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

Abstract

Introduction We conducted this systematic review to identify emergency department (ED) relevant recommendations in current guidelines for care of transgender and gender-diverse (TGD) people internationally. Methods Using PRISMA criteria, we did a systematic search of Ovid Medline, EMBASE, and CINAHL and a hand search of gray literature for clinical practice guidelines (CPG) or best practice statements (BPS) published until June 31, 2021. Articles were included if they were in English, included medical or paramedical care of TGD populations of any age, in any setting, region or nation, and were national or international in scope. Exclusion criteria included primary research studies, review articles, narrative reviews or otherwise non-CPG or BPS, editorials, or letters to the editor, articles of regional or individual hospital scope, non-medical articles, articles not in English, or if a more recent version of the guideline existed. Recommendations relevant to ED care were identified, recorded, and assessed for quality using the AGREE-II and AGREE-REX criteria. We performed interclass correlation coefficient for interrater reliability. Recommendations were coded for the relevant point of care while in the ED (triage, registration, rooming, investigations, etc.). Results We screened 1,658 unique articles, and 1,555 were excluded. Of the remaining 103 articles included, seven had recommendations relevant to care in the ED, comprising a total of 10 recommendations. Four guidelines and eight recommendations were of high quality. They included recommendations for testing, prevention, referral, and provision of post-exposure prophylaxis for HIV, and culturally competent care of TGD people. Conclusions This is the most comprehensive review to date of guidelines and best practices statements offering recommendations for care of ED TGD patients, and several are immediately actionable. There are also many opportunities to build community-led research programs to synthesize and inform a comprehensive dedicated guideline for care of TGD people in emergency settings.

Critically Appraising the Cass Report: Methodological Flaws and Unsupported Claims

“…However, its reliability in this context may be questionable since several other systematic reviews have applied this tool to some of the same studies and arrived at quite different conclusions, with some also criticising the usefulness of AGREE-II for GAC guidelines. [22][23][24] Notably, the most restrictive guidelines were rated highest in this systematic review, without a clear justification related to how these guidelines were developed, 6,25 while guidelines for more affirmative models of care were judged to be of higher quality in other reviews than by Taylor and colleagues. [22][23][24] An adapted version of the Newcastle-Ottawa Quality Assessment Scale 26 (NOS) was used in three of the systematics instead of the MMAT 2,3,7 -a deviation from the protocol that was not explained or clearly reported.…”

“…[22][23][24] Notably, the most restrictive guidelines were rated highest in this systematic review, without a clear justification related to how these guidelines were developed, 6,25 while guidelines for more affirmative models of care were judged to be of higher quality in other reviews than by Taylor and colleagues. [22][23][24] An adapted version of the Newcastle-Ottawa Quality Assessment Scale 26 (NOS) was used in three of the systematics instead of the MMAT 2,3,7 -a deviation from the protocol that was not explained or clearly reported. The NOS has been highly criticised 27 and the use of an adapted scoring negates any previous attempts to validate the NOS.…”