Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I wrap up my work for the summer, I am happy to reflect on my wonderful experiences. One of my greatest lessons from my mentors, Dr. Vineet Arora and Dr. Juan Rojas, is the development of a complete methods section and the careful necessity of approaching data and writing the abstract. I now realize the necessity of carefully maintaining a written account of how we approached the data, as it allows us to both communicate it to our audience and to look back on how to further organize it.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I wrap up my work for the summer, I am happy to reflect on my wonderful experiences. One of my greatest lessons from my mentors, Dr. Vineet Arora and Dr. Juan Rojas, is the development of a complete methods section and the careful necessity of approaching data and writing the abstract. I now realize the necessity of carefully maintaining a written account of how we approached the data, as it allows us to both communicate it to our audience and to look back on how to further organize it.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

As I wrap up my work for the summer, I am happy to reflect on my wonderful experiences. One of my greatest lessons from my mentors, Dr. Vineet Arora and Dr. Juan Rojas, is the development of a complete methods section and the careful necessity of approaching data and writing the abstract. I now realize the necessity of carefully maintaining a written account of how we approached the data, as it allows us to both communicate it to our audience and to look back on how to further organize it.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago. He received his bachelor of science degree in biology from Loyola University in Chicago in 2015 and his master of biomedical science degree from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

Lesbian, gay, bisexual and transgender (LGBT) populations face significant social stigmatization, discrimination, and marginalization that contribute to negative patient outcomes. Consequently, the LGBT population experiences high rates of mental health issues, such as suicide and depression, as well as sexually transmitted diseases (STDs), drug abuse, poverty, and homelessness.^1,2

Background

According to the CDC, gay men are at highest risk and have increased incidences of gonorrhea, chlamydia, herpes, human papilloma virus (HPV), and HIV.³ Lesbians and bisexual women are less likely to get preventive cancer screenings, such as Pap smears and mammograms, and have higher incidences of HIV, hepatitis C, self-reported gonorrhea, and are more likely to be overweight or obese.^3-6 In addition, LGBT populations have high rates of use of tobacco, alcohol, and other drugs.

The National Transgender Discrimination Survey of 6,450 transgender and nonconforming participants also provides extensive data on the challenges faced by transgender individuals. Discrimination was frequently experienced in accessing health care. Due to their transgender status, 19% were denied care, and 28% postponed care due to perceived harassment and violence within a health care setting.¹ The LGBT populations experience personal and structural barriers that interfere with their ability to access high-quality care. Sexual gender minority individuals also experience health care barriers due to isolation, insufficient social services, and a lack of culturally competent providers.⁴ At the same time, many health care providers (HCPs) experience various barriers to providing LGBT care and need to increase their cultural competence by improving awareness, receptivity, and knowledge.^7,8 One personal barrier to quality care is stigmatization toward LGBT persons as expressed through HCP prejudices, beliefs, attitudes, and behaviors.² Factors such as gender, race, and religious beliefs also influence attitudes to LGBT health care.

A study by Chapman and colleagues found significant differences in attitudes toward gay men by male and female medical and nursing students.⁹ Male students had a significantly more negative attitude toward gay men compared with the attitudes of female students. Cultural competence, defined in the study as gay affirmative action principles scores, were statistically significant and strongly correlated with negative attitudes. In this study there also was a statistically significant negative correlation between attitudes and knowledge scores indicating a considerable potential for personal values to influence the provision of health care.⁹

Various barriers inherent in the health care system restrict access to high-quality care. Institutional barriers that include a lack of legal recognition of same-sex partners, equality in visitation rights, and the ability of same-sex partners to access partner’s medical records hamper health care quality. The HCPs’ lack of knowledge of the health risks or health care needs of the LGBT population also present a structural barrier to quality of care and affects patient outcomes.²

Culturally competent interventions in health care delivery also have been studied to reduce LGBT health disparities. A systematic review of 56 studies by Butler and colleagues found that the term cultural competence was not well defined and often was denoted with the terms patient-centered or individualized care.¹⁰ A review on the impact of these interventions in LGBT populations also noted that the long-term effects of culturally competent interventions on health disparities in LGBT populations are still unknown.

The Joint Commission has identified the health and welfare of LGBT populations as a major priority. Beginning in 2012, The Joint Commission started assessing compliance with standards for cultural competence and patient-centered care for LGBT recipients as part of the accreditation criteria.¹¹ The Joint Commission recommended that health care facilities begin to transform the health care environment to be a more welcoming, safe, and inclusive environment for LGBT patients and their families.¹¹ Health care providers can play an important role in reducing the significant health disparities and unequal treatment.¹²

Problem Identification

Improving health outcomes and reducing health disparities are an important part of the HCP’s role. Yet, many HCPs lack the significant knowledge, skills, and cultural competencies needed to provide quality LGBT care.¹⁰ Evidence suggests that HCPs continue to receive little or no training to prepare them to manage this vulnerable population.¹⁰ Due to the growing evidence of health disparities and negative health outcomes affecting LGBT populations, the federal government has identified LGBT care and patient outcomes as a major health concern and priority under the Healthy 2020 goals.^2,4

About 3.5% (9 million) of the U.S. adult population are identified as lesbian, gay, or bisexual and 0.3% or 700,000 as transgender.^13,14 The VHA serves 9 million veterans at 1,245 facilities.¹⁵The 2000 census estimated that about 1 million veterans reported having same-sex partners.¹⁶The number of LGBTs in the VHA system is unknown because the VHA has not historically collected LGBT demographic data. The estimation of LGBT veterans that use the VHA is based on a proportion of the population of LGBT military service personnel and may not provide the best representation of LGBT veterans enrolled or seeking care in the VHA.¹⁷ By conservative estimates, about 134,000 veterans are thought to be transgender.¹⁴ Between 2006 and 2013, the reported prevalence and incidence of transgender-related diagnoses in the VHA have steadily increased with 40% of new diagnoses occurring since 2011.¹⁸ In fiscal year 2013, there were 32.9 per 100,000 veterans with transgender-related diagnoses, and the numbers are increasing.¹⁸

Because the cooperation of HCPs can play a significant part in reducing health disparities and unequal treatment in the care LGBT patients receive, the VHA launched several initiatives to create a more welcoming, inclusive, and empowering environment for LGBT veterans and families. Among the initiatives, VHA established the Office of Health Equity to address health disparities and ensure that patient-centered care is provided in a positive environment.^19,20 The VHA also issued a national directive mandating standardized services be provided for transgender veterans.²⁰

Despite these initiatives, obstacles remain to the delivery of patient-centered LGBT care at the VA. A first step to identifying barriers to patient-centered, high-quality care to LGBT veterans is to evaluate personal and institutional barriers as expressed through HCPs’ preceptions and knowledge about the health of LGBT patients. The magnitude of barriers to providing patient-centered care must first be identified and understood before institutional recommendations can be made and implemented at the facility or national level.

Methods

This study examined attitudes and knowledge about LGBT patient health among 45 primary care providers (PCPs) in 4 VA community-based outpatient clinics (CBOCs). The first clinical question examined whether PCPs desired more education and training on LGBT health. The second clinical question asked whether there were gender differences in attitudes among providers about the need for LGBT health education. Subsequently, the study’s findings are expected to be disseminated to VHA stakeholders to further examine HCP education and training needs on LGBT topics to facilitate improvement of HCP point of care behaviors, patient outcomes, and LGBT empowerment within the VHA environment.

The model presented in The Process of Cultural Competence in the Delivery of Healthcare Services by Campinha-Bacote provides an applicable conceptualization to guide HCPs’ actions toward delivering culturally responsive health care services to increasingly diverse health populations.²¹ The model defines cultural competence as an ongoing dynamic process of striving to effectively work within the cultural context of the client (person, family, or community). The model integrates 5 constructs that are fundamental to becoming culturally competent to provide appropriate culturally responsive care to diverse clients: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desires.²¹ The level of competence of the HCP is believed to have a direct relationship with their ability to provide culturally competent health care services. Table 1 provides the definitions of the 5 constructs and highlights the role of education and training in influencing competence in providing LGBT health services.²¹

This project used a descriptive, cross-sectional one-group design to target physicians, nurse practitioners (NPs), and physician assistants (PAs) at VA Southern Nevada Healthcare System (VASNHS) CBOCs. Participation in the project was voluntary. The duration of project from data collection to completion of analysis and summation of the results was 4 months. The study was approved by the institutional review board (IRB) at the University of Alabama in Huntsville, and it was exempt from the VA IRB.

The survey consisted of 74 questions, including 8 demographic questions and 66 LGBT-related questions. The survey instrument, renamed the Perception and Knowledge of Sexual and Gender Minority Health (PKSGMH) survey was adapted with permission from an original study by Jabson and colleagues and used its format without revision or restructuring.²²

Attitudinal questions asked personal opinions on LGBT orientation and gender identity (eAppendix:

Measures

The survey instrument integrated components of 4 different measures on attitudes and knowledge of LGBT health with questions about familiarity with organizational policies on discrimination, visitation, and staff training in LGBT care. The PKSGMH survey measured attitudes and knowledge levels on LGBT health by calculating the mean scores for each of 4 measures.

General Attitudes Toward LGBT Nonpatients. The attitudes toward LGBT nonpatients measure includes 4 subscales with 3 identical questions on how providers felt about LGBT individuals: (a) attitudes toward lesbians (α: .78); (b) attitudes toward gay men (α: .76); (c) attitudes toward bisexuals (α: 78); and (d) attitudes toward transgender people (α: .70). Each subscale used a 5-point Likert scale (5 = strongly agree).

Physician Attitudes Toward LGBT (ATLG) Patients. The attitudes toward LGBT scale assessed physicians’ feelings toward providing care to LGBT patients. This scale of 6 questions had modest reliability with a Cronbach α of .5. The measure used a 5-point Likert scale (5 = strongly agree). For this project, this scale was renamed the Provider subscale.

Knowledge of LGBT (KLGBT) Patients. The knowledge of LGBT patients’ scale included 13 true/false questions and had a Cronbach α of .74.

Gender and Sexual Minority Affirmative Practice (GSMAP). The GSMAP affirmative practice scale evaluated HCPs’ attitudes and beliefs about the treatment of LGBT patients. The 11-question measure with 2 subscales used a 5-point Likert scale with high reliability on the clinicians’ beliefs and behaviors subscales. Both subscales had a Cronbach α of .93 and .94, respectively.

Demographics and Data Analyses

Health care providers answered demographic questions about gender, sexual orientation, and marital status. They also were asked whether they had ever received any focused training in LGBT patient care. Descriptive and demographic data analyses were performed using SPSS version 24.0 (Armonk, New York). A significance level of P < .05 was used for all analyses. Analysis of variance (ANOVA) statistical analysis was conducted to evaluate the differences in mean scores between male and female PCP groups on the 4 attitudes toward LGBT subscales and the Provider subscale.

Results

Seventy-two PCPs participated in completing the PKSGMH survey. Fifty-seven surveys were returned; however, only 45 surveys were completely answered and included in the final analysis. Twelve surveys containing unanswered questions to the knowledge sections were excluded from the data analysis, and 14 distributed surveys were not returned. The overall response rate for completed surveys was 62.5% (Table 2).

Attitudes Toward Care

Attitudes about competence in providing LGBT care was answered in question 23 of the PKSGMH survey. Overall, a total of 51.1% (n = 23) of PCPs agreed that they were competentto provide LGBT care, and 15.5% (n = 7) disagreed. By gender, 50% (n = 9) of males said they were competent in providing LGBT care compared with 51.8% (n = 14) of females.

Analysis of variance was used to test for differences between groups on the 5 ATLG subscales (gay, lesbian, bisexual, transgender, provider) of the PKSGMH survey (Table 3). A grouping variable was created by separating participants by gender and by their responses to a question that asked about their desire for more education about the health care needs of LGBT patients. The grouping resulted in 4 groups: (1) males who responded yes to need for additional education; (2) males who responded no to need for additional education; (3) females who responded yes to need for additional education; and (4) females who responded no to need for additional education. Results of the ANOVA demonstrated significant differences between groups for the bisexual subscale (F = 3.005, df = 3, 32; P = .045), transgender subscale (F = 4.545, df = 3, 32; P = .009), and the provider subscale (F = 12.602, df = 3, 32; P < .001).

Knowledge of LGBT Care

Knowledge level responses among PCPs were not found to be statistically significant. However, 98% of PCPs agreed that practitioners should be knowledgeable about issues unique to LGBT patients and acquire the knowledge necessary to practice effectively. A review of answers to knowledge-specific questions in the KLGBT and GSMAP scales found more than 50% of PCPs responded correctly to true/false questions about prevalence of depression and anxiety, alcohol use, substance abuse, sexual transmitted infections, and physical and sexual trauma in LGBT patients. However, < 50% of the sample correctly answered true in 3 knowledge areas of LGBT health: increased prevalence of tobacco use; increased prevalence of obesity/overweight; and greater risk for chronic disease.

Discussion

Federal health care agencies consider the health and welfare of LGBT persons to be a health priority despite the lack of available science-based knowledge about this population.² In 2011, the National Academies of Medicine (NAM) noted that there are still research gaps concerning the well-being of LGBT individuals. The report stated that a significant contributor of health care inequities in LGBT patients is the lack of provider training and medical education.² A major recommendation of the NAM is that additional training and education is needed to reduce barriers and improve patient outcomes in the LGBT population.

Provider attitudes and education are among the gaps that contribute to inequities in the health care of LGBT populations as previously discussed. The findings from this survey suggest that PCPs in the VHA perceive that they have deficits in competencies and knowledge levels on LGBT care and that education influences attitudes toward LGBT care. The association between providers’ self-assessment of their competency and their knowledge and attitudes toward care for LGBT patients was not stated in the clinical question and was not investigated in this study.

An online search of 12,966 courses at the VA Talent Management System (TMS) was conducted to find web-based and/or instructor-led training courses focused on LGBT care. The search found 4 LGBT-focused courses that targeted physicians and nurses. Two 90-minute courses presented clinical and public health data on sexual health and addressed how providers can improve skills on taking sexual histories and incorporating these data into routine practice. Training and skills development in sexual history taking by clinicians is vital in reducing health disparities, such as STDs, and in helping LGBT patients feel more comfortable in accessing health care.⁴

A 1-hour TMS course focused on training HCPs to develop as researchers, teachers, and leaders in improving the LGBT veteran experience by providing competent care. Information on LGBT-related subjects, such as sexual and physical trauma and STDs, were included in the content of some online courses. However, no other comprehensive courses specifically focused on LGBT care. The only exceptions were the Specialty Care Access Network Extension of Community Healthcare outcome video conferencing-based sequential training on transgender care and the VA Lesbian, Gay and Bisexual Education sharepoint and the transgender education sharepoint. At the VA, online LGBT health training is still limited.

Recommendations

Providing additional LGBT-focused TMS courses could help increase provider knowledge and cultural competencies. An online introductory LGBT health course could be offered at VA facilities for all new employees and HCPs as part of employee orientation. More specific courses with continuing education credits geared toward the HCP and focused on LGBT health could be included in the TMS learning portfolio for each HCP as annual learning refresher courses. This course could include specific knowledge questions on LGBT care and a posttest with a required passing score of 80%.

Training HCPs as designated LGBT educators in VA facilities should be considered. Classroom training could be offered annually or during times of increased LGBT patient focus, such as during LGBT Pride month when learning activities can be planned and/or coordinated with the VA Office of Diversity and Inclusion. Nurses, social workers, pharmacists, and medical assistants who provide supportive care to LGBT patients also should be included in the target audience for LGBT health education and training.

Limitations

The use of a cross-sectional project design with such a small convenience sample prevents generalizability of the findings to all PCPs. The lack of a survey design that included randomization and blinding in survey distribution could certainly deter participants from offering candid responses, particularly to some attitudinal questions that were emotional in context. The true-false responses wherein respondents had a 50% chance at guessing the correct response was not the most reliable method of measuring knowledge levels and thereby limited the ability to draw any strong conclusions about providers’ knowledge levels. Additionally, the project design did not allow for measures of other confounding factors, such as age, race/ethnicity, religion, and other social factors that could have influenced how participants responded. Additional randomized controlled studies with larger samples are needed to test specific interventions that evaluate the influence of gender on provider attitudes and knowledge as well as the effect of more HCP education and training on LGBT patient outcomes. Moreover, a literature review found no guidelines on how to specifically address provider gender differences in LGBT education and training or strategies for education and training interventions to address these differences.

Conclusion

Findings suggest that PCPs need additional education and training involving LGBT health issues. Although both male and female providers want more education, female PCPs as a group expressed a greater desire for more training compared with the responses of male PCPs. However, given the study’s small sample size, a strong conclusion regarding gender differences cannot be made. Research has shown that education is a factor that positively influences attitudes and feelings about providing LGBT care. The availability of education and training that is focused on LGBT health topics is still limited within the VHA. Within its stated mission to provide patient-centered care to all veterans, the VHA’s Office of Health Equity has a specific objective for addressing LGBT health disparities and ensuring the delivery of standardized services to LGBT veterans.

Better training on LGBT health topics is vital to improving health care delivery to LGBT populations. To meet this goal, ongoing HCP training to improve attitudes and knowledge and develop the skills necessary to effectively address LGBT health issues also must be a priority at VHA facilities. The VHA also should consider institutional changes that incorporate increased LGBT-focused health education into the learning activities of PCPs. This is essential to evaluating the quality of care given the impact on patient outcomes and health disparities in LGBT populations.

Lesbian, gay, bisexual and transgender (LGBT) populations face significant social stigmatization, discrimination, and marginalization that contribute to negative patient outcomes. Consequently, the LGBT population experiences high rates of mental health issues, such as suicide and depression, as well as sexually transmitted diseases (STDs), drug abuse, poverty, and homelessness.^1,2

Background

According to the CDC, gay men are at highest risk and have increased incidences of gonorrhea, chlamydia, herpes, human papilloma virus (HPV), and HIV.³ Lesbians and bisexual women are less likely to get preventive cancer screenings, such as Pap smears and mammograms, and have higher incidences of HIV, hepatitis C, self-reported gonorrhea, and are more likely to be overweight or obese.^3-6 In addition, LGBT populations have high rates of use of tobacco, alcohol, and other drugs.

The National Transgender Discrimination Survey of 6,450 transgender and nonconforming participants also provides extensive data on the challenges faced by transgender individuals. Discrimination was frequently experienced in accessing health care. Due to their transgender status, 19% were denied care, and 28% postponed care due to perceived harassment and violence within a health care setting.¹ The LGBT populations experience personal and structural barriers that interfere with their ability to access high-quality care. Sexual gender minority individuals also experience health care barriers due to isolation, insufficient social services, and a lack of culturally competent providers.⁴ At the same time, many health care providers (HCPs) experience various barriers to providing LGBT care and need to increase their cultural competence by improving awareness, receptivity, and knowledge.^7,8 One personal barrier to quality care is stigmatization toward LGBT persons as expressed through HCP prejudices, beliefs, attitudes, and behaviors.² Factors such as gender, race, and religious beliefs also influence attitudes to LGBT health care.

A study by Chapman and colleagues found significant differences in attitudes toward gay men by male and female medical and nursing students.⁹ Male students had a significantly more negative attitude toward gay men compared with the attitudes of female students. Cultural competence, defined in the study as gay affirmative action principles scores, were statistically significant and strongly correlated with negative attitudes. In this study there also was a statistically significant negative correlation between attitudes and knowledge scores indicating a considerable potential for personal values to influence the provision of health care.⁹

Various barriers inherent in the health care system restrict access to high-quality care. Institutional barriers that include a lack of legal recognition of same-sex partners, equality in visitation rights, and the ability of same-sex partners to access partner’s medical records hamper health care quality. The HCPs’ lack of knowledge of the health risks or health care needs of the LGBT population also present a structural barrier to quality of care and affects patient outcomes.²

Culturally competent interventions in health care delivery also have been studied to reduce LGBT health disparities. A systematic review of 56 studies by Butler and colleagues found that the term cultural competence was not well defined and often was denoted with the terms patient-centered or individualized care.¹⁰ A review on the impact of these interventions in LGBT populations also noted that the long-term effects of culturally competent interventions on health disparities in LGBT populations are still unknown.

The Joint Commission has identified the health and welfare of LGBT populations as a major priority. Beginning in 2012, The Joint Commission started assessing compliance with standards for cultural competence and patient-centered care for LGBT recipients as part of the accreditation criteria.¹¹ The Joint Commission recommended that health care facilities begin to transform the health care environment to be a more welcoming, safe, and inclusive environment for LGBT patients and their families.¹¹ Health care providers can play an important role in reducing the significant health disparities and unequal treatment.¹²

Problem Identification

Improving health outcomes and reducing health disparities are an important part of the HCP’s role. Yet, many HCPs lack the significant knowledge, skills, and cultural competencies needed to provide quality LGBT care.¹⁰ Evidence suggests that HCPs continue to receive little or no training to prepare them to manage this vulnerable population.¹⁰ Due to the growing evidence of health disparities and negative health outcomes affecting LGBT populations, the federal government has identified LGBT care and patient outcomes as a major health concern and priority under the Healthy 2020 goals.^2,4

About 3.5% (9 million) of the U.S. adult population are identified as lesbian, gay, or bisexual and 0.3% or 700,000 as transgender.^13,14 The VHA serves 9 million veterans at 1,245 facilities.¹⁵The 2000 census estimated that about 1 million veterans reported having same-sex partners.¹⁶The number of LGBTs in the VHA system is unknown because the VHA has not historically collected LGBT demographic data. The estimation of LGBT veterans that use the VHA is based on a proportion of the population of LGBT military service personnel and may not provide the best representation of LGBT veterans enrolled or seeking care in the VHA.¹⁷ By conservative estimates, about 134,000 veterans are thought to be transgender.¹⁴ Between 2006 and 2013, the reported prevalence and incidence of transgender-related diagnoses in the VHA have steadily increased with 40% of new diagnoses occurring since 2011.¹⁸ In fiscal year 2013, there were 32.9 per 100,000 veterans with transgender-related diagnoses, and the numbers are increasing.¹⁸

Because the cooperation of HCPs can play a significant part in reducing health disparities and unequal treatment in the care LGBT patients receive, the VHA launched several initiatives to create a more welcoming, inclusive, and empowering environment for LGBT veterans and families. Among the initiatives, VHA established the Office of Health Equity to address health disparities and ensure that patient-centered care is provided in a positive environment.^19,20 The VHA also issued a national directive mandating standardized services be provided for transgender veterans.²⁰

Despite these initiatives, obstacles remain to the delivery of patient-centered LGBT care at the VA. A first step to identifying barriers to patient-centered, high-quality care to LGBT veterans is to evaluate personal and institutional barriers as expressed through HCPs’ preceptions and knowledge about the health of LGBT patients. The magnitude of barriers to providing patient-centered care must first be identified and understood before institutional recommendations can be made and implemented at the facility or national level.

Methods

This study examined attitudes and knowledge about LGBT patient health among 45 primary care providers (PCPs) in 4 VA community-based outpatient clinics (CBOCs). The first clinical question examined whether PCPs desired more education and training on LGBT health. The second clinical question asked whether there were gender differences in attitudes among providers about the need for LGBT health education. Subsequently, the study’s findings are expected to be disseminated to VHA stakeholders to further examine HCP education and training needs on LGBT topics to facilitate improvement of HCP point of care behaviors, patient outcomes, and LGBT empowerment within the VHA environment.

The model presented in The Process of Cultural Competence in the Delivery of Healthcare Services by Campinha-Bacote provides an applicable conceptualization to guide HCPs’ actions toward delivering culturally responsive health care services to increasingly diverse health populations.²¹ The model defines cultural competence as an ongoing dynamic process of striving to effectively work within the cultural context of the client (person, family, or community). The model integrates 5 constructs that are fundamental to becoming culturally competent to provide appropriate culturally responsive care to diverse clients: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desires.²¹ The level of competence of the HCP is believed to have a direct relationship with their ability to provide culturally competent health care services. Table 1 provides the definitions of the 5 constructs and highlights the role of education and training in influencing competence in providing LGBT health services.²¹

This project used a descriptive, cross-sectional one-group design to target physicians, nurse practitioners (NPs), and physician assistants (PAs) at VA Southern Nevada Healthcare System (VASNHS) CBOCs. Participation in the project was voluntary. The duration of project from data collection to completion of analysis and summation of the results was 4 months. The study was approved by the institutional review board (IRB) at the University of Alabama in Huntsville, and it was exempt from the VA IRB.

The survey consisted of 74 questions, including 8 demographic questions and 66 LGBT-related questions. The survey instrument, renamed the Perception and Knowledge of Sexual and Gender Minority Health (PKSGMH) survey was adapted with permission from an original study by Jabson and colleagues and used its format without revision or restructuring.²²

Attitudinal questions asked personal opinions on LGBT orientation and gender identity (eAppendix:

Measures

The survey instrument integrated components of 4 different measures on attitudes and knowledge of LGBT health with questions about familiarity with organizational policies on discrimination, visitation, and staff training in LGBT care. The PKSGMH survey measured attitudes and knowledge levels on LGBT health by calculating the mean scores for each of 4 measures.

General Attitudes Toward LGBT Nonpatients. The attitudes toward LGBT nonpatients measure includes 4 subscales with 3 identical questions on how providers felt about LGBT individuals: (a) attitudes toward lesbians (α: .78); (b) attitudes toward gay men (α: .76); (c) attitudes toward bisexuals (α: 78); and (d) attitudes toward transgender people (α: .70). Each subscale used a 5-point Likert scale (5 = strongly agree).

Physician Attitudes Toward LGBT (ATLG) Patients. The attitudes toward LGBT scale assessed physicians’ feelings toward providing care to LGBT patients. This scale of 6 questions had modest reliability with a Cronbach α of .5. The measure used a 5-point Likert scale (5 = strongly agree). For this project, this scale was renamed the Provider subscale.

Knowledge of LGBT (KLGBT) Patients. The knowledge of LGBT patients’ scale included 13 true/false questions and had a Cronbach α of .74.

Gender and Sexual Minority Affirmative Practice (GSMAP). The GSMAP affirmative practice scale evaluated HCPs’ attitudes and beliefs about the treatment of LGBT patients. The 11-question measure with 2 subscales used a 5-point Likert scale with high reliability on the clinicians’ beliefs and behaviors subscales. Both subscales had a Cronbach α of .93 and .94, respectively.

Demographics and Data Analyses

Health care providers answered demographic questions about gender, sexual orientation, and marital status. They also were asked whether they had ever received any focused training in LGBT patient care. Descriptive and demographic data analyses were performed using SPSS version 24.0 (Armonk, New York). A significance level of P < .05 was used for all analyses. Analysis of variance (ANOVA) statistical analysis was conducted to evaluate the differences in mean scores between male and female PCP groups on the 4 attitudes toward LGBT subscales and the Provider subscale.

Results

Seventy-two PCPs participated in completing the PKSGMH survey. Fifty-seven surveys were returned; however, only 45 surveys were completely answered and included in the final analysis. Twelve surveys containing unanswered questions to the knowledge sections were excluded from the data analysis, and 14 distributed surveys were not returned. The overall response rate for completed surveys was 62.5% (Table 2).

Attitudes Toward Care

Attitudes about competence in providing LGBT care was answered in question 23 of the PKSGMH survey. Overall, a total of 51.1% (n = 23) of PCPs agreed that they were competentto provide LGBT care, and 15.5% (n = 7) disagreed. By gender, 50% (n = 9) of males said they were competent in providing LGBT care compared with 51.8% (n = 14) of females.

Analysis of variance was used to test for differences between groups on the 5 ATLG subscales (gay, lesbian, bisexual, transgender, provider) of the PKSGMH survey (Table 3). A grouping variable was created by separating participants by gender and by their responses to a question that asked about their desire for more education about the health care needs of LGBT patients. The grouping resulted in 4 groups: (1) males who responded yes to need for additional education; (2) males who responded no to need for additional education; (3) females who responded yes to need for additional education; and (4) females who responded no to need for additional education. Results of the ANOVA demonstrated significant differences between groups for the bisexual subscale (F = 3.005, df = 3, 32; P = .045), transgender subscale (F = 4.545, df = 3, 32; P = .009), and the provider subscale (F = 12.602, df = 3, 32; P < .001).

Knowledge of LGBT Care

Knowledge level responses among PCPs were not found to be statistically significant. However, 98% of PCPs agreed that practitioners should be knowledgeable about issues unique to LGBT patients and acquire the knowledge necessary to practice effectively. A review of answers to knowledge-specific questions in the KLGBT and GSMAP scales found more than 50% of PCPs responded correctly to true/false questions about prevalence of depression and anxiety, alcohol use, substance abuse, sexual transmitted infections, and physical and sexual trauma in LGBT patients. However, < 50% of the sample correctly answered true in 3 knowledge areas of LGBT health: increased prevalence of tobacco use; increased prevalence of obesity/overweight; and greater risk for chronic disease.

Discussion

Federal health care agencies consider the health and welfare of LGBT persons to be a health priority despite the lack of available science-based knowledge about this population.² In 2011, the National Academies of Medicine (NAM) noted that there are still research gaps concerning the well-being of LGBT individuals. The report stated that a significant contributor of health care inequities in LGBT patients is the lack of provider training and medical education.² A major recommendation of the NAM is that additional training and education is needed to reduce barriers and improve patient outcomes in the LGBT population.

Provider attitudes and education are among the gaps that contribute to inequities in the health care of LGBT populations as previously discussed. The findings from this survey suggest that PCPs in the VHA perceive that they have deficits in competencies and knowledge levels on LGBT care and that education influences attitudes toward LGBT care. The association between providers’ self-assessment of their competency and their knowledge and attitudes toward care for LGBT patients was not stated in the clinical question and was not investigated in this study.

An online search of 12,966 courses at the VA Talent Management System (TMS) was conducted to find web-based and/or instructor-led training courses focused on LGBT care. The search found 4 LGBT-focused courses that targeted physicians and nurses. Two 90-minute courses presented clinical and public health data on sexual health and addressed how providers can improve skills on taking sexual histories and incorporating these data into routine practice. Training and skills development in sexual history taking by clinicians is vital in reducing health disparities, such as STDs, and in helping LGBT patients feel more comfortable in accessing health care.⁴

A 1-hour TMS course focused on training HCPs to develop as researchers, teachers, and leaders in improving the LGBT veteran experience by providing competent care. Information on LGBT-related subjects, such as sexual and physical trauma and STDs, were included in the content of some online courses. However, no other comprehensive courses specifically focused on LGBT care. The only exceptions were the Specialty Care Access Network Extension of Community Healthcare outcome video conferencing-based sequential training on transgender care and the VA Lesbian, Gay and Bisexual Education sharepoint and the transgender education sharepoint. At the VA, online LGBT health training is still limited.

Recommendations

Providing additional LGBT-focused TMS courses could help increase provider knowledge and cultural competencies. An online introductory LGBT health course could be offered at VA facilities for all new employees and HCPs as part of employee orientation. More specific courses with continuing education credits geared toward the HCP and focused on LGBT health could be included in the TMS learning portfolio for each HCP as annual learning refresher courses. This course could include specific knowledge questions on LGBT care and a posttest with a required passing score of 80%.

Training HCPs as designated LGBT educators in VA facilities should be considered. Classroom training could be offered annually or during times of increased LGBT patient focus, such as during LGBT Pride month when learning activities can be planned and/or coordinated with the VA Office of Diversity and Inclusion. Nurses, social workers, pharmacists, and medical assistants who provide supportive care to LGBT patients also should be included in the target audience for LGBT health education and training.

Limitations

The use of a cross-sectional project design with such a small convenience sample prevents generalizability of the findings to all PCPs. The lack of a survey design that included randomization and blinding in survey distribution could certainly deter participants from offering candid responses, particularly to some attitudinal questions that were emotional in context. The true-false responses wherein respondents had a 50% chance at guessing the correct response was not the most reliable method of measuring knowledge levels and thereby limited the ability to draw any strong conclusions about providers’ knowledge levels. Additionally, the project design did not allow for measures of other confounding factors, such as age, race/ethnicity, religion, and other social factors that could have influenced how participants responded. Additional randomized controlled studies with larger samples are needed to test specific interventions that evaluate the influence of gender on provider attitudes and knowledge as well as the effect of more HCP education and training on LGBT patient outcomes. Moreover, a literature review found no guidelines on how to specifically address provider gender differences in LGBT education and training or strategies for education and training interventions to address these differences.

Conclusion

Findings suggest that PCPs need additional education and training involving LGBT health issues. Although both male and female providers want more education, female PCPs as a group expressed a greater desire for more training compared with the responses of male PCPs. However, given the study’s small sample size, a strong conclusion regarding gender differences cannot be made. Research has shown that education is a factor that positively influences attitudes and feelings about providing LGBT care. The availability of education and training that is focused on LGBT health topics is still limited within the VHA. Within its stated mission to provide patient-centered care to all veterans, the VHA’s Office of Health Equity has a specific objective for addressing LGBT health disparities and ensuring the delivery of standardized services to LGBT veterans.

Better training on LGBT health topics is vital to improving health care delivery to LGBT populations. To meet this goal, ongoing HCP training to improve attitudes and knowledge and develop the skills necessary to effectively address LGBT health issues also must be a priority at VHA facilities. The VHA also should consider institutional changes that incorporate increased LGBT-focused health education into the learning activities of PCPs. This is essential to evaluating the quality of care given the impact on patient outcomes and health disparities in LGBT populations.

Lesbian, gay, bisexual and transgender (LGBT) populations face significant social stigmatization, discrimination, and marginalization that contribute to negative patient outcomes. Consequently, the LGBT population experiences high rates of mental health issues, such as suicide and depression, as well as sexually transmitted diseases (STDs), drug abuse, poverty, and homelessness.^1,2

Background

According to the CDC, gay men are at highest risk and have increased incidences of gonorrhea, chlamydia, herpes, human papilloma virus (HPV), and HIV.³ Lesbians and bisexual women are less likely to get preventive cancer screenings, such as Pap smears and mammograms, and have higher incidences of HIV, hepatitis C, self-reported gonorrhea, and are more likely to be overweight or obese.^3-6 In addition, LGBT populations have high rates of use of tobacco, alcohol, and other drugs.

The National Transgender Discrimination Survey of 6,450 transgender and nonconforming participants also provides extensive data on the challenges faced by transgender individuals. Discrimination was frequently experienced in accessing health care. Due to their transgender status, 19% were denied care, and 28% postponed care due to perceived harassment and violence within a health care setting.¹ The LGBT populations experience personal and structural barriers that interfere with their ability to access high-quality care. Sexual gender minority individuals also experience health care barriers due to isolation, insufficient social services, and a lack of culturally competent providers.⁴ At the same time, many health care providers (HCPs) experience various barriers to providing LGBT care and need to increase their cultural competence by improving awareness, receptivity, and knowledge.^7,8 One personal barrier to quality care is stigmatization toward LGBT persons as expressed through HCP prejudices, beliefs, attitudes, and behaviors.² Factors such as gender, race, and religious beliefs also influence attitudes to LGBT health care.

A study by Chapman and colleagues found significant differences in attitudes toward gay men by male and female medical and nursing students.⁹ Male students had a significantly more negative attitude toward gay men compared with the attitudes of female students. Cultural competence, defined in the study as gay affirmative action principles scores, were statistically significant and strongly correlated with negative attitudes. In this study there also was a statistically significant negative correlation between attitudes and knowledge scores indicating a considerable potential for personal values to influence the provision of health care.⁹

Various barriers inherent in the health care system restrict access to high-quality care. Institutional barriers that include a lack of legal recognition of same-sex partners, equality in visitation rights, and the ability of same-sex partners to access partner’s medical records hamper health care quality. The HCPs’ lack of knowledge of the health risks or health care needs of the LGBT population also present a structural barrier to quality of care and affects patient outcomes.²

Culturally competent interventions in health care delivery also have been studied to reduce LGBT health disparities. A systematic review of 56 studies by Butler and colleagues found that the term cultural competence was not well defined and often was denoted with the terms patient-centered or individualized care.¹⁰ A review on the impact of these interventions in LGBT populations also noted that the long-term effects of culturally competent interventions on health disparities in LGBT populations are still unknown.

The Joint Commission has identified the health and welfare of LGBT populations as a major priority. Beginning in 2012, The Joint Commission started assessing compliance with standards for cultural competence and patient-centered care for LGBT recipients as part of the accreditation criteria.¹¹ The Joint Commission recommended that health care facilities begin to transform the health care environment to be a more welcoming, safe, and inclusive environment for LGBT patients and their families.¹¹ Health care providers can play an important role in reducing the significant health disparities and unequal treatment.¹²

Problem Identification

Improving health outcomes and reducing health disparities are an important part of the HCP’s role. Yet, many HCPs lack the significant knowledge, skills, and cultural competencies needed to provide quality LGBT care.¹⁰ Evidence suggests that HCPs continue to receive little or no training to prepare them to manage this vulnerable population.¹⁰ Due to the growing evidence of health disparities and negative health outcomes affecting LGBT populations, the federal government has identified LGBT care and patient outcomes as a major health concern and priority under the Healthy 2020 goals.^2,4

About 3.5% (9 million) of the U.S. adult population are identified as lesbian, gay, or bisexual and 0.3% or 700,000 as transgender.^13,14 The VHA serves 9 million veterans at 1,245 facilities.¹⁵The 2000 census estimated that about 1 million veterans reported having same-sex partners.¹⁶The number of LGBTs in the VHA system is unknown because the VHA has not historically collected LGBT demographic data. The estimation of LGBT veterans that use the VHA is based on a proportion of the population of LGBT military service personnel and may not provide the best representation of LGBT veterans enrolled or seeking care in the VHA.¹⁷ By conservative estimates, about 134,000 veterans are thought to be transgender.¹⁴ Between 2006 and 2013, the reported prevalence and incidence of transgender-related diagnoses in the VHA have steadily increased with 40% of new diagnoses occurring since 2011.¹⁸ In fiscal year 2013, there were 32.9 per 100,000 veterans with transgender-related diagnoses, and the numbers are increasing.¹⁸

Because the cooperation of HCPs can play a significant part in reducing health disparities and unequal treatment in the care LGBT patients receive, the VHA launched several initiatives to create a more welcoming, inclusive, and empowering environment for LGBT veterans and families. Among the initiatives, VHA established the Office of Health Equity to address health disparities and ensure that patient-centered care is provided in a positive environment.^19,20 The VHA also issued a national directive mandating standardized services be provided for transgender veterans.²⁰

Despite these initiatives, obstacles remain to the delivery of patient-centered LGBT care at the VA. A first step to identifying barriers to patient-centered, high-quality care to LGBT veterans is to evaluate personal and institutional barriers as expressed through HCPs’ preceptions and knowledge about the health of LGBT patients. The magnitude of barriers to providing patient-centered care must first be identified and understood before institutional recommendations can be made and implemented at the facility or national level.

Methods

This study examined attitudes and knowledge about LGBT patient health among 45 primary care providers (PCPs) in 4 VA community-based outpatient clinics (CBOCs). The first clinical question examined whether PCPs desired more education and training on LGBT health. The second clinical question asked whether there were gender differences in attitudes among providers about the need for LGBT health education. Subsequently, the study’s findings are expected to be disseminated to VHA stakeholders to further examine HCP education and training needs on LGBT topics to facilitate improvement of HCP point of care behaviors, patient outcomes, and LGBT empowerment within the VHA environment.

The model presented in The Process of Cultural Competence in the Delivery of Healthcare Services by Campinha-Bacote provides an applicable conceptualization to guide HCPs’ actions toward delivering culturally responsive health care services to increasingly diverse health populations.²¹ The model defines cultural competence as an ongoing dynamic process of striving to effectively work within the cultural context of the client (person, family, or community). The model integrates 5 constructs that are fundamental to becoming culturally competent to provide appropriate culturally responsive care to diverse clients: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desires.²¹ The level of competence of the HCP is believed to have a direct relationship with their ability to provide culturally competent health care services. Table 1 provides the definitions of the 5 constructs and highlights the role of education and training in influencing competence in providing LGBT health services.²¹

This project used a descriptive, cross-sectional one-group design to target physicians, nurse practitioners (NPs), and physician assistants (PAs) at VA Southern Nevada Healthcare System (VASNHS) CBOCs. Participation in the project was voluntary. The duration of project from data collection to completion of analysis and summation of the results was 4 months. The study was approved by the institutional review board (IRB) at the University of Alabama in Huntsville, and it was exempt from the VA IRB.

The survey consisted of 74 questions, including 8 demographic questions and 66 LGBT-related questions. The survey instrument, renamed the Perception and Knowledge of Sexual and Gender Minority Health (PKSGMH) survey was adapted with permission from an original study by Jabson and colleagues and used its format without revision or restructuring.²²

Attitudinal questions asked personal opinions on LGBT orientation and gender identity (eAppendix:

Measures

The survey instrument integrated components of 4 different measures on attitudes and knowledge of LGBT health with questions about familiarity with organizational policies on discrimination, visitation, and staff training in LGBT care. The PKSGMH survey measured attitudes and knowledge levels on LGBT health by calculating the mean scores for each of 4 measures.

General Attitudes Toward LGBT Nonpatients. The attitudes toward LGBT nonpatients measure includes 4 subscales with 3 identical questions on how providers felt about LGBT individuals: (a) attitudes toward lesbians (α: .78); (b) attitudes toward gay men (α: .76); (c) attitudes toward bisexuals (α: 78); and (d) attitudes toward transgender people (α: .70). Each subscale used a 5-point Likert scale (5 = strongly agree).

Physician Attitudes Toward LGBT (ATLG) Patients. The attitudes toward LGBT scale assessed physicians’ feelings toward providing care to LGBT patients. This scale of 6 questions had modest reliability with a Cronbach α of .5. The measure used a 5-point Likert scale (5 = strongly agree). For this project, this scale was renamed the Provider subscale.

Knowledge of LGBT (KLGBT) Patients. The knowledge of LGBT patients’ scale included 13 true/false questions and had a Cronbach α of .74.

Gender and Sexual Minority Affirmative Practice (GSMAP). The GSMAP affirmative practice scale evaluated HCPs’ attitudes and beliefs about the treatment of LGBT patients. The 11-question measure with 2 subscales used a 5-point Likert scale with high reliability on the clinicians’ beliefs and behaviors subscales. Both subscales had a Cronbach α of .93 and .94, respectively.

Demographics and Data Analyses

Health care providers answered demographic questions about gender, sexual orientation, and marital status. They also were asked whether they had ever received any focused training in LGBT patient care. Descriptive and demographic data analyses were performed using SPSS version 24.0 (Armonk, New York). A significance level of P < .05 was used for all analyses. Analysis of variance (ANOVA) statistical analysis was conducted to evaluate the differences in mean scores between male and female PCP groups on the 4 attitudes toward LGBT subscales and the Provider subscale.

Results

Seventy-two PCPs participated in completing the PKSGMH survey. Fifty-seven surveys were returned; however, only 45 surveys were completely answered and included in the final analysis. Twelve surveys containing unanswered questions to the knowledge sections were excluded from the data analysis, and 14 distributed surveys were not returned. The overall response rate for completed surveys was 62.5% (Table 2).

Attitudes Toward Care

Attitudes about competence in providing LGBT care was answered in question 23 of the PKSGMH survey. Overall, a total of 51.1% (n = 23) of PCPs agreed that they were competentto provide LGBT care, and 15.5% (n = 7) disagreed. By gender, 50% (n = 9) of males said they were competent in providing LGBT care compared with 51.8% (n = 14) of females.

Analysis of variance was used to test for differences between groups on the 5 ATLG subscales (gay, lesbian, bisexual, transgender, provider) of the PKSGMH survey (Table 3). A grouping variable was created by separating participants by gender and by their responses to a question that asked about their desire for more education about the health care needs of LGBT patients. The grouping resulted in 4 groups: (1) males who responded yes to need for additional education; (2) males who responded no to need for additional education; (3) females who responded yes to need for additional education; and (4) females who responded no to need for additional education. Results of the ANOVA demonstrated significant differences between groups for the bisexual subscale (F = 3.005, df = 3, 32; P = .045), transgender subscale (F = 4.545, df = 3, 32; P = .009), and the provider subscale (F = 12.602, df = 3, 32; P < .001).

Knowledge of LGBT Care

Knowledge level responses among PCPs were not found to be statistically significant. However, 98% of PCPs agreed that practitioners should be knowledgeable about issues unique to LGBT patients and acquire the knowledge necessary to practice effectively. A review of answers to knowledge-specific questions in the KLGBT and GSMAP scales found more than 50% of PCPs responded correctly to true/false questions about prevalence of depression and anxiety, alcohol use, substance abuse, sexual transmitted infections, and physical and sexual trauma in LGBT patients. However, < 50% of the sample correctly answered true in 3 knowledge areas of LGBT health: increased prevalence of tobacco use; increased prevalence of obesity/overweight; and greater risk for chronic disease.

Discussion

Federal health care agencies consider the health and welfare of LGBT persons to be a health priority despite the lack of available science-based knowledge about this population.² In 2011, the National Academies of Medicine (NAM) noted that there are still research gaps concerning the well-being of LGBT individuals. The report stated that a significant contributor of health care inequities in LGBT patients is the lack of provider training and medical education.² A major recommendation of the NAM is that additional training and education is needed to reduce barriers and improve patient outcomes in the LGBT population.

Provider attitudes and education are among the gaps that contribute to inequities in the health care of LGBT populations as previously discussed. The findings from this survey suggest that PCPs in the VHA perceive that they have deficits in competencies and knowledge levels on LGBT care and that education influences attitudes toward LGBT care. The association between providers’ self-assessment of their competency and their knowledge and attitudes toward care for LGBT patients was not stated in the clinical question and was not investigated in this study.

An online search of 12,966 courses at the VA Talent Management System (TMS) was conducted to find web-based and/or instructor-led training courses focused on LGBT care. The search found 4 LGBT-focused courses that targeted physicians and nurses. Two 90-minute courses presented clinical and public health data on sexual health and addressed how providers can improve skills on taking sexual histories and incorporating these data into routine practice. Training and skills development in sexual history taking by clinicians is vital in reducing health disparities, such as STDs, and in helping LGBT patients feel more comfortable in accessing health care.⁴

A 1-hour TMS course focused on training HCPs to develop as researchers, teachers, and leaders in improving the LGBT veteran experience by providing competent care. Information on LGBT-related subjects, such as sexual and physical trauma and STDs, were included in the content of some online courses. However, no other comprehensive courses specifically focused on LGBT care. The only exceptions were the Specialty Care Access Network Extension of Community Healthcare outcome video conferencing-based sequential training on transgender care and the VA Lesbian, Gay and Bisexual Education sharepoint and the transgender education sharepoint. At the VA, online LGBT health training is still limited.

Recommendations

Providing additional LGBT-focused TMS courses could help increase provider knowledge and cultural competencies. An online introductory LGBT health course could be offered at VA facilities for all new employees and HCPs as part of employee orientation. More specific courses with continuing education credits geared toward the HCP and focused on LGBT health could be included in the TMS learning portfolio for each HCP as annual learning refresher courses. This course could include specific knowledge questions on LGBT care and a posttest with a required passing score of 80%.

Training HCPs as designated LGBT educators in VA facilities should be considered. Classroom training could be offered annually or during times of increased LGBT patient focus, such as during LGBT Pride month when learning activities can be planned and/or coordinated with the VA Office of Diversity and Inclusion. Nurses, social workers, pharmacists, and medical assistants who provide supportive care to LGBT patients also should be included in the target audience for LGBT health education and training.

Limitations

The use of a cross-sectional project design with such a small convenience sample prevents generalizability of the findings to all PCPs. The lack of a survey design that included randomization and blinding in survey distribution could certainly deter participants from offering candid responses, particularly to some attitudinal questions that were emotional in context. The true-false responses wherein respondents had a 50% chance at guessing the correct response was not the most reliable method of measuring knowledge levels and thereby limited the ability to draw any strong conclusions about providers’ knowledge levels. Additionally, the project design did not allow for measures of other confounding factors, such as age, race/ethnicity, religion, and other social factors that could have influenced how participants responded. Additional randomized controlled studies with larger samples are needed to test specific interventions that evaluate the influence of gender on provider attitudes and knowledge as well as the effect of more HCP education and training on LGBT patient outcomes. Moreover, a literature review found no guidelines on how to specifically address provider gender differences in LGBT education and training or strategies for education and training interventions to address these differences.

Conclusion

Findings suggest that PCPs need additional education and training involving LGBT health issues. Although both male and female providers want more education, female PCPs as a group expressed a greater desire for more training compared with the responses of male PCPs. However, given the study’s small sample size, a strong conclusion regarding gender differences cannot be made. Research has shown that education is a factor that positively influences attitudes and feelings about providing LGBT care. The availability of education and training that is focused on LGBT health topics is still limited within the VHA. Within its stated mission to provide patient-centered care to all veterans, the VHA’s Office of Health Equity has a specific objective for addressing LGBT health disparities and ensuring the delivery of standardized services to LGBT veterans.

Better training on LGBT health topics is vital to improving health care delivery to LGBT populations. To meet this goal, ongoing HCP training to improve attitudes and knowledge and develop the skills necessary to effectively address LGBT health issues also must be a priority at VHA facilities. The VHA also should consider institutional changes that incorporate increased LGBT-focused health education into the learning activities of PCPs. This is essential to evaluating the quality of care given the impact on patient outcomes and health disparities in LGBT populations.

The outbreak of Ebola in West Africa in 2014 provided a wake-up call for global health care experts. Responding to the next global health care crisis will require a more coherent and strategic response, and U.S. leadership, to protect both U.S. and global health security. The Ebola crisis “raised consciousness generally that health and security have become more directly linked,” said CAPT Paul Reed, MD, USPHS, interim director of the Center for Global Health Engagement (CGHE) at the Uniformed Services University.

According to CAPT Reed, global health engagement is an essential part of force preparedness and a key part of U.S. dialogue with global partners. The CGHE will host a series of sessions at the upcoming AMSUS meeting on November 28, outside Washington, DC, that will focus on global health strategies, the importance of global health engagement to combat commands, and projects underway to expand global health engagement.

The CGHE mission is to lead, integrate, and bring together thought leadership, research, and advocacy from public health experts, Uniformed Services University faculty, combatant commands, and the Military Health System to national security objectives. The CGHE is focused on developing partnerships to build global capacity and increase resiliency for disaster preparation. In addition, the center is engaged in research studies, including the Measures Of Effectiveness in Defense Engagement and Learning (MODEL) and the Improving Processes and Coordination in Theater (IMPACT) studies.

As the Ebola outbreak made clear, global health threats can impact both military and domestic operations. “There is not distinction between global and domestic health issues,” Dr. Reed told Federal Practitioner. “Global health engagement is a unique aspects of public health. We need to develop a new doctrine. We have to do it collectively and we can't do that in silos. We can't even do it within a federal government silo.”

The outbreak of Ebola in West Africa in 2014 provided a wake-up call for global health care experts. Responding to the next global health care crisis will require a more coherent and strategic response, and U.S. leadership, to protect both U.S. and global health security. The Ebola crisis “raised consciousness generally that health and security have become more directly linked,” said CAPT Paul Reed, MD, USPHS, interim director of the Center for Global Health Engagement (CGHE) at the Uniformed Services University.

According to CAPT Reed, global health engagement is an essential part of force preparedness and a key part of U.S. dialogue with global partners. The CGHE will host a series of sessions at the upcoming AMSUS meeting on November 28, outside Washington, DC, that will focus on global health strategies, the importance of global health engagement to combat commands, and projects underway to expand global health engagement.

The CGHE mission is to lead, integrate, and bring together thought leadership, research, and advocacy from public health experts, Uniformed Services University faculty, combatant commands, and the Military Health System to national security objectives. The CGHE is focused on developing partnerships to build global capacity and increase resiliency for disaster preparation. In addition, the center is engaged in research studies, including the Measures Of Effectiveness in Defense Engagement and Learning (MODEL) and the Improving Processes and Coordination in Theater (IMPACT) studies.

As the Ebola outbreak made clear, global health threats can impact both military and domestic operations. “There is not distinction between global and domestic health issues,” Dr. Reed told Federal Practitioner. “Global health engagement is a unique aspects of public health. We need to develop a new doctrine. We have to do it collectively and we can't do that in silos. We can't even do it within a federal government silo.”

The outbreak of Ebola in West Africa in 2014 provided a wake-up call for global health care experts. Responding to the next global health care crisis will require a more coherent and strategic response, and U.S. leadership, to protect both U.S. and global health security. The Ebola crisis “raised consciousness generally that health and security have become more directly linked,” said CAPT Paul Reed, MD, USPHS, interim director of the Center for Global Health Engagement (CGHE) at the Uniformed Services University.

According to CAPT Reed, global health engagement is an essential part of force preparedness and a key part of U.S. dialogue with global partners. The CGHE will host a series of sessions at the upcoming AMSUS meeting on November 28, outside Washington, DC, that will focus on global health strategies, the importance of global health engagement to combat commands, and projects underway to expand global health engagement.

The CGHE mission is to lead, integrate, and bring together thought leadership, research, and advocacy from public health experts, Uniformed Services University faculty, combatant commands, and the Military Health System to national security objectives. The CGHE is focused on developing partnerships to build global capacity and increase resiliency for disaster preparation. In addition, the center is engaged in research studies, including the Measures Of Effectiveness in Defense Engagement and Learning (MODEL) and the Improving Processes and Coordination in Theater (IMPACT) studies.

As the Ebola outbreak made clear, global health threats can impact both military and domestic operations. “There is not distinction between global and domestic health issues,” Dr. Reed told Federal Practitioner. “Global health engagement is a unique aspects of public health. We need to develop a new doctrine. We have to do it collectively and we can't do that in silos. We can't even do it within a federal government silo.”

Which method is better for breast cancer screening: 3-D mammography or 2-D mammography? Researchers from the ECOG-ACRIN Cancer Research Group and the National Cancer Institute are hoping to find out, with the Tomosynthesis Mammographic Imaging Screening Trial (TMIST).

It has been decades since the last large-scale randomized trial of mammography, points out Worta McCaskill-Stevens, MD, director of the NCI Community Oncology Research Program. In the meantime, mammography technology has evolved, from “conventional” 2-D mammography to tomosynthesis, also known as 3-D mammography.

However, although 3-D mammography is more likely to detect more findings that require follow-up, it is also likely to lead to more procedures and treatments. “If a newer screening technology does not reduce the numbers of advanced, life-threatening cancers, then are we really improving screening for breast cancer?” said Etta Pisano, MD, ECOG-ACRIN study chair.

Researchers plan to enroll 165,000 participants aged between 45 and 74 years who already are scheduled for routine mammograms. They will follow all participants for breast cancer status, treatment, and outcomes until at least 2025. About 100 mammography clinics are expected to take part.

Which method is better for breast cancer screening: 3-D mammography or 2-D mammography? Researchers from the ECOG-ACRIN Cancer Research Group and the National Cancer Institute are hoping to find out, with the Tomosynthesis Mammographic Imaging Screening Trial (TMIST).

It has been decades since the last large-scale randomized trial of mammography, points out Worta McCaskill-Stevens, MD, director of the NCI Community Oncology Research Program. In the meantime, mammography technology has evolved, from “conventional” 2-D mammography to tomosynthesis, also known as 3-D mammography.

However, although 3-D mammography is more likely to detect more findings that require follow-up, it is also likely to lead to more procedures and treatments. “If a newer screening technology does not reduce the numbers of advanced, life-threatening cancers, then are we really improving screening for breast cancer?” said Etta Pisano, MD, ECOG-ACRIN study chair.

Researchers plan to enroll 165,000 participants aged between 45 and 74 years who already are scheduled for routine mammograms. They will follow all participants for breast cancer status, treatment, and outcomes until at least 2025. About 100 mammography clinics are expected to take part.

Which method is better for breast cancer screening: 3-D mammography or 2-D mammography? Researchers from the ECOG-ACRIN Cancer Research Group and the National Cancer Institute are hoping to find out, with the Tomosynthesis Mammographic Imaging Screening Trial (TMIST).

It has been decades since the last large-scale randomized trial of mammography, points out Worta McCaskill-Stevens, MD, director of the NCI Community Oncology Research Program. In the meantime, mammography technology has evolved, from “conventional” 2-D mammography to tomosynthesis, also known as 3-D mammography.

However, although 3-D mammography is more likely to detect more findings that require follow-up, it is also likely to lead to more procedures and treatments. “If a newer screening technology does not reduce the numbers of advanced, life-threatening cancers, then are we really improving screening for breast cancer?” said Etta Pisano, MD, ECOG-ACRIN study chair.

Researchers plan to enroll 165,000 participants aged between 45 and 74 years who already are scheduled for routine mammograms. They will follow all participants for breast cancer status, treatment, and outcomes until at least 2025. About 100 mammography clinics are expected to take part.

Photo by Elise Amendola

ANAHEIM, CA—Results of a large study suggest a restrictive transfusion strategy is safe for moderate- to high-risk patients undergoing cardiac surgery.

Researchers found that patients had similar rates of various outcomes—death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis—whether they received red blood cell (RBC) transfusions according to a restrictive strategy or a liberal one.

C. David Mazer, MD, of St. Michael’s Hospital in Toronto, Ontario, Canada, presented these results at the American Heart Association’s Scientific Sessions 2017.

Results were simultaneously published in NEJM.

Dr Mazer and his colleagues studied 5243 adults undergoing cardiac surgery. They all had a European System for Cardiac Operative Risk Evaluation I score of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery).

Patients were randomized to receive RBC transfusions according to a restrictive strategy or a liberal one.

With the restrictive strategy, patients received transfusions if their hemoglobin level was below 7.5 g/dL, starting from induction of anesthesia.

With the liberal strategy, patients were transfused if their hemoglobin level was less than 9.5 g/dL in the operating room or intensive care unit (ICU) or was less than 8.5 g/dL in the non-ICU ward.

Results

There were 4860 patients in the per-protocol analysis—2430 in each transfusion group. Baseline characteristics were similar between the groups.

The rate of RBC transfusion was 52.3% in the restrictive group and 72.6% in the liberal group. The odds ratio (OR) was 0.41 (95% confidence interval [CI], 0.37 to 0.47).

Transfused patients received a median of 2 RBC units (interquartile range [IQR], 1 to 4) in the restrictive group and 3 units (IQR, 2 to 5) in the liberal group.

The study’s primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or by day 28, whichever came first.

This outcome occurred in 11.4% of patients in the restrictive group and 12.5% of those in the liberal group. The absolute risk difference was −1.11 percentage points (95% CI, −2.93 to 0.72), and the odds ratio was 0.90 (95% CI, 0.76 to 1.07; P<0.001 for noninferiority).

There were no significant differences between the groups when it came to the individual components of the composite outcome.

“We have shown that this [restrictive] approach to transfusion is safe in moderate- to high-risk patients undergoing cardiac surgery,” Dr Mazer said.

“Such practices can also reduce the number of patients transfused, the amount of blood transfused, the impact on blood supply, and costs to the healthcare system.”

Photo by Elise Amendola

ANAHEIM, CA—Results of a large study suggest a restrictive transfusion strategy is safe for moderate- to high-risk patients undergoing cardiac surgery.

Researchers found that patients had similar rates of various outcomes—death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis—whether they received red blood cell (RBC) transfusions according to a restrictive strategy or a liberal one.

C. David Mazer, MD, of St. Michael’s Hospital in Toronto, Ontario, Canada, presented these results at the American Heart Association’s Scientific Sessions 2017.

Results were simultaneously published in NEJM.

Dr Mazer and his colleagues studied 5243 adults undergoing cardiac surgery. They all had a European System for Cardiac Operative Risk Evaluation I score of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery).

Patients were randomized to receive RBC transfusions according to a restrictive strategy or a liberal one.

With the restrictive strategy, patients received transfusions if their hemoglobin level was below 7.5 g/dL, starting from induction of anesthesia.

With the liberal strategy, patients were transfused if their hemoglobin level was less than 9.5 g/dL in the operating room or intensive care unit (ICU) or was less than 8.5 g/dL in the non-ICU ward.

Results

There were 4860 patients in the per-protocol analysis—2430 in each transfusion group. Baseline characteristics were similar between the groups.

The rate of RBC transfusion was 52.3% in the restrictive group and 72.6% in the liberal group. The odds ratio (OR) was 0.41 (95% confidence interval [CI], 0.37 to 0.47).

Transfused patients received a median of 2 RBC units (interquartile range [IQR], 1 to 4) in the restrictive group and 3 units (IQR, 2 to 5) in the liberal group.

The study’s primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or by day 28, whichever came first.

This outcome occurred in 11.4% of patients in the restrictive group and 12.5% of those in the liberal group. The absolute risk difference was −1.11 percentage points (95% CI, −2.93 to 0.72), and the odds ratio was 0.90 (95% CI, 0.76 to 1.07; P<0.001 for noninferiority).

There were no significant differences between the groups when it came to the individual components of the composite outcome.

“We have shown that this [restrictive] approach to transfusion is safe in moderate- to high-risk patients undergoing cardiac surgery,” Dr Mazer said.

“Such practices can also reduce the number of patients transfused, the amount of blood transfused, the impact on blood supply, and costs to the healthcare system.”

Photo by Elise Amendola

ANAHEIM, CA—Results of a large study suggest a restrictive transfusion strategy is safe for moderate- to high-risk patients undergoing cardiac surgery.

Researchers found that patients had similar rates of various outcomes—death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis—whether they received red blood cell (RBC) transfusions according to a restrictive strategy or a liberal one.

C. David Mazer, MD, of St. Michael’s Hospital in Toronto, Ontario, Canada, presented these results at the American Heart Association’s Scientific Sessions 2017.

Results were simultaneously published in NEJM.

Dr Mazer and his colleagues studied 5243 adults undergoing cardiac surgery. They all had a European System for Cardiac Operative Risk Evaluation I score of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery).

Patients were randomized to receive RBC transfusions according to a restrictive strategy or a liberal one.

With the restrictive strategy, patients received transfusions if their hemoglobin level was below 7.5 g/dL, starting from induction of anesthesia.

With the liberal strategy, patients were transfused if their hemoglobin level was less than 9.5 g/dL in the operating room or intensive care unit (ICU) or was less than 8.5 g/dL in the non-ICU ward.

Results

There were 4860 patients in the per-protocol analysis—2430 in each transfusion group. Baseline characteristics were similar between the groups.

The rate of RBC transfusion was 52.3% in the restrictive group and 72.6% in the liberal group. The odds ratio (OR) was 0.41 (95% confidence interval [CI], 0.37 to 0.47).

Transfused patients received a median of 2 RBC units (interquartile range [IQR], 1 to 4) in the restrictive group and 3 units (IQR, 2 to 5) in the liberal group.

The study’s primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or by day 28, whichever came first.

This outcome occurred in 11.4% of patients in the restrictive group and 12.5% of those in the liberal group. The absolute risk difference was −1.11 percentage points (95% CI, −2.93 to 0.72), and the odds ratio was 0.90 (95% CI, 0.76 to 1.07; P<0.001 for noninferiority).

There were no significant differences between the groups when it came to the individual components of the composite outcome.

“We have shown that this [restrictive] approach to transfusion is safe in moderate- to high-risk patients undergoing cardiac surgery,” Dr Mazer said.

“Such practices can also reduce the number of patients transfused, the amount of blood transfused, the impact on blood supply, and costs to the healthcare system.”

Photo by Aaron Logan

Preclinical research suggests PRO 140, a humanized anti-CCR5 monoclonal antibody, can prevent graft-versus-host disease (GVHD) in mice.

Mice that received 2 mg of PRO 140 twice weekly showed no signs of GVHD throughout the study period.

On the other hand, all control mice exhibited signs of GVHD, starting 25 days after engraftment, and had to be sacrificed early.

Researchers reported these results in Biology of Blood and Marrow Transplantation.

The study’s lead author, Denis R. Burger, PhD, is chief science officer of CytoDyn, the company developing PRO 140.

PRO 140 targets the CCR5 receptor, a molecule that modulates the immune cell trafficking crucial for the development of acute GVHD.

Previous clinical studies have shown that inhibiting CCR5 can reduce the clinical impact of acute GVHD without significantly affecting the engraftment of transplanted hematopoietic stem cells (HSCs).

This new study supports the idea that the CCR5 receptor on engrafted cells is critical for the development of acute GVHD and that preventing this receptor from recognizing certain immune signaling molecules is a viable approach to mitigating acute GVHD.

Dr Burger and his colleagues tested PRO 140 in NOD-scid IL-2Ry^null mice transplanted with human HSCs.

Mice received 2 different doses of PRO 140 or a control antibody—2 mg or 0.2 mg—twice weekly and were followed for a maximum of 75 days.

Engraftment at the higher dose

Mice that received the 2 mg dose of PRO 140 or the control antibody had received HSCs from a 56-year-old donor.

Engraftment was similar between control and PRO 140-treated mice for the first 30+ days. However, at day 50, there were significantly fewer human CD45+ cells in the PRO 140-treated mice (P=0.034).

At 54 days, control mice had greater engraftment of mature T cells than treated mice in the peripheral blood (63.2% vs 49.8%) and bone marrow (40.2% vs 26.4%).

GVHD at the higher dose

Throughout the study period, there were no physical signs of GVHD in the PRO 140-treated mice.

However, control mice exhibited signs of GVHD starting at day 25 after bone marrow engraftment. Signs included ruffled fur, lethargy, hunching, and weight loss.

There was a significant difference in survival between the 2 groups (P<0.01). All of the control mice had to be sacrificed early, by day 56, whereas all of the PRO 140-treated animals were alive until planned sacrifice at day 75.

Engraftment at the low dose

Mice that received the 0.2 mg dose of PRO 140 or the control antibody had received HSCs from a 26-year-old donor.

Mice in the treatment and control groups achieved the same percentage of CD45+ engraftment. However, PRO 140-treated mice achieved engraftment about 20 days later than control mice (P<0.01).

GVHD at the low dose

Both control and PRO 140-treated mice showed signs of GVHD. However, weight loss was significantly greater among control mice (P<0.05).

Survival was significantly worse among control mice as well (P<0.05). All control mice were dead by 31 days, and all PRO 140-treated mice were dead by 54 days.

The researchers said the difference in survival times between these mice and the mice treated with the higher dose of antibody suggest the younger HSC donor produced more aggressive GVHD.

“This research provided CytoDyn with strong rationale for exploring the use of PRO 140 in . . . the prevention of GVHD,” Dr Burger said.

“The potential of PRO 140 to prevent this life-threatening condition could help extend the use of [HSC] transplantation, an important and effective therapy, to more patients.”

CytoDyn is currently enrolling patients in a phase 2 trial of PRO 140 in leukemia patients undergoing transplant.

Photo by Aaron Logan

Preclinical research suggests PRO 140, a humanized anti-CCR5 monoclonal antibody, can prevent graft-versus-host disease (GVHD) in mice.

Mice that received 2 mg of PRO 140 twice weekly showed no signs of GVHD throughout the study period.

On the other hand, all control mice exhibited signs of GVHD, starting 25 days after engraftment, and had to be sacrificed early.

Researchers reported these results in Biology of Blood and Marrow Transplantation.

The study’s lead author, Denis R. Burger, PhD, is chief science officer of CytoDyn, the company developing PRO 140.

PRO 140 targets the CCR5 receptor, a molecule that modulates the immune cell trafficking crucial for the development of acute GVHD.

Previous clinical studies have shown that inhibiting CCR5 can reduce the clinical impact of acute GVHD without significantly affecting the engraftment of transplanted hematopoietic stem cells (HSCs).

This new study supports the idea that the CCR5 receptor on engrafted cells is critical for the development of acute GVHD and that preventing this receptor from recognizing certain immune signaling molecules is a viable approach to mitigating acute GVHD.

Dr Burger and his colleagues tested PRO 140 in NOD-scid IL-2Ry^null mice transplanted with human HSCs.

Mice received 2 different doses of PRO 140 or a control antibody—2 mg or 0.2 mg—twice weekly and were followed for a maximum of 75 days.

Engraftment at the higher dose

Mice that received the 2 mg dose of PRO 140 or the control antibody had received HSCs from a 56-year-old donor.

Engraftment was similar between control and PRO 140-treated mice for the first 30+ days. However, at day 50, there were significantly fewer human CD45+ cells in the PRO 140-treated mice (P=0.034).

At 54 days, control mice had greater engraftment of mature T cells than treated mice in the peripheral blood (63.2% vs 49.8%) and bone marrow (40.2% vs 26.4%).

GVHD at the higher dose

Throughout the study period, there were no physical signs of GVHD in the PRO 140-treated mice.

However, control mice exhibited signs of GVHD starting at day 25 after bone marrow engraftment. Signs included ruffled fur, lethargy, hunching, and weight loss.

There was a significant difference in survival between the 2 groups (P<0.01). All of the control mice had to be sacrificed early, by day 56, whereas all of the PRO 140-treated animals were alive until planned sacrifice at day 75.

Engraftment at the low dose

Mice that received the 0.2 mg dose of PRO 140 or the control antibody had received HSCs from a 26-year-old donor.

Mice in the treatment and control groups achieved the same percentage of CD45+ engraftment. However, PRO 140-treated mice achieved engraftment about 20 days later than control mice (P<0.01).

GVHD at the low dose

Both control and PRO 140-treated mice showed signs of GVHD. However, weight loss was significantly greater among control mice (P<0.05).

Survival was significantly worse among control mice as well (P<0.05). All control mice were dead by 31 days, and all PRO 140-treated mice were dead by 54 days.

The researchers said the difference in survival times between these mice and the mice treated with the higher dose of antibody suggest the younger HSC donor produced more aggressive GVHD.

“This research provided CytoDyn with strong rationale for exploring the use of PRO 140 in . . . the prevention of GVHD,” Dr Burger said.

“The potential of PRO 140 to prevent this life-threatening condition could help extend the use of [HSC] transplantation, an important and effective therapy, to more patients.”

CytoDyn is currently enrolling patients in a phase 2 trial of PRO 140 in leukemia patients undergoing transplant.

Photo by Aaron Logan

Preclinical research suggests PRO 140, a humanized anti-CCR5 monoclonal antibody, can prevent graft-versus-host disease (GVHD) in mice.

Mice that received 2 mg of PRO 140 twice weekly showed no signs of GVHD throughout the study period.

On the other hand, all control mice exhibited signs of GVHD, starting 25 days after engraftment, and had to be sacrificed early.

Researchers reported these results in Biology of Blood and Marrow Transplantation.

The study’s lead author, Denis R. Burger, PhD, is chief science officer of CytoDyn, the company developing PRO 140.

PRO 140 targets the CCR5 receptor, a molecule that modulates the immune cell trafficking crucial for the development of acute GVHD.

Previous clinical studies have shown that inhibiting CCR5 can reduce the clinical impact of acute GVHD without significantly affecting the engraftment of transplanted hematopoietic stem cells (HSCs).

This new study supports the idea that the CCR5 receptor on engrafted cells is critical for the development of acute GVHD and that preventing this receptor from recognizing certain immune signaling molecules is a viable approach to mitigating acute GVHD.

Dr Burger and his colleagues tested PRO 140 in NOD-scid IL-2Ry^null mice transplanted with human HSCs.

Mice received 2 different doses of PRO 140 or a control antibody—2 mg or 0.2 mg—twice weekly and were followed for a maximum of 75 days.

Engraftment at the higher dose

Mice that received the 2 mg dose of PRO 140 or the control antibody had received HSCs from a 56-year-old donor.

Engraftment was similar between control and PRO 140-treated mice for the first 30+ days. However, at day 50, there were significantly fewer human CD45+ cells in the PRO 140-treated mice (P=0.034).

At 54 days, control mice had greater engraftment of mature T cells than treated mice in the peripheral blood (63.2% vs 49.8%) and bone marrow (40.2% vs 26.4%).

GVHD at the higher dose

Throughout the study period, there were no physical signs of GVHD in the PRO 140-treated mice.

However, control mice exhibited signs of GVHD starting at day 25 after bone marrow engraftment. Signs included ruffled fur, lethargy, hunching, and weight loss.

There was a significant difference in survival between the 2 groups (P<0.01). All of the control mice had to be sacrificed early, by day 56, whereas all of the PRO 140-treated animals were alive until planned sacrifice at day 75.

Engraftment at the low dose

Mice that received the 0.2 mg dose of PRO 140 or the control antibody had received HSCs from a 26-year-old donor.

Mice in the treatment and control groups achieved the same percentage of CD45+ engraftment. However, PRO 140-treated mice achieved engraftment about 20 days later than control mice (P<0.01).

GVHD at the low dose

Both control and PRO 140-treated mice showed signs of GVHD. However, weight loss was significantly greater among control mice (P<0.05).

Survival was significantly worse among control mice as well (P<0.05). All control mice were dead by 31 days, and all PRO 140-treated mice were dead by 54 days.

The researchers said the difference in survival times between these mice and the mice treated with the higher dose of antibody suggest the younger HSC donor produced more aggressive GVHD.

“This research provided CytoDyn with strong rationale for exploring the use of PRO 140 in . . . the prevention of GVHD,” Dr Burger said.

“The potential of PRO 140 to prevent this life-threatening condition could help extend the use of [HSC] transplantation, an important and effective therapy, to more patients.”

CytoDyn is currently enrolling patients in a phase 2 trial of PRO 140 in leukemia patients undergoing transplant.

Photo by Steven Harbour

US state laws intended to ensure fair prices for oral cancer drugs have had a mixed impact on patients’ pocketbooks, according to a study published in JAMA Oncology.

A total of 43 states and Washington, DC, have enacted parity laws, which require that patients pay no more for an oral cancer treatment than they would for an infusion of the same treatment.

Researchers analyzed the impact of these laws and observed modest improvements in costs for some patients.

However, patients who were already paying the most for their medications saw their monthly costs go up.

“Although parity laws appear to help reduce out-of-pocket spending for some patients, they may not fully address affordability for patients needing cancer drugs,” said study author Stacie B. Dusetzina, PhD, of the University of North Carolina at Chapel Hill.

“We need to consider ways to address drug pricing directly and to improve benefit design to make sure that all patients can access prescribed drugs.”

To gauge the impact of parity laws on treatment costs, Dr Dusetzina and her colleagues analyzed health claims data for 63,780 adults from 3 large, nationwide insurance companies before and after the laws were enacted, from 2008 to 2012.

The team compared the cost of filling an oral cancer drug prescription for patients with health insurance plans that were covered by the state laws (fully insured) and patients whose plans were not (self-funded). All patients lived in 1 of 16 states that had passed parity laws at the time of the study.

About half of patients (51.4%) had fully insured plans, and the other half (48.6%) had self-funded plans.

For the entire cohort, the use of oral cancer drugs increased from 18% in the months before parity laws were passed to 22% in the months after (adjusted difference-in-differences risk ratio [aDDRR], 1.04; 95% confidence interval [CI], 0.96-1.13; P=0.34).

The proportion of prescription fills for oral drugs without copayment increased from 15.0% to 53.0% for patients with fully insured plans and from 12.3% to 18.0% in patients with self-funded plans (aDDRR, 2.36; 95% CI, 2.00-2.79; P<0.001).

“From our results, it looks like many plans decided they would just set the co-pay for oral drugs to $0,” Dr Dusetzina said. “Instead of $30 per month, those fills were now $0.”

The proportion of prescription fills with out-of-pocket cost of more than $100 per month increased from 8.4% to 11.1% for patients with fully insured plans but decreased from 12.0% to 11.7% for those with self-funded plans (aDDRR, 1.36; 95% CI, 1.11-1.68; P=0.004).

Patients paying the most for their oral cancer drug prescriptions experienced increases in their monthly out-of-pocket costs after parity laws were passed.

For patients whose costs were more expensive than 95% of other patients, their out-of-pocket costs increased an estimated $143.25 per month. Those paying more than 90% of what other patients paid saw their costs increase by $37.19 per month.

“One of the biggest problems with parity laws as they are written is that they don’t address the prices of these medications, which can be very high,” Dr Dusetzina noted.

“Parity can be reached as long as the coverage is the same for both oral and infused cancer therapies. Because we’re now seeing more people insured by plans with high deductibles or plans that require them to pay a percentage of their drug costs, parity may not reduce spending for some patients.”

However, Dr Dusetzina and her colleagues did find that patients who paid the least for their oral cancer treatments saw their estimated monthly out-of-pocket spending decrease.

Patients in the 25th percentile saw an estimated decrease of $19.44 per month, those in the 50th percentile saw a $32.13 decrease, and patients in the 75th percentile saw a decrease of $10.83.

On the other hand, the researchers also found that average 6-month healthcare costs—including what was paid by insurance companies and patients—did not change significantly as a result of parity laws.

The aDDRR was 0.96 (95% CI, 0.90-1.02; P=0.09) for all cancer treatments and 1.06 (95% CI, 0.93-1.20; P=0.40) for oral cancer drugs.

“One of the key arguments against passing parity, both for states that haven’t passed it and for legislation at the federal level, has been that it may increase costs to health plans,” Dr Dusetzina said. “But we didn’t find evidence of that.”

Photo by Steven Harbour

US state laws intended to ensure fair prices for oral cancer drugs have had a mixed impact on patients’ pocketbooks, according to a study published in JAMA Oncology.

A total of 43 states and Washington, DC, have enacted parity laws, which require that patients pay no more for an oral cancer treatment than they would for an infusion of the same treatment.

Researchers analyzed the impact of these laws and observed modest improvements in costs for some patients.

However, patients who were already paying the most for their medications saw their monthly costs go up.

“Although parity laws appear to help reduce out-of-pocket spending for some patients, they may not fully address affordability for patients needing cancer drugs,” said study author Stacie B. Dusetzina, PhD, of the University of North Carolina at Chapel Hill.

“We need to consider ways to address drug pricing directly and to improve benefit design to make sure that all patients can access prescribed drugs.”

To gauge the impact of parity laws on treatment costs, Dr Dusetzina and her colleagues analyzed health claims data for 63,780 adults from 3 large, nationwide insurance companies before and after the laws were enacted, from 2008 to 2012.

The team compared the cost of filling an oral cancer drug prescription for patients with health insurance plans that were covered by the state laws (fully insured) and patients whose plans were not (self-funded). All patients lived in 1 of 16 states that had passed parity laws at the time of the study.

About half of patients (51.4%) had fully insured plans, and the other half (48.6%) had self-funded plans.

For the entire cohort, the use of oral cancer drugs increased from 18% in the months before parity laws were passed to 22% in the months after (adjusted difference-in-differences risk ratio [aDDRR], 1.04; 95% confidence interval [CI], 0.96-1.13; P=0.34).

The proportion of prescription fills for oral drugs without copayment increased from 15.0% to 53.0% for patients with fully insured plans and from 12.3% to 18.0% in patients with self-funded plans (aDDRR, 2.36; 95% CI, 2.00-2.79; P<0.001).

“From our results, it looks like many plans decided they would just set the co-pay for oral drugs to $0,” Dr Dusetzina said. “Instead of $30 per month, those fills were now $0.”

The proportion of prescription fills with out-of-pocket cost of more than $100 per month increased from 8.4% to 11.1% for patients with fully insured plans but decreased from 12.0% to 11.7% for those with self-funded plans (aDDRR, 1.36; 95% CI, 1.11-1.68; P=0.004).

Patients paying the most for their oral cancer drug prescriptions experienced increases in their monthly out-of-pocket costs after parity laws were passed.

For patients whose costs were more expensive than 95% of other patients, their out-of-pocket costs increased an estimated $143.25 per month. Those paying more than 90% of what other patients paid saw their costs increase by $37.19 per month.

“One of the biggest problems with parity laws as they are written is that they don’t address the prices of these medications, which can be very high,” Dr Dusetzina noted.

“Parity can be reached as long as the coverage is the same for both oral and infused cancer therapies. Because we’re now seeing more people insured by plans with high deductibles or plans that require them to pay a percentage of their drug costs, parity may not reduce spending for some patients.”

However, Dr Dusetzina and her colleagues did find that patients who paid the least for their oral cancer treatments saw their estimated monthly out-of-pocket spending decrease.

Patients in the 25th percentile saw an estimated decrease of $19.44 per month, those in the 50th percentile saw a $32.13 decrease, and patients in the 75th percentile saw a decrease of $10.83.

On the other hand, the researchers also found that average 6-month healthcare costs—including what was paid by insurance companies and patients—did not change significantly as a result of parity laws.

The aDDRR was 0.96 (95% CI, 0.90-1.02; P=0.09) for all cancer treatments and 1.06 (95% CI, 0.93-1.20; P=0.40) for oral cancer drugs.

“One of the key arguments against passing parity, both for states that haven’t passed it and for legislation at the federal level, has been that it may increase costs to health plans,” Dr Dusetzina said. “But we didn’t find evidence of that.”

Photo by Steven Harbour

US state laws intended to ensure fair prices for oral cancer drugs have had a mixed impact on patients’ pocketbooks, according to a study published in JAMA Oncology.

A total of 43 states and Washington, DC, have enacted parity laws, which require that patients pay no more for an oral cancer treatment than they would for an infusion of the same treatment.

Researchers analyzed the impact of these laws and observed modest improvements in costs for some patients.

However, patients who were already paying the most for their medications saw their monthly costs go up.

“Although parity laws appear to help reduce out-of-pocket spending for some patients, they may not fully address affordability for patients needing cancer drugs,” said study author Stacie B. Dusetzina, PhD, of the University of North Carolina at Chapel Hill.

“We need to consider ways to address drug pricing directly and to improve benefit design to make sure that all patients can access prescribed drugs.”

To gauge the impact of parity laws on treatment costs, Dr Dusetzina and her colleagues analyzed health claims data for 63,780 adults from 3 large, nationwide insurance companies before and after the laws were enacted, from 2008 to 2012.

The team compared the cost of filling an oral cancer drug prescription for patients with health insurance plans that were covered by the state laws (fully insured) and patients whose plans were not (self-funded). All patients lived in 1 of 16 states that had passed parity laws at the time of the study.

About half of patients (51.4%) had fully insured plans, and the other half (48.6%) had self-funded plans.

For the entire cohort, the use of oral cancer drugs increased from 18% in the months before parity laws were passed to 22% in the months after (adjusted difference-in-differences risk ratio [aDDRR], 1.04; 95% confidence interval [CI], 0.96-1.13; P=0.34).

The proportion of prescription fills for oral drugs without copayment increased from 15.0% to 53.0% for patients with fully insured plans and from 12.3% to 18.0% in patients with self-funded plans (aDDRR, 2.36; 95% CI, 2.00-2.79; P<0.001).

“From our results, it looks like many plans decided they would just set the co-pay for oral drugs to $0,” Dr Dusetzina said. “Instead of $30 per month, those fills were now $0.”

The proportion of prescription fills with out-of-pocket cost of more than $100 per month increased from 8.4% to 11.1% for patients with fully insured plans but decreased from 12.0% to 11.7% for those with self-funded plans (aDDRR, 1.36; 95% CI, 1.11-1.68; P=0.004).

Patients paying the most for their oral cancer drug prescriptions experienced increases in their monthly out-of-pocket costs after parity laws were passed.

For patients whose costs were more expensive than 95% of other patients, their out-of-pocket costs increased an estimated $143.25 per month. Those paying more than 90% of what other patients paid saw their costs increase by $37.19 per month.

“One of the biggest problems with parity laws as they are written is that they don’t address the prices of these medications, which can be very high,” Dr Dusetzina noted.

“Parity can be reached as long as the coverage is the same for both oral and infused cancer therapies. Because we’re now seeing more people insured by plans with high deductibles or plans that require them to pay a percentage of their drug costs, parity may not reduce spending for some patients.”

However, Dr Dusetzina and her colleagues did find that patients who paid the least for their oral cancer treatments saw their estimated monthly out-of-pocket spending decrease.

Patients in the 25th percentile saw an estimated decrease of $19.44 per month, those in the 50th percentile saw a $32.13 decrease, and patients in the 75th percentile saw a decrease of $10.83.

On the other hand, the researchers also found that average 6-month healthcare costs—including what was paid by insurance companies and patients—did not change significantly as a result of parity laws.

The aDDRR was 0.96 (95% CI, 0.90-1.02; P=0.09) for all cancer treatments and 1.06 (95% CI, 0.93-1.20; P=0.40) for oral cancer drugs.

“One of the key arguments against passing parity, both for states that haven’t passed it and for legislation at the federal level, has been that it may increase costs to health plans,” Dr Dusetzina said. “But we didn’t find evidence of that.”

Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.

Vidyard Video

Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.

Vidyard Video

Philip R. Schauer, MD, FACS, discusses innovations, hot topics, and controversies covered in the sessions of this year’s Minimally Invasive Surgery Symposium, held in Las Vegas. In addition to highlighting what’s new this year, Dr. Schauer also spoke about plans for next year’s meeting and what makes the MISS unique and valuable to attendees.

Vidyard Video

My chest and back are sore this week because I was on call last week. It’s my secret to beating burnout. Just keep reading.

The phrase “dermatologist burnout” may seem as oxymoronic as jumbo shrimp, yet both are real. Our work is easier than some other physicians’. Dermatologists don’t sleep in the hospital, and we have many fewer dope-seeking or dying patients. Yet we suffer the same EHR frustrations as any physician. We struggle with an ever-increasing volume of patients and regulations which stultify our ability to care for patients.

[polldaddy:9875293]

Challenges

First, I mark difficult weeks on my calendar in red. Do I have extra clinics? Is it post vacation? Am I giving a talk? Then, I set up challenges. For example, I knew last week’s call was going to be tough. So, each morning I challenged myself to do 100 push-ups in 2 minutes, 12 pull-ups, and run 2 miles. I also set goals of plowing through my backlog of journals and upgrading my EHR shortcuts and order sets.

Colleagues

A Navy SEAL training instructor once told me the key to success in BUD/S (the grueling 6-month SEAL training course), is to take care of your teammates:“When you’re focused on the guy to your right and the guy to your left, you find inner strength to endure suffering.” No matter how busy I am, when my phone rings or I get a text, I think to myself, Good, one of my partners needs my help. Framing it that way makes any added work feel lighter.

(Re)Charging

Lastly, I schedule time to recharge and recover. For example, this morning instead of going to the gym, I had a cappuccino and read the entire Sunday New York Times. Later today, my wife and I are going to see Thor: Ragnarok. In reclining seats. With a craft beer.

My call week was sometimes easy and occasionally arduous. Yet, I taught an ER resident how to recognize zoster in its very early stages. I learned the difference between erythema multiforme major and mycoplasma-induced rash with mucositis, and I reassured a family that their hospitalized 9-year-old was going to be just fine. I didn’t miss a workout (however, no SEAL instructor would have credited my pathetic pull-ups #11 and #12).

My next call isn’t long off, and soon, I must work on a big presentation. Medicine is a marathon, punctuated by sprinting. During stressful periods, I challenge myself physically and mentally, focus on helping others, and take the time to rest and recharge after. I think it has helped me beat burnout, I hope it helps you too.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]

My chest and back are sore this week because I was on call last week. It’s my secret to beating burnout. Just keep reading.

The phrase “dermatologist burnout” may seem as oxymoronic as jumbo shrimp, yet both are real. Our work is easier than some other physicians’. Dermatologists don’t sleep in the hospital, and we have many fewer dope-seeking or dying patients. Yet we suffer the same EHR frustrations as any physician. We struggle with an ever-increasing volume of patients and regulations which stultify our ability to care for patients.

[polldaddy:9875293]

Challenges

First, I mark difficult weeks on my calendar in red. Do I have extra clinics? Is it post vacation? Am I giving a talk? Then, I set up challenges. For example, I knew last week’s call was going to be tough. So, each morning I challenged myself to do 100 push-ups in 2 minutes, 12 pull-ups, and run 2 miles. I also set goals of plowing through my backlog of journals and upgrading my EHR shortcuts and order sets.

Colleagues

A Navy SEAL training instructor once told me the key to success in BUD/S (the grueling 6-month SEAL training course), is to take care of your teammates:“When you’re focused on the guy to your right and the guy to your left, you find inner strength to endure suffering.” No matter how busy I am, when my phone rings or I get a text, I think to myself, Good, one of my partners needs my help. Framing it that way makes any added work feel lighter.

(Re)Charging

Lastly, I schedule time to recharge and recover. For example, this morning instead of going to the gym, I had a cappuccino and read the entire Sunday New York Times. Later today, my wife and I are going to see Thor: Ragnarok. In reclining seats. With a craft beer.

My call week was sometimes easy and occasionally arduous. Yet, I taught an ER resident how to recognize zoster in its very early stages. I learned the difference between erythema multiforme major and mycoplasma-induced rash with mucositis, and I reassured a family that their hospitalized 9-year-old was going to be just fine. I didn’t miss a workout (however, no SEAL instructor would have credited my pathetic pull-ups #11 and #12).

My next call isn’t long off, and soon, I must work on a big presentation. Medicine is a marathon, punctuated by sprinting. During stressful periods, I challenge myself physically and mentally, focus on helping others, and take the time to rest and recharge after. I think it has helped me beat burnout, I hope it helps you too.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]

My chest and back are sore this week because I was on call last week. It’s my secret to beating burnout. Just keep reading.

The phrase “dermatologist burnout” may seem as oxymoronic as jumbo shrimp, yet both are real. Our work is easier than some other physicians’. Dermatologists don’t sleep in the hospital, and we have many fewer dope-seeking or dying patients. Yet we suffer the same EHR frustrations as any physician. We struggle with an ever-increasing volume of patients and regulations which stultify our ability to care for patients.

[polldaddy:9875293]

Challenges

First, I mark difficult weeks on my calendar in red. Do I have extra clinics? Is it post vacation? Am I giving a talk? Then, I set up challenges. For example, I knew last week’s call was going to be tough. So, each morning I challenged myself to do 100 push-ups in 2 minutes, 12 pull-ups, and run 2 miles. I also set goals of plowing through my backlog of journals and upgrading my EHR shortcuts and order sets.

Colleagues

A Navy SEAL training instructor once told me the key to success in BUD/S (the grueling 6-month SEAL training course), is to take care of your teammates:“When you’re focused on the guy to your right and the guy to your left, you find inner strength to endure suffering.” No matter how busy I am, when my phone rings or I get a text, I think to myself, Good, one of my partners needs my help. Framing it that way makes any added work feel lighter.

(Re)Charging

Lastly, I schedule time to recharge and recover. For example, this morning instead of going to the gym, I had a cappuccino and read the entire Sunday New York Times. Later today, my wife and I are going to see Thor: Ragnarok. In reclining seats. With a craft beer.

My call week was sometimes easy and occasionally arduous. Yet, I taught an ER resident how to recognize zoster in its very early stages. I learned the difference between erythema multiforme major and mycoplasma-induced rash with mucositis, and I reassured a family that their hospitalized 9-year-old was going to be just fine. I didn’t miss a workout (however, no SEAL instructor would have credited my pathetic pull-ups #11 and #12).

My next call isn’t long off, and soon, I must work on a big presentation. Medicine is a marathon, punctuated by sprinting. During stressful periods, I challenge myself physically and mentally, focus on helping others, and take the time to rest and recharge after. I think it has helped me beat burnout, I hope it helps you too.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]