Results Summary
What was the research about?
Hospitals do not usually collect information about people’s sexual orientation and gender identity, or SO/GI. People who are lesbian, gay, bisexual, transgender, or queer—sometimes called sexual and gender minorities, or SGM—have said it is important for doctors to know their identities to provide good care. The research team wanted to find the best way to ask all patients for this information.
In this study, the research team compared two ways to ask patients about their SO/GI in the emergency room, or ER. In one method, a nurse asked the patient. In the other method, the patient filled out a form. The team then gave a survey to a smaller group of patients about their comfort in sharing SO/GI information during their ER visits.
What were the results?
Patients who identified as SGM were more comfortable filling out a form than giving answers to a nurse. Patients who did not identify as SGM were equally comfortable with either way.
Who was in the study?
During the study, 198,137 patients went to one of four ERs in the Northeastern United States. Of these, 19,742 patients gave verbal information about SO/GI, and 3,630 patients filled out a form. The research team then gave a survey to 180 patients who were SGM and to 180 patients who did not identify as SGM about how comfortable they felt in the ER. The team also asked another 180 patients who did not answer questions about SO/GI about their comfort in the ER.
What did the research team do?
For a six-month period, ER nurses asked patients about their SO/GI. Then, for the next six months, ER staff gave patients hospital intake forms with SO/GI questions. After each six-month period, the team asked a smaller group of patients about their comfort with sharing SO/GI information with hospital staff.
What were the limits of the study?
The hospitals in the study were in the Northeastern United States. Results may differ in other locations. The study didn’t include patients who chose “other” for SO/GI. Also, the study didn’t include patients who didn’t speak English or who had a mental health condition. Not including these patients could have changed the results. Nurses may have talked only to patients they thought would answer the questions. Asking only some patients may also have changed the results.
Future research could look at how hospitals and their staff decide how to ask about SO/GI with all patients. Future studies could also include patients who don’t use common SO/GI labels and patients with mental health conditions.
How can people use the results?
Hospital staff can use these results to design a process to ask patients about SO/GI. Regularly asking all patients about SO/GI may make patients feel more comfortable sharing this information.
Professional Abstract
Objective
To compare the effectiveness of two patient-centered methods for collecting sexual orientation and gender identity (SO/GI) information in the emergency department (ED)
Study Design
| Design Elements | Description |
|---|---|
| Design | Quasi-experimental study |
| Population | 540 patients who were asked about comfort outcome during ED visit |
| Interventions/ Comparators |
|
| Outcomes | Patient comfort during the ED visit |
| Same-visit follow-up for study outcome |
This multisite, matched intervention trial compared two methods for collecting patient SO/GI information at four hospital EDs in the Northeastern United States, to address a lack of data on SO/GI that poses a major challenge to addressing health disparities for sexual and gender minorities (SGM). For the first six months of the study, nurses collected this information verbally; during the second six months, registrars collected this information nonverbally, using a form they distributed to patients. All English-speaking adult patients who entered one of four EDs during the trial period were eligible to participate in the study unless they had a mental health condition, were under the influence of substances that might interfere with cognition, had an Emergency Severity Index score <2, or had a hand or arm injury. Researchers then surveyed patients who identified as SGM—gay, lesbian, bisexual, transgender, or queer—about their ED experiences. Researchers also asked about ED experiences with patients who did not identify as SGM and with a matched group of ED patients who did not answer questions about SO/GI.
During the verbal collection period, 19,742 patients (18% of 109,994 patients who entered the EDs) provided SO/GI information. During collection using forms, 3,620 patients (4% of 88,143 patients who went to the EDs) reported SO/GI. In total, 673 patients identified as SGM. Researchers collected follow-up survey data about patient comfort with ED communications from 180 patients who identified as SGM, 180 matched patients who did not identify as SGM, and 180 matched patients who did not answer questions about SO/GI. The researchers used survey data for all analyses.
Results
- Patients who identified as SGM had significantly higher comfort scores during nonverbal collection compared with verbal collection (p=0.0274). Patients who were not SGM were equally comfortable with either collection method.
- Patients who identified as SGM were 2.57 times more likely to prefer nonverbal collection over verbal collection after controlling for age, race, and illness severity (95% confidence interval: 1.13, 5.82, p=0.02).
- Comfort scores for ED visits overall did not differ between patients who answered or did not answer questions about SO/GI.
Limitations
The study took place in the Northeastern United States. Results may differ in other parts of the country. The outcome surveys did not include patients who identified as “other” for their SO/GI or patients who did not speak English or who had a psychiatric diagnosis. These patients may have had different experiences in the ED. The relatively low percentage of patients who provided SO/GI information may be due to selection bias. Nurses and registrars may have asked for SO/GI information only from patients they thought would answer the questions.
Conclusions and Relevance
Patients who identified as SGM reported higher comfort using the nonverbal collection method compared with the verbal disclosure method.
Future Research Needs
Future studies could focus on how community, hospital, or staff factors affect SO/GI data collection and on how to implement SO/GI collection for all patients. Researchers could also include patients with psychiatric diagnoses and patients who use nonconventional terms for SO/GI.
Final Research Report
View this project's final research report
More About This Research
Media Mentions
Gay and Transgender Patients to Doctors: We’ll Tell. Just Ask.
Jan Hoffman, New York Times, May 29, 2017
This Times feature on healthcare providers seeking information about patients' sexual orientation and gender identity included an interview with Principal Investigator Adil Haider, MD, MPH, on the findings of his study .
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer review identified the following strengths and limitations in the report:
- The reviewers asked the researchers to provide more rationale for the multivariate analyses the study chose. The researchers responded by stating that they chose to use ordered logistic regression for their main analyses. The researchers explained that the Communication Climate Assessment Toolkit scores were categorical rather than continuous, so treating the scores as continuous could introduce bias into calculations. The researchers also provided their rationale for controlling for some factors and not others. The rationale was that the sample size for some factors may have been too small for adequate power to detect meaningful differences.
- The reviewers expressed concern that the researchers stratified results by sex for the homosexual group but not for the bisexual and heterosexual groups. The researchers explained that their decision came after recommendations from stakeholders as well as from peer reviewers for journal articles about this study. In addition, the researchers expressed concern that stratifying by sex in the bisexual group would lead to small sample sizes with insufficient power to detect meaningful differences.
- The reviewers noted that the report did not describe how the researchers addressed the effects of missing data on the results. The reviewers asked for more information about such effects. The researchers responded that they matched groups using only participants with complete data, so missing data did not raise issues. The researchers chose this strategy because they predicted that inputting data for missing variables was just as likely to increase bias in the sample as it was to alleviate it.
- The reviewers were unclear about how many patients in the emergency department either weren’t asked about their sexual orientation or gender identity or declined to answer those questions. The researchers acknowledged that this lack of clarity was a limitation of the study. The researchers added that 88 percent of patients in the emergency department were not asked these questions, while 0.01 percent refused to answer. The researchers explained that patients were not asked despite the researchers’ efforts to make the questions about sexual orientation and gender identity part of routine intake procedures. However, the researchers did not believe this low rate of asking patients significantly affected the results. The team still achieved the planned sample size and produced the same communication climate results with every analysis of the data.
Conflict of Interest Disclosures
View the COI disclosure form.
Journal Citations
Results of This Project
Related Journal Citations
Stories and Videos
Media Mentions
Jan Hoffman, New York Times, May 29, 2017
This Times feature on healthcare providers seeking information about patients' sexual orientation and gender identity included an interview with Principal Investigator Adil Haider, MD, MPH, on the findings of his study .
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer review identified the following strengths and limitations in the report:
- The reviewers asked the researchers to provide more rationale for the multivariate analyses the study chose. The researchers responded by stating that they chose to use ordered logistic regression for their main analyses. The researchers explained that the Communication Climate Assessment Toolkit scores were categorical rather than continuous, so treating the scores as continuous could introduce bias into calculations. The researchers also provided their rationale for controlling for some factors and not others. The rationale was that the sample size for some factors may have been too small for adequate power to detect meaningful differences.
- The reviewers expressed concern that the researchers stratified results by sex for the homosexual group but not for the bisexual and heterosexual groups. The researchers explained that their decision came after recommendations from stakeholders as well as from peer reviewers for journal articles about this study. In addition, the researchers expressed concern that stratifying by sex in the bisexual group would lead to small sample sizes with insufficient power to detect meaningful differences.
- The reviewers noted that the report did not describe how the researchers addressed the effects of missing data on the results. The reviewers asked for more information about such effects. The researchers responded that they matched groups using only participants with complete data, so missing data did not raise issues. The researchers chose this strategy because they predicted that inputting data for missing variables was just as likely to increase bias in the sample as it was to alleviate it.
- The reviewers were unclear about how many patients in the emergency department either weren’t asked about their sexual orientation or gender identity or declined to answer those questions. The researchers acknowledged that this lack of clarity was a limitation of the study. The researchers added that 88 percent of patients in the emergency department were not asked these questions, while 0.01 percent refused to answer. The researchers explained that patients were not asked despite the researchers’ efforts to make the questions about sexual orientation and gender identity part of routine intake procedures. However, the researchers did not believe this low rate of asking patients significantly affected the results. The team still achieved the planned sample size and produced the same communication climate results with every analysis of the data.
Conflict of Interest Disclosures
Project Information
Key Dates
Study Registration Information
^Adil Haider, MD, MPH, was affiliated with Johns Hopkins University when this project was funded.