Marco Marcelli, MD

According to the United States Transgender Survey, 39% of respondents reported experiencing serious psychological distress (based on the Kessler 6 Psychological Distress Scale) in the past 30 days compared with 5% in the general population.¹ Additionally, 40% of respondents attempted suicide in their lifetime, compared with 5% in the general population.¹ Almost half of respondents reported being sexually assaulted at some time in their life, and 10% reported being sexually assaulted in the past year.¹

Studies have also shown that veterans and active-duty service members experience worse mental health outcomes and are at increased risk for suicide than civilians and nonveterans.^2-5 About 1 in 4 active-duty service members meet the criteria for diagnosis of a mental illness.⁴ Service members were found to have higher rates of probable anxiety and posttraumatic stress disorder (PTSD) compared with the general population.^2,6 In 2018, veteran suicide deaths accounted for about 13% of all deaths by suicide in the US even though veterans only accounted for about 7% of the adult population in that year.^5,7 Also in 2018, about 17 veterans committed suicide per day.⁵ According to the Health Related Behaviors Survey of active-duty service members, about 18% reported thinking about attempting suicide some time in their lives compared with 4% of the general population.^2,3 Additionally, 5% of service members reported previous suicide attempts compared with 0.5% in the general population.^2,3 It is clear that transgender individuals, veterans, and service members have certain mental health outcomes that are worse than that of the general population.^1-7

Transgender individuals along with LGB (lesbian, gay, bisexual) individuals have long faced discrimination and unfair treatment in the military.^8-11 In the 1920s, the first written policies were established that banned gay men from serving in the military.⁹ The US Department of Defense (DoD) continued these policies until in 1993, the “Don’t Ask Don’t Tell” policy was established, which had the façade of being more inclusive for LGB individuals but forced LGB service members to hide their sexual identity and continued the anti-LGBTQ messages that previous policies had created.^8,10,11 In 2010, “Don’t Ask Don’t Tell” was repealed, which allowed LGB individuals to serve in the military without concealing their sexual orientation and without fear of discharge based on their sexual identity.¹¹ This repeal did not allow transgender individuals to serve their country as the DoD categorized transgender identity as a medical and mental health disorder.^8,11

In 2016, the ban on transgender individuals serving in the military was lifted, and service members could no longer be discharged or turned away from joining the military based on gender identity.^8,12 However, in 2018, this order was reversed. The new policy stated that new service members must meet requirements and standards of their sex assigned at birth, and individuals with a history of gender dysphoria or those who have received gender-affirming medical or surgical treatment were prohibited to serve in the military.^8,13 This policy did not apply to service members who joined before it took effect. Finally, in April 2021, the current policy took effect, permitting transgender individuals to openly serve in the military. The current policy states that service members cannot be discharged or denied reenlistment based on their gender identity and provides support to receive gender-affirming medical care.¹⁴ Although transgender individuals are now accepted in military service, there is still much progress needed to promote equity among transgender service members.

Methods

We conducted a systematic review of articles presenting data on mental health outcomes in transgender veterans and active-duty service members. The National Library of Medicine PubMed database was searched using the following search terms in various combinations: mental health outcomes, transgender, veterans, military, active duty, substance use, and sexual trauma. The literature search was performed in August 2021 and included articles published through July 31, 2021. Methodology, size, demographics, measures, and main findings were extracted from each article. All studies were eligible for inclusion regardless of sample size. Studies that examined the LGBTQ population without separating transgender individuals were excluded. Studies that examined mental health outcomes including, but not limited to, PTSD, depression, suicidality, anxiety, and substance use disorders (SUDs) in addition to sexual trauma were included. Studies that only examined physical health outcomes were excluded. Qualitative studies, case reports, and papers that did not present original data were excluded (Figure).

Results

Our search resulted in 86 publications. After excluding 65 articles that did not meet the inclusion criteria, 19 studies were included in this review. The Appendix shows the summary of findings from each study, including the study size and results. All studies were conducted in the United States. Most papers used a cross-sectional study design. Most of the studies focused on transgender veterans, but some included data on transgender active-duty service members.

We separated the findings into the following categories based on the variables measured: mental health, including depression, anxiety, PTSD, and serious mental illness; suicidality and self-harm; substance use; and military sexual trauma (MST). Many studies overlapped multiple categories.

Mental Health

Most of the studies included reported that transgender veterans have statistically significant worse mental health outcomes compared with cisgender veterans.^28-30 In addition, transgender active-duty service members were found to have worse mental health outcomes than cisgender active-duty service members.³¹ MST and discrimination were associated with worse mental health outcomes among transgender veterans.^32,33 One study showed a different result than others and found that transgender older adults with prior military service had higher psychological health-related quality of life and lower depressive symptoms than those without prior military service (P = .02 and .04, respectively).³⁴ Another study compared transgender veterans with active-duty service members and found that transgender veterans reported higher rates of depression (64.6% vs 30.9%; χ² = 11.68; P = .001) and anxiety (41.3% vs 18.2%; χ² = 6.54; P = .01) compared with transgender service members.³⁵

Suicidality and Self-harm

Eleven of the 19 studies included measured suicidality and/or self-harm as an outcome. Transgender veterans and active-duty service members were found to have higher odds of suicidality than their cisgender counterparts.^16,28,29,31 In addition, transgender veterans may die by suicide at a younger age than cisgender veterans.³⁶ Stigma and gender-related discrimination were found to be associated with suicidal ideation.^33,37-39 Transgender veterans were less likely than transgender nonveterans to report nonsuicidal self-injury (NSSI).⁴⁰

Substance Use

Two studies focused on substance use, while 5 other studies included substance use in their measures. One of these 2 studies that focused only on substance use outcomes found that transgender veterans were more likely than cisgender veterans to have any SUD (7.2% vs 3.9%; P < .001), in addition to specifically cannabis (3.4% vs 1.5%; P < .001), amphetamine (1.1% vs 0.3%; P < .001), and cocaine use disorders (1.5% vs 1.1%; P < .001).⁴¹

Another study reported that transgender veterans had lower odds of self-reported alcohol use but had greater odds of having alcohol-related diagnoses compared with cisgender veterans.⁴² Of the other studies, it was found that a higher percentage of transgender veterans were diagnosed with an SUD compared with transgender active-duty service members, and transgender veterans were more likely than cisgender veterans to be diagnosed with alcohol use disorder.^29,31 Additionally, rural transgender veterans had increased odds of tobacco use disorder compared with transgender veterans who lived in urban areas.⁴³

Military Sexual Trauma

Five of the studies included examined MST, defined as sexual assault or sexual harassment that is experienced during military service.⁴⁴ Studies found that 15% to 17% of transgender veterans experienced MST.^32,45 Transgender veterans were more likely to report MST than cisgender veterans.^28,29 MST was found to be consistently associated with depression and PTSD.^32,45 A high percentage (83.9%) of transgender active-duty service members reported experiencing sexual harassment and almost one-third experienced sexual assault.⁴⁶

Discussion

Outcomes examined in this review included MST, substance use, suicidality, and symptoms of depression, anxiety, and PTSD among transgender active-duty service members and veterans. To our knowledge, no other review on this topic exists. There is a review of the health and well-being of LGBTQ veterans and service members, but a majority of the included studies did not separate transgender individuals from LGB persons.¹⁷ This review of transgender individuals showed similar results to the review of LGBTQ individuals.¹⁷ This review also presented similar results to previous studies that indicated that transgender individuals in the general population have worse mental health outcomes compared with their cisgender counterparts, in addition to studies that showed that veterans and active-duty service members have worse mental health outcomes compared with civilians and nonveterans.^1-5 The population of focus in this review faced a unique set of challenges, being that they belonged to both of these subsets of the population, both of which experienced worse mental health outcomes, according to the literature.

Studies included in our review found that transgender veterans and service members have worse mental health outcomes than cisgender veterans and service members.^28-31 This outcome was predicted based on previous data collection among transgender individuals, veterans, and active-duty service members. One of the studies included found different results and concluded that prior military service was a protective factor against poorer mental health outcomes.³⁴ This could be, in part, due to veterans’ access to care through the US Department of Veterans Affairs (VA) system. It has been found that transgender veterans use VA services at higher rates than the general population of veterans and that barriers to care were found more for medical treatment than for mental health treatment.⁴⁷ One study found that almost 70% of transgender veterans who used VA services were satisfied with their mental health care.⁴⁸ In contrast, another study included in our review found that transgender veterans had worse mental health outcomes than transgender service members, possibly showing that even with access to care, the burden of stigma and discrimination worsens mental health over time.³¹ Although it has been shown that transgender veterans may feel comfortable disclosing their gender identity to their health care professional, many barriers to care have been identified, such as insensitivity and lack of knowledge about transgender care among clinicians.^49-51 With this information, it would be useful to ensure proper training for health care professionals on providing gender-affirming care.

Most of the studies also found that transgender veterans and service members had greater odds of suicidal thoughts and events than cisgender veterans and service members.^16,28,29,35 On the contrary, transgender veterans were less likely than transgender nonveterans to report NSSI, which could be for various reasons.⁴⁰ Transgender veterans may report less NSSI but experience it at similar rates, or veteran status may be a protective factor for NSSI.

Limitations

This review was limited due to the lack of data collected from transgender veterans and service members. The studies included did not allow for standardized comparisons and did not use identical measures. Some papers compared transgender veterans with transgender nonveterans, some transgender veterans and/or service members with cisgender veterans and/or service members, and some transgender veterans with transgender service members. There were some consistent results found across the studies, but some studies showed contradictory results or no significant differences within a certain category. It is difficult to compare such different study designs and various participant populations. Additional research is required to verify and replicate these results.

Conclusions

Although this review was limited due to the lack of consistent study designs in the literature examining the mental health of transgender veterans and active-duty service members, overall results showed that transgender veterans and service members experience worse mental health outcomes than their cisgender counterparts. With this knowledge and exploring the history of discrimination that this population has faced, improved systems must be put into place to better serve this population and improve health outcomes. Additional research is required to examine the effects of gender-affirming care on mental health among transgender veterans and service members.

According to the United States Transgender Survey, 39% of respondents reported experiencing serious psychological distress (based on the Kessler 6 Psychological Distress Scale) in the past 30 days compared with 5% in the general population.¹ Additionally, 40% of respondents attempted suicide in their lifetime, compared with 5% in the general population.¹ Almost half of respondents reported being sexually assaulted at some time in their life, and 10% reported being sexually assaulted in the past year.¹

Studies have also shown that veterans and active-duty service members experience worse mental health outcomes and are at increased risk for suicide than civilians and nonveterans.^2-5 About 1 in 4 active-duty service members meet the criteria for diagnosis of a mental illness.⁴ Service members were found to have higher rates of probable anxiety and posttraumatic stress disorder (PTSD) compared with the general population.^2,6 In 2018, veteran suicide deaths accounted for about 13% of all deaths by suicide in the US even though veterans only accounted for about 7% of the adult population in that year.^5,7 Also in 2018, about 17 veterans committed suicide per day.⁵ According to the Health Related Behaviors Survey of active-duty service members, about 18% reported thinking about attempting suicide some time in their lives compared with 4% of the general population.^2,3 Additionally, 5% of service members reported previous suicide attempts compared with 0.5% in the general population.^2,3 It is clear that transgender individuals, veterans, and service members have certain mental health outcomes that are worse than that of the general population.^1-7

Transgender individuals along with LGB (lesbian, gay, bisexual) individuals have long faced discrimination and unfair treatment in the military.^8-11 In the 1920s, the first written policies were established that banned gay men from serving in the military.⁹ The US Department of Defense (DoD) continued these policies until in 1993, the “Don’t Ask Don’t Tell” policy was established, which had the façade of being more inclusive for LGB individuals but forced LGB service members to hide their sexual identity and continued the anti-LGBTQ messages that previous policies had created.^8,10,11 In 2010, “Don’t Ask Don’t Tell” was repealed, which allowed LGB individuals to serve in the military without concealing their sexual orientation and without fear of discharge based on their sexual identity.¹¹ This repeal did not allow transgender individuals to serve their country as the DoD categorized transgender identity as a medical and mental health disorder.^8,11

In 2016, the ban on transgender individuals serving in the military was lifted, and service members could no longer be discharged or turned away from joining the military based on gender identity.^8,12 However, in 2018, this order was reversed. The new policy stated that new service members must meet requirements and standards of their sex assigned at birth, and individuals with a history of gender dysphoria or those who have received gender-affirming medical or surgical treatment were prohibited to serve in the military.^8,13 This policy did not apply to service members who joined before it took effect. Finally, in April 2021, the current policy took effect, permitting transgender individuals to openly serve in the military. The current policy states that service members cannot be discharged or denied reenlistment based on their gender identity and provides support to receive gender-affirming medical care.¹⁴ Although transgender individuals are now accepted in military service, there is still much progress needed to promote equity among transgender service members.

Methods

We conducted a systematic review of articles presenting data on mental health outcomes in transgender veterans and active-duty service members. The National Library of Medicine PubMed database was searched using the following search terms in various combinations: mental health outcomes, transgender, veterans, military, active duty, substance use, and sexual trauma. The literature search was performed in August 2021 and included articles published through July 31, 2021. Methodology, size, demographics, measures, and main findings were extracted from each article. All studies were eligible for inclusion regardless of sample size. Studies that examined the LGBTQ population without separating transgender individuals were excluded. Studies that examined mental health outcomes including, but not limited to, PTSD, depression, suicidality, anxiety, and substance use disorders (SUDs) in addition to sexual trauma were included. Studies that only examined physical health outcomes were excluded. Qualitative studies, case reports, and papers that did not present original data were excluded (Figure).

Results

Our search resulted in 86 publications. After excluding 65 articles that did not meet the inclusion criteria, 19 studies were included in this review. The Appendix shows the summary of findings from each study, including the study size and results. All studies were conducted in the United States. Most papers used a cross-sectional study design. Most of the studies focused on transgender veterans, but some included data on transgender active-duty service members.

We separated the findings into the following categories based on the variables measured: mental health, including depression, anxiety, PTSD, and serious mental illness; suicidality and self-harm; substance use; and military sexual trauma (MST). Many studies overlapped multiple categories.

Mental Health

Most of the studies included reported that transgender veterans have statistically significant worse mental health outcomes compared with cisgender veterans.^28-30 In addition, transgender active-duty service members were found to have worse mental health outcomes than cisgender active-duty service members.³¹ MST and discrimination were associated with worse mental health outcomes among transgender veterans.^32,33 One study showed a different result than others and found that transgender older adults with prior military service had higher psychological health-related quality of life and lower depressive symptoms than those without prior military service (P = .02 and .04, respectively).³⁴ Another study compared transgender veterans with active-duty service members and found that transgender veterans reported higher rates of depression (64.6% vs 30.9%; χ² = 11.68; P = .001) and anxiety (41.3% vs 18.2%; χ² = 6.54; P = .01) compared with transgender service members.³⁵

Suicidality and Self-harm

Eleven of the 19 studies included measured suicidality and/or self-harm as an outcome. Transgender veterans and active-duty service members were found to have higher odds of suicidality than their cisgender counterparts.^16,28,29,31 In addition, transgender veterans may die by suicide at a younger age than cisgender veterans.³⁶ Stigma and gender-related discrimination were found to be associated with suicidal ideation.^33,37-39 Transgender veterans were less likely than transgender nonveterans to report nonsuicidal self-injury (NSSI).⁴⁰

Substance Use

Two studies focused on substance use, while 5 other studies included substance use in their measures. One of these 2 studies that focused only on substance use outcomes found that transgender veterans were more likely than cisgender veterans to have any SUD (7.2% vs 3.9%; P < .001), in addition to specifically cannabis (3.4% vs 1.5%; P < .001), amphetamine (1.1% vs 0.3%; P < .001), and cocaine use disorders (1.5% vs 1.1%; P < .001).⁴¹

Another study reported that transgender veterans had lower odds of self-reported alcohol use but had greater odds of having alcohol-related diagnoses compared with cisgender veterans.⁴² Of the other studies, it was found that a higher percentage of transgender veterans were diagnosed with an SUD compared with transgender active-duty service members, and transgender veterans were more likely than cisgender veterans to be diagnosed with alcohol use disorder.^29,31 Additionally, rural transgender veterans had increased odds of tobacco use disorder compared with transgender veterans who lived in urban areas.⁴³

Military Sexual Trauma

Five of the studies included examined MST, defined as sexual assault or sexual harassment that is experienced during military service.⁴⁴ Studies found that 15% to 17% of transgender veterans experienced MST.^32,45 Transgender veterans were more likely to report MST than cisgender veterans.^28,29 MST was found to be consistently associated with depression and PTSD.^32,45 A high percentage (83.9%) of transgender active-duty service members reported experiencing sexual harassment and almost one-third experienced sexual assault.⁴⁶

Discussion

Outcomes examined in this review included MST, substance use, suicidality, and symptoms of depression, anxiety, and PTSD among transgender active-duty service members and veterans. To our knowledge, no other review on this topic exists. There is a review of the health and well-being of LGBTQ veterans and service members, but a majority of the included studies did not separate transgender individuals from LGB persons.¹⁷ This review of transgender individuals showed similar results to the review of LGBTQ individuals.¹⁷ This review also presented similar results to previous studies that indicated that transgender individuals in the general population have worse mental health outcomes compared with their cisgender counterparts, in addition to studies that showed that veterans and active-duty service members have worse mental health outcomes compared with civilians and nonveterans.^1-5 The population of focus in this review faced a unique set of challenges, being that they belonged to both of these subsets of the population, both of which experienced worse mental health outcomes, according to the literature.

Studies included in our review found that transgender veterans and service members have worse mental health outcomes than cisgender veterans and service members.^28-31 This outcome was predicted based on previous data collection among transgender individuals, veterans, and active-duty service members. One of the studies included found different results and concluded that prior military service was a protective factor against poorer mental health outcomes.³⁴ This could be, in part, due to veterans’ access to care through the US Department of Veterans Affairs (VA) system. It has been found that transgender veterans use VA services at higher rates than the general population of veterans and that barriers to care were found more for medical treatment than for mental health treatment.⁴⁷ One study found that almost 70% of transgender veterans who used VA services were satisfied with their mental health care.⁴⁸ In contrast, another study included in our review found that transgender veterans had worse mental health outcomes than transgender service members, possibly showing that even with access to care, the burden of stigma and discrimination worsens mental health over time.³¹ Although it has been shown that transgender veterans may feel comfortable disclosing their gender identity to their health care professional, many barriers to care have been identified, such as insensitivity and lack of knowledge about transgender care among clinicians.^49-51 With this information, it would be useful to ensure proper training for health care professionals on providing gender-affirming care.

Most of the studies also found that transgender veterans and service members had greater odds of suicidal thoughts and events than cisgender veterans and service members.^16,28,29,35 On the contrary, transgender veterans were less likely than transgender nonveterans to report NSSI, which could be for various reasons.⁴⁰ Transgender veterans may report less NSSI but experience it at similar rates, or veteran status may be a protective factor for NSSI.

Limitations

This review was limited due to the lack of data collected from transgender veterans and service members. The studies included did not allow for standardized comparisons and did not use identical measures. Some papers compared transgender veterans with transgender nonveterans, some transgender veterans and/or service members with cisgender veterans and/or service members, and some transgender veterans with transgender service members. There were some consistent results found across the studies, but some studies showed contradictory results or no significant differences within a certain category. It is difficult to compare such different study designs and various participant populations. Additional research is required to verify and replicate these results.

Conclusions

Although this review was limited due to the lack of consistent study designs in the literature examining the mental health of transgender veterans and active-duty service members, overall results showed that transgender veterans and service members experience worse mental health outcomes than their cisgender counterparts. With this knowledge and exploring the history of discrimination that this population has faced, improved systems must be put into place to better serve this population and improve health outcomes. Additional research is required to examine the effects of gender-affirming care on mental health among transgender veterans and service members.

According to the United States Transgender Survey, 39% of respondents reported experiencing serious psychological distress (based on the Kessler 6 Psychological Distress Scale) in the past 30 days compared with 5% in the general population.¹ Additionally, 40% of respondents attempted suicide in their lifetime, compared with 5% in the general population.¹ Almost half of respondents reported being sexually assaulted at some time in their life, and 10% reported being sexually assaulted in the past year.¹

Studies have also shown that veterans and active-duty service members experience worse mental health outcomes and are at increased risk for suicide than civilians and nonveterans.^2-5 About 1 in 4 active-duty service members meet the criteria for diagnosis of a mental illness.⁴ Service members were found to have higher rates of probable anxiety and posttraumatic stress disorder (PTSD) compared with the general population.^2,6 In 2018, veteran suicide deaths accounted for about 13% of all deaths by suicide in the US even though veterans only accounted for about 7% of the adult population in that year.^5,7 Also in 2018, about 17 veterans committed suicide per day.⁵ According to the Health Related Behaviors Survey of active-duty service members, about 18% reported thinking about attempting suicide some time in their lives compared with 4% of the general population.^2,3 Additionally, 5% of service members reported previous suicide attempts compared with 0.5% in the general population.^2,3 It is clear that transgender individuals, veterans, and service members have certain mental health outcomes that are worse than that of the general population.^1-7

Transgender individuals along with LGB (lesbian, gay, bisexual) individuals have long faced discrimination and unfair treatment in the military.^8-11 In the 1920s, the first written policies were established that banned gay men from serving in the military.⁹ The US Department of Defense (DoD) continued these policies until in 1993, the “Don’t Ask Don’t Tell” policy was established, which had the façade of being more inclusive for LGB individuals but forced LGB service members to hide their sexual identity and continued the anti-LGBTQ messages that previous policies had created.^8,10,11 In 2010, “Don’t Ask Don’t Tell” was repealed, which allowed LGB individuals to serve in the military without concealing their sexual orientation and without fear of discharge based on their sexual identity.¹¹ This repeal did not allow transgender individuals to serve their country as the DoD categorized transgender identity as a medical and mental health disorder.^8,11

In 2016, the ban on transgender individuals serving in the military was lifted, and service members could no longer be discharged or turned away from joining the military based on gender identity.^8,12 However, in 2018, this order was reversed. The new policy stated that new service members must meet requirements and standards of their sex assigned at birth, and individuals with a history of gender dysphoria or those who have received gender-affirming medical or surgical treatment were prohibited to serve in the military.^8,13 This policy did not apply to service members who joined before it took effect. Finally, in April 2021, the current policy took effect, permitting transgender individuals to openly serve in the military. The current policy states that service members cannot be discharged or denied reenlistment based on their gender identity and provides support to receive gender-affirming medical care.¹⁴ Although transgender individuals are now accepted in military service, there is still much progress needed to promote equity among transgender service members.

Methods

We conducted a systematic review of articles presenting data on mental health outcomes in transgender veterans and active-duty service members. The National Library of Medicine PubMed database was searched using the following search terms in various combinations: mental health outcomes, transgender, veterans, military, active duty, substance use, and sexual trauma. The literature search was performed in August 2021 and included articles published through July 31, 2021. Methodology, size, demographics, measures, and main findings were extracted from each article. All studies were eligible for inclusion regardless of sample size. Studies that examined the LGBTQ population without separating transgender individuals were excluded. Studies that examined mental health outcomes including, but not limited to, PTSD, depression, suicidality, anxiety, and substance use disorders (SUDs) in addition to sexual trauma were included. Studies that only examined physical health outcomes were excluded. Qualitative studies, case reports, and papers that did not present original data were excluded (Figure).

Results

Our search resulted in 86 publications. After excluding 65 articles that did not meet the inclusion criteria, 19 studies were included in this review. The Appendix shows the summary of findings from each study, including the study size and results. All studies were conducted in the United States. Most papers used a cross-sectional study design. Most of the studies focused on transgender veterans, but some included data on transgender active-duty service members.

We separated the findings into the following categories based on the variables measured: mental health, including depression, anxiety, PTSD, and serious mental illness; suicidality and self-harm; substance use; and military sexual trauma (MST). Many studies overlapped multiple categories.

Mental Health

Most of the studies included reported that transgender veterans have statistically significant worse mental health outcomes compared with cisgender veterans.^28-30 In addition, transgender active-duty service members were found to have worse mental health outcomes than cisgender active-duty service members.³¹ MST and discrimination were associated with worse mental health outcomes among transgender veterans.^32,33 One study showed a different result than others and found that transgender older adults with prior military service had higher psychological health-related quality of life and lower depressive symptoms than those without prior military service (P = .02 and .04, respectively).³⁴ Another study compared transgender veterans with active-duty service members and found that transgender veterans reported higher rates of depression (64.6% vs 30.9%; χ² = 11.68; P = .001) and anxiety (41.3% vs 18.2%; χ² = 6.54; P = .01) compared with transgender service members.³⁵

Suicidality and Self-harm

Eleven of the 19 studies included measured suicidality and/or self-harm as an outcome. Transgender veterans and active-duty service members were found to have higher odds of suicidality than their cisgender counterparts.^16,28,29,31 In addition, transgender veterans may die by suicide at a younger age than cisgender veterans.³⁶ Stigma and gender-related discrimination were found to be associated with suicidal ideation.^33,37-39 Transgender veterans were less likely than transgender nonveterans to report nonsuicidal self-injury (NSSI).⁴⁰

Substance Use

Two studies focused on substance use, while 5 other studies included substance use in their measures. One of these 2 studies that focused only on substance use outcomes found that transgender veterans were more likely than cisgender veterans to have any SUD (7.2% vs 3.9%; P < .001), in addition to specifically cannabis (3.4% vs 1.5%; P < .001), amphetamine (1.1% vs 0.3%; P < .001), and cocaine use disorders (1.5% vs 1.1%; P < .001).⁴¹

Another study reported that transgender veterans had lower odds of self-reported alcohol use but had greater odds of having alcohol-related diagnoses compared with cisgender veterans.⁴² Of the other studies, it was found that a higher percentage of transgender veterans were diagnosed with an SUD compared with transgender active-duty service members, and transgender veterans were more likely than cisgender veterans to be diagnosed with alcohol use disorder.^29,31 Additionally, rural transgender veterans had increased odds of tobacco use disorder compared with transgender veterans who lived in urban areas.⁴³

Military Sexual Trauma

Five of the studies included examined MST, defined as sexual assault or sexual harassment that is experienced during military service.⁴⁴ Studies found that 15% to 17% of transgender veterans experienced MST.^32,45 Transgender veterans were more likely to report MST than cisgender veterans.^28,29 MST was found to be consistently associated with depression and PTSD.^32,45 A high percentage (83.9%) of transgender active-duty service members reported experiencing sexual harassment and almost one-third experienced sexual assault.⁴⁶

Discussion

Outcomes examined in this review included MST, substance use, suicidality, and symptoms of depression, anxiety, and PTSD among transgender active-duty service members and veterans. To our knowledge, no other review on this topic exists. There is a review of the health and well-being of LGBTQ veterans and service members, but a majority of the included studies did not separate transgender individuals from LGB persons.¹⁷ This review of transgender individuals showed similar results to the review of LGBTQ individuals.¹⁷ This review also presented similar results to previous studies that indicated that transgender individuals in the general population have worse mental health outcomes compared with their cisgender counterparts, in addition to studies that showed that veterans and active-duty service members have worse mental health outcomes compared with civilians and nonveterans.^1-5 The population of focus in this review faced a unique set of challenges, being that they belonged to both of these subsets of the population, both of which experienced worse mental health outcomes, according to the literature.

Studies included in our review found that transgender veterans and service members have worse mental health outcomes than cisgender veterans and service members.^28-31 This outcome was predicted based on previous data collection among transgender individuals, veterans, and active-duty service members. One of the studies included found different results and concluded that prior military service was a protective factor against poorer mental health outcomes.³⁴ This could be, in part, due to veterans’ access to care through the US Department of Veterans Affairs (VA) system. It has been found that transgender veterans use VA services at higher rates than the general population of veterans and that barriers to care were found more for medical treatment than for mental health treatment.⁴⁷ One study found that almost 70% of transgender veterans who used VA services were satisfied with their mental health care.⁴⁸ In contrast, another study included in our review found that transgender veterans had worse mental health outcomes than transgender service members, possibly showing that even with access to care, the burden of stigma and discrimination worsens mental health over time.³¹ Although it has been shown that transgender veterans may feel comfortable disclosing their gender identity to their health care professional, many barriers to care have been identified, such as insensitivity and lack of knowledge about transgender care among clinicians.^49-51 With this information, it would be useful to ensure proper training for health care professionals on providing gender-affirming care.

Most of the studies also found that transgender veterans and service members had greater odds of suicidal thoughts and events than cisgender veterans and service members.^16,28,29,35 On the contrary, transgender veterans were less likely than transgender nonveterans to report NSSI, which could be for various reasons.⁴⁰ Transgender veterans may report less NSSI but experience it at similar rates, or veteran status may be a protective factor for NSSI.

Limitations

This review was limited due to the lack of data collected from transgender veterans and service members. The studies included did not allow for standardized comparisons and did not use identical measures. Some papers compared transgender veterans with transgender nonveterans, some transgender veterans and/or service members with cisgender veterans and/or service members, and some transgender veterans with transgender service members. There were some consistent results found across the studies, but some studies showed contradictory results or no significant differences within a certain category. It is difficult to compare such different study designs and various participant populations. Additional research is required to verify and replicate these results.

Conclusions

Although this review was limited due to the lack of consistent study designs in the literature examining the mental health of transgender veterans and active-duty service members, overall results showed that transgender veterans and service members experience worse mental health outcomes than their cisgender counterparts. With this knowledge and exploring the history of discrimination that this population has faced, improved systems must be put into place to better serve this population and improve health outcomes. Additional research is required to examine the effects of gender-affirming care on mental health among transgender veterans and service members.

In the U.S., the prevalence of diabetes continues to escalate at alarming rates. From 1980-2010 the incidence of diabetes increased by 200% for people aged < 45 years, 124% for people 45 to 64 years, and 126% for people 65 to 74 years. Furthermore, based on the National Institute of Health, diabetes currently affects 25.8 million people in the U.S.^1,2 Glycemic control has been demonstrated to reduce the risk of microvascular disease in patients with diabetes.³ Most patients with diabetes are managed by primary care practitioners (PCPs), and as the number of patients with diabetes continues to increase, there is an increasing demand on PCPs to achieve recommended glycemic targets.⁴

The Veterans Health Administration (VHA) VISN 16 has a notably higher prevalence of diabetes compared with that of the national rate. Failure to achieve glycemic targets continues to impose an escalating economic burden.³ Endocrine assistance is often sought by PCPs, but due to a scarcity of endocrinologists, patients commonly wait weeks or months before being seen. Furthermore, rural patients often must travel for several hours before they can reach a specialty center.

The Office of Specialty Care Transformation has provided a unique opportunity for PCPs to gain greater access to specialty advice via electronic consultations. This initiative allows PCPs and specialists to communicate promptly, to institute definitive solutions for patient care, and to augment the clinical and academic aims of primary and specialty care providers. The Michael E. DeBakey VAMC (MEDVAMC) in Houston, Texas, was chosen to initiate a VISN 16-wide diabetes management e-consult service (DMECS).

Endocrinologists at MEDVAMC developed DMECS to serve as a multifunctional tool to reach as many veterans as possible throughout VISN 16, broaden the scope of the existing diabetes endocrine practice, and engender a collaborative spirit between PCPs and specialty care providers. Initiation of this service has been particularly useful for patients with physical disabilities or financial constraints whose care is managed at the community-based outpatient clinics (CBOCs). The purpose of this article is to discuss the concept and initiation of the DMECS, the structure of the consult note, the implementation process, early provider feedback on the project, and future plans.

The DMECS Process
The DMECS allows endocrinologists to provide advice to PCPs to help improve diabetes care while minimizing travel to specialty centers. The advice generated by the DMECS is electronically conveyed to the referring physician (usually the PCP), not to the patient. The requesting physician is then responsible for implementing the recommendations. The DMECS does not comanage patients with diabetes but rather provides support to the PCP in complex cases that would otherwise require an outside referral.

The diabetes management e-consult team has 1 administrator and 3 health care providers (HCPs). Promotion of the service consisted of electronic distribution of flyers to all primary care teams, posters in the main lobby of the hospital, and electronic distribution of a letter to all VISN 16 HCPs. The DMECS team contacted the chiefs of primary care and CBOC directors to promote the service. Communication was augmented by scheduling videoconferencing with all interested facilities. Presentations were given to the VISN-wide transformational care collaborative and women’s health groups.

Any specialties that assist in diabetes management, including ophthalmology and vascular medicine, were encouraged to refer consults to DMECS if clinically indicated. The recommendation is that PCPs submit an e-consult for any patient with a hemoglobin A1C (A1C) > 9%. The only prerequisite to placing the e-consult order is an A1C > 7.5% within the preceding 3 months. Any patient with reported or objective evidence of hypoglycemia is eligible for an e-consult, regardless of the A1C value. Women who are pregnant and patients on an insulin pump are excluded from the program.

All diabetes e-consults are supervised by a board-certified endocrinologist and are resolved within 2 to 3 business days. On receipt of the consult request, the DMECS provider reviews the chart, including active medication lists, blood glucose levels documented in progress notes, care and coordination of home telehealth data regarding blood glucose levels and changes in  diabetes medication management, laboratory results and pharmacy refill patterns.

Recommendations are completed and the DMECS provider alerts the requesting physician by adding them as a cosigner to the note in the Computerized Patient Record System (CPRS). When possible, the patient’s nurse manager is also added to the note. For interfacility consults, the DMECS provider contacts the requesting provider directly via email or telephone. Consistent communication with the requesting physician ensures clarity of understanding between specialist and PCP.

The e-consult recommendations are consolidated into 3 distinct sections. The Impression section provides an explanation to the provider about the specialist’s impression of current diabetes control and the reasoning behind the recommendations. The Recommendation section lists in medical terminology the recommended changes to diabetes medications. A unique component to the e-consult is the Instructions to Patient section, which summarizes both oral and insulin medications that can be provided to the patient. Every note includes a Diabetes Surveillance section and several web links to diabetes education that can be downloaded through the MyHealtheVet website.

Current approaches to e-consult implementation are subject to the discretion of the requesting provider. The most commonly observed approach is that the requesting provider reviews the e-consult note and requests that the patient’s nurse manager instructs the patient on the recommendations. Some providers schedule the patient for a physician or nurse visit to discuss the diabetes management recommendations in a clinic setting. Other providers contact the patient by telephone and mail the instructions to the patient.

To streamline the e-consult implementation process, the DMECS team has the option of placing an e-consult 1 week before a patient’s scheduled clinic visit with the PCP. This helps ensure that the e-consult is completed within 2 to 3 business days before the patient’s scheduled primary care appointment, at which time the recommendations can be implemented. Using the option of a “pre-clinic e-consult” method expedites the implementation process.

Initial Results of DMECS
The first e-consult was completed on January 23, 2012. Since its inception, 3,703 e-consults have been completed. There has been a steady increase in the number of referrals, with an average of 154 e-consults completed monthly from January 2012 to December 2013 (Figure 1). Most e-consults have been completed based on requests submitted by providers in Houston, Texas and affiliated CBOCs. However, a growing number of interfacility consults have been completed for providers at VISN-16 facilities located in Louisiana, Mississippi, Arkansas, and Oklahoma (Figure 2).

The initial response to the e-consult service has been positive. One provider described DMECS as a means to “obtain faster access to an endocrinologist’s input for complex diabetics, which has resulted in faster intervention for patients, particularly those at high risk.”

Additionally, another provider noted, “Along with all the benefits of accelerated access to specialty care recommendations, the patients benefit because they do not have to travel to the VA to receive this care. In many cases, they don’t have to be scheduled to see the endocrinologist, if the treatment recommendations are successful.”

One of the nurse managers explained that “The e-consult service has given me a guide to manage each veteran’s diabetes…One veteran stated that he initially was seeing a private endocrinologist at an outside clinic for his diabetes, but when he lost his insurance and began to receive his care at the VA, he stated that he never realized how high the quality of services for diabetes is at the VA.” With regard to implementation, she noted that “the diabetes instructions as provided by the e-consult specialist enhance the patient’s sense of personalized care.”

Limitations
Another challenge observed by DMECS providers is the variation in the length of time for implementing DMECS recommendations by the requesting providers. Due to the novelty of this service, providers across the VISN are still becoming acquainted with the e-consult process.

In an effort to assist PCPs, DMECS providers perform an objective chart review about 3 months after the e-consult is completed. A note is placed in the CPRS that documents whether e-consult recommendations were implemented and the date of implementation. With time, it is anticipated that a standardized set of recommendations for requesting providers may be instituted to serve as a suggested algorithm for timely and efficient implementation of the e-consult recommendations.

DMECS Goals
In addition to supporting the MEDVAMC initiative to improve glycemic trends among all patients with diabetes within the facility, DMECS providers hope to share in VISN-wide efforts to improve diabetes control by broadening the interfacility referral base. The most successful methods of advertisement and consult recruitment include the recommendation that all patients with diabetes with an A1C > 9% receive an e-consult. Also, when any patient with an A1C > 9% is seen at any of the MEDVAMC eye clinics, an alert is sent to the PCP from the DMECS team, suggesting placement of an e-consult. These strategies have increased the number of referrals within the MEDVAMC, and the goal is to implement similar strategies in all primary care, geriatrics, and women’s health clinics across VISN 16.

There are many sites across the VISN that may not have ready access to certified diabetes educators. In support of the VHA goals to promote virtual health, the DMECS team plans to initiate diabetes patient education sessions through clinical videoconferencing with patients in groups or individually.

In addition to the continued growth of the e-consult service and their efforts at patient education, the DMECS providers are also initiating a CME-accredited course for PCPs and HCPs on outpatient management of diabetes, which will be led by 1 of the 4 endocrinology staff at MEDVAMC. The benefits of provider education have been demonstrated by the University of New Mexico Health Science Center’s Project ECHO, which not only improved the quality of care for hepatitis C in a rural territory, but also increased PCP awareness and capacity to treat and manage complex patients.5 Project ECHO was used as the model for the initiation of the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) program at the VA. Accordingly, the DMECS providers envision that continued efforts at provider education should facilitate an improvement in clinical management strategies used by PCPs to optimize diabetes control.

Now that the diabetes management e-consult program has been set up and seems to play an additive role in the management of outpatient diabetes, the next step is to assess the effect of the diabetes e-consult service on patient clinical outcomes. Currently, DMECS is completing retrospective outcome studies to investigate the baseline characteristics of patients who are referred for the e-consult. These DMECS results will be compared with face-to-face diabetes care and management in a specialty clinic. In addition researchers will attempt to assess whether the time-to-implementation of recommendations has an impact on changes in glycemic parameters.       

Conclusion
In support of the VHA goal of veteran-centered care, the diabetes e-consult service for VISN 16 is an innovative and creative addition to the armamentarium of outpatient diabetes management that has accelerated access to endocrine diabetes care. The service has reached > 1,000 veterans with diabetes since its inception and is set to continue expanding its referral base across VISN 16. Through DMECS, specialty care has become more readily accessible to providers and patients across a greater geographic area. The diabetes management e-consult service has been particularly useful for patients with physical disabilities or financial constraints and has been able to bridge the communication gap between primary and specialty care, with the goal of improving diabetes outcomes for veterans across the VISN.

Acknowledgments
The authors would like to express their appreciation for the assistance provided by the program analysts who extracted the number of completed diabetes e-consults from the VISN 16 data warehouse: Pamela Croston, Melody Darbe, and Andrew Spiegelman, PhD.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

References
1. Centers for Disease Control and Prevention. Percentage of civilian non-institutionalized population with diagnosed diabetes, by age, United States, 1980-2010. Centers for Disease Control and Prevention Website. http://www.cdc.gov/Diabetes/statistics/prev/national/figbyage.htm. Accessed February 5, 2014.

2. National Center for Chronic Disease Prevention and Health Promotion. National Diabetes Fact Sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Centers for Disease Control and Prevention Website. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed February 4, 2014.

3. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577-1589.

4. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

5. Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med.  2010;364(23):2199-2207.

In the U.S., the prevalence of diabetes continues to escalate at alarming rates. From 1980-2010 the incidence of diabetes increased by 200% for people aged < 45 years, 124% for people 45 to 64 years, and 126% for people 65 to 74 years. Furthermore, based on the National Institute of Health, diabetes currently affects 25.8 million people in the U.S.^1,2 Glycemic control has been demonstrated to reduce the risk of microvascular disease in patients with diabetes.³ Most patients with diabetes are managed by primary care practitioners (PCPs), and as the number of patients with diabetes continues to increase, there is an increasing demand on PCPs to achieve recommended glycemic targets.⁴

The Veterans Health Administration (VHA) VISN 16 has a notably higher prevalence of diabetes compared with that of the national rate. Failure to achieve glycemic targets continues to impose an escalating economic burden.³ Endocrine assistance is often sought by PCPs, but due to a scarcity of endocrinologists, patients commonly wait weeks or months before being seen. Furthermore, rural patients often must travel for several hours before they can reach a specialty center.

The Office of Specialty Care Transformation has provided a unique opportunity for PCPs to gain greater access to specialty advice via electronic consultations. This initiative allows PCPs and specialists to communicate promptly, to institute definitive solutions for patient care, and to augment the clinical and academic aims of primary and specialty care providers. The Michael E. DeBakey VAMC (MEDVAMC) in Houston, Texas, was chosen to initiate a VISN 16-wide diabetes management e-consult service (DMECS).

Endocrinologists at MEDVAMC developed DMECS to serve as a multifunctional tool to reach as many veterans as possible throughout VISN 16, broaden the scope of the existing diabetes endocrine practice, and engender a collaborative spirit between PCPs and specialty care providers. Initiation of this service has been particularly useful for patients with physical disabilities or financial constraints whose care is managed at the community-based outpatient clinics (CBOCs). The purpose of this article is to discuss the concept and initiation of the DMECS, the structure of the consult note, the implementation process, early provider feedback on the project, and future plans.

The DMECS Process
The DMECS allows endocrinologists to provide advice to PCPs to help improve diabetes care while minimizing travel to specialty centers. The advice generated by the DMECS is electronically conveyed to the referring physician (usually the PCP), not to the patient. The requesting physician is then responsible for implementing the recommendations. The DMECS does not comanage patients with diabetes but rather provides support to the PCP in complex cases that would otherwise require an outside referral.

The diabetes management e-consult team has 1 administrator and 3 health care providers (HCPs). Promotion of the service consisted of electronic distribution of flyers to all primary care teams, posters in the main lobby of the hospital, and electronic distribution of a letter to all VISN 16 HCPs. The DMECS team contacted the chiefs of primary care and CBOC directors to promote the service. Communication was augmented by scheduling videoconferencing with all interested facilities. Presentations were given to the VISN-wide transformational care collaborative and women’s health groups.

Any specialties that assist in diabetes management, including ophthalmology and vascular medicine, were encouraged to refer consults to DMECS if clinically indicated. The recommendation is that PCPs submit an e-consult for any patient with a hemoglobin A1C (A1C) > 9%. The only prerequisite to placing the e-consult order is an A1C > 7.5% within the preceding 3 months. Any patient with reported or objective evidence of hypoglycemia is eligible for an e-consult, regardless of the A1C value. Women who are pregnant and patients on an insulin pump are excluded from the program.

All diabetes e-consults are supervised by a board-certified endocrinologist and are resolved within 2 to 3 business days. On receipt of the consult request, the DMECS provider reviews the chart, including active medication lists, blood glucose levels documented in progress notes, care and coordination of home telehealth data regarding blood glucose levels and changes in  diabetes medication management, laboratory results and pharmacy refill patterns.

Recommendations are completed and the DMECS provider alerts the requesting physician by adding them as a cosigner to the note in the Computerized Patient Record System (CPRS). When possible, the patient’s nurse manager is also added to the note. For interfacility consults, the DMECS provider contacts the requesting provider directly via email or telephone. Consistent communication with the requesting physician ensures clarity of understanding between specialist and PCP.

The e-consult recommendations are consolidated into 3 distinct sections. The Impression section provides an explanation to the provider about the specialist’s impression of current diabetes control and the reasoning behind the recommendations. The Recommendation section lists in medical terminology the recommended changes to diabetes medications. A unique component to the e-consult is the Instructions to Patient section, which summarizes both oral and insulin medications that can be provided to the patient. Every note includes a Diabetes Surveillance section and several web links to diabetes education that can be downloaded through the MyHealtheVet website.

Current approaches to e-consult implementation are subject to the discretion of the requesting provider. The most commonly observed approach is that the requesting provider reviews the e-consult note and requests that the patient’s nurse manager instructs the patient on the recommendations. Some providers schedule the patient for a physician or nurse visit to discuss the diabetes management recommendations in a clinic setting. Other providers contact the patient by telephone and mail the instructions to the patient.

To streamline the e-consult implementation process, the DMECS team has the option of placing an e-consult 1 week before a patient’s scheduled clinic visit with the PCP. This helps ensure that the e-consult is completed within 2 to 3 business days before the patient’s scheduled primary care appointment, at which time the recommendations can be implemented. Using the option of a “pre-clinic e-consult” method expedites the implementation process.

Initial Results of DMECS
The first e-consult was completed on January 23, 2012. Since its inception, 3,703 e-consults have been completed. There has been a steady increase in the number of referrals, with an average of 154 e-consults completed monthly from January 2012 to December 2013 (Figure 1). Most e-consults have been completed based on requests submitted by providers in Houston, Texas and affiliated CBOCs. However, a growing number of interfacility consults have been completed for providers at VISN-16 facilities located in Louisiana, Mississippi, Arkansas, and Oklahoma (Figure 2).

The initial response to the e-consult service has been positive. One provider described DMECS as a means to “obtain faster access to an endocrinologist’s input for complex diabetics, which has resulted in faster intervention for patients, particularly those at high risk.”

Additionally, another provider noted, “Along with all the benefits of accelerated access to specialty care recommendations, the patients benefit because they do not have to travel to the VA to receive this care. In many cases, they don’t have to be scheduled to see the endocrinologist, if the treatment recommendations are successful.”

One of the nurse managers explained that “The e-consult service has given me a guide to manage each veteran’s diabetes…One veteran stated that he initially was seeing a private endocrinologist at an outside clinic for his diabetes, but when he lost his insurance and began to receive his care at the VA, he stated that he never realized how high the quality of services for diabetes is at the VA.” With regard to implementation, she noted that “the diabetes instructions as provided by the e-consult specialist enhance the patient’s sense of personalized care.”

Limitations
Another challenge observed by DMECS providers is the variation in the length of time for implementing DMECS recommendations by the requesting providers. Due to the novelty of this service, providers across the VISN are still becoming acquainted with the e-consult process.

In an effort to assist PCPs, DMECS providers perform an objective chart review about 3 months after the e-consult is completed. A note is placed in the CPRS that documents whether e-consult recommendations were implemented and the date of implementation. With time, it is anticipated that a standardized set of recommendations for requesting providers may be instituted to serve as a suggested algorithm for timely and efficient implementation of the e-consult recommendations.

DMECS Goals
In addition to supporting the MEDVAMC initiative to improve glycemic trends among all patients with diabetes within the facility, DMECS providers hope to share in VISN-wide efforts to improve diabetes control by broadening the interfacility referral base. The most successful methods of advertisement and consult recruitment include the recommendation that all patients with diabetes with an A1C > 9% receive an e-consult. Also, when any patient with an A1C > 9% is seen at any of the MEDVAMC eye clinics, an alert is sent to the PCP from the DMECS team, suggesting placement of an e-consult. These strategies have increased the number of referrals within the MEDVAMC, and the goal is to implement similar strategies in all primary care, geriatrics, and women’s health clinics across VISN 16.

There are many sites across the VISN that may not have ready access to certified diabetes educators. In support of the VHA goals to promote virtual health, the DMECS team plans to initiate diabetes patient education sessions through clinical videoconferencing with patients in groups or individually.

In addition to the continued growth of the e-consult service and their efforts at patient education, the DMECS providers are also initiating a CME-accredited course for PCPs and HCPs on outpatient management of diabetes, which will be led by 1 of the 4 endocrinology staff at MEDVAMC. The benefits of provider education have been demonstrated by the University of New Mexico Health Science Center’s Project ECHO, which not only improved the quality of care for hepatitis C in a rural territory, but also increased PCP awareness and capacity to treat and manage complex patients.5 Project ECHO was used as the model for the initiation of the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) program at the VA. Accordingly, the DMECS providers envision that continued efforts at provider education should facilitate an improvement in clinical management strategies used by PCPs to optimize diabetes control.

Now that the diabetes management e-consult program has been set up and seems to play an additive role in the management of outpatient diabetes, the next step is to assess the effect of the diabetes e-consult service on patient clinical outcomes. Currently, DMECS is completing retrospective outcome studies to investigate the baseline characteristics of patients who are referred for the e-consult. These DMECS results will be compared with face-to-face diabetes care and management in a specialty clinic. In addition researchers will attempt to assess whether the time-to-implementation of recommendations has an impact on changes in glycemic parameters.       

Conclusion
In support of the VHA goal of veteran-centered care, the diabetes e-consult service for VISN 16 is an innovative and creative addition to the armamentarium of outpatient diabetes management that has accelerated access to endocrine diabetes care. The service has reached > 1,000 veterans with diabetes since its inception and is set to continue expanding its referral base across VISN 16. Through DMECS, specialty care has become more readily accessible to providers and patients across a greater geographic area. The diabetes management e-consult service has been particularly useful for patients with physical disabilities or financial constraints and has been able to bridge the communication gap between primary and specialty care, with the goal of improving diabetes outcomes for veterans across the VISN.

Acknowledgments
The authors would like to express their appreciation for the assistance provided by the program analysts who extracted the number of completed diabetes e-consults from the VISN 16 data warehouse: Pamela Croston, Melody Darbe, and Andrew Spiegelman, PhD.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

References
1. Centers for Disease Control and Prevention. Percentage of civilian non-institutionalized population with diagnosed diabetes, by age, United States, 1980-2010. Centers for Disease Control and Prevention Website. http://www.cdc.gov/Diabetes/statistics/prev/national/figbyage.htm. Accessed February 5, 2014.

2. National Center for Chronic Disease Prevention and Health Promotion. National Diabetes Fact Sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Centers for Disease Control and Prevention Website. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed February 4, 2014.

3. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577-1589.

4. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

5. Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med.  2010;364(23):2199-2207.

In the U.S., the prevalence of diabetes continues to escalate at alarming rates. From 1980-2010 the incidence of diabetes increased by 200% for people aged < 45 years, 124% for people 45 to 64 years, and 126% for people 65 to 74 years. Furthermore, based on the National Institute of Health, diabetes currently affects 25.8 million people in the U.S.^1,2 Glycemic control has been demonstrated to reduce the risk of microvascular disease in patients with diabetes.³ Most patients with diabetes are managed by primary care practitioners (PCPs), and as the number of patients with diabetes continues to increase, there is an increasing demand on PCPs to achieve recommended glycemic targets.⁴

The Veterans Health Administration (VHA) VISN 16 has a notably higher prevalence of diabetes compared with that of the national rate. Failure to achieve glycemic targets continues to impose an escalating economic burden.³ Endocrine assistance is often sought by PCPs, but due to a scarcity of endocrinologists, patients commonly wait weeks or months before being seen. Furthermore, rural patients often must travel for several hours before they can reach a specialty center.

The Office of Specialty Care Transformation has provided a unique opportunity for PCPs to gain greater access to specialty advice via electronic consultations. This initiative allows PCPs and specialists to communicate promptly, to institute definitive solutions for patient care, and to augment the clinical and academic aims of primary and specialty care providers. The Michael E. DeBakey VAMC (MEDVAMC) in Houston, Texas, was chosen to initiate a VISN 16-wide diabetes management e-consult service (DMECS).

Endocrinologists at MEDVAMC developed DMECS to serve as a multifunctional tool to reach as many veterans as possible throughout VISN 16, broaden the scope of the existing diabetes endocrine practice, and engender a collaborative spirit between PCPs and specialty care providers. Initiation of this service has been particularly useful for patients with physical disabilities or financial constraints whose care is managed at the community-based outpatient clinics (CBOCs). The purpose of this article is to discuss the concept and initiation of the DMECS, the structure of the consult note, the implementation process, early provider feedback on the project, and future plans.

The DMECS Process
The DMECS allows endocrinologists to provide advice to PCPs to help improve diabetes care while minimizing travel to specialty centers. The advice generated by the DMECS is electronically conveyed to the referring physician (usually the PCP), not to the patient. The requesting physician is then responsible for implementing the recommendations. The DMECS does not comanage patients with diabetes but rather provides support to the PCP in complex cases that would otherwise require an outside referral.

The diabetes management e-consult team has 1 administrator and 3 health care providers (HCPs). Promotion of the service consisted of electronic distribution of flyers to all primary care teams, posters in the main lobby of the hospital, and electronic distribution of a letter to all VISN 16 HCPs. The DMECS team contacted the chiefs of primary care and CBOC directors to promote the service. Communication was augmented by scheduling videoconferencing with all interested facilities. Presentations were given to the VISN-wide transformational care collaborative and women’s health groups.

Any specialties that assist in diabetes management, including ophthalmology and vascular medicine, were encouraged to refer consults to DMECS if clinically indicated. The recommendation is that PCPs submit an e-consult for any patient with a hemoglobin A1C (A1C) > 9%. The only prerequisite to placing the e-consult order is an A1C > 7.5% within the preceding 3 months. Any patient with reported or objective evidence of hypoglycemia is eligible for an e-consult, regardless of the A1C value. Women who are pregnant and patients on an insulin pump are excluded from the program.

All diabetes e-consults are supervised by a board-certified endocrinologist and are resolved within 2 to 3 business days. On receipt of the consult request, the DMECS provider reviews the chart, including active medication lists, blood glucose levels documented in progress notes, care and coordination of home telehealth data regarding blood glucose levels and changes in  diabetes medication management, laboratory results and pharmacy refill patterns.

Recommendations are completed and the DMECS provider alerts the requesting physician by adding them as a cosigner to the note in the Computerized Patient Record System (CPRS). When possible, the patient’s nurse manager is also added to the note. For interfacility consults, the DMECS provider contacts the requesting provider directly via email or telephone. Consistent communication with the requesting physician ensures clarity of understanding between specialist and PCP.

The e-consult recommendations are consolidated into 3 distinct sections. The Impression section provides an explanation to the provider about the specialist’s impression of current diabetes control and the reasoning behind the recommendations. The Recommendation section lists in medical terminology the recommended changes to diabetes medications. A unique component to the e-consult is the Instructions to Patient section, which summarizes both oral and insulin medications that can be provided to the patient. Every note includes a Diabetes Surveillance section and several web links to diabetes education that can be downloaded through the MyHealtheVet website.

Current approaches to e-consult implementation are subject to the discretion of the requesting provider. The most commonly observed approach is that the requesting provider reviews the e-consult note and requests that the patient’s nurse manager instructs the patient on the recommendations. Some providers schedule the patient for a physician or nurse visit to discuss the diabetes management recommendations in a clinic setting. Other providers contact the patient by telephone and mail the instructions to the patient.

To streamline the e-consult implementation process, the DMECS team has the option of placing an e-consult 1 week before a patient’s scheduled clinic visit with the PCP. This helps ensure that the e-consult is completed within 2 to 3 business days before the patient’s scheduled primary care appointment, at which time the recommendations can be implemented. Using the option of a “pre-clinic e-consult” method expedites the implementation process.

Initial Results of DMECS
The first e-consult was completed on January 23, 2012. Since its inception, 3,703 e-consults have been completed. There has been a steady increase in the number of referrals, with an average of 154 e-consults completed monthly from January 2012 to December 2013 (Figure 1). Most e-consults have been completed based on requests submitted by providers in Houston, Texas and affiliated CBOCs. However, a growing number of interfacility consults have been completed for providers at VISN-16 facilities located in Louisiana, Mississippi, Arkansas, and Oklahoma (Figure 2).

The initial response to the e-consult service has been positive. One provider described DMECS as a means to “obtain faster access to an endocrinologist’s input for complex diabetics, which has resulted in faster intervention for patients, particularly those at high risk.”

Additionally, another provider noted, “Along with all the benefits of accelerated access to specialty care recommendations, the patients benefit because they do not have to travel to the VA to receive this care. In many cases, they don’t have to be scheduled to see the endocrinologist, if the treatment recommendations are successful.”

One of the nurse managers explained that “The e-consult service has given me a guide to manage each veteran’s diabetes…One veteran stated that he initially was seeing a private endocrinologist at an outside clinic for his diabetes, but when he lost his insurance and began to receive his care at the VA, he stated that he never realized how high the quality of services for diabetes is at the VA.” With regard to implementation, she noted that “the diabetes instructions as provided by the e-consult specialist enhance the patient’s sense of personalized care.”

Limitations
Another challenge observed by DMECS providers is the variation in the length of time for implementing DMECS recommendations by the requesting providers. Due to the novelty of this service, providers across the VISN are still becoming acquainted with the e-consult process.

In an effort to assist PCPs, DMECS providers perform an objective chart review about 3 months after the e-consult is completed. A note is placed in the CPRS that documents whether e-consult recommendations were implemented and the date of implementation. With time, it is anticipated that a standardized set of recommendations for requesting providers may be instituted to serve as a suggested algorithm for timely and efficient implementation of the e-consult recommendations.

DMECS Goals
In addition to supporting the MEDVAMC initiative to improve glycemic trends among all patients with diabetes within the facility, DMECS providers hope to share in VISN-wide efforts to improve diabetes control by broadening the interfacility referral base. The most successful methods of advertisement and consult recruitment include the recommendation that all patients with diabetes with an A1C > 9% receive an e-consult. Also, when any patient with an A1C > 9% is seen at any of the MEDVAMC eye clinics, an alert is sent to the PCP from the DMECS team, suggesting placement of an e-consult. These strategies have increased the number of referrals within the MEDVAMC, and the goal is to implement similar strategies in all primary care, geriatrics, and women’s health clinics across VISN 16.

There are many sites across the VISN that may not have ready access to certified diabetes educators. In support of the VHA goals to promote virtual health, the DMECS team plans to initiate diabetes patient education sessions through clinical videoconferencing with patients in groups or individually.

In addition to the continued growth of the e-consult service and their efforts at patient education, the DMECS providers are also initiating a CME-accredited course for PCPs and HCPs on outpatient management of diabetes, which will be led by 1 of the 4 endocrinology staff at MEDVAMC. The benefits of provider education have been demonstrated by the University of New Mexico Health Science Center’s Project ECHO, which not only improved the quality of care for hepatitis C in a rural territory, but also increased PCP awareness and capacity to treat and manage complex patients.5 Project ECHO was used as the model for the initiation of the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) program at the VA. Accordingly, the DMECS providers envision that continued efforts at provider education should facilitate an improvement in clinical management strategies used by PCPs to optimize diabetes control.

Now that the diabetes management e-consult program has been set up and seems to play an additive role in the management of outpatient diabetes, the next step is to assess the effect of the diabetes e-consult service on patient clinical outcomes. Currently, DMECS is completing retrospective outcome studies to investigate the baseline characteristics of patients who are referred for the e-consult. These DMECS results will be compared with face-to-face diabetes care and management in a specialty clinic. In addition researchers will attempt to assess whether the time-to-implementation of recommendations has an impact on changes in glycemic parameters.       

Conclusion
In support of the VHA goal of veteran-centered care, the diabetes e-consult service for VISN 16 is an innovative and creative addition to the armamentarium of outpatient diabetes management that has accelerated access to endocrine diabetes care. The service has reached > 1,000 veterans with diabetes since its inception and is set to continue expanding its referral base across VISN 16. Through DMECS, specialty care has become more readily accessible to providers and patients across a greater geographic area. The diabetes management e-consult service has been particularly useful for patients with physical disabilities or financial constraints and has been able to bridge the communication gap between primary and specialty care, with the goal of improving diabetes outcomes for veterans across the VISN.

Acknowledgments
The authors would like to express their appreciation for the assistance provided by the program analysts who extracted the number of completed diabetes e-consults from the VISN 16 data warehouse: Pamela Croston, Melody Darbe, and Andrew Spiegelman, PhD.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

References
1. Centers for Disease Control and Prevention. Percentage of civilian non-institutionalized population with diagnosed diabetes, by age, United States, 1980-2010. Centers for Disease Control and Prevention Website. http://www.cdc.gov/Diabetes/statistics/prev/national/figbyage.htm. Accessed February 5, 2014.

2. National Center for Chronic Disease Prevention and Health Promotion. National Diabetes Fact Sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Centers for Disease Control and Prevention Website. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed February 4, 2014.

3. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577-1589.

4. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63.

5. Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med.  2010;364(23):2199-2207.