Risk factors for oral infection and dry socket post-tooth extraction in medically complex patients in the absence of antibiotic prophylaxis: A case-control study.

INTRODUCTION: Dry socket and infection are complications of tooth extractions. The objective was to determine risk factors for post-extraction complications in patients without antibiotic prophylaxis stratified by early- and late-complications and complication type (oral infection and dry socket). METHODS: Retrospective, case (with complications)-control (without complications) study of patients (n = 708) who had ≥1 extraction performed at any Veterans Health Administration facility between 2015-2019 and were not prescribed an antibiotic 30 days pre-extraction. RESULTS: Early complication cases (n = 109) were more likely to be female [odds ratio (OR) = 2.06; 95% confidence interval (CI):1.05-4.01], younger (OR = 0.29; 95% CI:0.09-0.94 patients ≥ 80 years old, reference:18-44 years), Native American/Alaska Native (OR = 21.11; 95% CI:2.33-191.41) and have fewer teeth extracted (OR = 0.53 3+ teeth extracted; 95% CI:0.31-0.88, reference:1 tooth extracted). Late complication cases (n = 67) were more likely to have a bipolar diagnosis (OR = 2.98; 95% CI:1.04-8.57), history of implant placement (OR = 8.27; 95% CI:1.63-41.82), and history of past smoking (OR = 2.23; 95% CI:1.28-3.88). CONCLUSION: Predictors for post-extraction complications among patients who did not receive antibiotic prophylaxis were similar to prior work in cohorts who received prophylaxis. Unique factors identified in a medically complex population included being younger, Native American/Alaska Native, having mental health conditions, history of a dental implant, and fewer teeth extracted.

Causes of Death of Transgender and Gender Diverse Veterans.

INTRODUCTION: Transgender and gender diverse (TGD) veterans face numerous challenges due to stigma and marginalization, which have a significant impact on their health and well-being. However, there is insufficient data on cause-specific mortality in TGD veteran populations in the U.S. The purpose of this study was to describe the leading causes of death in a sample of TGD veterans who received care from the Veterans Health Administration. METHODS: A secondary data analysis was conducted using Veterans Health Administration electronic health record data matched with death certificate records from the National Death Index from October 1, 1999 to December 31, 2019. Using record axis codes from National Death Index data, the 25 most frequent underlying and all causes of death were summarized. RESULTS: Deaths occurred in 1,415 TGD veterans. Ranking by any mention on the death certificate, mental and behavioral disorders due to psychoactive substance use (17.2%), conduction disorders and cardiac dysrhythmias (15.3%), chronic obstructive pulmonary disease (15.1%), diabetes mellitus (13.9%), and chronic ischemic heart disease (13.3%) were the top five causes of death. Three distinct methods of suicide appeared as the 7th (firearms), 17th (self-poisoning), and 24th (hanging) underlying causes of death for TGD veterans. CONCLUSIONS: Targeted prevention efforts or interventions to reduce the frequency and severity of causes of death, particularly mental and behavioral health disorders and metabolic disorders, could prevent premature mortality among TGD adults.

Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration.

BACKGROUND: Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients. OBJECTIVE: This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations. PARTICIPANTS: TGD patients (n = 30) and VHA providers (n = 22). APPROACH: Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data. KEY RESULTS: VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal. CONCLUSIONS: A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Barriers and Facilitators to Gender-affirming Hormone Therapy in the Veterans Health Administration.

BACKGROUND: In 2011, the Veterans Health Administration (VHA) established a policy for the delivery of transition-related services, including gender-affirming hormone therapy (GAHT), for transgender and gender diverse (TGD) patients. In the decade since this policy's implementation, limited research has investigated barriers and facilitators of VHA's provision of this evidence-based therapy that can improve life satisfaction among TGD patients. PURPOSE: This study provides a qualitative summary of barriers and facilitators to GAHT at the individual (e.g., knowledge, coping mechanisms), interpersonal (e.g., interactions with other individuals or groups), and structural (e.g., gender norms, policies) levels. METHODS: Transgender and gender diverse patients (n = 30) and VHA healthcare providers (n = 22) completed semi-structured, in-depth interviews in 2019 regarding barriers and facilitators to GAHT access and recommendations for overcoming perceived barriers. Two analysts used content analysis to code and analyze transcribed interview data and employed the Sexual and Gender Minority Health Disparities Research Framework to organize themes into multiple levels. RESULTS: Facilitators included having GAHT offered through primary care or TGD specialty clinics and knowledgeable providers, with patients adding supportive social networks and self-advocacy. Several barriers were identified, including a lack of providers trained or willing to prescribe GAHT, patient dissatisfaction with prescribing practices, and anticipated or enacted stigma. To overcome barriers, participants recommended increasing provider capacity, providing opportunities for continual education, and enhancing communication around VHA policy and training. CONCLUSIONS: Multi-level system improvements within and outside the VHA are needed to ensure equitable and efficient access to GAHT.

Veterans Health Administration (VHA) policy mandates the provision of several gender-affirming health services, including gender-affirming hormone therapy (GAHT). GAHT can improve quality of life among transgender and gender diverse (TGD) patients by more closely aligning their physical self with their internal sense of self. We conducted interviews with 30 TGD patients and 22 VHA healthcare providers to gather their perspectives on barriers and facilitators to GAHT in the VHA. Findings revealed that facilitators of GAHT access included information sharing through social networks and relying on providers in primary care or specialized TGD health clinics for prescribing, while barriers included a shortage of trained providers and patient dissatisfaction with prescribing practices. Anticipating or experiencing stigma from providers and other patients was also identified as a barrier to GAHT. To overcome barriers, participants recommended increasing provider capacity, offering continuous education on GAHT prescribing, and improving communication about VHA policies and training. Comprehensive improvements at various levels, both within and outside the VHA, are necessary to improve access to this important evidence-based treatment for TGD patients.

Opioid and High-Risk Prescribing Among Racial and Ethnic Minority Veterans.

INTRODUCTION: The purpose of this study is to compare opioid prescribing and high-risk prescribing by race and ethnicity in a national cohort of U.S. veterans. METHODS: A cross-sectional analysis of veteran characteristics and healthcare use was performed on electronic health record data for 2018 Veterans Health Administration users and enrollees in 2022. RESULTS: Overall, 14.8% received an opioid prescription. The adjusted odds of being prescribed an opioid were lower for all race/ethnicity groups than for non-Hispanic White veterans, except for non-Hispanic multiracial (AOR=1.03; 95% CI=0.999, 1.05) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=1.03, 1.09) veterans. The odds of any day of overlapping opioid prescriptions (i.e., opioid overlap) were lower for all race/ethnicity groups than for the non-Hispanic White group, except for the non-Hispanic American Indian/Alaska Native group (AOR=1.01; 95% CI=0.96, 1.07). Similarly, all race/ethnicity groups had lower odds of any day of daily dose >120 morphine milligram equivalents than the non-Hispanic White group, except for the non-Hispanic multiracial (AOR=0.96; 95% CI=0.87, 1.07) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=0.96, 1.17) groups. Non-Hispanic Asian veterans had the lowest odds for any day of opioid overlap (AOR=0.54; 95% CI=0.50, 0.57) and daily dose >120 morphine milligram equivalents (AOR=0.43; 95% CI=0.36, 0.52). For any day of opioid-benzodiazepine overlap, all races/ethnicities had lower odds than non-Hispanic White. Non-Hispanic Black/African American (AOR=0.71; 95% CI=0.70, 0.72) and non-Hispanic Asian (AOR=0.73; 95% CI=0.68, 0.77) veterans had the lowest odds of any day of opioid-benzodiazepine overlap. CONCLUSIONS: Non-Hispanic White and non-Hispanic American Indian/Alaska Native veterans had the greatest likelihood to receive an opioid prescription. When an opioid was prescribed, high-risk prescribing was more common in White and American Indian/Alaska Native veterans than in all other racial/ethnic groups. As the nation's largest integrated healthcare system, the Veterans Health Administration can develop and test interventions to achieve health equity for patients experiencing pain.

Analysis by Gender and Race and Ethnicity of Reviewers and Awardees for Intramural Research Funding in the Veterans Health Administration.

Importance: Underrepresentation of women and racial and ethnic minority individuals among reviewers and funded investigators in health research has been widely reported. It is unknown whether such underrepresentation exists in the Veterans Health Administration (VHA). Objective: To describe gender and racial and ethnic makeup of VHA Health Services Research and Development (HSR&D) study sections and funding awardees and to explore the associations between gender and racial and ethnic makeup of study sections and awardees who were women and racial and ethnic minority individuals. Design, Setting, and Participants: This cross-sectional study at the VHA evaluated study section members and funding awardees from 5 review cycles from March 13, 2018, through March 6, 2020, identified via the HSR&D and National Institutes of Health websites. Main Outcomes and Measures: Univariable and multivariable logistic regression models were used to determine the likelihood of an awardee being a woman or a racial or ethnic minority individual based on the gender and racial and ethnic makeup of study sections, respectively. Separate models were conducted for investigator-initiated research proposals only. Results: Thirty-six study sections comprised 664 reviewers, including 381 women (57.4%) and 81 racial and ethnic minority individuals (12.2%). Of the 146 funded proposals, 77 (52.7%) were awarded to women and 25 (17.1%) to racial and ethnic minority investigators; 29 (19.9%) were reviewed by study sections with no racial and ethnic minority reviewers. The odds of a woman awardee were more than 5 times greater for proposals reviewed by study sections comprising the highest proportion of women (fourth quartile; >58.3%) than the lowest proportion of women (first quartile; ≤50.0%) (adjusted odds ratio [aOR], 5.24 [95% CI, 1.70-16.13]). Similarly, the odds of a racial or ethnic minority awardee were 3 times greater for proposals reviewed by study sections in the top 50th percentile for proportion of racial and ethnic minority individuals (>7.3%) than the bottom 50th percentile (aOR, 3.08 [95% CI, 1.18-8.09]). Secondary analyses limited to investigator-initiated research proposals identified similar associations. Conclusions and Relevance: In this cross-sectional study of VHA HSR&D-funded research, racial and ethnic minority individuals were underrepresented among investigators and reviewers. More women and racial and ethnic minority reviewers on study sections were associated with women and racial and ethnic minority individuals awarded funding.

Exploring Research Engagement and Priorities of Transgender and Gender Diverse Veterans.

INTRODUCTION: In recent years, the U.S. Veterans Health Administration (VHA) has seen an increasing population of transgender and gender diverse (TGD) veterans accessing care. Approximately 139 per 100,000 VHA users had a gender identity disorder diagnosis documented in 2018 compared to 32.9 per 100,000 in 2013. Despite TGD patients being overrepresented within VHA, TGD veterans may distrust or face unique barriers with various aspects of the VHA, including health services research. Existing VHA health research focused on TGD populations is largely limited to secondary analyses of electronic health record data. Identifying strategies to enhance primary data collection is crucial for more deeply investigating health care challenges experienced by TGD veterans using VHA care. Additionally, describing health topics of importance for TGD veterans is important for making the research agenda more patient-centered. In this study, we offer veterans' recommendations for researchers working with underrepresented populations based on our findings. MATERIALS AND METHODS: From September through October 2019, 30 TGD veterans were recruited through VHA lesbian, gay, bisexual, transgender, and queer/questioning Veteran Care Coordinators (LGBTQ+ VCC) located nationwide. Semi-structured interviews were used to explore barriers and facilitators to research participation, recommendations for improving outreach and engagement, and overall perspectives about priorities in health services research. Transcripts were independently and jointly reviewed and coded by two TGD research analysts, including a veteran using VHA care. Codes were derived inductively. Themes were identified using conventional content analysis. The VA Pittsburgh Healthcare System institutional review board approved this study. RESULTS: Participants cited privacy concerns of being "outed" and potentially having VHA benefits revoked, in addition to a level of distrust in researchers' intentions as barriers to participating in studies. Facilitators for participating included feeling a sense of serving the TGD community and accessibility to study locations, especially VHA-affiliated sites. Suggestions for recruitment included tailored messaging and using other TGD peers or affirming VHA staff (e.g., LGBTQ+ VCCs) for study outreach. Mental health and gender-affirming hormone therapy were the most understudied topics identified by participants. Additionally, participants prioritized the inclusion and study of underrepresented subpopulations, such as transgender women of color, transgender men, and non-binary/gender diverse veterans, in future research. CONCLUSIONS: By harnessing the VHA LGBTQ+ VCC network, this study recruited a national sample of TGD veterans to provide insight on methods for more effectively engaging TGD veterans in research and elicited their suggestions for health services research topics. The findings provide numerous suggestions for medicine and public health that are ripe for future research endeavors. Despite the study's lack of gender, racial, and ethnic diversity, findings highlight the need for engagement and study of underrepresented veteran populations. These suggested areas of focus for research in combination with valuable insight on research participation provide researchers with guidance for developing research agendas and designing recruitment and data collection methods that can facilitate future primary research advancing health services research involving TGD patients. Similarly, VHA and non-VHA researchers conducting research involving other underrepresented populations can also gain insight from these findings.

A qualitative approach to examining antimicrobial prescribing in the outpatient dental setting.

Objective: To understand barriers and facilitators to evidence-based prescribing of antibiotics in the outpatient dental setting. Design: Semistructured interviews. Setting: Outpatient dental setting. Participants: Dentists from 40 Veterans' Health Administration (VA) facilities across the United States. Methods: Dentists were identified based on their prescribing patterns and were recruited to participate in a semistructured interview on perceptions toward prescribing. All interviews were recorded, transcribed, and double-coded for analysis, with high reliability between coders. We identified general trends using the theoretical domains framework and mapped overarching themes onto the behavior change wheel to identify prospective interventions that improve evidence-based prescribing. Results: In total, 90 dentists participated in our study. The following barriers and facilitators to evidence-based prescribing emerged as impacts on a dentist's decision making on prescribing an antibiotic: access to resources, social influence of peers and other care providers, clinical judgment, beliefs about consequences, local features of the clinic setting, and beliefs about capabilities. Conclusions: Findings from this work reveal the need to increase awareness of up-to-date antibiotic prescribing behaviors in dentistry and may inform the best antimicrobial stewardship interventions to support dentists' ongoing professional development and improve evidence-based prescribing.

Binary and Nonbinary Transgender Adolescents' Healthcare Experiences, Avoidance, and Well Visits.

PURPOSE: To explore differences in healthcare experiences, healthcare avoidance, and well visit attendance between binary and nonbinary transgender adolescents; also, to explore the association between distinct healthcare experiences and healthcare avoidance and well visits. METHODS: We surveyed transgender adolescents ages 12-26 (n = 156) recruited from a multidisciplinary gender clinic from July through November 2018. Differences in distinct healthcare experiences by demographics were assessed using multivariable linear regression. Multivariable logistic regression was used to examine independent associations between demographics and lifetime healthcare avoidance and past-year well visit and also, associations between distinct healthcare experiences and lifetime healthcare avoidance and past-year well visit. RESULTS: Compared to transfeminine adolescents, more non-affirming healthcare experiences were reported by nonbinary (ß = 1.41, 95% confidence interval [CI]: 0.49, 2.33) and transmasculine adolescents (ß = 0.78, 95% CI: 0.02, 1.53). Gender-affirming healthcare experiences did not differ by demographics. Transmasculine adolescents had over three times the odds of lifetime healthcare avoidance (adjusted odds ratio [aOR] = 3.58, 95% CI: 1.41, 9.08) than transfeminine peers. Only younger age was associated with past-year well visit (aOR = 3.83, 95% CI: 1.44, 10.17). Non-affirming healthcare experiences were positively associated with healthcare avoidance (aOR = 1.85, 95% CI: 1.47, 2.34). Gender-affirming healthcare experiences were not associated with healthcare avoidance or past-year well visit. DISCUSSION: Nonbinary and transmasculine adolescents experienced more non-affirming healthcare experiences than transfeminine adolescents. Non-affirming healthcare experiences were associated with healthcare avoidance, which was disproportionately more prevalent among transmasculine adolescents. Providers must be better equipped to provide inclusive, gender-affirming care to increase receipt of care for transgender adolescents beyond specialized gender clinics.

Comparing Outpatient Opioids, High-Risk Prescribing, and Opioid Poisoning Between Transgender and Cisgender Veterans: A Cross-sectional Analysis.

INTRODUCTION: Transgender veterans have a high prevalence of substance use disorder and physical and mental-health comorbidities, which are associated with prescription opioid use and overdose risk. This study compares receipt of outpatient opioids, high-risk opioid prescribing, and opioid poisoning between transgender and cisgender (i.e., nontransgender) veterans. METHODS: A secondary analysis of Veterans Health Administration health record data from January 1, 2018 to December 31, 2018 was conducted in 2021. Transgender veterans (n=9,686) were randomly matched to 3 cisgender veterans (n=29,058) on the basis of age and county. Using the same matching criteria, a second cohort was created of all transgender veterans and a matched sample of cisgender veterans who were prescribed an outpatient opioid (n=7,576). Stratified Cox proportional hazard regression measured the RR of each prescription outcome and opioid poisoning. RESULTS: Transgender veterans had a 20% higher risk of being prescribed any outpatient opioid than cisgender veterans (adjusted RR=1.20, 95% CI=1.13, 1.27). Transgender and cisgender veterans who were prescribed an opioid did not have different risks of high-risk prescribing: overlapping opioid prescriptions (adjusted RR=0.93, 95% CI=0.85, 1.02), daily dose >120 morphine milligram equivalents (adjusted RR=0.86, 95% CI=0.66, 1.10), or overlapping opioid and benzodiazepine prescriptions (adjusted RR=1.05, 95% CI=0.96, 1.14). Overall, transgender veterans had more than twice the risk of opioid poisoning than cisgender veterans (RR=2.76, 95% CI=1.57, 4.86). The risk of opioid poisoning did not differ between transgender and cisgender veterans who were prescribed an opioid (RR=1.09, 95% CI=0.56, 2.11). CONCLUSIONS: Transgender veterans had a greater risk of being prescribed an outpatient opioid than cisgender veterans but did not have different risks of high-risk opioid prescribing.

Concordance of Data About Sex From Electronic Health Records and the National Death Index: Implications for Transgender Populations.

BACKGROUND: Transgender individuals have greater health risks than cisgender individuals, which may bode for greater mortality. However, research is limited by lack of gender identity information at the time of death. Novel opportunities to combine administrative data with National Death Index (NDI) data may facilitate mortality research about transgender populations, but binary measures of sex and gender may pose problems for analyses. This study explored differences in sex recorded in Veterans Health Administration (VHA) electronic health record (EHR) and NDI data between transgender and cisgender decedents. METHODS: We used VHA EHR data from fiscal years 2000-2016 to identify deaths among a sample of transgender and cisgender patients. We cross-tabulated sex recorded in the NDI with EHR-based sex from VHA EHR data. We extracted data in 2018 and conducted analyses in 2020. RESULTS: Death occurred for 1109 transgender patients and 7757 cisgender patients. For cisgender decedents, EHR-based sex and NDI-based sex were 100% concordant. For transgender decedents, 46 (4%) were discordant between data sources. Of transgender decedents with female EHR-based sex (n = 259), 17% were indicated as male in NDI data; of those with male EHR-based sex (n = 850), 0.2% were indicated as female in NDI data. CONCLUSIONS: Data linkage between EHR and the NDI can facilitate transgender mortality research, but examining mortality specific to various transgender identities remains difficult. Improved documentation of sex and gender is needed within US mortality surveillance.

Suicide, Homicide, and All-Cause Mortality Among Transgender and Cisgender Patients in the Veterans Health Administration.

Purpose: This study examines the differences in suicide, homicide, and all-cause mortality between transgender and cisgender Veterans Health Administration (VHA) patients. Methods: VHA electronic medical record data from October 1, 1999 to December 31, 2016 were used to create a sample of transgender and cisgender patients (n = 32,441). Cox proportional hazard regression was used to evaluate differences in survival time (date of birth to death date/study end). Death data were from the National Death Index. Results: Transgender patients had more than twofold greater hazard of suicide than cisgender patients (adjusted hazard ratio [aHR] = 2.77, 95% confidence interval [CI] = 1.88-4.09), especially among younger (18-39 years) (aHR = 3.35, 95% CI = 1.30-8.60) and older (≥65 years) patients (aHR = 9.48, 95% CI = 3.88-23.19). Alternatively, transgender patients had an overall lower hazard of all-cause mortality (aHR = 0.90, 95% CI = 0.84-0.97) compared with cisgender patients, which was driven by patients 40-64 years old (aHR = 0.78, 95% CI = 0.72-0.86) and reversed by those 65 years and older (aHR = 1.17, 95% CI = 1.03-1.33). Conclusion: Transgender patients' hazard of suicide mortality was significantly greater than that of cisgender VHA patients.

Differences in Methods of Suicide Death Among Transgender and Nontransgender Patients in the Veterans Health Administration, 1999-2016.

BACKGROUND: Limited research suggests that rates of suicide death among transgender people may be higher than their nontransgender peers. OBJECTIVE: The objective of this study was to compare rates of suicide deaths by different means between transgender and nontransgender patients. RESEARCH DESIGN: This secondary analysis used VHA administrative and electronic health record (EHR) data from October 1, 1999 through December 31, 2016. SUBJECTS: Transgender patients (n=8981) were categorized as such based on a set of International Classification of Disease codes, and a comparison sample was selected by randomly choosing 3 nontransgender patients (n=26,924). MEASURES AND ANALYSES: Cause and date of death data are from the National Death Index. Because of low frequencies amid different methods of suicide death, we combined categories into self-poisoning; hanging, strangulation and suffocation; discharge of firearms; and self-harm by all other and unspecified means. We conducted Cox regression analyses to model time-to-event for each method of suicide, adjusted for age, sex based on EHR, race, ethnicity, marital status, and whether patients had ever been diagnosed with depression. RESULTS: Among transgender patients, 73 died by suicide (22 female EHR-based sex, 51 male EHR-based sex), and among nontransgender patients, 71 died by suicide (4 female EHR-based sex, 67 male EHR-based sex). In adjusted models, transgender patients had significantly greater hazards of death by self-poisoning and firearms than their nontransgender peers. CONCLUSIONS: Differences in methods of suicide death suggest that firearms and self-poisoning may be specific areas of concern for transgender individuals experiencing suicidal crisis, which underscore needs for examining effective delivery of evidence-based care.