Health Outcomes and Healthcare Use Among Transgender Veterans

 描述(由申请人提供)： 大约有100万退伍军人认为自己是女同性恋者、男同性恋者、双性恋者或变性人(LGBT)，健康平等--无论性别或性取向--是第一个明确的目标 2013-2018年退伍军人健康管理局(VHA)战略计划的目标。同性恋者、双性恋者、双性恋者和变性者有很高的健康风险因素(例如，药物使用、暴力、护理障碍)，以及 他们在几种身体和精神疾病(例如，精神疾病、某些癌症、丙型肝炎、艾滋病毒和自杀)方面存在差异。认识到有必要为LGBT退伍军人服务，退伍军人管理局颁布了2013-003号指令，概述了为LGBT人群：变性人退伍军人提供的医疗保健。然而，退伍军人管理局对这一少数群体的社会人口结构、健康状况和医疗保健利用情况知之甚少。我之前的工作开始解决退伍军人管理局在LGBT健康公平研究中的差距，确定了变性人退伍军人的一个亚群：那些被诊断为性别认同障碍(GID)的人。我的长期职业目标是成为一名独立的退伍军人健康服务调查员，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。我在CDA-2期间的近期目标是(1)获得卫生服务研究技能，以绘制变性人退伍军人之间的健康差距图景，(2)创建证据基础，以此为基础制定干预和实施研究举措，以解决变性人健康差距，(3)与业务合作伙伴合作，解决退伍军人中的LGBT健康问题，以及(4)与变性人退伍军人建立健康公平研究基础设施，该基础设施可以扩大到包括对LGB退伍军人的研究。我实现CDA-2目标的职业规划的四个关键要素是：(1)学习卫生服务研究的制定、管理和传播；使用电子病历数据和复杂的纵向统计分析和数据管理；(2)通过纵向数据管理、分析和收集提高量化技能；(3)获得定性研究方法方面的高级技能，包括半结构化访谈协议、编码和分析；以及(4)在为变性人的医疗保健制定干预和实施科学倡议方面获得知识。对于目标1，我将比较变性人(n=6,308)退伍军人和非变性人退伍军人(n=18,924)在患者层面(例如，人口统计学、医疗、精神和行为状况)、系统层面(例如，医疗中心的教学状况)和社区层面(例如，农村状况)健康决定因素的差异。在目标2中，我将研究变性人和非变性人退伍军人的卫生服务利用率、护理质量指标以及随时间推移的死亡率。对于目标3，我将对提供变性人健康服务的变性人退伍军人和退伍军人管理局临床医生进行半结构化访谈，以探索变性人退伍军人和退伍军人管理局提供者在退伍军人医疗保健方面的经验、护理方面的改进领域以及让变性人退伍军人参与研究的战略。为了指导基于研究结果的具体分析、干预措施的制定和政策影响的建议，我将建立一个由方法专家和具有VHA LGBT问题专业知识的退伍军人管理局业务合作伙伴组成的6人咨询委员会。作为健康公平研究和促进中心(CHEP-HSR&D COIN)的博士后研究员，我处于医疗服务研究导师和培训的理想环境中，我与弗吉尼亚州患者护理服务办公室和弗吉尼亚州公共卫生办公室的运营伙伴有着牢固的关系。这项CDA将产生第一代和第二代差异研究，为未来质量改进项目和未来HSR&D功绩回顾研究的下一步提供基础，以开发和测试患者级别的干预措施(例如，为降低自杀风险量身定做的计划)或提供者或系统级别的干预措施(例如，临床教育和培训)，以改善健康和健康 关爱变性退伍军人。

 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.