Lack of sex bias in the referral letters for patients with inflammatory bowel disease: a mixed methods evaluation

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Abstract Introduction Women with inflammatory bowel disease (IBD) experience greater delays and misdiagnosis than men. Data from other conditions suggest that sex and/or gender bias in the process of referral to speciality care may contribute. Methods We undertook a mixed methods analysis of 120 referral letters to gastroenterology for people ultimately diagnosed with IBD in Calgary, Alberta. Letters were masked for patient sex and gender prior to analysis. Gastroenterologists who were masked to the objective of the study rated the quality of referral letters and triaged letters for urgency. Two study team members performed a Framework analysis to identify agentic (masculine) and commensal (feminine) adjectives, mentions of caregiving and work roles, and psychosocial history. After analysis, letters were unmasked and findings were compared by patient sex. Results There were 116 referral letters included in the analysis (n = 59, 50.9% for male patients). There were no differences in letter quality or triage urgency between male and female patients (median quality 4 [IQR 4-7] and 5 out of 10 [IQR 4-6], respectively, higher scores represent better quality; P = .37, and P = .44 for triage category). There was no difference in the use of adjectives and mention of caregiving or work roles, psychiatric history, or social history between letters for female and male patients. Conclusions This mixed methods analysis identified no difference in referral letter language, contents, or quality for female and male patients with IBD. Masked letters were triaged similarly to unmasked letters, suggesting an absence of sex and/or gender bias in the gastroenterology triaging process in our setting.