Nationwide Evaluation of Quality of Care Indicators for Individuals with Severe Mental Illness and Diabetes Mellitus, Following Israel's Mental Health Reform.

Diabetes Mellitus (DM) is more common among individuals with severe mental illness (SMI). We aimed to assess quality-of-care-indicators in individuals with SMI following the 2015 Israel's Mental-Health-reform. We analyzed yearly changes in 2015-2019 of quality-of-care-measures and intermediate-DM-outcomes, with adjustment for gender, age-group, and socioeconomic status (SES) and compared individuals with SMI to the general adult population. Adults with SMI had higher prevalences of DM (odds ratio (OR) = 1.64; 95% confidence intervals (CI): 1.61-1.67) and obesity (OR = 2.11; 95% CI: 2.08-2.13), compared to the general population. DM prevalence, DM control, and obesity rates increased over the years in this population. In 2019, HbA1c testing was marginally lower (OR = 0.88; 95% CI: 0.83-0.94) and uncontrolled DM (HbA1c > 9%) slightly more common among patients with SMI (OR = 1.22; 95% CI: 1.14-1.30), control worsened by decreasing SES. After adjustment, uncontrolled DM (adj. OR = 1.02; 95% CI: 0.96-1.09) was not associated with SMI. Cardio-metabolic morbidity among patients with SMI may be related to high prevalences of obesity and DM rather than poor DM control. Effective screening for metabolic diseases in this population and social reforms are required.

Toward reconciling the roles of FGF21 in protein appetite, sweet preference, and energy expenditure.

Fibroblast growth factor 21 (FGF21), an endocrine signal robustly increased by protein restriction independently of an animal's energy status, exerts profound effects on feeding behavior and metabolism. Here, we demonstrate that considering the nutritional contexts within which FGF21 is elevated can help reconcile current controversies over its roles in mediating macronutrient preference, food intake, and energy expenditure. We show that FGF21 is primarily a driver of increased protein intake in mice and that the effect of FGF21 on sweet preference depends on the carbohydrate balance of the animal. Under no-choice feeding, FGF21 infusion either increased or decreased energy expenditure depending on whether the animal was fed a high- or low-energy diet, respectively. We show that while the role of FGF21 in mediating feeding behavior is complex, its role in promoting protein appetite is robust and that the effects on sweet preference and energy expenditure are macronutrient-state-dependent effects of FGF21.

Using the Elixhauser risk adjustment model to predict outcomes among patients hospitalized in internal medicine at a large, tertiary-care hospital in Israel.

BACKGROUND: In Israel, internal medicine admissions are currently reimbursed without accounting for patient complexity. This is at odds with most other developed countries and has the potential to lead to market distortions such as avoiding sicker patients. Our objective was to apply a well-known, freely available risk adjustment model, the Elixhauser model, to predict relevant outcomes among patients hospitalized on the internal medicine service of a large, Israeli tertiary-care hospital. METHODS: We used data from the Shaare Zedek Medical Center, a large tertiary referral hospital in Jerusalem. The study included 55,946 hospitalizations between 01.01.2016 and 31.12.2019. We modeled four patient outcomes: in-hospital mortality, escalation of care (intensive care unit (ICU) transfer, mechanical ventilation, daytime bi-level positive pressure ventilation, or vasopressors), 30-day readmission, and length of stay (LOS). We log-transformed LOS to address right skew. As is usual with the Elixhauser model, we identified 29 comorbid conditions using international classification of diseases codes, clinical modification, version 9. We derived and validated the coefficients for these 29 variables using split-sample derivation and validation. We checked model fit using c-statistics and R2, and model calibration using a Hosmer-Lemeshow test. RESULTS: The Elixhauser model achieved acceptable prediction of the three binary outcomes, with c-statistics of 0.712, 0.681, and 0.605 to predict in-hospital mortality, escalation of care, and 30-day readmission respectively. The c-statistic did not decrease in the validation set (0.707, 0.687, and 0.603, respectively), suggesting that the models are not overfitted. The model to predict log length of stay achieved an R2 of 0.102 in the derivation set and 0.101 in the validation set. The Hosmer-Lemeshow test did not suggest issues with model calibration. CONCLUSION: We demonstrated that a freely-available risk adjustment model can achieve acceptable prediction of important clinical outcomes in a dataset of patients admitted to a large, Israeli tertiary-care hospital. This model could potentially be used as a basis for differential payment by patient complexity.

Bridging language barriers in developing valid health policy research tools: insights from the translation and validation process of the SHEMESH questionnaire.

BACKGROUND: The use of research tools developed and validated in one cultural and linguistic context to another often faces challenges. One major challenge is poor performance of the tool in the new context. This potentially impact the legitimacy of health policy research conducted with informal adaptations of existing tools which have not been subjected to formal validation. Best practices exist to guide researchers in adapting and validating research tools effectively. We present here, as an extended example, our validation of the SHEMESH questionnaire ('Organizational Readiness to Change Assessment'; In Hebrew: 'SHE'elon Muchanut Ergunit le'SHinuy'), a Hebrew-language version of the Organizational Readiness to Change Assessment (ORCA). SHEMESH is tailored to support implementation science projects, whose aim is to promote a more rapid and complete adoption of evidence-based health policies and practices. METHODS: The SHEMESH included originally eleven questions from the Evidence (item 1-4) and Context (items 5-11) domains. We validated SHEMESH through the following steps: 1. Professional translation to Hebrew and discussion of the translation by multidisciplinary committee; 2. Back-translation into English by a different translator to detect discrepancies; 3. Eleven cognitive interviews with psychiatric emergency department physicians and nurses; and 4. Pilot testing and psychometric analyses, including Cronbach's alpha for subscales and factor analyses. RESULTS: Following translation and cognitive interviews, SHEMESH was administered to 222 psychiatrists and nurses. Pearson correlation showed significant and strong correlations of items 1-4 to the Evidence construct and items 6-11 to the Context construct. Item 5 did not correlate with the other items, and therefore was removed from the other psychometric procedures and eventually from the SHEMESH. Factor analysis with the remaining 10 items yielded two factors, which together explained a total of 69.7% of variance. Cronbach's Alpha scores for the two subscales were high (Evidence, 0.887, and Context, 0.852). CONCLUSIONS: This multi-step validation process of the SHEMESH questionnaire may serve as a comprehensive guideline for others who are willing to adapt research tools that were developed in other languages. Practically, SHEMESH has been validated for use in implementation science research projects in Israel.

Enabling Expedited Disposition of Emergencies Using Telepsychiatry in Israel: Protocol for a Hybrid Implementation Study.

BACKGROUND: Telepsychiatry is the use of virtual communication, such as a video link, to deliver mental health assessment, treatment, and follow-up. Previous studies have shown telepsychiatry to be feasible, accurate compared with in-person practice, and satisfying for psychiatrists and patients. Telepsychiatry has also been associated with reduced waiting times for evaluation and, in some studies, lower admission rates. However, most previous studies focused on using telepsychiatry in community settings and not on involuntary admission. OBJECTIVE: The aim of this study is to examine the effectiveness and implementation process of patient assessment for involuntary admissions in the psychiatric emergency department (ED) using a video link. METHODS: This type 1 hybrid implementation study will examine telepsychiatry effectiveness and the implementation process, by comparing telepsychiatry (n=240) with historical controls who had a face-to-face evaluation (n=240) during the previous, usual care period in 5 psychiatric EDs in Israel. A temporary waiver of the standing policy requiring in-person evaluations only, for the purpose of research, was obtained from the Israeli Ministry of Health. During the telepsychiatry phase, clinical staff and patients will join a video call from the ED, while the attending physician will log in elsewhere. The Promoting Action on Research Implementation in Health Services (PARIHS) framework will guide the evaluation of the telepsychiatry implementation process in the ED. PARIHS has the following 3 constructs: (1) evidence: staff's opinions regarding the innovation's viability and practicality, their satisfaction levels with its use, and patients' perceptions of the change; (2) context: level of approval of new strategies in the ED, decision-making processes, and the manner in which clinical teams converse and work together; (3) facilitation: adequacy of the facilitation efforts using champions reports. Primary clinical outcomes include ED length of stay and violent incidents obtained from medical records. RESULTS: This study received Helsinki approval from the Ethics Committee of Abarbanel Mental Health Center (174; March 13, 2023), Jerusalem Mental Health Center (22-21; November 6, 2022), Lev-Hasharon Mental Health Medical Center (LH12023; February 12, 2023), Tel-Aviv Medical Center (TLV-22-0656; January 3, 2023), and Sha'ar Menashe (1-4-23; April 18, 2023). Data collection began in July 2023 in 2 study sites and will begin soon at the others. CONCLUSIONS: Telepsychiatry could have significant benefits for patients in the psychiatric ED. Examining telepsychiatry effectiveness in the ED, in addition to identifying the facilitators and barriers of implementing it in different emergency settings, will facilitate better policy decisions regarding its implementation. TRIAL REGISTRATION: ClinicalTrials.gov NCT05771545; https://clinicaltrials.gov/study/NCT05771545. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49405.

Post-nursing early life macronutrient balance promotes persistent and malleable biometric and metabolic traits in mice.

It is known that dietary factors within the gestational and nursing period affect early life and stably affect later life traits in animals. However, there is very little understanding of whether dietary factors within the early life period from post-nursing to adulthood affect traits in adulthood. To address this, we conducted studies on male C57Bl/6J mice fed from 3 weeks (immediately post-nursing) until 12 weeks (full maturity) using nine different diets varying in all three major macronutrients to parse out the effects of individual macronutrients. Early life macronutrient balance affected body composition and glucose homeostasis in early adulthood, with dietary protein and fat showing major effects. Despite this, mice showed rapid reversal of the effects on body composition and glucose homeostasis of early life diet feeding, upon standard diet feeding in adulthood. However, some traits were persistent, with early life low dietary protein levels stably affecting lean and muscle mass, and early life dietary fat levels stably affecting serum and liver triglyceride levels. In summary, macronutrient balance in the post-nursing early life period does not stably affect adiposity or glucose homeostasis but does impact muscle mass and lipid homeostasis in adulthood, with prominent effects of both protein and fat levels. KEY POINTS: Early life dietary low protein and high fat levels lowered and heightened body mass, respectively. These effects did not substantially persist into adulthood with rapid catch-up growth on a normal diet. Early life protein (negative) and fat (positive) levels affected fat mass. Early life low protein levels negatively affected lean mass. Low protein effects on lower lean and muscle mass persisted into adulthood. Early life macronutrient balance effects did not affect later life glucose homeostasis but early life high fat level affected later life dyslipidaemia. Effects of dietary carbohydrate levels in early and later life were minor.

Greater temporal regularity of primary care visits was associated with reduced hospitalizations and mortality, even after controlling for continuity of care.

BACKGROUND: Previous studies have shown that more temporally regular primary care visits are associated with improved patient outcomes. OBJECTIVE: To examine the association of temporal regularity (TR) of primary care with hospitalizations and mortality in patients with chronic illnesses. Also, to identify threshold values for TR for predicting outcomes. DESIGN: Retrospective cohort study. PARTICIPANTS: We used data from the electronic health record of a health maintenance organization in Israel to study primary care visits of 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease). MAIN MEASURES: We calculated TR for each patient during a two-year period (2016-2017), and divided patients into quintiles based on TR. Outcomes (hospitalization, death) were observed in 2018-2019. Covariates included the Bice-Boxerman continuity of care score, demographics, and comorbidities. We used multivariable logistic regression to examine TR's association with hospitalization and death, controlling for covariates. KEY RESULTS: Compared to patients receiving the most regular care, patients receiving less regular care had increased odds of hospitalization and mortality, with a dose-response curve observed across quintiles (p for linear trend < 0.001). For example, patients with the least regular care had an adjusted odds ratio of 1.40 for all-cause mortality, compared to patients with the most regular care. Analyses stratified by age, sex, ethnic group, area-level SES, and certain comorbid conditions did not show strong differential associations of TR across groups. CONCLUSIONS: We found an association between more temporally regular care in antecedent years and reduced hospitalization and mortality of patients with chronic illness in subsequent years, after controlling for covariates. There was no clear threshold value for temporal regularity; rather, more regular primary care appeared to be better across the entire range of the variable.

Gaps in evidence on treatment of male osteoporosis: a Research Agenda.

OBJECTIVE: To identify key research gaps regarding medication therapy to prevent osteoporotic fractures in men. DATA SOURCES: Articles from the peer-reviewed literature containing empirical studies of the use of medication therapy for fracture prevention in men, either in clinical trials or observational studies. STUDY SELECTION AND DATA EXTRACTION: We searched PubMed with search terms including "osteoporosis AND medication therapy management". We read all articles to ensure that they were indeed empirical studies of our topic. For each included study, we searched for all articles in the bibliography, all articles that cited the article, and all related articles, using these functions in PubMed. DATA SYNTHESIS: We have identified six research gaps that could inform the more rational, evidence-based treatment of male osteoporosis. Specifically, among men, we lack key information about: (1) whether treatment can prevent clinical fractures, (2) rates of side effects and complications of therapy, (3) the role of testosterone in treatment, (4) the comparative effectiveness of different therapeutic regimens, (5) role of drug holidays for those receiving bisphosphonates and sequential therapies, and (6) effectiveness of therapy for secondary prevention. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Addressing these six topics should be key goal for the next decade of research on male osteoporosis.

Patient-level predictors of temporal regularity of primary care visits.

BACKGROUND: Patients with chronic diseases should meet with their primary care doctor regularly to facilitate proactive care. Little is known about what factors are associated with more regular follow-up. METHODS: We studied 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease), cared for by Leumit Health Services, an Israeli health maintenance organization. Patients were divided into the quintile with the least temporally regular care (i.e., the most irregular intervals between visits) vs. the other four quintiles. We examined patient-level predictors of being in the least-temporally-regular quintile. We calculated the risk-adjusted regularity of care at 239 LHS clinics with at least 30 patients. For each clinic, compared the number of patients with the least temporally regular care with the number predicted to be in this group based on patient characteristics. RESULTS: Compared to older patients, younger patients (age 40-49), were more likely to be in the least-temporally-regular group. For example, age 70-79 had an adjusted odds ratio (AOR) of 0.82 compared to age 40-49 (p < 0.001 for all findings discussed here). Males were more likely to be in the least-regular group (AOR 1.18). Patients with previous myocardial infarction (AOR 1.07), atrial fibrillation (AOR 1.08), and current smokers (AOR 1.12) were more likely to have an irregular pattern of care. In contrast, patients with diabetes (AOR 0.79) or osteoporosis (AOR 0.86) were less likely to have an irregular pattern of care. Clinic-level number of patients with irregular care, compared with the predicted number, ranged from 0.36 (fewer patients with temporally irregular care) to 1.71 (more patients). CONCLUSIONS: Some patient characteristics are associated with more or less temporally regular patterns of primary care visits. Clinics vary widely on the number of patients with a temporally irregular pattern of care, after adjusting for patient characteristics. Health systems can use the patient-level model to identify patients at high risk for temporally irregular patterns of primary care. The next step is to examine which strategies are employed by clinics that achieve the most temporally regular care, since these strategies may be possible to emulate elsewhere.

Where internal medical patients receive intensive interventions: results from a tertiary-care hospital in Israel.

BACKGROUND: Patients admitted to internal medicine may be moved to more advanced-care settings when their condition deteriorates. In these advanced care settings, there may be higher levels of monitoring and greater ability to deliver Intensive Medical Treatments (IMTs). To the best of our knowledge, no previous study has examined the proportion of patients at different levels of care who receive different types of IMTs. METHODS: In this retrospective observational cohort study, we examined data from 56,002 internal medicine hospitalizations at Shaare Zedek Medical Center, between 01.01.2016 and 31.12.2019. Patients were divided according to where they received care: general-ward, Intermediate-Care Unit, Intensive Care Unit (ICU), or both (Intermediate-Care and ICU). We examined the rates at which these different groups of patients received one or more of the following IMTs: mechanical ventilation, daytime bi-level positive airway pressure (BiPAP), or vasopressor therapy. RESULTS: Most IMTs were delivered in a general-ward setting - ranging from 45.9% of IMT-treated hospitalizations involving combined mechanical ventilation and vasopressor therapy to as high as 87.4% of IMT-treated hospitalizations involving daytime BiPAP. Compared to ICU patients, Intermediate-Care Unit patients were older (mean age 75.1 vs 69.1, p < 0.001 for this and all other comparisons presented here), had longer hospitalizations (21.3 vs 14.5 days), and were more likely to die in-hospital (22% vs 12%). They were also more likely to receive most of the IMTs compared to ICU patients. For example, 9.7% of Intermediate-Care Unit patients received vasopressors, compared to 5.5% of ICU patients. CONCLUSION: In this study, most of the patients who received IMTs actually received them in a general-bed and not in a dedicated unit. These results imply that IMTs are predominantly delivered in unmonitored settings, and suggest an opportunity to re-examine where and how IMTs are given. In terms of health policy, these findings suggest a need to further examine the setting and patterns of intensive interventions, as well as a need to increase the number of beds dedicated to delivering intensive interventions.

Trends in Feminizing Hormone Therapy for Transgender Patients, 2006-2017.

Combination therapy with estrogen and spironolactone may help some transgender women achieve desired results. We used two databases, OptumLabs® Data Warehouse (OLDW) and Veterans Health Administration (VHA), to examine trends in feminizing therapy. We included 3368 transgender patients from OLDW and 3527 from VHA, all of whom received estrogen, spironolactone, or both between 2006 and 2017. In OLDW, the proportion receiving combination therapy increased from 47% to 75% during this period. Similarly, in VHA, the proportion increased from 39% to 69% during this period. We conclude that the use of combination hormone therapy has become much more common over the past decade.

Work like a Doc: A comparison of regulations on residents' working hours in 14 high-income countries.

BACKGROUND: Medical residents work long, continuous hours. Working in conditions of extreme fatigue has adverse effects on the quality and safety of care, and on residents' quality of life. Many countries have attempted to regulate residents' work hours. OBJECTIVES: We aimed to review residents' work hours regulations in different countries with an emphasis on night shifts. METHODS: Standardized qualitative data on residents' working hours were collected with the assistance of experts from 14 high-income countries through a questionnaire. An international comparative analysis was performed. RESULTS: All countries reviewed limit the weekly working hours; North-American countries limit to 60-80 h, European countries limit to 48 h. In most countries, residents work 24 or 26 consecutive hours, but the number of long overnight shifts varies, ranging from two to ten. Many European countries face difficulties in complying with the weekly hour limit and allow opt-out contracts to exceed it. CONCLUSIONS: In the countries analyzed, residents still work long hours. Attempts to limit the shift length or the weekly working hours resulted in modest improvements in residents' quality of life with mixed effects on quality of care and residents' education.

Vaccine hesitancy among health-care professionals in the era of COVID-19.

Health-care professionals (HCPs) are key trusted figures in addressing coronavirus disease 2019 (COVID-19) challenges. They are thought to influence others' health decisions by personal example. However, during the COVID-19 crisis, some HCPs hesitated to be vaccinated. We examined factors contributing to that decision. We performed 12 semi-structured interviews, between February and May 2021, with Israeli HCPs who had declined or delayed COVID-19 vaccination. Three coders conducted a combined top-down and bottom-up analysis. We identified four main themes shaping vaccine decision-making: (i) sources of information, (ii) perceptions of necessity and risks of the vaccine, (iii) individual versus collective responsibility and (iv) political climate and media influence. Participants were worried about long-term effectiveness and safety, and while many agreed that high-risk populations should be vaccinated, all considered themselves to be at low risk for serious disease. Some felt they should avoid taking a perceived risk (accepting a new vaccine) to protect society, although they felt pressured to do so. Vaccination campaign politization and the way the media approached the subject also contributed to mistrust and hesitancy to be vaccinated. These findings help us understand HCP beliefs and uncertainties about COVID-19 vaccinations. This study can help inform future campaigns targeted at HCPs to promote the acceptance of vaccines.

Characterizing patient attitudes and beliefs towards testosterone therapy in Veterans Affairs: A qualitative study.

OBJECTIVE: We examined patient attitudes and beliefs and provider perspectives on patients' attitudes and beliefs towards testosterone therapy in Veterans Affairs (VA). METHODS: We used a thematic analysis approach to understand variation in patient attitudes and beliefs towards testosterone at six VA sites with high and low levels of testosterone prescribing in VA. Semi-structured phone interviews with 18 patients and 22 providers at these sites were transcribed and coded using a priori theoretical constructs and emergent themes. A cross-case matrix of coded data was used to evaluate themes related to patient-level factors. RESULTS: Patients' beliefs toward testosterone did not differ across sites. Patients, not providers, generally initiated conversations about testosterone. We identified five key domains related to patient beliefs and provider perceived patient beliefs towards testosterone: reasons for initiating testosterone, patient information sources and expectations about testosterone, receptivity towards discontinuation of testosterone, patient/provider engagement in information sharing, and self-advocacy by the patients in decision-making. CONCLUSIONS: Patient factors play an important role in testosterone prescribing decisions. PRACTICE IMPLICATIONS: By considering these patient factors, providers can potentially help create a partnership with patients and foster shared decision-making for testosterone and other, similar medications.

Israeli COVID lockdowns mildly reduced overall use of preventive health services, but exacerbated some disparities.

BACKGROUND: During 2020, Israel experienced two COVID-19-related lockdowns that impacted the provision of primary and secondary preventive care. METHODS: We examined the month-by-month performance of selected preventive care services using data from Israel's national Quality Indicators in Community Healthcare program. Process of care measures included hemoglobin A1c (HbA1c) testing, cholesterol testing, colon cancer screening and mammography. Intermediate outcome measures included low-density lipoprotein control and HbA1c control. Measures were stratified by sex and by area-level socioeconomic position (SEP). Diabetes and mammography are presented in this abstract due to space limitations. RESULTS: Annual HbA1c testing among persons with diabetes decreased from 90.9% in 2019 to 88.0% in 2020. Performance of HbA1c tests during lockdown months was as low as half the usual amount. There were compensatory increases in testing during post-lockdown months that did not quite make up for the missed tests. In 2019, 9.0% of Israelis with diabetes had poor glycemic control (HbA1c ≥ 9.0); in 2020, it was 8.8%. In total, 4.5% fewer mammograms were performed in 2020 compared with 2019. Women in the lowest SEP level performed 10.4% fewer mammograms in 2020 than in 2019, while women in the highest SEP level performed 3.1% more mammograms. CONCLUSIONS: Prolonged COVID lockdowns in 2020 were associated with marked decreases in the performance of preventive health services during those months. Compensatory spikes following the end of lockdowns partly, but did not completely, make up for the missed care. COVID lockdowns may have exacerbated socioeconomic disparities in some preventive health services.

Health Services and Primary Care Research Study: Comprehensive Report.

This study presents the results of a congressionally mandated, independent assessment of federally funded health services research (HSR) and primary care research (PCR) spanning the U.S. Department of Health and Human Services (HHS) and U.S. Department of Veterans Affairs (VA) from FYs 2012 to 2018. Through technical expert panels, stakeholder interviews, and a systematic environmental scan of research grants and contracts funded by HHS and the VA, the authors characterize the distinct contributions of agencies in these departments to the federal HSR and PCR enterprise. The authors also identify opportunities to improve detection and coordination of overlap in agency research portfolios, the impacts of HSR and PCR and how they cumulate across research portfolios, and gaps in research funding, methods, and dissemination. The authors offer recommendations to maximize the outcomes and value of future investments in federal HSR and PCR to better guide and serve the needs of a complex and rapidly changing U.S. health care system.

Considering Quality Measures for the Care of Transgender Patients: Preliminary Findings from a Technical Expert Panel.

Purpose: Transgender (TG) individuals are a historically understudied and underserved patient population. Although clinical guidelines for the care of TG patients exist, quality measures (QMs) specific to this population are lacking. The goal of this study was to obtain expert input on aspects of care for which quality measurement may be appropriate and describe feedback on candidate QMs. Methods: We convened a virtual technical expert panel in September 2020 with six experts in TG medical care. Experts participated in a guided discussion and provided numeric ratings on dimensions of measure suitability (importance, validity/reliability, feasibility, and ease of understanding) for eight candidate QMs spanning multiple care domains (e.g., laboratory testing/monitoring, cancer screening, and sexually transmitted infection screening). Results: Panelists acknowledged high importance and potential to improve care for some candidate QMs, particularly those related to laboratory testing before initiating and during hormone therapy. Numeric ratings of QMs varied but tended to be higher for testing-focused QMs. Experts raised concerns about overly prescriptive language for some QMs and emphasized the importance of considering more flexible specifications to accommodate diverse care scenarios-including care provided to nonbinary individuals-and align with the individualized nature of gender-affirming care. Conclusion: These preliminary findings support a potential role for QMs in improving quality of care for TG patients. Measures related to laboratory testing/monitoring for patients who receive or plan to initiate hormone therapy may be feasible and promising to explore in the future. Additional larger-scale efforts are needed to develop and test QMs for the care of TG individuals.

Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults.

Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals.