Digital health outreach to promote postpartum screening after gestational diabetes: A randomized factorial pilot study

Objective

We examined the acceptability and feasibility of a multi-component digital health outreach intervention to promote uptake of guideline-recommended postpartum screening for type 2 diabetes among patients with gestational diabetes (GDM).

Methods

We conducted a 24 randomized factorial experiment as part of the Multiphase Optimization Strategy (MOST) preparation phase for developing behavioral interventions. Participants with current or recent GDM in an integrated healthcare system were randomized to receive an outreach message with up to four intervention components, designed to be self-administered in about 10 min and efficiently delivered online via REDCap: a streamlined values affirmation, personalized information on diabetes risk, an interactive motivational interviewing-based component, and an interactive action planning component. Patient-reported acceptability and feasibility outcomes were assessed via survey.

Results

Among 162 participants, 72% self-identified with a racial/ethnic minority group. Across components, acceptability scores averaged 3.9/5; ≥91% of participants read most or all of the outreach message; ≥89% perceived the amount of information as "about right"; and ≥ 87% completed ≥1 interactive prompt.

Conclusion

Each intervention component was acceptable to diverse patients and feasible to deliver in a brief, self-directed, online format.

Innovation

These novel components target unaddressed barriers to patient engagement in guideline-recommended postpartum diabetes screening and adapt theory-based behavior change techniques for large-scale use.

Telemedicine's Impact on Diabetes Care during the COVID-19 Pandemic: A Cohort Study in a Large Integrated Healthcare System

Introduction

To examine if patients exposed to primary care telemedicine (telephone or video) early in the COVID-19 pandemic had higher rates of downstream HbA1c measurement and improved HbA1c levels in the second year of the pandemic.

Research Design and Methods

In a cohort of 242, 848 Kaiser Permanente Northern California patients with diabetes, we examined associations between early-pandemic patient-initiated telemedicine visit and downstream HbA1c monitoring and results during the second year of the pandemic.

Results

Adjusted HbA1c measurement rates were significantly higher among patients with telemedicine exposure in the early-pandemic prior year than those with no visits in the prior year (91.0% testing for patients with video visits, 90.5% for telephone visits, visits, 86.7% for no visits, p < 0.05). Among those with HbA1c measured, the rates of having an HbA1c < 8% in the second year of the COVID-19 pandemic were also statistically significantly higher among patients with telemedicine exposure in the early-pandemic prior year than those with no visits in the prior year (68.5% with HbA1c< 8% for video visits, 67.3% for telephone visits, 66.6% for no visits, p < 0.05).

Conclusions

Access to telephone and video telemedicine throughout the early COVID-19 pandemic was associated with patients' continued engagement in recommended diabetes care. Although our study analyzed telemedicine use during a pandemic, telemedicine visits may continue to support ongoing health care access and positive clinical outcomes.

Intrinsic motivation for physical activity, healthy eating, and self-weighing in association with corresponding behaviors in early pregnancy

Healthy lifestyle behaviors influence maternal cardiovascular health, but motivation for them in pregnancy is poorly understood. We examined whether intrinsic motivation (assessed on 5-point scales for each behavior) is associated with three lifestyle behaviors in early pregnancy: physical activity, by intensity level; healthy eating, quantified with the Alternate Healthy Eating Index for Pregnancy (AHEI-P); and weight self-monitoring, a standard weight management technique. Participants in the Northern California Pregnancy, Lifestyle and Environment Study (PETALS) population-based cohort completed validated surveys in early pregnancy (2017-18; N = 472; 22 % Asian, 6 % Black, 30 % Hispanic, 13 % multiracial, 30 % White). Cross-sectional data were analyzed in 2021-22. Overall, 40.7 % (n = 192) met United States national physical activity guidelines; the average AHEI-P score was 62.3 out of 130 (SD 11.4); and 36.9 % reported regular self-weighing (≥once/week; n = 174). In models adjusted for participant characteristics, 1-unit increases in intrinsic motivation were associated with increased likelihood of meeting physical activity guidelines (risk ratio [95 % CI]: 1.66 [1.48, 1.86], p < 0.0001); meeting sample-specific 75th percentiles for vigorous physical activity (1.70 [1.44, 1.99], p < 0.0001) and AHEI-P (1.75 [1.33, 2.31], p < 0.0001); and regular self-weighing (2.13 [1.92, 2.37], p < 0.0001). A 1-unit increase in intrinsic motivation lowered the risk of meeting the 75th percentile for sedentary behavior (0.79 [0.67, 0.92], p < 0.003). Intrinsic motivation was not associated with reaching 75th percentiles for total, light, or moderate activity. Intrinsic motivation is associated with physical activity, healthy eating, and self-weighing among diverse individuals in early pregnancy. Results can inform intervention design to promote maternal health via increased enjoyment of lifestyle behaviors.

Patient-reported Primary Care Video and Telephone Telemedicine Preference Shifts During the COVID-19 Pandemic

BACKGROUND

Patient perceptions of primary care telephone and video telemedicine and whether COVID-19 pandemic-related telemedicine exposure shifted patients' visit preference is unknown.

OBJECTIVES

We examined patient surveys to understand the health care experience of patients seeking primary care through telemedicine and how patients expected their preferences to shift as a result of the COVID-19 pandemic.

RESEARCH DESIGN/SUBJECTS

In an integrated delivery system that shifted to a "telemedicine-first" health care model during the COVID-19 pandemic, we sampled monthly and collected 1000 surveys from adults with primary care telemedicine visits scheduled through the online patient portal between 3/16/2020 and 10/31/2020.

MEASURES

Participants reported their preferred primary care visit modality (telephone, video, or in-person visits) across 3 time points: before, during and (hypothetically) after the COVID-19 pandemic, and reported their general assessment of primary care visits during the pandemic.

RESULTS

The majority of participants preferred in-person visits before (69%) and after the COVID-19 pandemic (57%). However, most participants reported a preference for telemedicine visits during the pandemic and continue to prefer telemedicine visits at a 12% higher rate post-pandemic. Many participants (63%) expressed interest in using telemedicine at least some of the time. Among participants reporting a recent telemedicine visit, 85% agreed that the visit addressed their health needs.

CONCLUSION

As primary care visit modality preferences continue to evolve, patients anticipate that they will continue to prefer telemedicine visits, both video and telephone, at an increased rate than before the COVID-19 pandemic.

Telemedicine Versus In-Person Primary Care: Treatment and Follow-up Visits

BACKGROUND

Beyond initial COVID-19 pandemic emergency expansions of telemedicine use, it is unclear how well primary care telemedicine addresses patients' needs.

OBJECTIVE

To compare treatment and follow-up visits (office, emergency department, hospitalization) between primary care video or telephone telemedicine and in-person office visits.

DESIGN

Retrospective design based on administrative and electronic health record (EHR) data.

SETTING

Large, integrated health care delivery system with more than 1300 primary care providers, between April 2021 and December 2021 (including the COVID-19 pandemic Delta wave).

PATIENTS

1 589 014 adult patients; 26.5% were aged 65 years or older, 54.9% were female, 22.2% were Asian, 7.4% were Black, 22.3% were Hispanic, 46.5% were White, 21.5% lived in neighborhoods with lower socioeconomic status, and 31.8% had a chronic health condition.

MEASUREMENTS

Treatment outcomes included medication or antibiotic prescribing and laboratory or imaging ordering. Follow-up visits included in-person visits to the primary care office or emergency department or hospitalization within 7 days. Outcomes were adjusted for sociodemographic and clinical characteristics overall and stratified by clinical area (abdominal pain, gastrointestinal concerns, back pain, dermatologic concerns, musculoskeletal pain, routine care, hypertension or diabetes, and mental health).

RESULTS

Of 2 357 598 primary care visits, 50.8% used telemedicine (19.5% video and 31.3% telephone). After adjustment, medications were prescribed in 46.8% of office visits, 38.4% of video visits, and 34.6% of telephone visits. After the visit, 1.3% of in-person visits, 6.2% of video visits, and 7.6% of telephone visits had a 7-day return in-person primary care visit; 1.6% of in-person visits, 1.8% of video visits, and 2.1% of telephone visits were followed by an emergency department visit. Differences in follow-up office visits were largest after index office versus telephone visits for acute pain conditions and smallest for mental health.

LIMITATIONS

In the study setting, telemedicine is fully integrated with ongoing EHRs and with clinicians, and the study examines an insured population during the late COVID-19 pandemic period. Observational comparison lacks detailed severity or symptom measures. Follow-up was limited to 7 days. Clinical area categorization uses diagnosis code rather than symptom.

CONCLUSION

In-person return visits were somewhat higher after telemedicine compared with in-person primary care visits but varied by specific clinical condition.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Abstract MP72: Intrinsic Motivation is Associated With Greater Physical Activity and Less Sedentary Behavior During Early Pregnancy

Background: National guidelines recommend physical activity (PA) during pregnancy for optimal cardiovascular and overall health. Yet most individuals do not engage in sufficient PA and motivation for PA during pregnancy is poorly understood.

Methods: We examined intrinsic motivation for PA (i.e., engaging in activity for enjoyment or satisfaction) and its cross-sectional associations with PA, by intensity level, in the first trimester of pregnancy. Data come from the Pregnancy, Lifestyle and Environment Study (PETALS), a population-based cohort study set in an integrated health system. Following recruitment at 10-13 weeks’ gestation, participants ( N =472; 71% from racial/ethnic groups other than White) completed the validated Behavioral Regulation in Exercise Questionnaire-2 (BREQ-2, intrinsic subscale); and Pregnancy Physical Activity Questionnaire (PPAQ) to estimate typical PA in the prior 2 months, as expressed in MET [metabolic equivalent] hours/week (by intensity and, for MVPA, by domain—i.e., limited to intentional activity such as sports, walking, aerobic exercise, etc.). Data were collected in 2017-18.

Results: As hypothesized, intrinsic motivation was higher among those who met ( n =192, 40.7%) vs. did not meet national guidelines for 150 minutes/week of moderate-to-vigorous intensity PA (MVPA; mean BREQ-2 scores [SD]: 2.84 [0.89] vs. 1.94 [1.02], p <0.0001). Likewise, intrinsic motivation was higher among those who scored at or above ( n =131, 27.8%) vs. below the sample-specific 75 th percentile for vigorous PA (2.86 [0.93] vs. 2.09 [1.03], p <0.0001); and lower among those who scored at or above ( n =119, 25.2%) vs. below the 75 th percentile for sedentary behavior (1.99 [1.14] vs. 2.41 [1.01], p =0.0005). Intrinsic motivation was not associated with reaching the 75 th percentiles for total, light, or moderate PA. In modified Poisson regression models adjusted for age, pre-pregnancy body mass index, race/ethnicity, education, and parity, a 1-unit increase in BREQ-2 score was associated with an increased probability of meeting or exceeding MVPA guidelines (rate ratio [95% CI]: 1.66 [1.48, 1.86]) and scoring at or above the 75 th percentile for vigorous PA (1.70 [1.44, 1.99]). A 1-unit increase in BREQ-2 score decreased the probability of scoring at or above the 75 th percentile for sedentary behavior (0.79 [0.67, 0.92]).

Conclusions: Only 4 in 10 participants met national guidelines for MVPA in the first trimester of pregnancy. Intrinsic motivation was associated with greater MVPA and vigorous PA, and less sedentary behavior, in this diverse sample. Intrinsic motivation is potentially modifiable and thus a promising target for new behavioral interventions to improve maternal cardiovascular health.

Primary care video and telephone telemedicine during the COVID-19 pandemic: treatment and follow-up health care utilization

OBJECTIVES

Telemedicine use expanded greatly during the COVID-19 pandemic, and broad use of telemedicine is expected to persist beyond the pandemic. More evidence on the efficiency and safety of different telemedicine modalities is needed to inform clinical and policy decisions around telemedicine use. To evaluate the efficiency and safety of telemedicine, we compared treatment and follow-up care between video and telephone visits during the COVID-19 pandemic.

STUDY DESIGN

Observational study of patient-scheduled telemedicine visits for primary care.

METHODS

We used multivariate logistic regression to compare treatment (medication prescribing, laboratory/imaging orders) and 7-day follow-up care (in-person office visits, emergency department visits, and hospitalizations) between video and telephone visits, adjusted for patient characteristics.

RESULTS

Among 734,442 telemedicine visits, 58.4% were telephone visits. Adjusted rates of medication prescribing and laboratory/imaging orders were higher in video visits than telephone visits, with differences of 3.5% (95% CI, 3.3%-3.8%) and 3.9% (95% CI, 3.6%-4.1%), respectively. Adjusted rates of 7-day follow-up in-person office visits, emergency department visits, and hospitalizations were lower after video than telephone visits, with differences of 0.7% (95% CI, 0.5%-0.9%), 0.3% (95% CI, 0.2%-0.3%), and 0.04% (95% CI, 0.02%-0.06%), respectively.

CONCLUSIONS

Among telemedicine visits with primary care clinicians, return visits were not common and downstream emergency events were rare. Adjusted rates of treatment measures were higher and adjusted rates of follow-up care were lower for video visits than telephone visits. Although video visits were marginally more efficient than telephone visits, telephone visits may offer an accessible option to address patient primary care needs without raising safety concerns.

Primary care telemedicine during the COVID-19 pandemic: patient’s choice of video versus telephone visit

The aim of this study is to examine the association between patient characteristics and primary care telemedicine choice among integrated delivery system patients self-scheduling visits during the COVID-19 pandemic. We used multivariate logistic regression to examine the association between the choice of video versus telephone and patient sociodemographic characteristics and technology access among patient-initiated primary care telemedicine visits scheduled online from March to October 2020. Among 978 272 patient-scheduled primary care telemedicine visits, 39% were video visits. Patients of Black or Hispanic race/ethnicity, or living in low socioeconomic status or low internet access neighborhoods were less likely to schedule video visits. Patients 65 years or older, with prior video visit experience or mobile portal access, or visiting their own personal provider were more likely to schedule video visits. While video adoption was substantial in all patient groups examined, differences in telemedicine choice suggest the persistence of a digital divide, emphasizing the importance of maintaining a telephone telemedicine option.

Treatment and Follow-up Care Associated With Patient-Scheduled Primary Care Telemedicine and In-Person Visits in a Large Integrated Health System

IMPORTANCE

Telemedicine visits can offer patients convenient access to a clinician, but it is unclear whether treatment differs from that with in-person visits or how often patients require in-person follow-up.

OBJECTIVE

To examine whether physician prescribing and orders differ between telemedicine and office visits, whether physicians conducting telemedicine visits are more likely to require in-person follow-up, and whether telemedicine visits are associated with more health events.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included all patients who scheduled primary care appointments through the patient portal of a large integrated health care delivery system newly implementing patient-scheduled video telemedicine visits from January 2016 to May 2018.

MAIN OUTCOMES AND MEASURES

Adjusted rates of any medication prescribed or laboratory tests or imaging ordered and rates of follow-up health care utilization (in-person visits, emergency department visits, and hospitalizations) within 7 days after the index visit, stratified by index primary care visit type, were generated using multivariable adjustment for patient, access, and clinical characteristics.

RESULTS

This study included 1 131 722 patients (611 821 [54%] female; mean [SD] age, 43 [22] years) with 2 178 440 total appointments (307 888 [14%] telemedicine), of which 13.5% were for patients younger than 18 years, 22.2% were for patients 65 years or older, and 54.9% were for female patients. After adjustment, 38.6% (95% CI, 38.0%-39.3%) of video visits, 34.7% (95% CI, 34.5%-34.9%) of telephone visits, and 51.9% (95% CI, 51.8%-52.0%) of office visits had any medication prescribed; laboratory tests or imaging were ordered for 29.2% (95% CI, 28.5%-29.8%) of video visits, 27.3% (95% CI, 27.1%-27.5%) of telephone visits, and 59.3% (95% CI, 59.3%-59.4%) of clinic visits. After adjustment, follow-up visits within 7 days occurred after 25.4% (95% CI, 24.7%-26.0%) of video visits, 26.0% (95% CI, 25.9%-26.2%) of telephone visits, and 24.5% (95% CI, 24.5%-24.6%) of office visits. Adjusted emergency department visits and rates of hospitalizations were not statistically significantly different by primary care index visit type.

CONCLUSIONS AND RELEVANCE

In this cohort study of patient self-scheduled primary care telemedicine visits within ongoing patient-physician relationships, prescribing and orders were significantly lower for telemedicine visits than for clinic visits, with slightly higher follow-up office visits for telemedicine but no difference in health events (emergency department visits or hospitalizations). Video or telephone visits may be a convenient and efficient way to access primary care and address patient needs.

Agreement between medical records and self-reports: Implications for transgender health research

A key priority of transgender health research is the evaluation of long-term effects of gender affirmation treatment. Thus, accurate assessment of treatment receipt is critical. The data for this analysis came from an electronic medical records (EMR) based cohort of transgender individuals. A subset of cohort members were also asked to complete a self-administered survey. Information from the EMR was compared with survey responses to assess the extent of agreement regarding transmasculine (TM)/transfeminine (TF) status, hormone therapy receipt, and type of surgery performed. Logistic regression models were used to assess whether participant characteristics were associated with disagreement between data sources. Agreement between EMR and survey-derived information was high regarding TM/TF status (99%) and hormone therapy receipt (97%). Lower agreement was observed for chest reconstruction surgery (72%) and genital reconstruction surgery (84%). Using survey responses as the "gold standard", both chest and genital reconstruction surgeries had high specificity (95 and 93%, respectively), but the corresponding sensitivities were low (49 and 68%, respectively). A lower proportion of TM had concordant results for chest reconstruction surgery (64% versus 79% for TF) while genital reconstruction surgery concordance was lower among TF (79% versus 89% for TM). For both surgery types, agreement was highest among the youngest participants. Our findings offer assurance that EMR-based data appropriately classify cohort participants with respect to their TM/TF status or hormone therapy receipt. However, current EMR data may not capture the complete history of gender affirmation surgeries. This information is useful in future studies of outcomes related to gender affirming therapy.

Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study

BACKGROUND

Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use.

OBJECTIVE

To examine the incidence of these events in a cohort of transgender persons.

DESIGN

Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment.

SETTING

Kaiser Permanente in Georgia and northern and southern California.

PATIENTS

2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women.

MEASUREMENTS

VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts.

RESULTS

Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants.

LIMITATION

Inability to determine which transgender members received hormones elsewhere.

CONCLUSION

The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute and Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers

BACKGROUND

Understanding the magnitude of mental health problems, particularly life-threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth can lead to improved management of these conditions.

METHODS

Electronic medical records were used to identify a cohort of 588 transfeminine and 745 transmasculine children (3-9 years old) and adolescents (10-17 years old) enrolled in integrated health care systems in California and Georgia. Ten male and 10 female referent cisgender enrollees were matched to each TGNC individual on year of birth, race and/or ethnicity, study site, and membership year of the index date (first evidence of gender nonconforming status). Prevalence ratios were calculated by dividing the proportion of TGNC individuals with a specific mental health diagnosis or diagnostic category by the corresponding proportion in each reference group by transfeminine and/or transmasculine status, age group, and time period before the index date.

RESULTS

Common diagnoses for children and adolescents were attention deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios (95% confidence intervals [CIs]) for history of self-inflicted injury in adolescents 6 months before the index date ranged from 18 (95% CI 4.4-82) to 144 (95% CI 36-1248). The corresponding range for suicidal ideation was 25 (95% CI 14-45) to 54 (95% CI 18-218).

CONCLUSIONS

TGNC youth may present with mental health conditions requiring immediate evaluation and implementation of clinical, social, and educational gender identity support measures.

Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals

BACKGROUND

Transgender individuals sometimes seek gender confirmation treatments (GCT), including hormone therapy (HT) and/or surgical change of the chest and genitalia ("top" and "bottom" gender confirmation surgeries). These treatments may ameliorate distress resulting from the incongruence between one's physical appearance and gender identity.

AIM

The aim was to examine the degree to which individuals' body-gender congruence, body image satisfaction, depression, and anxiety differed by GCT groups in cohorts of transmasculine (TM) and transfeminine (TF) individuals.

METHODS

The Study of Transition, Outcomes, and Gender is a cohort study of transgender individuals recruited from 3 health plans located in Georgia, Northern California, and Southern California; cohort members were recruited to complete a survey between 2015-2017. Participants were asked about: history of GCT; body-gender congruence; body image satisfaction; depression; and anxiety. Participants were categorized as having received: (1) no GCT to date; (2) HT only; (3) top surgery; (4) partial bottom surgery; and (5) definitive bottom surgery.

OUTCOMES

Outcomes of interest included body-gender congruence, body image satisfaction, depression, and anxiety.

RESULTS

Of the 2,136 individuals invited to participate, 697 subjects (33%) completed the survey, including 347 TM and 350 TF individuals. The proportion of participants with low body-gender congruence scores was significantly higher in the "no treatment" group (prevalence ratio [PR] = 3.96, 95% CI 2.72-5.75) compared to the definitive bottom surgery group. The PR for depression comparing participants who reported no treatment relative to those who had definitive surgery was 1.94 (95% CI 1.42-2.66); the corresponding PR for anxiety was 4.33 (95% CI 1.83-10.54).

CLINICAL TRANSLATION

Withholding or delaying GCT until depression or anxiety have been treated may not be the optimal treatment course given the benefits of reduced levels of distress after undergoing these interventions.

CONCLUSIONS

Strengths include the well-defined sampling frame, which allowed correcting for non-response, a sample with approximately equal numbers of TF and TM participants, and the ability to combine data on HT and gender confirmation surgeries. Limitations include the cross-sectional design and the fact that participants may not be representative of the transgender population in the United States. Body-gender congruence and body image satisfaction were higher, and depression and anxiety were lower among individuals who had more extensive GCT compared to those who received less treatment or no treatment at all. Owen-Smith AA, Gerth J, Sineath RC, et al. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction and Mental Health in a Cohort Of Transgender Individuals. J Sex Med 2018;15:591-600.

Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people

PURPOSE

The Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population.

PARTICIPANTS

A stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016.

FINDINGS TO DATE

About 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%-5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers.

FUTURE PLANS

STRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg, polycythemia and bone density), overall and in relation to gender affirmation therapy.

Time to send the preemie home? Additional maturity at discharge and subsequent health care costs and outcomes

OBJECTIVE

To determine whether longer stays of premature infants allowing for increased physical maturity result in subsequent postdischarge cost savings that help counterbalance increased inpatient costs.

DATA SOURCES

One thousand four hundred and two premature infants born in the Northern California Kaiser Permanente Medical Care Program between 1998 and 2002.

STUDY DESIGN/METHODS

Using multivariate matching with a time-dependent propensity score we matched 701 "Early" babies to 701 "Late" babies (developmentally similar at the time the earlier baby was sent home but who were discharged on average 3 days later) and assessed subsequent costs and clinical outcomes.

PRINCIPAL FINDINGS

Late babies accrued inpatient costs after the Early baby was already home, yet costs after discharge through 6 months were virtually identical across groups, as were clinical outcomes. Overall, after the Early baby went home, the Late-Early cost difference was $5,016 (p<.0001). A sensitivity analysis suggests our conclusions would not easily be altered by failure to match on some unmeasured covariate.

CONCLUSIONS

In a large integrated health care system, if a baby is ready for discharge (as defined by the typical criteria), staying longer increased inpatient costs but did not reduce postdischarge costs nor improve postdischarge clinical outcomes.

Use of prolonged travel to improve pediatric risk-adjustment models

OBJECTIVE

To determine whether travel variables could explain previously reported differences in lengths of stay (LOS), readmission, or death at children's hospitals versus other hospital types.

DATA SOURCE

Hospital discharge data from Pennsylvania between 1996 and 1998.

STUDY DESIGN

A population cohort of children aged 1-17 years with one of 19 common pediatric conditions was created (N=51,855). Regression models were constructed to determine difference for LOS, readmission, or death between children's hospitals and other types of hospitals after including five types of additional illness severity variables to a traditional risk-adjustment model.

PRINCIPAL FINDINGS

With the traditional risk-adjustment model, children traveling longer to children's or rural hospitals had longer adjusted LOS and higher readmission rates. Inclusion of either a geocoded travel time variable or a nongeocoded travel distance variable provided the largest reduction in adjusted LOS, adjusted readmission rates, and adjusted mortality rates for children's hospitals and rural hospitals compared with other types of hospitals.

CONCLUSIONS

Adding a travel variable to traditional severity adjustment models may improve the assessment of an individual hospital's pediatric care by reducing systematic differences between different types of hospitals.

Virtual temporal bone: creation and application of a new computer-based teaching tool

The human temporal bone is a 3-dimensionally complex anatomic region with many unique qualities that make anatomic teaching and learning difficult. Current teaching tools have proved only partially adequate for the needs of the aspiring otologic surgeon in learning this anatomy. We used a variety of computerized image processing and reconstruction techniques to reconstruct an anatomically accurate 3-dimensional computer model of the human temporal bone from serial histologic sections. The model is viewed with a specialized visualization system that allows it to be manipulated easily in a stereoscopic virtual environment. The model may then be interactively studied from any viewpoint, greatly simplifying the task of conceptualizing and learning this anatomy. The system also provides for simultaneous computer networking that can bring distant participants into a single shared virtual teaching environment. Future directions of the project are discussed.

The virtual temporal bone

The human temporal bone is a 3-dimensionally complex portion of the skull that contains delicate and vital anatomic structures imbedded within dense bone. Current teaching tools have proven to be only marginally adequate for the needs of the aspiring otologic surgeon in learning this anatomy. A variety of image processing and reconstruction techniques were used to reconstruct an anatomically accurate 3-dimensional model of the human temporal bone from serial histologic sections. Using CAVE technology, the model can be manipulated in a stereoscopic virtual environment so that it can be studied from any viewpoint, greatly simplifying the task of learning this anatomy. Applications in surgical planning and Internet based teaching are discussed.

Web-based segmentation and display of three-dimensional radiologic image data

In many clinical circumstances, viewing sequential radiological image data as three-dimensional models is proving beneficial. However, designing customized computer-generated radiological models is beyond the scope of most physicians, due to specialized hardware and software requirements. We have created a simple method for Internet users to remotely construct and locally display three-dimensional radiological models using only a standard web browser. Rapid model construction is achieved by distributing the hardware intensive steps to a remote server. Once created, the model is automatically displayed on the requesting browser and is accessible to multiple geographically distributed users. Implementation of our server software on large scale systems could be of great service to the worldwide medical community.

Echocardographic features of papillary fibroelastoma and their consequences and management

Thirty-five percent of patients (5 of 15) were diagnosed with ischemic stroke from left-sided papillary fibroelastomas by diagnosis of exclusion, whereas 40% of patients (6 of 15) did not have ischemic stroke.

Transesophageal echocardiography-guided transvenous endomyocardial biopsy used to diagnose primary cardiac angiosarcoma

Primary cardiac tumors are rare clinical entities with the histologic diagnosis usually made from surgically obtained tissue or at postmortem examination. Transvenous endomyocardial biopsy has been used less frequently, under fluoroscopic or transthoracic echocardiographic guidance. In this case report, we utilized the transesophageal echocardiography to guide the endomyocardial biopsy from a right atrial tumor in a 35-year-old man.

ABC of medical computing. Keeping your computer healthy and legal

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ABC of medical computing. Hospital based computer systems

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ABC of medical computing. Computers in general practice--III

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ABC of medical computing. Computers in general practice--II

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ABC of medical computing. Computers in general practice--I

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ABC of medical computing. Using computers in clinical audit

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ABC of medical computing. Online searching

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ABC of medical computing. Linking your computer to the outside world

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ABC of medical computing. Getting your thoughts on paper

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ABC of medical computing. Choosing and installing software

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ABC of medical computing. Getting your computer up and running

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ABC of medical computing. Choosing a computer system

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ABC of medical computing. An introduction to computing in medical practice

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Wound healing and the aged patient

The aged patient is more susceptible to wound healing problems because of the interactions of body systems, environmental stresses, and disease with an aging process that takes place over many years. The multifactorial nature of wound healing in the elderly makes it difficult to determine whether observed healing problems are attributable to results of aging or other factors. Healing is affected by multiple factors in addition to patient age, which itself is not a dependable indicator of physiologic health. Some of these factors are disease, nutrition, perfusion, skin quality, environment, and individual responses to life events. It is particularly difficult for the aged patient to sustain the motivation to participate in care required during the healing process when cascading problems are allowed to build on the decreasing functions and reserve capacities of aging body systems and deplete available energy levels. Assessment of each individual is required because of the wide variety of aging changes and healing responses seen in aged patients. Compared with a younger adult, the aged patient generally heals well, following the same healing process but at a slower rate. Wound healing for the aged can be optimized through techniques of energy conservation, correction of existing problems, and management of risks related to aging and the individual patient. Healing problems are usually the result of decreases in systemic and local perfusion, decreases in the ability to ward off infection, and fragility of aging skin. The aged patient requires the same care as younger patients. It is more critical that this care be meticulously delivered with particular attention to care of intact skin, effects of chronic disease and medications, motivation, social habits, and discharge planning. Nurses can promote improved healing through the care they provide and by studying the progression of healing in aged patients.