Table_3_Centralized and Decentralized Delivery of Transgender Health Care Services: A Systematic Review and a Global Expert Survey in 39 Countries.doc

IntroductionTransgender health care is delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). However, the health care delivery setting has not gained attention in research so far. Based on a systematic review and a global expert survey, we aim to investigate its role in transgender health care quality.MethodsWe performed two studies. In 2019, we systematically reviewed the literature published in databases (Cochrane, MEDLINE, EMBASE, Web of Science) from January 2000 to April 2019. Secondly, we conducted a cross-sectional global expert survey. To complete the evidence on the question of (de-)centralized delivery of transgender health care, we performed a grey literature search for additional information than the systematic review and the expert survey revealed. These analyses were conducted in 2020.ResultsEleven articles met the inclusion criteria of the systematic review. 125 participants from 39 countries took part in the expert survey. With insights from the grey literature search, we found transgender health care in Europe was primarily delivered centralized. In most other countries, both centralized and decentralized delivery structures were present. Comprehensive care with medical standards and individual access to care were central topics associated with the different health care delivery settings.DiscussionThe setting in which transgender health care is delivered differs between countries and health systems and could influence different aspects of transgender health care quality. Consequently, it should gain significant attention in clinical practice and future health care research.

引言跨性别医疗服务既可在集中式（由单一跨学科机构提供）亦可在分散式（由多个遍布不同地点的医疗机构提供）的环境中实施。然而，迄今为止，医疗服务提供环境在研究领域的关注度尚显不足。基于系统评价及全球专家调查，本研究旨在探讨其在跨性别医疗服务质量中所扮演的角色。
方法我们开展了两项研究。2019年，我们对2000年1月至2019年4月在数据库（Cochrane、MEDLINE、EMBASE、Web of Science）中发表的文献进行了系统回顾。其次，我们进行了一项横断面全球专家调查。为完善关于（去）集中式提供跨性别医疗服务的证据，我们对系统评价和专家调查所揭示的额外信息进行了灰色文献搜索。这些分析于2020年完成。
结果系统评价中符合纳入标准的共有11篇文章。来自39个国家的125名参与者参与了专家调查。结合灰色文献搜索的见解，我们发现欧洲的跨性别医疗服务主要采取集中式提供。在大多数其他国家和地区，集中式与分散式的医疗服务提供结构并存。具有医疗标准及个性化医疗服务访问的综合医疗服务是关联不同医疗服务提供环境的核心议题。
讨论跨性别医疗服务提供的环境在不同国家和地区以及卫生体系中存在差异，并可能影响跨性别医疗服务质量的各个方面。因此，其在临床实践及未来的医疗服务研究中应受到充分的关注。