Best Way to Determine Gender Identity, Sexual Orientation in the ED Identified

Pauline Anderson

January 10, 2019

The optimal method of collecting information on sexual orientation and gender identify (SOGI) in patients attending hospital emergency departments (EDs) is through written self-reports at registration, new research shows.

Investigators found individuals who identify as a sexual or gender minority (SGM) prefer a standardized collection process to report SOGI along with other demographic information vs revealing this information to a nurse during a clinical encounter.

"These findings support nonverbal self-report as an acceptable and feasible method of SOGI collection," write the authors, led by Adil Haider, MD, Center for Surgery and Public Health, Brigham & Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

The study was published online December 28 in JAMA Network Open.

Patient Preferences Unknown

Estimates show about 4% of the US population identifies as a sexual or gender minority such as lesbian, gay, bisexual, or transgender. The number of American adults identifying as a sexual or gender minority has increased from 8 million in 2012 to 10 million in 2016, according to a January 2017 Gallup poll.

The investigators note that health and government agencies recommend routine collection of SOGI information in healthcare settings. However, the investigators note, "patient preferences for collection methods remain unknown," particularly in the ED setting.

The Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity (EQUALITY) study sought to identify the optimal patient-centered method of collecting SOGI information from patients in the ED.

Phase 1 of EQUALITY revealed that about 80% of clinicians believe patients would refuse to provide SOGI, yet only 10% of patients reported they would refuse to do so.

In phase 2, stakeholder advisory board (SAB) members identified the two most preferred methods of SOGI collection: verbal collection by a nurse and nonverbal collection during patient registration.

The current phase 3 of the study compared these two modes:

  • Mode 1: ED nurses collected SOGI information as part of the social history portion of the patient assessment and entered it directly into the electronic health record

  • Mode 2: Registrars asked patients to confidentially complete a demographic information form that included SOGI information, administered via iPad

The study was conducted at two academic and two community EDs in metropolitan Boston and Baltimore, Maryland. Physicians, physician assistants, nurses, and registrars received education and training on sexual and gender identity health disparities and terminology.

Patients whose chief concern was psychiatric or alcohol and/or drug-related were not included in the study.

Researchers collected data on sexual orientation and gender identity from 23,372 patients during the intervention period (19,742 through mode 1 and 3630 through mode 2).

In both modes, researchers regularly ran analytic reports to identify adult patients who were eligible for a survey on preferable method of SOGI collection.

Results of this five-item Communication Climate Assessment Toolkit (CCAT) survey were the primary outcome. The score for each scale item ranged from 0 to 5, with higher scores considered better. Researchers calculated the average score and multiplied this by 20 to provide an overall score out of 100.

Guidelines Needed

The final analysis included 540 subjects (342 from mode 1 and 198 from mode 2). This included 180 patients each in the SGM group, a non-SGM group, and a group of patients whose SOGI information was missing (blank field). The groups were matched on age and illness severity (Emergency Severity Index score).

The mean age of the 540 study participants was 36.4 years and 66.5% of those who identified their gender were female.

Mean modified CCAT scores were 6 points higher among SGM patients whose SOGI information was collected by form during registration compared with nurse verbal collection (mean 95.6 vs 89.5; P = .03)

There were no significant differences between the two approaches among non-SGM patients (mean 91.8 vs 93.2; P = .59) or those with a blank field (mean 92.7 vs 93.6; P = .70).

In unadjusted regression models stratified by group, SGM patients had 1.98 times the odds of having a higher CCAT score between modes 1 and 2 (95% confidence interval [CI] 0.99 - 3.98). After adjusting for age, race, illness severity, and study site, the strength of the association increased to 2.57 (95% CI, 1.13 - 5.82).

The odds of a better CCAT score between modes 1 and 2 among non-SGM or blank field patients were not significant.

Secondary outcomes included overall patient comfort, patient experiences, and patient comfort with SOGI collection as measured on a Likert-type scale. For these outcomes, there were no significant differences between modes 1 and 2 among SGM patients.

A possible limitation of the study was that collection of SOGI information in the ED was not compulsory, which resulted in low SOGI collection rates for both verbal and nonverbal methods.

The low overall SOGI collection rates "reinforce the need to develop guidelines and patient-centered methods to collect these important data before it becomes a national requirement," the authors write.

Other possible limitations were that the study may have missed patients who chose not to define themselves in a particular sexual and gender minority category. The study also did not include patients with a psychiatric diagnosis.

"Because [sexual and gender minority] patients have increased risk of poor mental health, we may have missed SGM patients who may benefit most from increased SGM sensitivity," the authors write.

"Crucial" Research

Commenting on the findings for Medscape Medical News, Allegra R. Gordon, ScD, Research Scientist, Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, and Instructor, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, said the study helps "change the landscape of health care" by "better equipping" health care settings to provide high-quality care to all patients across sexual orientations and gender identities.

Gordon elaborated on various factors that make the new study important.

It helps health care providers and hospitals understand that correctly collecting SOGI information "can actually improve" satisfaction of SGM patients in acute care settings.

The study also demonstrates that non-SGM patients are "just fine" in answering SOGI-related questions; their satisfaction with ED care was not impacted by this, she said.

"What's more, the researchers found no difference in how comfortable patients felt reporting their sexual orientation and gender identity whether or they were SGM themselves — or even if they chose to leave those questions blank."

Gordon noted that most study patients felt it was important for EDs to collect SOGI information from all patients.

"This should allay the concern that I often hear, that patients will refuse or be upset if they’re asked about their sexual orientation or gender identity. Even in this study, which took place in an acute care setting, that was not the case."

For more than a decade, researchers and providers specializing in SGM health have called for sensitive, routine collection of SOGI information in healthcare settings, said Gordon.

"This study is a very important start to better understanding how to improve patient care experiences for SGM populations that experience significant disparities in access to care."

Gordon added that conducting this kind of research in diverse regions across the country is "crucial."

The study authors and Gordon have disclosed no relevant financial relationships.

JAMA Network Open. Published December 28, 2018. Abstract

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