No abstract

Background: Transgender individuals have greater health risks than cisgender individuals, which may bode for greater mortality. However, research is limited by lack of gender identity information at the time of death. Novel opportunities to combine administrative data with National Death Index (NDI) data may facilitate mortality research about transgender populations, but binary measures of sex and gender may pose problems for analyses. This study explored differences in sex recorded in Veterans Health Administration (VHA) electronic health record (EHR) and NDI data between transgender and cisgender decedents. Methods: We used VHA EHR data from fiscal years 2000-2016 to identify deaths among a sample of transgender and cisgender patients. We cross-tabulated sex recorded in the NDI with EHRbased sex from VHA EHR data. We extracted data in 2018 and conducted analyses in 2020. Results: Death occurred for 1109 transgender patients and 7757 cisgender patients. For cisgender decedents, EHR-based sex and NDI-based sex were 100% concordant. For transgender decedents, 46 (4%) were discordant between data sources. Of transgender decedents with female EHR-based sex (n = 259), 17% were indicated as male in NDI data; of those with male EHR-based sex (n = 850), 0.2% were indicated as female in NDI data. Conclusions: Data linkage between EHR and the NDI can facilitate transgender mortality research, but examining mortality specific to various transgender identities remains difficult. Improved documentation of sex and gender is needed within US mortality surveillance.

Objective: To understand barriers and facilitators to evidence-based prescribing of antibiotics in the outpatient dental setting. Design: Semistructured interviews. Setting: Outpatient dental setting. Participants: Dentists from 40 Veterans’ Health Administration (VA) facilities across the United States. Methods: Dentists were identified based on their prescribing patterns and were recruited to participate in a semistructured interview on perceptions toward prescribing. All interviews were recorded, transcribed, and double-coded for analysis, with high reliability between coders. We identified general trends using the theoretical domains framework and mapped overarching themes onto the behavior change wheel to identify prospective interventions that improve evidence-based prescribing. Results: In total, 90 dentists participated in our study. The following barriers and facilitators to evidence-based prescribing emerged as impacts on a dentist’s decision making on prescribing an antibiotic: access to resources, social influence of peers and other care providers, clinical judgment, beliefs about consequences, local features of the clinic setting, and beliefs about capabilities. Conclusions: Findings from this work reveal the need to increase awareness of up-to-date antibiotic prescribing behaviors in dentistry and may inform the best antimicrobial stewardship interventions to support dentists’ ongoing professional development and improve evidence-based prescribing.

Background: Limited research suggests that rates of suicide death among transgender people may be higher than their nontransgender peers. Objective: The objective of this study was to compare rates of suicide deaths by different means between transgender and nontransgender patients. Research Design: This secondary analysis used VHA administrative and electronic health record (EHR) data from October 1, 1999 through December 31, 2016. Subjects: Transgender patients (n=8981) were categorized as such based on a set of International Classification of Disease codes, and a comparison sample was selected by randomly choosing 3 nontransgender patients (n=26,924). Measures and Analyses: Cause and date of death data are from the National Death Index. Because of low frequencies amid different methods of suicide death, we combined categories into self-poisoning; hanging, strangulation and suffocation; discharge of firearms; and self-harm by all other and unspecified means. We conducted Cox regression analyses to model time-to-event for each method of suicide, adjusted for age, sex based on EHR, race, ethnicity, marital status, and whether patients had ever been diagnosed with depression. Results: Among transgender patients, 73 died by suicide (22 female EHR-based sex, 51 male EHR-based sex), and among nontransgender patients, 71 died by suicide (4 female EHR-based sex, 67 male EHR-based sex). In adjusted models, transgender patients had significantly greater hazards of death by self-poisoning and firearms than their nontransgender peers. Conclusions: Differences in methods of suicide death suggest that firearms and self-poisoning may be specific areas of concern for transgender individuals experiencing suicidal crisis, which underscore needs for examining effective delivery of evidence-based care.