Health Outcomes and Healthcare Use Among Transgender Veterans

 描述（由申请人提供）： 大约有100万退伍军人被认定为女同性恋、男同性恋、双性恋或变性人（LGBT），而健康公平--无论性别或性取向如何--是第一个目标中的一个具体目标。 退伍军人健康管理局（VHA）2013-2018年战略计划的目标。LGBT人群的健康风险因素普遍存在（例如，药物使用、暴力、护理障碍），以及 他们在几种身体和精神状况上经历差异（例如，精神疾病、某些癌症、丙型肝炎（HCV）、艾滋病毒和自杀）。认识到需要为退伍军人谁是LGBT，VA颁布指令2013-003，概述了医疗保健提供LGBT个人的亚群：变性退伍军人。然而，VA对这一少数群体的社会人口统计学、健康状况和医疗保健利用情况知之甚少。我以前的工作开始通过确定跨性别退伍军人的亚群来解决VA在LGBT健康公平研究方面的差距：那些被诊断患有性别认同障碍（GID）的人。我的长期职业目标是成为一名独立的VA健康服务调查员，专注于提高LGBT退伍军人的健康和医疗保健的质量和公平性。我的CDA-2期间的近期目标是（1）获得卫生服务研究技能，以绘制跨性别退伍军人之间的健康差距的景观，（2）创建证据库，从中制定干预和实施研究计划，以解决跨性别健康差距，（3）与业务合作伙伴合作，以解决弗吉尼亚州内的LGBT健康问题，和（4）开发一个跨性别退伍军人的健康公平研究基础设施，可以扩展到包括对LGB退伍军人的研究。我的职业生涯计划的四个关键要素，以实现我的CDA-2的目标是（1）学习制定，管理和卫生服务研究的传播;使用电子病历数据和复杂的纵向统计分析和数据管理;（2）提高定量技能与纵向数据管理，分析和收集;（3）获得定性研究方法的高级技能，包括半结构化访谈协议，编码和分析;（4）获得跨性别退伍军人医疗保健干预和实施科学举措的发展知识。对于目标1，我将比较患者水平的差异（例如，人口统计学、医学、精神病学和行为状况），系统级（例如，医疗中心教学状况）和社区一级（例如，农村地位）的健康决定因素之间的变性人（n=6,308）退伍军人和对照组的非变性退伍军人（n=18,924）。在目标2中，我将研究跨性别和非跨性别退伍军人的医疗服务利用率，护理指标的质量和死亡率。对于目标3，我将进行半结构化访谈与变性退伍军人和VA临床医生谁提供变性健康服务，探索变性退伍军人和VA提供者的经验与VA医疗保健，改善护理领域，并战略从事研究变性退伍军人。为了指导具体分析的建议，干预措施的制定，以及基于研究结果的政策影响，我将建立一个由6名方法专家和VA运营伙伴组成的咨询委员会，他们在VHA LGBT问题上具有专业知识。作为健康公平研究和促进中心（CHERP-HSR&D COIN）的博士后研究员，我处于健康服务研究指导和培训的理想环境中，我与VA患者护理服务办公室和VA公共卫生办公室的运营合作伙伴关系密切。该CDA将产生第一代和第二代差异研究，为未来质量改进项目的下一步和未来HSR&D Merit Review研究提供基础，以开发和测试患者水平的干预措施（例如，为降低自杀风险而定制的程序）或提供者或系统级干预（例如，临床教育和培训），以改善健康和 照顾变性退伍军人。

 DESCRIPTION (provided by applicant): Approximately 1 million Veterans identify as lesbian, gay, bisexual, or transgender (LGBT), and health equity - irrespective of gender or sexual orientation - is a specific objective in the first goal of the Veteran Health Administration (VHA) Strategic Plan 2013-2018. LGBT individuals have high prevalence of health risk factors, (e.g., substance use, violence, barriers to care), and they experience disparities in several physical and mental conditions (e.g., mental illnesses, certain cancers, hepatitis C (HCV), HIV, and suicide). Recognizing the need to serve Veterans who are LGBT, VA promulgated Directive 2013-003, outlining healthcare provision for a subpopulation of LGBT individuals: transgender Veterans. Yet, VA knows little about the socio-demographics, health conditions, and healthcare utilization of this minority population. My prior work began addressing VA's gaps in LGBT health equity research by identifying a sub-population of transgender Veterans: those diagnosed with Gender Identity Disorder (GID). My long-term career goal is to become an independent VA health services investigator focused on improving the quality and equity of health and health care for LGBT Veterans. My immediate goals for the CDA-2 period are (1) to acquire the health services research skills to map the landscape of health disparities among transgender Veterans, (2) to create the evidence base from which to develop intervention and implementation research initiatives to address transgender health disparities, (3) to collaborate with operational partners to address LGBT health issues within VA, and (4) to develop a health equity research infrastructure with transgender Veterans that can expand to include research on LGB Veterans. The four key elements of my career plan to achieve my CDA-2 goals are (1) learn the formulation, administration, and dissemination of health services research; using electronic medical record data and complex longitudinal statistical analysis and data management; (2) improve quantitative skills with longitudinal data management, analysis, and collection; (3) acquire advanced skills in qualitative research methodology, including semi-structured interview protocols, coding, and analysis; and (4) gain knowledge in the development of intervention and implementation science initiatives for transgender Veterans' health care. For Aim 1, I will compare differences in patient-level (e.g., demographics, medical, psychiatric, and behavioral conditions), system-level (e.g., Medical Center teaching status), and community-level (e.g., rural status) determinants of health among transgender (n=6,308) Veterans and comparison group of non-transgender Veterans (n=18,924). In Aim 2, I will examine health services utilization, quality of care metrics, and mortality over time among transgender and non-transgender Veterans. For Aim 3, I will conduct semi-structured interviews with transgender Veterans and VA clinicians who provide transgender health services to explore transgender Veterans' and VA providers' experiences with VA health care, areas of improvement in care, and strategies to engage transgender Veterans in research. To guide recommendation for specific analyses, development of interventions, and policy implications based on study findings, I will develop a 6-member advisory board of methodology experts and VA operational partners with expertise in VHA LGBT issues. As a postdoctoral fellow with the Center for Health Equity Research and Promotion (CHERP-HSR&D COIN), I am in an ideal environment for health services research mentorship and training, and I have strong relationships with operational partners in the VA Office of Patient Care Services and VA Office of Public Health. This CDA will produce the first- and second-generation disparities research to provide the foundation for next steps of future quality improvement projects and future HSR&D Merit Review research to develop and test patient- level interventions (e.g., programs tailored to reduce suicide risk) or provider- or system-level interventions (e.g., clinical education and training) to improve the health and health care for transgender Veterans.