Evaluating Clinical Guidelines and Recommendations

Reference: Kruse et al. Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People Recommendations for Immediate Action to Improve Care. WJEM December 2023 Date: May 30, 2024 Guest Skeptic: Dr. Kay Dingwell is a rural emergency physician working in Prince County, PEI with a special interest in gender-affirming care and improving the care of trans and gender-diverse patients. Case: A 16-year-old nonbinary youth on testosterone blockers and oestrogen has come into your emergency department (ED) having twisted their ankle while playing soccer. You learn they are ordering hormones online as they do not have any gender-affirming primary care. You don’t see a large number of trans patients in your ED and you wonder if there might be specific recommendations that can guide your care of this adolescent. Background: In North America, trans and gender diverse (TGD) people make up 0.3% to 0.6% of the overall population, and up to 4.1% of the adolescent population according to Statistics Canada [1] and The Williams Institute in the US [2]. It has been shown in previous research that TGD individuals have both high ED avoidance due to discrimination, as well as a high need for emergency services due to the impacts of minority stress on this population [3,4]. Trans individuals are at higher risk of experiencing violence, adverse substance use, homelessness, and mental health challenges, among other challenges which may impact their health. These patients often report negative experiences when accessing emergency care, and there is an established lack of research to guide their care in the emergency department. A group of researchers, including members of the queer community, set out to perform a systematic review, quality assessment, and synthesis of clinical practice guidelines and best practice statements on the care of transgender and gender-diverse individuals at any stage of accessing emergency department care. Clinical Question: What clinical practice guidelines (CPGs) exist to inform the care of transgender and gender diverse (TGD) patients in the emergency department? Reference: Kruse et al. Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People Recommendations for Immediate Action to Improve Care. WJEM December 2023 Population: Transgender and gender-diverse populations of any age, in any setting, region, or nation. It included both medical and paramedical care within these groups. Exclusions: Not a guideline or best practice statement, or guidelines/BPS not relating to TGD patients or ED care, full text not available, or not in English Intervention: There was no intervention. The study looked at implementing clinical practice guidelines (CPG) and best practice statements (BPS) for the care of TGD individuals in ED. Comparison: The guidelines and statements were assessed against quality standards using the AGREE-II and AGREE-REX criteria, rather than comparing different types of care or interventions against each other. Primary Outcome: The identification and assessment of the quality and applicability of guideline recommendations relevant to ED care of TGD people. Authors’ Conclusions: “This is the most comprehensive review of clinical practice guidelines and best practice statements for ED care of transgender-diverse populations to date and reveals several important actionable recommendations for the care of TGD people in the emergency department.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable. Yes The search for studies was detailed and exhaustive. No The primary studies were of high methodological quality. Unsure The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes