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Sequeira GM, Asante PG, Bocek K, Kahn NF, Sethness JL, Hodax JK, Kidd KM, Pratt W, Christakis DA, Richardson LP. Evaluating an Electronic Consultation Platform to Support Pediatric Primary Care Providers in Caring for Transgender and Nonbinary Adolescents. Telemed J E Health 2024; 30:595-600. [PMID: 37624647 PMCID: PMC10877380 DOI: 10.1089/tmj.2023.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 08/27/2023] Open
Abstract
Background: An electronic consultation (e-consult) platform was implemented to support pediatric primary care providers (PCPs) in providing gender-affirming care to transgender and nonbinary (TNB) adolescents. Following implementation, a study was conducted to (1) explore how access to this e-consult platform impacts PCP confidence and referral patterns, (2) describe the content of questions, and (3) evaluate PCP's perspectives regarding platform usability. Methods: Following each submission, providers completed a 17-item survey. A total of 20 providers submitted 38 e-consults and 26 follow-up surveys between October 2021 and December 2022. Results: All PCPs reported a high overall value and increased confidence caring for TNB adolescents. Nearly one in five (19%) felt it allowed them to avoid submitting a specialty referral. Mean System Usability Scale score was 78.2 indicating good usability. Conclusion: This e-consult platform shows great promise in increasing PCP confidence providing gender-affirming care adolescents. More widespread utilization could help improve access to care and decrease specialty care referrals.
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Affiliation(s)
- Gina M. Sequeira
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Peter G. Asante
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kevin Bocek
- Seattle Children's Hospital, Seattle, Washington, USA
| | | | - Janis L. Sethness
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Juanita K. Hodax
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kacie M. Kidd
- West Virginia University, Morgantown, West Virginia, USA
| | - Wanda Pratt
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Dimitri A. Christakis
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Laura P. Richardson
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Peeters KMM, Reichel LAM, Muris DMJ, Cals JWL. Family Physician-to-Hospital Specialist Electronic Consultation and Access to Hospital Care: A Systematic Review. JAMA Netw Open 2024; 7:e2351623. [PMID: 38214930 PMCID: PMC10787322 DOI: 10.1001/jamanetworkopen.2023.51623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024] Open
Abstract
Importance Globally, health care systems face challenges in managing health care costs while maintaining access to hospital care, quality of care, and a good work balance for caregivers. Electronic consultations (e-consultations)-defined as asynchronous, consultative communication between family physicians and hospital specialists-may offer advantages to face these challenges. Objective To provide a quantitative synthesis of the association of e-consultation with access to hospital care and the avoidance of hospital referrals. Evidence Review A systematic search through PubMed, MEDLINE, and Embase was conducted. Eligible studies included original research studies published from January 2010 to March 2023 in English, Dutch, or German that reported on outcomes associated with access to hospital care and the avoidance of hospital referrals. Reference lists of included articles were searched for additional studies. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) scores were assigned to assess quality of evidence. Findings The search strategy resulted in 583 records, of which 72 studies were eligible for data extraction after applying exclusion criteria. Most studies were observational, focused on multispecialty services, and were performed in either Canada or the US. Outcomes on access to hospital care and the avoidance of referrals indicated that e-consultation was associated with improved access to hospital care and an increase in avoided referrals to the hospital specialist, although outcomes greatly differed across studies. GRADE scores were low or very low across studies. Conclusions and Relevance In this systematic review of the association of e-consultation with access to hospital care and the avoidance of hospital referrals, results indicated that the use of e-consultation has greatly increased over the years. Although e-consultation was associated with improved access to hospital care and avoidance of hospital referrals, it was hard to draw a conclusion about these outcomes due to heterogeneity and lack of high-quality evidence (eg, from randomized clinical trials). Nevertheless, these results suggest that e-consultation seems to be a promising digital health care implementation, but more rigorous studies are needed; nonrandomized trial designs should be used, and appropriate outcomes should be chosen in future research on this topic.
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Affiliation(s)
- Ken M. M. Peeters
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
- Zuyderland Medical Centre, Sittard, the Netherlands
- Omnes Medical Coordinating Centre for Diagnostics and Innovation, Sittard, the Netherlands
| | - Loïs A. M. Reichel
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Dennis M. J. Muris
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
- Omnes Medical Coordinating Centre for Diagnostics and Innovation, Sittard, the Netherlands
- Public Health Service South Limburg, Heerlen, the Netherlands
| | - Jochen W. L. Cals
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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Hodax JK, Crouch JM, Sethness JL, Loren D, Kahn NF, Asante PG, Sequeira GM. Strategies for Providing Gender-Affirming Care for Adolescents in the Primary Care Setting. Pediatr Ann 2023; 52:e442-e449. [PMID: 38049184 DOI: 10.3928/19382359-20231016-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Transgender and gender diverse (TGD) youth have high rates of health disparities and face significant barriers to accessing medical care. Primary care providers (PCPs) are often the first health care providers that TGD youth seek out to discuss gender identity and find support. Thus, it is crucial for PCPs to have an understanding of gender diversity and knowledge to support TGD youth with gender-affirming care. The purpose of this article is to offer strategies PCPs can implement to increase their comfort and capacity in providing care for TGD people. Key steps to support TGD youth in the primary care setting include creating affirming clinical environments, discussing gender identity at routine visits, supporting parents and families, supporting social transition, and providing menstrual suppression for those who desire it. Multidisciplinary gender clinics can partner with PCPs to support adolescents in accessing gender-affirming medical care and to provide additional education and support. [Pediatr Ann. 2023;52(12):e442-e449.].
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Kamran R, Jackman L, Chan C, Suk Y, Jacklin C, Deck E, Wietek N, Stepney M, Harrison C, Jain A, Rodrigues J. Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review. JAMA Netw Open 2023; 6:e236425. [PMID: 37010869 PMCID: PMC10071345 DOI: 10.1001/jamanetworkopen.2023.6425] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/12/2023] [Indexed: 04/04/2023] Open
Abstract
Importance Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy. Objective To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation. Evidence Review In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080). Findings In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate. Conclusions and Relevance In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.
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Affiliation(s)
- Rakhshan Kamran
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Liam Jackman
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Chan
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Yujin Suk
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Eve Deck
- Department of Family Medicine, Western University, London, Ontario, Canada
| | - Nina Wietek
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Melissa Stepney
- Centre for Academic Primary Care, University of Bristol, Bristol, United Kingdom
| | - Conrad Harrison
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Abhilash Jain
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jeremy Rodrigues
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- Department of Plastic Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, United Kingdom
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Sequeira GM, Kahn NF, Bocek KM, Shafii T, Asante PG, Christakis DA, Pratt W, Richardson LP. Pediatric Primary Care Providers' Perspectives on Telehealth Platforms to Support Care for Transgender and Gender-Diverse Youths: Exploratory Qualitative Study. JMIR Hum Factors 2023; 10:e39118. [PMID: 36719714 PMCID: PMC9929719 DOI: 10.2196/39118] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 10/20/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Access to gender-affirming care services for transgender and gender-diverse youths is limited, in part because this care is currently provided primarily by specialists. Telehealth platforms that enable primary care providers (PCPs) to receive education from and consult specialists may help improve the access to such services. However, little is known about PCPs' preferences regarding receiving this support. OBJECTIVE This study aimed to explore pediatric PCPs' perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting. METHODS PCPs who had previously requested support from the Seattle Children's Gender Clinic were recruited to participate in semistructured, 1-hour web-based interviews. Overall, 3 specialist-to-PCP telehealth modalities (tele-education, electronic consultation, and telephonic consultation) were described, and the participants were invited to share their perspectives on the benefits and drawbacks of each modality, which modality would be the most effective, and the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using a reflexive thematic analysis framework. RESULTS The interviews were completed with 15 pediatric PCPs. The benefits of the tele-education platform were developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, having scheduled education sessions, and increasing provider confidence. The drawbacks were requiring a substantial time commitment and not allowing for real-time, patient-specific consultation. The benefits of the electronic consultation platform were convenient and efficient communication, documentation in the electronic health record, the ability to bill for provider time, and sufficient time to synthesize information. The drawbacks of this platform were electronic health record-related difficulties, text-based communication challenges, inability to receive an answer in real time, forced conversations with patients about billing, and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, the benefits were having a dialogue with a specialist, receiving compensation for PCP's time, and helping with high acuity or complex cases. The drawbacks were challenges associated with using the phone for communication, the limited expertise of the responding providers, and the lack of utility for nonemergent issues. Regarding the most effective platform, the responses were mixed, with 27% (4/15) preferring the electronic consultation, 27% (4/15) preferring tele-education, 20% (3/15) preferring telephonic consultation, and the remaining 27% (4/15) suggesting a hybrid of the 3 models. CONCLUSIONS A diverse suite of telehealth-based training and consultation services must be developed to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence and promote wider access to gender-affirming care.
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Affiliation(s)
- Gina M Sequeira
- Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Nicole F Kahn
- Seattle Children's Research Institute, Seattle, WA, United States
| | - Kevin M Bocek
- Seattle Children's Research Institute, Seattle, WA, United States
| | - Taraneh Shafii
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Peter G Asante
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Dimitri A Christakis
- Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Wanda Pratt
- Information School, University of Washington, Seattle, WA, United States
| | - Laura P Richardson
- Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
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Radix AE, Bond K, Carneiro PB, Restar A. Transgender Individuals and Digital Health. Curr HIV/AIDS Rep 2022; 19:592-599. [PMID: 36136217 PMCID: PMC9493149 DOI: 10.1007/s11904-022-00629-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to assess the use of digital technologies to promote the health and well-being of transgender and gender diverse (TGD) people. RECENT FINDINGS TGD individuals experience numerous health disparities, including low uptake of HIV prevention strategies, such as pre-exposure prophylaxis, increased HIV incidence, and suboptimal HIV-related outcomes. These health disparities are the result of widespread intersectional stigma on the basis of gender identity, gender expression, socioeconomic class, race, and ethnicity, which negatively impact access to general medical and transgender-specific health care. TGD individuals often delay or avoid essential medical services due to fear of discrimination. Clinicians frequently lack training, competence, and skills in transgender medicine, further exacerbating the health disparities faced by TGD people. Digital technologies have been used to improve research and clinical care for TGD populations through various modalities; telemedicine, telehealth and mHealth. Digital health technologies, including HIT-enabled clinical decision support, telehealth, telemedicine, and mHealth, offer innovative ways to improve health care access, improve quality of care, and reduce health disparities for TGD populations, including and beyond HIV outcomes, through enhanced care delivery, clinician education, and enhancing social support networks.
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Affiliation(s)
- Asa E Radix
- Department of Medicine, Callen-Lorde Community Health Center, New York, NY, USA.
- NYU Grossman School of Medicine, New York, NY, USA.
| | - Keosha Bond
- Community Health & Social Medicine, CUNY School of Medicine, New York, NY, USA
| | - Pedro B Carneiro
- Department of Community Health and Social Sciences, City University of New York, New York, NY, USA
| | - Arjee Restar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
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Wong HTH, Prankumar SK, Cui J, Tumwine C, Addo IY, Kan W, Noor MN. Information and communication technology-based health interventions for transgender people: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001054. [PMID: 36962672 PMCID: PMC10021903 DOI: 10.1371/journal.pgph.0001054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022]
Abstract
In the recent past, there has been a strong interest in the use of information and communication technology (ICT) to deliver healthcare to 'hard-to-reach' populations. This scoping review aims to explore the types of ICT-based health interventions for transgender people, and the concerns on using these interventions and ways to address these concerns. Guided by the scoping review frameworks offered by Arksey & O'Malley and the PRISMA-ScR checklist, literature search was conducted in May 2021 and January 2022 in three databases (PubMed, CINAHL and Scopus). The two searches yielded a total of 889 non-duplicated articles, with 47 of them meeting the inclusion criteria. The 47 articles described 39 unique health projects/programs, covering 8 types of ICT-based interventions: videoconferencing, smartphone applications, messaging, e-coaching, self-learning platforms, telephone, social media, and e-consultation platforms. Over 80% of the health projects identified were conducted in North America, and 62% focused on HIV/sexual health. The findings of this review suggest that transgender people had often been regarded as a small subsample in ICT-based health projects that target other population groups (such as 'men who have sex with men' or 'sexual minority'). Many projects did not indicate whether transgender people were included in the development or evaluation of the project. Relatively little is known about the implementation of ICT-based trans health interventions outside the context of HIV/sexual health, in resource limiting settings, and among transgender people of Asian, Indigenous or other non-White/Black/Hispanic backgrounds. While the range of interventions identified demonstrate the huge potentials of ICT to improve healthcare access for transgender people, the current body of literature is still far from adequate for making comprehensive recommendations on the best practice of ICT-based interventions for transgender people. Future ICT-based interventions need to be more inclusive and specified, in order to ensure the interventions are safe, accessible and effective for transgender people.
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Affiliation(s)
- Horas T H Wong
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, Australia
- The Albion Centre and t150 Transgender Health Service, NSW Health, Surry Hills, Australia
- Centre for Social Research in Health, UNSW Sydney, Kensington, Australia
| | - Sujith Kumar Prankumar
- Centre for Social Research in Health, UNSW Sydney, Kensington, Australia
- ARC Centre of Excellence for Automated Decision-Making and Society, Swinburne University, Melbourne, Australia
| | - Jialiang Cui
- Department of Social Work, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Christopher Tumwine
- Department of Mental Health, School of Medicine, Kabale University, Kabale, Uganda
| | | | - Wansang Kan
- Department of Social Work, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Muhammad Naveed Noor
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
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