Patient Perspectives of Obstetrician- Gynecologists as Primary Care Providers

Patient Perspectives of Obstetrician- Gynecologists as Primary Care Providers The Journal of Reproductive Medicine Sara Mazzoni, M.D., M.P.H., Sarah Brewer, M.P.A., Josh Durfee, M.S.P.H., Jennifer Pyrzanowski, M.S.P.H., Juliana Barnard, M.A., Amanda F. Dempsey, M.D., Ph.D., M.P.H., and Sean T. O Leary, M.D., M.P.H. ORIGINAL ARTICLES OBJECTIVE: To examine women s perceptions of their obstetrician/gynecologist (ob-gyn) as primary care provider (PCP) and comfort in receiving primary care services in an ob-gyn setting. STUDY DESIGN: Survey regarding women s use of their ob-gyn provider as a PCP, their desire and comfort in receiving primary care services from them, and their perceptions of their ob-gyn s delivery of primary care. Associations were assessed between use of an ob-gyn as PCP and various demographic and attitudinal factors, as well as patients perceptions of primary care performance. RESULTS: The response rate was 48% (1,404/2,916). Overall, the majority of participants responded that routine primary care services are available at their obgyn office and that they were comfortable receiving those services from their ob-gyn. Twenty percent of respondents considered their ob-gyn as their PCP, 52% considered another provider their PCP, and 28% of women did not identify a PCP. Women who were pregnant, mothers of newborns, and patients without a chronic health condition were more likely to identify their ob-gyn as their PCP. ob-gyns should be included in the nation s emphasis on primary care. CONCLUSION: A substantial proportion of women consider their ob-gyn their primary care provider and do not visit another provider regularly. While ob-gyns may not consider themselves as PCPs, they are often perceived as such by patients. (J Reprod Med 2017;62: 3 8) Keywords: gynecology, obstetrics, patient perspectives, primary care, primary health care, women s health. The Affordable Care Act has elevated the importance of the provision of preventive care and the primary care provider (PCP). There are many definitions, provided by many organizations, of who constitutes a PCP. Some are quite broad, such as those by the Institute of Medicine and the World Health Organization, while others are more precise, such as the Association of American Medical Colleges, which states that PCPs have a selfdesignated specialty of adolescent medicine, family medicine, general practice, geriatric medicine, internal medicine, internal medicine/pediatrics, or pe From Denver Health and Hospitals; the Department of Obstetrics and Gynecology, University of Colorado; the Children s Outcomes Research Program, University of Colorado Denver; and the Department of Pediatrics, University of Colorado Denver. Funded by the Centers for Disease Control and Prevention (IP000501-03). Survey administration through REDCap [10] was supported by NIH/NCRR Colorado CTSI Grant (UL1 TR000154). Address correspondence to: Sara Mazzoni, M.D., M.P.H., Denver Health and Hospitals, 777 Bannock Street, Denver, CO 80204 (sara. mazzoni@dhha.org). Financial Disclosure: The authors have no connection to any companies or products mentioned in this article. 0024-7758/17/6201-02 0003/$18.00/0 Journal of Reproductive Medicine, Inc. The Journal of Reproductive Medicine 3

4 The Journal of Reproductive Medicine diatrics. 1 The American Congress of Obstetricians and Gynecologists (ACOG) defines a PCP as a physician directly accessible to patients for their initial contacts, someone who sees patients who desire health maintenance and provides continuity of care but notably does not specify a specialty. 2 ACOG describes obstetrician-gynecologists (ob-gyns) as personal physicians to women, acknowledging their broader role in coordinating women s health maintenance, 1 and recognizes that ob-gyns have a tradition of providing primary and preventive care. 3 The pendulum continues to swing regarding primary care training for ob-gyn residencies. In the 1990s a strong primary care component was added to the ACGME requirements; however, the current emphasis on primary care is somewhat nebulous and there are no requirements for training within more traditional primary care specialties such as family medicine, internal medicine, or pediatrics. 4 There have been many reports, with varying results, describing provision of primary care by ob-gyns and how they view their role as primary care providers. 5-12 However, there are fewer data from the patient s perspective. In the most recent National Ambulatory Medical Care Survey 21.8% of patients making an ambulatory visit to an ob-gyn office identified their ob-gyn as their primary care provider. 13 In one small report of young, low-income women attending an urban hospital ob-gyn clinic, 38% of subjects considered their ob-gyn as their PCP. 14 In this context of the importance of primary care in health care reform and the ever-evolving role of the ob-gyn, our objectives were to describe, among women presenting for care to an ob-gyn provider, (1) the proportion who considered their ob-gyn as their PCP, (2) availability and use of certain primary care services, (3) perceptions of ob-gyn s performance of primary care, and (4) characteristics of women who report an ob-gyn as their PCP. Materials and Methods The study population was a convenience sample of 2,916 women who presented for care at 1 of 9 private ob-gyn practices in Colorado (6 urban, 3 rural). Women were eligible for the study if they had agreed to be contacted for a follow-up survey after completing a previous paper-based survey (on a different topic), provided a working email address, and could complete the survey in English. A web-based survey administered via REDCap was provided to women via their contact email address beginning in February 2013. Women who had not completed the survey within 1 week of the initial mailing received up to 6 additional reminder emails over a period of 7 weeks. A $5 incentive was provided to women completing the survey. All study activities were approved by the Colorado Multiple Institutional Review Board. Respondents were first provided with a standard definition of an ob-gyn provider to include an obstetrician, nurse midwife, nurse practitioner, or physician assistant at their ob-gyn office. Based on the previous adaptation of the Primary Care Assessment Tool (PCAT) by other investigators, 14,15 participants were then asked 3 yes/ no questions used to define a PCP: (1) Is there a health care provider or place you go when you are sick or need advice about your health? (2) Is there a health care provider or place that knows you best as a person? and (3) Is there a health care provider or place that is most responsible for your health care? Those who responded Yes were given a list of possible providers (general internal medicine, family medicine, pediatrician, ob-gyn, specialty doctor, emergency department, public health clinic, and other). If the respondent named the same provider for 2 of the 3 questions, then that provider was considered to be their PCP. Women who answered no or named different providers for 2 or more questions were considered not to have a PCP. Participants were then asked to respond to questions about aspects of the primary care available through their ob-gyn provider s office using the domains from an adaptation of the PCAT as above. Before answering these questions, participants were provided with a brief description of a primary care provider ( a place/provider where someone can get most or all of their health care. Primary care providers either treat the person or help them find someone else who can treat them. Primary care providers also try to help people stay healthy instead of just treating them when they are sick. ). Constructs assessing their ob-gyn s performance of primary care provided included 4 items related to longevity of care, 6 items related to coordination of care (for those women who had seen another provider in the last 2 years), 4 items related to accessibility, 3 items related to family inclusion, and 2 items related to provider cultural awareness. Constructs assessing the extent of primary care available included 10

Volume 62, Number 1-2/January-February 2017 5 items on the patients first point of contact for primary care services, the same 10 items related to patients level of comfort receiving that care at an ob-gyn office, and 17 items about the services available at their ob-gyn provider s office. Each of these items was assessed on a 4-point Likert scale. Each response was then given a numerical value from 0 3, with 3 representing the most favorable rating. Each of these primary care constructs were summed into a composite score. Finally, a number of demographic characteristics were also assessed, including age, educational level, race/ethnicity, household income, and insurance type. Clinical information collected included currently being pregnant, date of delivery or expected delivery, and presence of a chronic health condition (defined as a health problem that has lasted longer than 3 months ). A full version of the survey is available upon request. After generating descriptive statistics for all survey questions and the association between each scale construct determined to have good internal reliability, each demographic variable was assessed for its association with the outcome of identifying the ob-gyn as the PCP. Subsequently, a multivariable model was constructed by the purposeful selection method, and independent variables were included in the model at the α=0.20 level and considered significant at the α=0.05 level. Models were examined for colinearity. Items included in the multivariable model included presence of a chronic condition, age, income, insurance status, currently pregnant, and being the mother of an infant <1 year old. All statistical analyses used SAS 9.3 (SAS Institute Inc., Cary, North Carolina). Results The survey response rate was 48% (1,404/2,916). Limited data were available regarding nonrespondents. Compared to nonrespondents, women who responded to the survey were slightly older (40 vs. 37 years, p<0.001) and were slightly more likely to respond Yes to the question Other than this office, when you are sick or want medical advice, do you have a regular doctor or health care provider you usually go to? on the previous unrelated survey (71% vs. 67%, p<0.023). Demographics are displayed in Table I. The average age of participants was 40 years, 91% had private insurance, 70% had completed college or advanced degrees, 88% self-described as white, 60% reported a yearly household income >$75,000, and 39% reported a chronic health problem. Nine percent were pregnant at the time of the survey, and 14% had a newborn 1 year old. In the previous 2 years 31% had visited their ob-gyn for a routine examination during pregnancy, 90% for an annual examination related to reproductive health, 37% for a new reproductive health problem, 32% for a check-up not focused on reproductive health, and 22% for a new health problem not related to reproductive health. Sixtyfive percent of participants responded they had seen another doctor for a reason not related to reproductive health in the past 2 years. Using the PCAT criteria described above, 64% of women had a primary care provider. Twenty percent of all respondents were categorized as Table I Respondent Demographics All patients (N=1,404) Sociodemographic % Average age, yrs (min, max) 40 (15, 94) Race White 88 Latina 7 Black/African American 1 Asian 2 Other 2 Insurance Public 7 Private 91 None 2 Yearly household income <$75,000 40 $75,000 49 Don t know/refuse 10 Education level High school or less 6 Some college 24 College degree 46 Advanced degree 25 Currently pregnant 9 Mother of infant <1 year old 14 Health condition lasting >3 months 39 Primary care provider (PCP) Have a PCP 64 PCP specialty among women who have a PCP (n=898) Obstetrics and gynecology 31 General internal medicine 16 Family medicine 49 Pediatrics 1 Specialist 2 Other 1 Percentages do not add up to 100% due to rounding.

6 The Journal of Reproductive Medicine identifying their ob-gyn as their primary care provider, and 44% considered another provider their PCP. Among those who considered another provider their PCP, the frequency of provider types were as follows: general internal medicine 24%, family medicine 70%, pediatrics 1%, specialty doctor 3%, and other 2%. Compared to all other participants, women categorized as having an ob-gyn as their PCP were more likely to describe themselves as white (92% vs. 86%, p<0.011), currently pregnant (16% vs. 7%, p<0.0001), and the mother of a newborn (19% vs. 13%, p<0.008), but less likely to have a chronic health condition (34% vs. 43% p<0.004). They were similar in all other demographic variables. In multivariable analysis, race was no longer associated with identification of ob-gyn as a PCP, but the other variables remained significantly associated: absence of chronic condition (OR 1.42, CI 1.06 1.91), mother of newborn (OR 1.72, CI 1.16 2.56), and pregnant (OR 2.40, CI 1.54 3.75) (Table II). These participants rated the performance of their ob-gyn as a primary care provider higher than did patients who did not identify an ob-gyn as their PCP in all arenas (Table III). They were more likely to respond that they would go to their ob-gyn first for all 10 primary care items assessed, and also more likely to respond that they would be com fortable going to their ob-gyn for 8 of the 10 items. The only exceptions were family planning and reproductive health annual examinations, for which there was essentially universal acceptance of the ob-gyn as a provider by all respondents (Table IV). Overall, the majority of participants responded that routine primary care services are available at Table II Factors Associated with Women Who Identify Their Ob-Gyn as Their Primary Care Provider Patient characteristic Adjusted odds ratio (95% CI) Absence of chronic health condition 1.42 (1.06 1.91) Age 1.00 (0.99 1.02) Income $75,000 0.90 (0.66 1.22) White race 1.55 (0.97 2.50) Private insurance 0.64 (0.36 1.12) Pregnant currently 2.40 (1.54 3.75) Mother of newborn <1 year 1.72 (1.16 2.56) Independent variables were included in the model at the α=0.20 level. Items included in the multivariable model included presence of a chronic condition, age, income, insurance status, currently pregnant, and being the mother of an infant <1 year old. Bolded items represent results that are statistically significant with p<0.05 Table III Perceived Performance of OB/GYN Provider as PCP Patients with ob-gyn as PCP (N=276) All other patients (N=1,128) Accessibility (0 12) 8.47 7.56 Longevity (0 12) 9.92 8.19 Coordination (0 15) 4.36 2.71 Family inclusion (0 9) 8.06 7.25 Cultural awareness (0 6) 4.01 3.64 Overall primary care performance (0 54) 32.16 28.08 p<0.001 for all constructs. Constructs assessing ob-gyn s performance of primary care provided included 4 items related to longevity of care, 6 items related to coordination of care (for those women who had seen another provider in the last 2 years), 4 items related to accessibility, 3 items related to family inclusion, and 2 items related to provider cultural awareness. Each of these items was assessed on a 4-point Likert scale. Each of these primary care constructs was summed into a composite score. Score ranges are presented for each category, with higher scores representing more favorable ratings. their ob-gyn office with the exception of skin cancer screening (38%), vaccinations other than human papillomavirus, influenza or Tdap (45%), injury prevention (25%), and treatment for colds (26%) (Table IV). Women who considered their ob-gyn as their PCP were more likely to indicate that all services were available, with the exception of family planning (99% vs. 97%, p<0.127) and cervical cancer screening (99% vs. 98%, p<0.398), which were equivalently reported as available by all participants (Table IV). Discussion In this large study done across multiple practice sites, we found that approximately a quarter of women identify their ob-gyn as their primary care provider, and approximately one-third had not been seen by another physician for the preceding 2 years. The majority of women believe that routine primary care services are available at their ob-gyn office and feel comfortable going to their ob-gyn for these services. Not surprisingly, women who identify their ob-gyn as their PCP rate their obgyn s performance higher than the rating of obgyns by women with other PCPs; however, overall PCP performance ratings of ob-gyns were favorable across all participants. To our knowledge, this is the largest study of patients perceptions of obgyns as PCPs. The proportion of women identifying their ob-gyn as their PCP is on par with other previously mentioned smaller studies. 13,14 Primary and preventive care in the United

Volume 62, Number 1-2/January-February 2017 7 Table IV Respondents Perceptions of Available Primary Care Services and Preferences for Receipt of Those Services at Their Ob-Gyn Provider Ob-gyn is Comfortable with ob-gyn Care is available first contact for care as source of care Patients Patients Patients with All with All with All All ob-gyn other All ob-gyn other All ob-gyn other patients as PCP patients patients as PCP patients patients as PCP patients Primary care service % % % % % % % % % Family planning or birth control 98 99 97 90 96* 88 99 100 98 Annual examination 96 99* 95 99 100 99 General checkup 24 48* 18 69 83* 65 Influenza vaccine 61 70* 59 11 22* 8 70 81* 68 Tetanus, diphtheria, pertussis vaccine 51 63* 48 13 29* 9 68 79* 66 HPV vaccine 92 96* 91 69 82* 66 92 95.5 89.8 Other vaccines 45 57* 42 12 26* 9 66 78* 63 New health problem 13 30* 9 53 70* 49 Managing ongoing health problem 14 31* 10 53 71* 49 Need to see a specialist other than ob/gyn 11 21* 9 47 64* 43 Screening for mental health problems 52 61* 50 Cervical cancer screening 99 99 98 Breast cancer screening 95 99* 94 Colon cancer screening 53 61* 51 Skin cancer screening 38 47* 36 Diabetes testing 51 63* 48 Cholesterol screening 53 69* 49 Dietary or nutrition counseling 64 73* 62 Weight management 60 70* 58 Injury prevention 25 32* 24 Cold/sinus infection treatment 26 35* 24 Percentages presented are for respondents answering Definitely or Probably for service is available and ob-gyn is first contact and Very comfortable or Somewhat comfortable for comfort with ob-gyn as source of care. Columns reflect the following number of respondents: all patients (N=1,404), patients with ob-gyn as PCP (N=276), and all other patients (N=1,128). p Values indicate significant differences between patients who identified their ob-gyn provider as PCP versus all other patients. Cells marked were not asked for that construct. *p<0.01. States have been strengthened by 2 key provisions in the Affordable Care Act: an increase in primary care reimbursement rates by 10% and a requirement of coverage for multiple preventive services without cost sharing. 16,17 However, obstetrics and gynecology was not included in the specialties eligible to receive this increased rate, or in the definition of primary care. This is despite the fact that ob-gyn is the fourth largest medical specialty in the U.S. and also the largest group of active physicians outside the traditional primary care fields. 1 In addition, ob-gyns are the providers many women choose to provide the 8 clinical services specific to women now required by the ACA such as diabetes screening during pregnancy, cervical cancer screening, counseling on sexually transmitted infections, and an annual well-woman preventive care visit. 16,18 This study echoes ACOG s efforts to expand the definition of primary care to include obstetricians and gynecologists who provide primary care services and prenatal care. 16 We found that a substantial proportion of women identified their ob-gyn as their PCP, even more do not routinely see another provider, and most importantly, the vast majority of women feel comfortable receiving primary care services from their ob-gyn. It is not surprising that pregnant women and new mothers are more likely to consider their obgyn their primary care provider. Given that our study population was highly insured, the propensity of healthy women without a chronic condition to consider their ob-gyn their PCP is not likely due to lack of access to other providers, but rather choice. Whether it is considered a lack of adequate number of physicians graduating from primary care

8 The Journal of Reproductive Medicine residencies, or a problem of supply and demand from an aging population, there is a shortage of primary care providers in this country that is only expected to worsen in the next decade. 19,20 Many solutions have been proposed in the literature, including e-medicine and increasing the use of midlevel providers. 21,22 These solutions do not account for the patient s perceptions and preferences. Our findings would suggest that by recognizing obgyns as PCPs, they can be part of the solution and may also be more successful fulfilling the role their patients expect of them, particularly for providing preventive services to healthy women who otherwise may not need to see a more traditional PCP. There are limitations to our study which should be factored into the interpretation of these findings. Participants were surveyed after presenting for care at an ob-gyn s office, therefore possibly introducing both selection and response bias. Our survey response rate was modest. Our sample population is relatively homogeneous, consisting primarily of white, upper-class, educated, and insured women. This limits the generalizability of our findings to populations at the highest risk for foregoing primary care, including racial minorities and those with lower incomes. 18,23 That being said, the current state of our nation is such that two-thirds of adult women are white, and most have private insurance. 23 The strengths to this study include a large sample size and representation from women living in both rural and urban areas. ACOG believes that ob-gyn has evolved into an elite specialty in preventive health care for women of all ages. 1 ACOG s Reform Agenda calls for an investment in primary and preventative care. 24 Our study from the patient s perspective finds that women are echoing these sentiments and that ob-gyns should be included in the nation s emphasis on primary care. References 1. Rayburn WF; American Congress of Obstetricians and Gynecologists: The obstetrician/gynecologist workforce in the United States: Facts, figures, and implications 2011. Washington, DC, The American Congress of Obstetricians and Gynecologists, 2011 2. Hale RW: The obstetrician and gynecologist: Primary care physician or specialist? Am J Obstet Gynecol 1995;172(4 Pt 1):1181-1183 3. American College of Obstetricians and Gynecologists: Guidelines for women s health care: A resource manual. Third edition. Washington, DC, American College of Obstetricians and Gynecologists, 2007 4. Review Committee for Obstetrics and Gynecology: Continuity of Care and Primary and Preventive Care Program Requirements Interpretation, Summer 2012. 2012. Available at www.acgme.org/acgmeweb/ Portals/0/PFAssets/ProgramResources/220_Obstetrics_Gynecolo gy_rc_interim_pr_interpretation.pdf. Accessed May 5, 2014 5. Coleman VH, Laube DW, Hale RW, et al: Obstetrician-gynecologists and primary care: Training during obstetrics-gynecology residency and current practice patterns. Acad Med 2007;82:602-607 6. Higgins RV, Hall JB, Laurent S: Primary care by obstetricians and gynecologists: Attitudes of the members of The South Atlantic Association of Obstetricians and Gynecologists. Am J Obstet Gynecol 1997;177:311-317; discussion 7-8 7. Laube DW, Ling FW: Primary care in obstetrics and gynecology resident education: A baseline survey of residents perceptions and experiences. Obstet Gynecol 1999;94:632-636 8. Leader S, Perales PJ: Provision of primary-preventive health care services by obstetrician-gynecologists. Obstet Gynecol 1995;85:391-395 9. Lentz GM, Ayala L, Eckert LO: A comprehensive women s health care center: are gynecologists offering primary care? Am J Obstet Gynecol 2006;194:1660-1666; discussion 6-7 10. Morgan MA, Lawrence H 3rd, Schulkin J: Obstetrician-gynecologists approach to well-woman care. Obstet Gynecol 2010;116:715-722 11. Scroggs JA, Griffin LP, Bayerl M, et al: Obstetrician-gynecologists as primary care physicians: The perspectives of health maintenance organization medical directors and obstetrician-gynecologists. Obstet Gynecol 1997;90:291-295 12. Scholle SH, Chang J, Harman J, et al: Characteristics of patients seen and services provided in primary care visits in obstetrics/ gynecology: Data from NAMCS and NHAMCS. Am J Obstet Gynecol 2004;190:1119-1127 13. Centers for Disease Control and Prevention (CDC): National Ambulatory Medical Care Survey: 2010 Summary Tables. 2013 14. Scholle SH, Kelleher K: Assessing primary care performance in an obstetrics/gynecology clinic. Women Health 2003;37:15-30 15. Starfield B, Cassady C, Nanda J, et al: Consumer experiences and provider perceptions of the quality of primary care: Implications for managed care. J Fam Pract 1998;46:216-226 16. Gee RE: Preventive services for women under the Affordable Care Act. Obstet Gynecol 2012;120:12-14 17. Gee RE, Levy B, Reyes C; Society for Maternal-Fetal Medicine Health Policy Committee: Health reform in action: Updates on implementation of the Affordable Care Act. Obstet Gynecol 2014;123:869-873 18. American College of Obstetricians and Gynecologists: ACOG Committee opinion no. 552: Benefits to women of Medicaid expansion through the Affordable Care Act. Obstet Gynecol 2013;121:223-225 19. Schwartz MD: Health care reform and the primary care workforce bottleneck. J Gen Intern Med 2012;27:469-472 20. Petterson SM, Liaw WR, Phillips RL Jr et al: Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med 2012;10:503-509 21. Green LV, Savin S, Lu Y: Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Affairs 2013;32:11-19 22. Bodenheimer TS, Smith MD: Primary care: Proposed solutions to the physician shortage without training more physicians. Health Affairs 2013;32:1881-1886 23. Salganicoff A, Ranji U, Beamesderfer A, et al: Women and health care in the early years of the Affordable Care Act: Key findings from the 2013 Kaiser Women s Health Survey. Menlo Park, CA, The Henry J. Kaiser Family Foundation, 2014 (Publication #8590) 24. American College of Obstetricians and Gynecologists Committee on Ethics: Committee Opinion No. 456: Forming a just health care system. Obstet Gynecol 2010;115:672-677