were included in the patient cohort. On MTurk, 982 volunteers were included in the volunteer cohort (Table A, available in the online version of the article).

Demographic InformationDemographic InformationDemographic Information

Table A:

Demographic Information

In the patient cohort, the level of importance for patient–physician concordance by age, sexual orientation, ethnicity, national origin, language, marital status, parental status, personality, and religion was not significantly different between PCPs and specialists (P>.005) (Table 1). The patient cohort, however, valued concordance by sex less in specialty physicians than in PCPs.

Differences in Patient Preference for Concordance Between Primary Care Physician and Specialist

Table 1:

Differences in Patient Preference for Concordance Between Primary Care Physician and Specialist

In the volunteer cohort, the level of importance for concordance by age, sex, sexual orientation, national origin, language, marital status, parental status, religion, and personality was not significantly different between PCPs and specialists (P>.005). The volunteer cohort, however, valued concordance by ethnicity (P<.005) less in specialty physicians than in PCPs.

Participants in the patient cohort and volunteer cohort were then compared with each other to elucidate differences in concordance between groups (Figure 1). The volunteer cohort had significantly higher concordance scores than the patient for every concordant variable except personality and language (P<.005).

The difference in concordance scores between patients in clinic and patients who were surveyors from the Mechanical Turk platform (Amazon, Seattle, Washington) for each concordance variable. In each grouping, the first bar represents patients and the second bar represents volunteers. Abbreviation: PCP, primary care physician.

Figure 1:

The difference in concordance scores between patients in clinic and patients who were surveyors from the Mechanical Turk platform (Amazon, Seattle, Washington) for each concordance variable. In each grouping, the first bar represents patients and the second bar represents volunteers. Abbreviation: PCP, primary care physician.

Table 2 demonstrates what characteristics patients in clinic found important in their specialty physicians and PCPs. Overall, participants value communication most in both types of physicians. They significantly prefer their specialists to have more years in practice (P<.05) and have trained at a good institution (P<.05). In addition, physician location is not as important to participants in specialists when compared with PCPs (P<.05).

Differences in What Patients Find Important Between Primary Care Physician and Specialist: Clinical Data

Table 2:

Differences in What Patients Find Important Between Primary Care Physician and Specialist: Clinical Data

Discussion

Concordance between patients and physicians has been shown to have a positive impact on the physician–patient relationship as well as health outcomes in primary care. The authors sought to determine whether participants valued having concordance with a specialty care provider at the same level as with a PCP. They found that participants value concordance with their specialist in age, origin, language, and personality as much as they do with their PCP. In addition, they found that patients are more fastidious when picking a specialty provider and are willing to travel farther to visit a more experienced, better trained specialist.

Past research has demonstrated that concordance between patients and physicians can lead to improved communication, adherence, and health outcomes.2,4,5,9 In certain specialties, such as orthopedics, obstetrics and gynecology, ear-nose-throat, and ophthalmology, physicians of minority status are still underrepresented.22 Specifically, only 6% of orthopedic surgeons are female and only 13% of orthopedic surgeons are not white.23 It is possible that this lack of diversity hinders a patient's ability to select a specialist with concordant traits. Continued efforts to increase diversity in orthopedic surgery, such as improving student exposure to subspecialties in medical school,24 are needed.

There are limits to how widely the results of this study can be extrapolated. The clinic at the institution where this analysis was performed has a selective patient population, much of which is suburban and has many socioeconomic advantages.25 This is likely not representative of the patient population seen across the United States and may limit external validity.26 To mitigate this limitation, the authors used 2 separate cohorts for their research approach. The use of MTurk allowed the authors to access a more diverse population that may be more generalizable to other populations and unbiased from a current clinical encounter with a specialist at the time of investigation. In addition, this is a de novo questionnaire, and the results from each question can only be analyzed independently, not in aggregate. Each attribute (eg, ethnicity) was selected after a review of existing literature on concordance, but it is possible that categories important to some patients may not have been captured in the survey.

Conclusion

Patient–physician concordance is as important in specialty care as it is in primary care. This research can promote efforts for increased diversity in orthopedic surgery by highlighting patient preferences for physicians with concordant characteristics. These results may explain heterogeneity in patient satisfaction and outcomes in orthopedic surgery. Future work should explore the effect that patient–physician concordance and discordance have on patient symptoms, outcomes, and recovery in orthopedic surgery.

References

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Differences in Patient Preference for Concordance Between Primary Care Physician and Specialist

CharacteristicClinical DataMechanical Turk Data


Average Concordance Score With PCP (SD)Average Concordance Score With Specialist (SD)PAverage Concordance Score With PCP (SD)Average Concordance Score With Specialist (SD)P
Age3.26 (2.59)3.30 (2.74).6784.32 (2.95)4.15 (2.98).106
Sex2.51 (2.48)1.67 (1.64)<.0013.99 (2.99)3.79 (2.84).015
Ethnicity1.50 (1.28)1.43 (1.32).2353.76 (2.83)3.57 (2.73).004
National origin1.63 (1.48)1.48 (1.39).1043.91 (2.68)3.83 (2.67).270
Sexual orientation1.66 (1.68)1.49 (1.44).0224.01 (3.02)3.90 (2.97).047
Language4.97 (3.43)4.88 (3.49).5575.86 (3.08)5.90 (3.08).770
Marital status1.24 (0.93)1.25 (1.03).8483.83 (2.92)3.84 (2.93).450
Parental status1.35 (1.12)1.40 (1.40).5554.03 (2.99)3.96 (3.01).260
Religion1.47 (1.26)1.41 (1.23).1314.05 (3.19)4.08 (3.23).300
Personality6.66 (2.88)6.24 (3.04).0256.37 (3.18)6.28 (3.26).300

Differences in What Patients Find Important Between Primary Care Physician and Specialist: Clinical Data

FactorFinds Important When Selecting a PCPFinds Important When Selecting a SpecialistP
Years in practice73.95%81.51%.019
Communication style88.24%85.71%.259
Training institution53.78%66.39%<.001
Location76.47%58.82%<.001

Demographic Information

Demographic InfoPatient CohortVolunteer cohortP Value*
<0.0001
<50y37 (32.17%)877 (89.58%)
50–6535 (30.44%)86 (9.09%)
>65y43 (37.39%)19 (1.94%)
Missing30
Sex0.763
Male51 (43.22%)437 (44.55%)
Female67 (56.78%)541 (55.15%)
Missing04
Income<0.0001
<50K23 (21.9%)490 (50.05%)
50 – 100K42 (40%)434 (44.33%)
>150K40 (38.1%)55 (5.61%)
Missing133
Race<0.0001
White88 (75.86%)546 (55.88%)
Black4 (3.45%)72 (7.36%)
Hispanic5 (4.31%)45 (4.6%)
Asian10 (8.62%)298 (30.5%)
Other9 (7.76%)16 (1.63%)
Missing25
Employment<0.0001
Unemployed11 (9.73%)124 (12.66%)
Employed53 (46.9%)756 (77.22%)
Student8 (7.08%)69 (7.04%)
Retired41 (36.28%)30 (3.06%)
Missing53
Academic<0.0001
High School or Trade School3 (2.56%)114 (11.64%)
Bachelors67 (57.26%)648 (66.18%)
Above Bachelors47 (40.17%)217 (22.16%)
Missing13
Relationship Status<0.0001
Single42 (35.90%)398 (40.61%)
Married75 (64.10%)582 (59.38%)
Missing12
Insurance<0.0001
Private58 (49.57%)511 (52.19%)
Medicare35 (29.91%)197 (20.12%)
Medicaid14 (11.97%)123 (12.56%)
Other10 (8.55%)148 (15.11%)
Missing13
Authors

The authors are from VOICES Health Policy Research Center (RFS, KM, SLE, DA, JY, LC, RS, MS, SSH, RNK), Department of Orthopaedic Surgery, Stanford University, Redwood City, California; and the Department of Orthopaedic Surgery (JAG), Brown University, Providence, Rhode Island.

Dr Shah, Mr Mertz, Dr Gil, Ms Eppler, Dr Yao, Dr Chou, Dr Steffner, Dr Safran, Dr Hu, and Dr Kamal have no relevant financial relationships to disclose. Dr Amanatullah is a paid consultant for Exatech, Stryker, Zimmer-Biomet, DePuy, Radial Medical, QT Ultrasound, Recoup Fitness, and Bullseye and has received grants from Stryker, Zimmer-Biomet, Roam Robotics, and Sparta Health Science.

This research was supported by the Department of Orthopaedic Surgery, Stanford University.

Correspondence should be addressed to: Robin N. Kamal, MD, VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, 450 Broadway St, MC: 6342, Redwood City, CA 94603 ( rnkamal@stanford.edu).

Received: June 03, 2019
Accepted: July 12, 2019

10.3928/01477447-20200818-01

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