A Mixed Methods Study Describing the Quality of Healthcare Received by Transgender and Gender Nonconforming Patients at a Large Integrated Health System.

Transgender and gender nonconforming (TGNC) patients have been seeking medical care in higher numbers and have faced unique social, personal, and health issues that affect the quality of care they receive. The purpose of this study was to conduct a mixed-methods study to describe TGNC care at Kaiser Permanente Mid-Atlantic States, a large integrated health system. We used a transgender registry to describe a TGNC patient population and compared healthcare utilization between TGNC patients and non-TGNC patients. Four focus groups were also conducted among 28 patients. Atlas.ti software was used to code and analyze themes for the qualitative analysis. Among the 282 adults TGNC patients, the mean age was 32.6 years. Of the study sample, 59% were White, and 27% were Black. TGNC patients demonstrated an increased use of email/telephone visits and the online patient portal and more cancellations and no-shows compared to non-TGNC controls. Of the 28 TGNC patients who participated in the focus groups, 39% identified as female, 21% as a transman, and 18% as non-binary/genderqueer. Participants were predominantly White (68%), highly educated (74%), and reported use of hormones (89%). Themes that emerged from our qualitative analysis included: limited availability of TGNC information; positive and negative sentiments regarding patient-provider interactions; issues with case management; limited access to care; lack of coordination of care; negative staff experiences. We identified specific areas in a health system to improve the quality of care of TGNC patients, including specific TGNC training for providers and staff, a source of TGNC information/resources, and hiring and training TGNC-specific case managers.

A Tobacco-Free Medical Campus Policy is Associated With Decreased Secondhand Smoke Exposure and Increased Satisfaction Among Military Medical Employees: Results of a Mixed-Methods Evaluation.

INTRODUCTION: Tobacco control is an ongoing concern for the U.S. Army. Although tobacco use is currently prohibited within all military hospitals and clinics, known as military treatment facilities (MTFs), no such facility had implemented a tobacco-free medical campus (TFMC) policy before 2012. This evaluation examined the effects of one Army installation's TFMC policy implementation at its medical facilities. MATERIALS AND METHODS: Online questionnaires were distributed to medical campus employees, including Active Duty Soldiers, civilians, and contractors, before policy implementation (N = 1,210) and 12 months following policy implementation (N = 1,147). Chi-square analyses, independent t tests, and logistic regression models were utilized to examine pretest/post-test changes in employees' secondhand smoke (SHS) exposure; tobacco use, motivation to quit, and cessation; and health outcomes. Twenty-three focus groups, interviews, and informal discussions with 65 employees and patients were conducted 13 months after initial policy implementation to capture both the intended and unintended policy effects. RESULTS: After controlling for demographic characteristics, the study found that employees had more than twice the odds of exposure to SHS in the workplace at baseline than at 12-month follow-up (odds ratio: 2.06, 95% confidence interval: 1.73-2.46, p < 0.001). Employees also reported a lower prevalence of diagnosis with chronic bronchitis (p < 0.05) at follow up compared to baseline. Although the mean number of sick days taken for respiratory illness decreased over time, results were not significant after controlling for demographic factors. No significant differences existed in tobacco-use prevalence or quit rates among tobacco users over time. Employees reported significantly higher levels of satisfaction with a TFMC policy than the original policy (p < 0.001) though this finding was moderated by smoker status such that smokers reported lower levels of satisfaction with the policy over time. Qualitative findings revealed that the most common policy effect was that the policy caused smokers to change the location of where they used tobacco to off campus. Findings further revealed several unintended policy effects, including safety concerns and greater visibility of smokers in front of the MTF. CONCLUSION: The first Army MTF TFMC policy was associated with reported reductions in SHS exposure and improvements in some short-term health outcomes. The policy had no observed association with tobacco-use prevalence, motivation to quit, or cessation at 12-month follow-up. Focus group participants discussed several positive and negative policy effects. These policies should be expanded and studied in more depth across military installations, and policy makers should plan mitigation strategies to reduce unintended effects. This is an important step in military tobacco control, but additional efforts will be necessary to curb tobacco use within this population.