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Background: Access to clinicians competent in transgender health remains a significant barrier and contributor toward health inequity for transgender people. Studies on access and barriers to care have predominantly evaluated transgender patients' perceptions, but scant research has included the perspectives of clinicians.Aims: We conducted a qualitative study to explore how clinicians (meaning physicians and advanced practice providers, in this paper) in the United States: (1) attain and utilize information, (2) perceive barriers and facilitators, and (3) understood gaps in their professional training, in regard to practicing transgender health care.Methods: A Qualitative Descriptive approach guided our conventional content analysis of field notes and interviews with clinicians within a parent study that explored health care access among transgender adults. Transcripts were coded into meaning units that were iteratively abstracted into themes. Standard measures were performed to promote the trustworthiness of the analysis and reduce bias.Results: Participants (n = 13) consisted of physicians (n = 8), physician assistants (n = 3), and nurse practitioners (n = 2). The majority were women (n = 11), identified as White (n = 9), cisgender (n = 13), and ages ranged from 31 - 58 years. Five main themes were identified: (1) Knowledge Acquisition: Formal and Informal Pathways to Competency; (2) Perceived Challenges and Barriers: I didn't know what I was doing; (3) Power to Deny: Prescriptive Authority and Gatekeeping; (4) Stigma: This is really strange, and I can't really understand it; (5) Reflections: Strategies for Success, Rewards, and Personal Motivations.Discussion: Clinicians gained a sense of comfort and competence with mentorship, self-directed learning, clinical experience, and person-centered, harm-reduction approaches. Stigma, bias, and structural-level factors were barriers to providing care. This study offers a unique perspective of clinicians' motivations and strategies for providing gender-affirming care and elucidates how stigma impacts the delivery of gender-affirming care. [ABSTRACT FROM AUTHOR]

Background: Since the early 90s, patient navigation programs were introduced in the United States to address inequitable access to cancer care. Programs have since expanded internationally and in scope. The goals of patient navigation programs are to: a) link patients and families to primary care services, specialist care, and community-based health and social services (CBHSS); b) provide more holistic patient-centred care; and, c) identify and resolve patient barriers to care. This paper fills a gap in knowledge to reveal what is known about motivators and factors influencing implementation and maintenance of patient navigation programs in primary care that link patients to CBHSS. It also reports on outcomes from these studies to help identify gaps in research that can inform future studies.Methods: This scoping literature review involved: i) electronic database searches; ii) a web site search; iii) a search of reference lists from literature reviews; and, iv) author follow up. It included papers from Canada, the United States, the United Kingdom, Australia, New Zealand, and/or Western Europe published between January 1990 and June 2013 if they discussed navigators or navigation programs in primary care settings that linked patients to CBHSS.Results: Of 34 papers, most originated in the United States (n = 29) while the remainder were from the United Kingdom, Canada and Australia. Motivators for initiating navigation programs were to: a) improve delivery of health and social care services; b) support and manage specific health needs or specific population needs, and; c) improve quality of life and wellbeing of patients. Eleven factors were found to influence implementation and maintenance of these patient navigation programs. These factors closely aligned with the Diffusion of Innovation in Service Organizations model, thus providing a theoretical foundation to support them. Various positive outcomes were reported for patients, providers and navigators, as well as the health and social care system, although they need to be considered with caution since the majority of studies were descriptive.Conclusions: This study contributes new knowledge that can inform the initiation and maintenance of primary care patient navigation programs that link patients with CBHSS. It also provides directions for future research. [ABSTRACT FROM AUTHOR]

Background: Studies on differences between immigrant and non-immigrant groups in health care utilization vary with respect to the extent and direction of differences in use. Therefore, our study aimed to provide a systematic overview of the existing research on differences in primary care utilization between immigrant groups and the majority population. Methods: For this review PubMed, PsycInfo, Cinahl, Sociofile, Web of Science and Current Contents were consulted. Study selection and quality assessment was performed using a predefined protocol by 2 reviewers independently of each other. Only original, quantitative, peer-reviewed papers were taken into account. To account for this hierarchical structure, logistic multilevel analyses were performed to examine the extent to which differences are found across countries and immigrant groups. Differences in primary care use were related to study characteristics, strength of the primary care system and methodological quality. Results: A total of 37 studies from 7 countries met all inclusion criteria. Remarkably, studies performed within the US more often reported a significant lower use among immigrant groups as compared to the majority population than the other countries. As studies scored higher on methodological quality, the likelihood of reporting significant differences increased. Adjustment for health status and use of culture-/language-adjusted procedures during the data collection were negatively related to reporting significant differences in the studies. Conclusion: Our review underlined the need for careful design in studies of differences in health care use between immigrant groups and the majority population. The results from studies concerning differences between immigrant and the majority population in primary health care use performed within the US might be interpreted as a reflection of a weaker primary care system in the US compared to Europe and Canada. [ABSTRACT FROM AUTHOR]

Background: In the United States, home-based primary care (HBPC) is increasingly proposed as a means of enabling frail elders to remain at home for as long as possible, while still receiving needed medical care. However, there are relatively few studies of either the medical outcome effects or cost benefits of HBPC. In this paper, we examine medical cost and mortality outcomes for enrollees in the HBPC program offered by Spectrum Health/Priority Health (SH/PH), a not-for-profit integrated health care/health insurance system located in Grand Rapids, MI, USA.Methods: We perform a concurrent matched cohort study. SH/PH HBPC enrollees during 2012-2014 are matched for prior costs, age, sex and comorbidities against controls selected from unenrolled insurance plan members. Twelve and twenty four-month medical costs are compared between HBPC participants and matched controls, overall and conditional on mortality status. Mortality rates of HBPC participants are studied on their own and in comparison to controls.Results: At 12 and 24 months, in comparison to matched controls HBPC participants show higher ($2933) and lower ($8620) costs respectively. Relative costs and savings of HBPC participants are a function of short term increased costs upon entry into the program (enrollees who survive the first year cost $5866 more than controls); substantial savings at end-of-life (approximately $37,037 in savings relative to controls are realized); and the overall mortality of HBPC participants (mean residual lifespan is 37.75 months from the time of enrollment). We project the present value of lifetime medical cost savings due to enrollment in the HBPC program to be at least $14,336.Conclusions: The SH/PC HBPC program reduces healthcare costs while enabling frail elders to remain at home. Reduction in costs is obtained at end-of-life and is offset with a smaller initial increase in costs upon enrollment. [ABSTRACT FROM AUTHOR]