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Table 2 Brief summary of 20 highest-ranked potential quality measures developed by our team based on review of eight prominent clinical practice guidelines

From: Conceptual approach to developing quality measures for transgender patients

  Title Category Denominator Numerator
Measure 1. Receiving ethinyl estradiol formulations (not recommended) Hormone Management (TF). TF patients who received an estrogen formulation Patients who specifically received an ethinyl estradiol formulation
Measure 2. Receiving cyclical preparations of estrogen therapy (not recommended) Hormone Management (TF). TF patients who received an estrogen formulation Patients who received cyclical preparations
Measure 3. Measurement of testosterone and estradiol levels after starting estrogen therapy Hormone Management (TF). TF patients who received an estrogen formulation for feminizing therapy Patients who had a testosterone level and/or an estradiol level measured within 3 months of starting therapy, and twice within 6 months
Measure 4. Measurement of testosterone levels after starting testosterone therapy Hormone Management (TM). TM patients who received a testosterone formulation for masculinizing therapy Patients who had a testosterone level measured within 3 months of starting therapy, and twice within 6 months
Measure 5. Supratherapeutic testosterone levels (not recommended) Hormone Management (TM). TM patients who received a testosterone formulation for masculinizing therapy Patients who recorded a testosterone level above the normal male physiologic range
Measure 6. Supratherapeutic estradiol levels (not recommended) Hormone Management (TF). TF patients who received an estrogen formulation for feminizing therapy Patients who recorded an estrogen level above the normal female physiologic range
Measure 7. Measurement of metabolic panel after starting spironolactone. Hormone Management (TF). TF patients who received spironolactone for feminizing therapy Patients who had measurement of K, Cr, and BUN within 3 months of starting spironolactone
Measure 8. Measurement of metabolic panel after increasing the dose of spironolactone Hormone Management (TF). TF patients who received spironolactone for feminizing therapy and experienced a dose increase Patients who had measurement of K, Cr, and BUN within 3 months of increasing the dose of spironolactone
Measure 9. Measurement of Hb and HCT after starting testosterone Hormone Management (TM). TM patients who started testosterone for masculinizing therapy Patients who had measurement of Hb and/or HCT within 3 months of starting testosterone therapy
Measure 10. Patients with a history of hyperkalemia or renal insufficiency should not be given spironolactone Hormone Management (TF). TF patients who began spironolactone for feminizing therapy Patients who had a history of hyperkalemia or renal insufficiency prior to beginning spironolactone
Measure 11. Adequate laboratory testing prior to beginning spironolactone Hormone Management (TF). TF patients who began spironolactone for feminizing therapy Patients who had undergone measurement of potassium, BUN, and/or creatinine during the prior 6 months
Measure 12. Adequate laboratory testing prior to beginning testosterone Hormone Management (TM). TM patients who began testosterone for masculinizing therapy Patients who had undergone measurement of Hb and/or HCT during the prior 6 months
Measure 13. Hormone therapy should not be given to patients with a history of hormone-responsive cancer Hormone Management (TF and TM). Patients who began estrogen or testosterone for feminizing or masculinizing therapy Patients who had a history of breast, prostate, ovarian, or testicular cancer prior to beginning therapy
Measure 14. Pap smear not appropriate below age 21 Cancer screening TM patients age 18–20 All such patients who received a Pap smear prior to age 21
Measure 15. Bone densitometry needed for trans patients Bone health For TF: those who received at least 180 days of feminizing therapy
For TM: all
DEXA scan at least once between age 60–70
Measure 16. Estrogen should be given by the transdermal route in patients with elevated cardiovascular risk Cardiovascular health Recipients of estrogen for feminizing therapy, divided into cardiovascular risk categories based on comorbidities Estrogen by transdermal vs. oral route
Measure 17. Estrogen should be given by the transdermal route in patients with prior venous thromboembolism Cardiovascular health Recipients of estrogen for feminizing therapy with history of prior venous thromboembolism Estrogen by transdermal vs. oral route
Measure 18. Oral testosterone preparations are no longer recommended Hormone Management (TM). Recipients of testosterone for masculinizing therapy Patients who received testosterone via the oral route (rather than transdermal or intramuscular)
Measure 19. Spironolactone should not be given, or should be given with caution, in those taking an angiotensin-converting-enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) Hormone Management (TF). Patients who received spironolactone for feminizing therapy Patients who also received an ACE inhibitor or ARB concurrently
Measure 20. Mammography should be performed every 24 months for TM patients and for TF patients who received estrogen for feminizing therapy Cancer screening All TM patients, and those TF patients who received estrogen for feminizing therapy for at least 180 total days Screening mammography at least every 24 months
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