Publications

PURPOSE

Transgender people have difficulty accessing gender-affirming hormone therapy (HT), a medically necessary treatment, in part due to a lack of provider knowledge. Patients often seek information on gender-affirming medical care using the Internet. Patients who are better informed about their own care may receive better care. This study evaluated the quantity and quality of online information about HT using several existing and novel measures.

METHODS

Structured Google searches were conducted. Sites were evaluated using previously described Journal of the American Medical Association (JAMA), DISCERN, and Health On the Net (HON) criteria, for citation of the Endocrine Society Guidelines and the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC), and other topic-specific measures.

RESULTS

Forty sites were evaluated. The median JAMA score was 3.5/7, and the median DISCERN score was 51/80. No sites held HON certification. Citation of the Endocrine Society Guidelines and the WPATH SOC was inconsistent. Institutional sites had higher DISCERN scores compared with other sites. The presence of a bibliography was most associated with measures of quality.

CONCLUSION

The quality of online information about HT is inconsistent and limited in quantity. Development of reliable online resources on HT for transgender patients is essential. Broadening awareness of key guidelines from the Endocrine Society and WPATH is essential.

BACKGROUND

Evidence-based quality improvement (EBQI) methods may facilitate practice redesign for more effective implementation of the patient-centered medical home (PCMH).

OBJECTIVE

We assessed changes in health care utilization and costs for patients receiving care from practices using an EBQI approach to implement PCMH and comparison practices over a 5-year period.

RESEARCH DESIGN

We used longitudinal, electronic data from patients in 6 practices using EBQI and 28 comparison practices implementing standard PCMH for 1 year before and 4 years after PCMH implementation. We analyzed trends in utilization and costs using bivariate analyses and independent effects of EBQI status on outcomes using multivariate regressions adjusting for year, patient and clinic factors, and patient random effects for repeated measures.

SUBJECTS

A total of 136,856 patients using Veterans Affairs primary care.

MEASURES

Veterans Affairs ambulatory care encounters, emergency department visits, admissions, and total health care costs per patient.

RESULTS

After PCMH implementation, overall utilization for primary care, specialty care, and mental health/substance abuse care decreased, whereas utilization for telephone care increased among all practices. Patients also had fewer hospitalizations and lower costs per patient. In adjusted analyses, EBQI practice was independently associated with fewer primary care (IRR=0.85), specialty care (IRR=0.83), and mental health care encounters (IRR=0.69); these effects attenuated over time (all P<0.01). There was no independent effect of EBQI on prescription drug use, acute care, health care costs, or mortality rate relative to comparison practices.

CONCLUSION

EBQI methods enhanced the effects of PCMH implementation by reducing ambulatory care while increasing non-face-to-face care.