News Release 

Annals publishes guide to caring for transgender patients

American College of Physicians

1. Annals publishes guide to caring for transgender patients

Barriers to accessing appropriate and culturally competent care contribute to health disparities

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0182

URLs go live when the embargo lifts

A new guide to caring for transgender patients aims to help clinicians understand the specific medical issues that are relevant to this population. This is vital because transgender patients face barriers to accessing appropriate and culturally competent care, which can lead to serious health disparities, such as increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases. The guide is published in Annals of Internal Medicine.

Transgender and gender-incongruent persons have gender identities that differ from their sex recorded at birth. As patients, they face disproportionate challenges in accessing health care services and may experience medical mistreatment. Historically, care for transgender patients was largely limited to select facilities, but improving access to medically and culturally competent care requires involvement of primary care providers and physicians outside such specialized settings. However, many providers and physicians may lack the knowledge needed to provide sensitive and appropriate care to their transgender patients.

The authors from Mount Sinai Health System and Icahn School of Medicine at Mount Sinai reviewed current evidence to develop "Care of the Transgender Patient." They provide clinicians with a detailed guide to initial evaluation, medical management, transgender-specific surgeries, laws and societal issues, and ways to improve practice. Each section includes helpful call-out boxes with terms and clinical pearls that the physician can integrate into practice. According to the authors, understanding their unique challenges will help clinicians to provide better care to their transgender patients.

The authors say that while health care can be a politically-charged topic, the mainstream medical community is more concerned with learning about best practices to provide appropriate health care services to this vulnerable patient population. The American College of Physicians (ACP), the largest medical specialty organization in the world, comprised of the largest number of primary care physicians, is publishing this guide in Annals of Internal Medicine to help its member physicians provide quality care to transgender individuals and to understand areas where future research is needed.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Joshua Safer, MD, please contact Kathryn Ullman at Kathryn.Ullman@mountsinai.org.

2. Residing in a disadvantaged neighborhood and being discharged from a hospital that serves many patients in such neighborhoods are independently associated with increased risk for hospital readmission

Programs that penalize safety-net hospitals serving a large proportion of disadvantaged patients may need refinement.

Abstract: http://annals.org/aim/article/doi/10.7326/M16-2671

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1510

URLs go live when the embargo lifts

In Maryland, living in a disadvantaged neighborhood and being discharged from a hospital serving patients from disadvantaged neighborhoods are each independently associated with increased risk for readmission. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Researchers from the Maryland Health Services Cost Review Commission and the University of Wisconsin studied hospital records for all Maryland residents discharged from a hospital in 2015 to examine whether readmission risk was associated with the area deprivation index (ADI) of the patient's residence and/or the average ADI of patients at the hospital providing treatment. The analysis used data from Maryland, which has a unique hospital rate-setting system, one of whose aims is to decrease financial risks for hospitals that serve disadvantaged patients.

The researchers found that residing in a disadvantaged neighborhood and being discharged from a hospital serving a large proportion of disadvantaged neighborhoods are independently associated with increased risk for readmission. According to the authors, these findings have practical implications. First, clinicians should be aware that the neighborhoods in which patients live and which the hospital serves are associated with readmission, an important clinical outcome. Second, although modest, these effects are similar to the national differences between hospitals that were penalized and those that were not. Third, the association of a hospital's safety-net index with readmission rates is substantial even though operating profit margins are higher in Maryland hospitals with a high safety-net index. Fourth, the association of a patient's neighborhood disadvantage with risk for readmission remains highly significant even after adjustment for hospital safety-net index. The study was funded in part by the National Institute on Minority Health and Health Disparities.

According to the authors of an accompanying editorial from the Health Resources and Services Administration, U.S. Department of Health and Human Services, the study may actually underestimate readmission rates. This is because the hospital safety-net index is derived from neighborhood disadvantage scores, and controlling for the safety-net index dilutes the overall effect of neighborhood ADI.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Stephen F. Jencks, MD, MPH, please contact him directly at steve.jencks@comcast.net.

3. Self-management strategies may modestly improve outcomes for patients with epilepsy

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0458

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1483

URLs go live when the embargo lifts

Limited evidence exists that self-management strategies modestly improve some patient outcomes important to persons with epilepsy. Findings from a systematic evidence review are published in Annals of Internal Medicine.

Epilepsy is one of the most common chronic neurologic conditions and has the potential to generate substantial morbidity, impaired quality of life, socioeconomic decline, and high health care costs. Seizure control and medication adherence are common challenges among patients. While self-management is recommended and programs are well-established for other chronic diseases, optimal strategies and the effects of self-management on patients with epilepsy are uncertain.

Researchers from Duke University Medical Center and the Durham Veterans Affairs Health System reviewed 15 published studies to evaluate the components and efficacy of self-management interventions for adults with epilepsy. They studied six general components of self-management: knowledge acquisition, independent symptom monitoring, medication management, enhancement of problem-solving and decision-making skills, safety promotion, and changes in health behaviors. The researchers found limited evidence that educational approaches may improve the use of self-management practices, and psychosocial therapy approaches may improve quality of life. Certainty is low to moderate that the interventions studied do not decrease seizure rates. Sparse evidence suggests that psychosocial therapy interventions may have a benefit on self-efficacy.

The author of an editorial from Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth suggests that the evidence is supportive of self-management strategies. However, despite the relatively low cost and supportive evidence, these strategies are underused. The hope is that U.S. insurance providers will begin to reimburse self-management strategies to encourage their use.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Matthew W. Luedke, MD, please contact Will Alexander at william.alexander@duke.edu.

Also new in this issue:

Sir William Osler: Would He Have Made His Relative Value Units (RVUs)?

Howard H. Weitz, MD

Ideas and Opinions

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0665

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