The paper demonstrates the potential of an unsteady RANS 3D approach to predict the effects of skewed winds on the performance of an H-type vertical-axis wind turbine (VAWT). The approach is ...validated through a comparison between numerical and experimental results for a full-scale Darrieus turbine, demonstrating an improved prediction ability of 3D CFD with respect to both 2D CFD and semi-empirical models based on the double multiple stream tubes method. A 3D URANS approach is then adopted to investigate the power increase observed for a straight-bladed small-scale turbine in a wind tunnel when the rotational axis is inclined from 0° to 15° from the vertical. The main advantage of this approach is a more realistic description of complex three-dimensional flow characteristics, such as dynamic stall, and the opportunity to derive local blade flow conditions on any blade portion during upwind and downwind paths. Consequently, in addition to deriving the turbine overall performance in terms of power coefficient, a better insight into the temporal and spatial evolution of the physical mechanisms is obtained. Our principal finding is that the power gain in skewed flows is obtained during the downwind phase of the revolution as the end part of the blade is less disturbed by the wake generated during the upwind phase.
•A URANS CFD simulation approach to investigate VAWT fluid dynamics is presented.•The focus is on the analysis of the performance increments observed in skewed flow.•The 3D CFD model is able to capture the unsteady 3D effects such as dynamic stall.•New light has been shed on understanding the origin of the performance increments.•Gain mainly due to the downwind part of the rotor being less disturbed by the wake.
Transgender individuals experience harassment, violence, and discrimination in a number of settings. Although health care discrimination against transgender people has been documented, this issue is ...understudied. Using a national cross-sectional survey data set (N = 1,711), the authors sought to determine how gender identity and presentation predict health care discrimination experiences among female-to-male (FTM) transgender people after demographic and socioeconomic characteristics are controlled. Analyses were conducted using chi-square tests and a two-step logistic regression. The majority of participants were white (73.9 percent) and between 25 and 44 years old (65.2 percent). Overall, 41.8 percent of FTM participants reported verbal harassment, physical assault, or denial of equal treatment in a doctor's office or hospital. When other factors were controlled, being Native American or multiracial, identifying as queer or asexual/other, having a graduate degree, living full-time as nonbirth gender, using hormones or surgery for medical transition, and having identification documents that list one's preferred gender were associated with increased reporting of health care discrimination experiences; being 45 years or older and reporting an annual income of $60,000 or more were associated with decreased risk. The study's findings can be useful to social workers, who play a role in educating health care providers and advocating for policies that improve health care experiences for FTM and other transgender patients.
Abstract Transgender patients report negative experiences in health care settings, but little is known about clinicians’ willingness to see transgender patients. We surveyed 308 primary care ...clinicians in an integrated Midwest health system and 53% responded. Most respondents were willing to provide routine care to transgender patients (85.7%) and Papanicolaou (Pap) tests (78.6%) to transgender men. Willingness to provide routine care decreased with age; willingness to provide Pap tests was higher among family physicians, those who had met a transgender person, and those with lower transphobia. Medical education should address professional and personal factors related to caring for the transgender population to increase access.
BACKGROUND:The transgender community experiences health care discrimination and approximately 1 in 4 transgender people were denied equal treatment in health care settings. Discrimination is one of ...the many factors significantly associated with health care utilization and delayed care.
OBJECTIVES:We assessed factors associated with delayed medical care due to discrimination among transgender patients, and evaluated the relationship between perceived provider knowledge and delayed care using Anderson’s behavioral model of health services utilization.
RESEARCH DESIGN:Multivariable logistic regression analysis was used to test whether predisposing, enabling, and health system factors were associated with delaying needed care for transgender women and transgender men.
SUBJECTS:A sample of 3486 transgender participants who took part in the National Transgender Discrimination Survey in 2008 and 2009.
MEASURES:Predisposing, enabling, and health system environment factors, and delayed needed health care.
RESULTS:Overall, 30.8% of transgender participants delayed or did not seek needed health care due to discrimination. Respondents who had to teach health care providers about transgender people were 4 times more likely to delay needed health care due to discrimination.
CONCLUSIONS:Transgender patients who need to teach their providers about transgender people are significantly more likely to postpone or not seek needed care. Systemic changes in provider education and training, along with health care system adaptations to ensure appropriate, safe, and respectful care, are necessary to close the knowledge and treatment gaps and prevent delayed care with its ensuing long-term health implications.
Background Delivery of preventive services sometimes falls short of guideline recommendations. Purpose To evaluate the multilevel factors associated with evidence-based preventive service delivery ...during periodic health examinations (PHEs). Methods Primary care physicians were recruited from an integrated delivery system in southeast Michigan. Audio recordings of PHE office visits conducted from 2007 to 2009 were used to ascertain physician recommendation for or delivery of 19 guideline-recommended preventive services. Alternating logistic regression was used to evaluate factors associated with service delivery. Data analyses were completed in 2011. Results Among 484 PHE visits to 64 general internal medicine and family physicians by insured patients aged 50–80 years, there were 2662 services for which patients were due; 54% were recommended or delivered. Regression analyses indicated that the likelihood of service delivery decreased with patient age and with each concern the patient raised, and it increased with increasing BMI and with each additional minute after the scheduled appointment time the physician first presented. The likelihood was greater with patient–physician gender concordance and less if the physician used the electronic medical record in the exam room or had seen the patient in the past 12 months. Conclusions A combination of patient, patient-physician relationship, and visit contextual factors are associated with preventive service delivery. Additional studies are warranted to understand the complex interplay of factors that support and compromise preventive service delivery.
Abstract Erectile dysfunction (ED) is a common issue that aging men encounter, but whether internalized gay ageism (i.e., the internalization of ageist messages within the context of aging as a gay ...man) is related to ED among older gay men is unknown. A cross-sectional web-based survey explored the relationship between internalized gay ageism, health-related and social factors, and ED among older gay men who resided in the Midwest United States ( N = 181). Internalized gay ageism was not significantly associated with ED. However, hierarchical regression analysis found that age (β = .224, t = 2.70, p = .008) and overall health (β = −.247, t = −3.05, p = .003) were significantly associated with ED among older gay men, suggesting that older gay men share similar risk factors for ED as the general male population. Future research should continue to explore other factors that are unique to gay men that may be associated with ED.
Limited evidence suggests that transgender individuals smoke at significantly higher rates than the general population. We aimed to determine whether structural or everyday discrimination experiences ...predict smoking behavior among transgender individuals when sociodemographic, health, and gender-specific factors were controlled.
Data from the National Transgender Discrimination Survey (N = 4781), a cross-sectional online and paper survey distributed to organizations serving the transgender community, were analyzed in order to determine the association between current smoking and discrimination experiences and other potential predictors. Logistic regression models were used to establish factors that predict smoking.
Participants reported experiencing both structural (80.4%) and everyday (65.9%) discrimination. Multivariate analyses showed that participants who reported attending some college, graduating college, or having a graduate degree were less likely to smoke compared to those with a high school degree or less. Uninsured participants were more likely to report smoking compared to those with private insurance. Those who used alcohol or drugs for coping were also more likely to smoke. Participants whose IDs and records listed their preferred gender were less likely to smoke (OR = 0.84); those who had experienced structural discrimination were more like to report smoking (OR = 1.65).
Further research is needed in order to explore the relationship between smoking and legal transition among transgender individuals. Strategies to prevent smoking and encourage cessation among this vulnerable population are also needed. In addition, comprehensive collection of gender identity data in the context of national surveys, tobacco-related research, and clinical settings is sorely needed.
This study establishes a link between experiences of structural discrimination among transgender individuals and smoking status.
Most transgender individuals either use or are interested in using gender-affirming hormone therapy (HT). Making gender-affirming HT available in primary care is critical for quality care to this ...vulnerable population. The barriers that transgender patients experience to accessing this treatment may be exacerbated if primary care providers (PCPs) will not provide it. Little is known about PCPs' willingness to administer HT to transgender patients.
To examine whether PCPs are willing to continue prescribing HT for transgender patients and the factors that predict such willingness.
An online survey of internal and family medicine physicians and residents practising in a large integrated Midwest health system (n = 308); 158 responded to the relevant questions (51.3%).
Approximately 50% of respondents were willing to continue HT for transgender patients. Most participants had previously met a transgender person (77%), and approximately half of them had cared for a transgender patient in the past 5 years. Multivariate logistic regression results indicate that attending physicians had lower odds of willingness to continue HT compared with medical residents, and those who reported perceived capability of providing routine care to transgender patients had higher odds of willingness.
Only about half of PCPs surveyed were willing to continue HT for transgender patients. Our study indicates that both personal and clinical factors play a role. Future research should address ways to increase PCPs' willingness and comfort related to continuing HT for transgender patients.
We describe online portal account adoption and feature access among subgroups of patients who traditionally have been disadvantaged or represent those with high healthcare needs.
Retrospective cohort ...study of insured primary care patients 18 years and older (N = 20,282) receiving care from an integrated health system.
Using data from an electronic health record repository, portal adoption was defined by 1 or more online sessions. Feature access (ie, messaging, appointment management, visit/admission summaries, and medical record access and management) was defined by user-initiated "clicks." Multivariable regression methods were used to identify patient factors associated with portal adoption and feature access among adopters.
One-third of patients were portal adopters, with African Americans (odds ratio OR, 0.50; 95% CI, 0.46-0.56), Hispanics (OR, 0.63; 95% CI, 0.47-0.84), those 70 years and older (OR, 0.48; 95% CI, 0.44-0.52), and those preferring a language other than English (OR, 0.43; 95% CI, 0.31-0.59) less likely to be adopters. On the other hand, the likelihood of portal adoption increased with a higher number of comorbidities (OR, 1.04; 95% CI, 1.02-1.07). Among adopters, record access and management features (95.9%) were accessed most commonly. The majority of adopters also accessed appointment management (76.6%) and messaging (59.1%) features. Similar race and age disparities were found in feature access among adopters.
The diversity of portal features accessed may bode well for the ability of portals to engage some patients, but without purposeful intervention, reliance on portals alone for patient engagement may exacerbate known social disparities-even among those with an activated portal account.
Background
Even after a physician recommendation, many people remain unscreened for colorectal cancer (CRC). The proliferation of electronic health records (EHRs) and tethered online portals may ...afford new opportunities to embed patient-facing interventions within clinic workflows and engage patients following a physician recommendation for care. We evaluated the effectiveness of a patient-facing intervention designed to complement physician office-based recommendations for CRC screening.
Design
Using a 2-arm pragmatic, randomized clinical trial, we evaluated the intervention’s effect on CRC screening use as documented in the EHR (primary outcome) and the extent to which the intervention reached the target population. Trial participants were insured, aged 50 to 75 y, with a physician recommendation for CRC screening. Typical EHR functionalities, including patient registries, health maintenance flags, best practice alerts, and secure messaging, were used to support research-related activities and deliver the intervention to enrolled patients.
Results
A total of 1,825 adults consented to trial participation, of whom 78% completed a baseline survey and were exposed to the intervention. Most trial participants (>80%) indicated an intent to be screened on the baseline survey, and 65% were screened at follow-up, with no significant differences by study arm. One-third of eligible patients were sent a secure message. Among those, more than three-quarters accessed study material.
Conclusions
By leveraging common EHR functionalities, we integrated a patient-facing intervention within clinic workflows. Despite practice integration, the intervention did not improve screening use, likely in part due to portal-based interventions not reaching those for whom the intervention may be most effective.
Implications
Embedding patient-facing interventions within the EHR enabled practice integration but may minimize program effectiveness by missing important segments of the patient population.
Highlights
Electronic health record tools can be used to facilitate practice-embedded pragmatic trial and patient-facing intervention processes, including patient identification, study arm allocation, and intervention delivery.
The online portal-embedded intervention did not improve colorectal cancer (CRC) screening uptake following a physician recommendation, likely in part because portal users tend to be already highly engaged with healthcare.
Relying on patient portals alone for CRC screening interventions may not alter screening use and could exacerbate well-known care disparities.
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