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Original Investigation
December 8, 2021

Association of Surgeon-Patient Sex Concordance With Postoperative Outcomes

Author Affiliations
  • 1Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
  • 2Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 3Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
  • 4Department of Anesthesia, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
  • 5Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
  • 6Division of Urology, Medical College of Georgia, Augusta University, Augusta
  • 7Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 8Division of Orthopedic Surgery, Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
  • 9Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 10Division of Surgical Oncology and Gastrointestinal Surgery, Department of Surgery, Houston Methodist Hospital, Houston, Texas
  • 11Department of Urology, Houston Methodist Hospital, Houston, Texas
  • 12Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
  • 13School of Medicine and Health Sciences, George Washington University, Washington, DC
  • 14Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 15Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 16Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
  • 17Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station
JAMA Surg. Published online December 8, 2021. doi:10.1001/jamasurg.2021.6339
Key Points

Question  What is the association of surgeon and patient sex concordance with postoperative outcomes?

Findings  In this population-based cohort study of 1 320 108 patients treated by 2937 surgeons, sex discordance between surgeon and patient was associated with a small but statistically significant increased likelihood of adverse postoperative outcomes. This was driven by worse outcomes for female patients treated by male physicians without a corresponding association among male patients treated by female physicians.

Meaning  This study found that sex discordance between surgeons and patients (particularly male surgeons and female patients) may contribute to worse surgical outcomes.

Abstract

Importance  Surgeon sex is associated with differential postoperative outcomes, though the mechanism remains unclear. Sex concordance of surgeons and patients may represent a potential mechanism, given prior associations with physician-patient relationships.

Objective  To examine the association between surgeon-patient sex discordance and postoperative outcomes.

Design, Setting, and Participants  In this population-based, retrospective cohort study, adult patients 18 years and older undergoing one of 21 common elective or emergent surgical procedures in Ontario, Canada, from 2007 to 2019 were analyzed. Data were analyzed from November 2020 to March 2021.

Exposures  Surgeon-patient sex concordance (male surgeon with male patient, female surgeon with female patient) or discordance (male surgeon with female patient, female surgeon with male patient), operationalized as a binary (discordant vs concordant) and 4-level categorical variable.

Main Outcomes and Measures  Adverse postoperative outcome, defined as death, readmission, or complication within 30-day following surgery. Secondary outcomes assessed each of these metrics individually. Generalized estimating equations with clustering at the level of the surgical procedure were used to account for differences between procedures, and subgroup analyses were performed according to procedure, patient, surgeon, and hospital characteristics.

Results  Among 1 320 108 patients treated by 2937 surgeons, 602 560 patients were sex concordant with their surgeon (male surgeon with male patient, 509 634; female surgeon with female patient, 92 926) while 717 548 were sex discordant (male surgeon with female patient, 667 279; female surgeon with male patient, 50 269). A total of 189 390 patients (14.9%) experienced 1 or more adverse postoperative outcomes. Sex discordance between surgeon and patient was associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio [aOR], 1.07; 95% CI, 1.04-1.09), as well as death (aOR, 1.07; 95% CI, 1.02-1.13), and complications (aOR, 1.09; 95% CI, 1.07-1.11) but not readmission (aOR, 1.02; 95% CI, 0.98-1.07). While associations were consistent across most subgroups, patient sex significantly modified this association, with worse outcomes for female patients treated by male surgeons (compared with female patients treated by female surgeons: aOR, 1.15; 95% CI, 1.10-1.20) but not male patients treated by female surgeons (compared with male patients treated by male surgeons: aOR, 0.99; 95% CI, 0.95-1.03) (P for interaction = .004).

Conclusions and Relevance  In this study, sex discordance between surgeons and patients negatively affected outcomes following common procedures. Subgroup analyses demonstrate that this is driven by worse outcomes among female patients treated by male surgeons. Further work should seek to understand the underlying mechanism.

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