Gender Gap in Docs’ Pay; HPV Vax Benefit: It’s TTHealthWatch!

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include a COVID vaccine in older people, differences in pediatric and adult populations in COVID response, the impact of HPV vaccination, and salary differences in men and women physicians.

Program notes:

0:38 Salary differences between male and female physicians

1:40 Revenue, patient visits

2:40 After adjustment equal revenue generation

3:40 Look at gender equity seriously

4:01 HPV vaccination and cervical cancer

5:01 Dramatic difference between those vaccinated and those not

6:06 Shame that more young ladies aren’t getting it

7:01 Boys should be vaccinated also

7:25 Difference in immune response in children and adults

8:25 Older age associated with lower inflammatory markers

9:25 Damp down in adults

10:05 An mRNA vaccine in older adults

11:06 Adenovirus elicit more broad response

12:15 Which one is best?

13:22 End

Transcript:

Elizabeth Tracey: Effectiveness of a COVID-19 vaccine in older people.

Rick Lange: Do pediatric and adult COVID patients have different immune responses?

Elizabeth: Does the HPV vaccination reduce the risk of cervical cancer?

Rick: Woman physicians get paid less. Is it because they work less?

Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: I’m Rick Lange, President of Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: I’m going to call you out here, Sir, and I’m going to ask you to turn to the New England Journal of Medicine, the one you served up as, “Is the reason women get compensated less because they work less in the physician role?” I’m very interested in hearing your defense of that one.

Rick: Well, not a defense, but just the evidence. Let’s just look at the data. Female physicians represent a growing share of the medical workforce and there are some studies that suggest that their outcomes are better than their male counterparts, but there have been numerous studies that show that there’s a wage gap. On average, woman physicians make 8% to as much as 29% less than male physicians. There’s been some thought that, “Well, just because women work less.”

What these authors did is a terrific study looking at claims and data from electronic health records, looking at over 24 million primary care office visits in 2017 to compare how male and female positions performed in the same practices.

They looked at their revenue. They looked at how many patient visits they saw, how many days they worked, and how much time they spent with the patients. What they found is women do bring in less money. They generated 11% less revenue from office visits than their male counterparts. There were fewer visits.

However, what women did is they spent more time with patients, so overall they worked the same amount of time. They just saw fewer patients during that time because they were spending more time with patients. Here’s the conundrum.

Unfortunately, we’re paid not by quality of care or how much time we spend with patients. It’s just based upon volume, so this is actually a disincentive to spend more time with patients and to generate bigger volumes.

There are some studies that suggest that women, as I said, have better outcomes and they spend this time doing things that are better for the patient, more time listening, more time delivering evidence-based care. We can’t say women make less because they generate less, because they work less. That’s not the case.

Elizabeth: Okay. If that factor is corrected for, does that explain the whole difference in the wage disparity?

Rick: Per visit, after you adjust for the primary care physician, and the patient, and the visit characteristics, in fact, female primary care physicians generated equal revenue. But after those adjustments, they spent about 16% more time with the patient.

Elizabeth: I’m really interested also — you sort of blew by it — and that was the idea of specialty and how those disparities are manifest. Also, what about the factor of how long an individual physician has been practicing?

Rick: There are certainly disparities between different specialties, and that’s been part of the explanation, but this study only involved primary care physicians — so that took the specialty completely out of it — and they adjusted for all the covariates, “How long have the people been in practice? How big are the practices?”

They slice and dice it in so many different ways really try to get down to the heart of things. Even among specialties, Elizabeth, for example in cardiology, it’s been clearly demonstrated that women make less than men and that’s true for pretty much every specialty across the medical field.

Elizabeth: I would ask you, then, to be prescriptive and to say this is how you would address this.

Rick: We look at gender equity very seriously so that we make sure that isn’t, intentionally or unintentionally, result in gender biases with regard to pay. Unfortunately, the way the current system is set up, it doesn’t pay for quality. It really does pay based upon volume. The more volume you have, the more you get paid. That needs to be changed if we’re going to address this in a meaningful way.

Elizabeth: Okay. Since we’re in the New England Journal of Medicine — and we’re going to be there actually for a bit — but let’s stay there and let’s talk about our other non-COVID one for this week. This is a gigantic study from Sweden that’s taking a look at the impact of the HPV vaccine on the outcome of cervical cancer. This, of course, has been something that has been asserted and borne out in other, smaller studies, but in this one they have 1.6-plus million girls and women who were ages 10 to 30 years from 2006 through 2017. I mean, it’s just ginormous, this dataset.

All these women, of course, were offered the HPV vaccination and during the study period they evaluated them for cervical cancer until they reached their 31st birthday. They only had 19 women during the study period who received the quadrivalent HPV vaccine who developed cervical cancer and 538 women who had not received the vaccine. It’s just so dramatic.

The incidence rate ratio was 0.12 among women who had been vaccinated before the age of 17 years and 0.47 among those who had been in a catch-up group who could get vaccinated between 17 and 30 years.

Of course, the conclusion of this is, “Yikes, it really does reduce cervical cancer if you get the quadrivalent vaccine.” They were able to look at what kind of cancers did they get and sure enough found that the ones that are vaccinated against are still the ones that we ought to be vaccinating against. I’ll tell you the thing that I would like to see is what ultimately happens to this cohort as they continue to age and, presumably, would manifest cervical cancer more often?

Rick: Elizabeth, I have to agree with you. This is remarkable. This is an 88% reduction in invasive cervical cancer in women before the age of 30, based upon a vaccine administered before age 17 and it’s a shame that more young ladies aren’t getting vaccinated before the age of 17. But there is even some benefit receiving the vaccine a little bit later, about a 53% reduction.

Here is why this is important. This vaccine previously has been shown to reduce HPV infection, to reduce genital warts, and to reduce precancerous high-grade lesions. This is the first study to show that it also decreases invasive cervical cancer.

The other thing that’s important to recognize is not only does it prevent cancer in these women, especially if it’s administered early before they get HPV infections, but there’s also some herd immunity benefit.

Other studies have suggested that that’s in fact the case because that’s been shown with genital warts. Even if 50% of the young ladies are infected, that herd immunity effect will likely translate to decreased invasive cervical cancer in women that aren’t vaccinated.

Elizabeth: Well, of course, it’s my hope that this translates into everybody getting this vaccine when it’s appropriate for them to do so, and of course, here domestically we also advocate for boys getting the vaccine.

Rick: That’s correct. Again, we’re advocating especially for children ages 13 to 17 and this particular vaccine is a two-dose vaccine. It addresses four particular types of human papillomavirus and the ones that are most common to cause cancer — penile or oropharyngeal cancer in young men and cervical cancer in women — so an absolutely remarkable study.

Elizabeth: Excellent. Let’s turn to Science Translational Medicine. This is something everyone’s been struggling to get their arms around, “What is it with kids versus adults when they become infected with SARS-CoV-2?” This paper potentially may identify at least one of those factors.

Rick: It’s clear children have a milder disease than adults. As you and I have talked before, trying to get down to the bottom of it and said, “What is it about the immune systems that differ between adults and children that may provide some insight?”

This was a study of 125 patients, 65 or more children or youth less than 24 years old and the other 60 were adults, and they all had COVID-19 infection, and they were hospitalized in New York City. Kids had a shorter length of stay, they were less likely to require mechanical ventilation, and they had a lower mortality compared to adults.

When they looked at cytokines, or inflammatory markers, children had a higher titer — or a higher concentration — of them than adults did. By the way, this is inversely related to age, so the older one got the less likely they were to have these inflammatory markers.

However, adults mounted a more robust T-cell response, particularly to the viral spike protein. They had more neutralizing antibodies and more of what’s called antibody dependent cellular phagocytosis, that is the ability for these white cells to actually ingest some of the virus. There is a difference between what’s called the innate immune response, which the kids have, and the adaptive response, which the adults have. That may explain why adults have a different disease presentation than kids.

Elizabeth: Also, maybe, point the way toward some interventions that might prove more efficacious in different populations.

Rick: Exactly. In fact, the cytokines or inflammatory markers that the kids have may actually protect against some of the lung disease. It’s an inflammatory marker, but it may prevent against some of the cellular responses that cause adult respiratory distress. If that’s the case, we could take advantage of that. Or if we were to damp down some of the adaptive immune response in adults, which is obviously what steroids do late in the course of the disease, perhaps that may be beneficial as well.

Elizabeth: It would be very interesting to know when is the crossover where kids age into this place where this other reaction to the virus starts to take precedence because we’ve been seeing data just in the last couple of days about teenagers domestically and how their disease is different.

Rick: Yes, and so you’re right. It’s a spectrum of responses. You don’t just wake up one day and have one response and the day before it was entirely different. There is a spectrum. In adults, it was thought, “Well, maybe they just don’t mount as much of an immune response.” But the answer is they do. It’s just a different response than exhibited in the pediatric population.

Elizabeth: More coming, no doubt. Let’s turn back to the New England Journal of Medicine and reveal that this is an abstract. This is the first data that I’m aware of that’s taking a look at the safety and immunogenicity of a SARS-CoV-2 vaccine in older adults.

In this case, they have a small population of people, 40 of them, who were stratified according to their age, either 56 to 70 years or greater than or equal to 71 years of age. All of the participants received two doses, either a 25 microgram dose or a 100 microgram dose of a vaccine, administered 28 days apart.

This was the mRNA vaccine. Interestingly, at least for me, because I just filed all my reports this week relative to vaccines, this particular vaccine elicits only one real antibody response and that’s to the spike protein.

While the other types of vaccines that are in phase III trials here domestically are all adenovirus vectors, and they elicit a more broad spectrum of antibodies, and it’s going to be… I think that’s an interesting thing. I’m going to put that out there now. I think we’re going to be talking about that.

In any case, they were able to really produce a robust immune response in these folks and that was a really good thing. That happened even in the people who were older. There were some complaints about mild or moderate fatigue, chills, headache, muscle aches, and pains at the injection site.

The adverse events were dose-dependent and were more common after the second immunization, which to me also suggests that that means that the immune response is bolstered. That’s probably a pretty good thing. In this very small study, in this group we’re worrying about, which is older folks who appear to be more impacted by severe COVID-19 disease. This is potentially a good thing.

Rick: Yep. Elizabeth, this follows on the previous studies that have shown that the mRNA vaccine can be useful in eliciting an antibody response. There are either three or four antibodies in phase III testing right now, two that are mRNA — and they require two doses separated by 28 days — and the other two trials in phase III are adenoviruses. They require one.

As you suggested, they have different responses, so we’re going to be trying to figure out which one is the best. But no studies have looked at this older population. We just got done talking about how the disease is milder in younger individuals and maybe they’re not the ones that need the vaccine. It’s the older individuals that are likely to have the more active disease and to have the complications, so this is terrific news in knowing that they develop a response.

It’s a response in three ways. They determined binding antibodies were present, and, by the way, present to the same degree as in younger individuals in previous studies. They had neutralizing antibody, that’s what kills the virus and that’s important, and they also had a strong T-cell response as well. The pilot study suggesting, “Yes, this could be beneficial in the population that’s probably going to need it the most.”

Elizabeth: We are going to talk about this again. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: I’m Rick Lange. Y’all listen up and make healthy choices.