Contribution of Health Care Practitioner and Maternity Services Factors to Racial Disparities in Alabama: A Qualitative Study.

OBJECTIVE: Black patients are three times more likely to die of pregnancy-related causes than White patients in the United States, and Alabama has the third worst maternal mortality rate in the nation. We sought to identify health care practitioner and maternity service factors contributing to disparities in Alabama, as well as potential strategies to address these contributors. METHODS: We conducted key informant interviews with obstetricians, nurses, doulas, lactation counselors, health system administrators, and representatives of professional organizations who deliver maternity care to racially and ethnically diverse patients in Alabama. The interview guide was developed using Howell's conceptual framework on racial and ethnic disparities in severe maternal morbidity and mortality. Adopting a thematic analysis approach, we coded and analyzed transcripts using NVivo 12 software. Open coding and selective coding were conducted to identify themes related to health care practitioner- and maternity services-level determinants. RESULTS: Overall, 20 health care practitioners or administrators were interviewed. Primary themes related to health care practitioners included implicit bias and explicit racism, lack of communication and lack of positive patient-health care practitioner relationships, lack of cultural sensitivity, and variation in clinical knowledge and experience. Primary themes related to maternity services included lack of accessibility, inadequate quality and content of care, lack of continuity of care, discriminatory facility policies, and workforce shortages and lack of diversity. Strategies suggested by participants to address these factors included bias trainings for health care practitioners, improvements in racial and interdisciplinary diversity in the maternity workforce, and evidence-based interventions such as group prenatal care, disparities dashboards, simulation trainings, early warning signs criteria, and coordinated care. CONCLUSION: We gained diverse perspectives from health care practitioners and administrators on how maternity health care practitioner and maternity health services factors contribute to inequities in maternal health in Alabama. Strategies to address these contributing factors were multifaceted.

Community and Systems Contributors and Strategies to Reduce Racial Inequities in Maternal Health in the Deep South: Provider Perspectives.

Purpose: Black pregnant individuals in Alabama are disproportionately affected by severe maternal morbidity and mortality (SMM). To understand why racial disparities in maternal health outcomes persist and identify potential strategies to reduce these inequities, we sought perspectives from obstetric health care providers, health administrators, and members of local organizations who provide pregnancy, delivery, and postpartum care services in Alabama. Methods: We conducted qualitative in-depth interviews with stakeholders (n=20), purposively recruited from community-based organizations, clinical settings, government organizations, and academic institutions. Interview guides were based on Howell's conceptual model of pathways to racial disparities in maternal mortality. Data were coded using a modified framework theory approach and analyzed thematically. Results: Racism, unjust laws and policies, and poverty/lack of infrastructure in communities emerged as major themes contributing to racial disparities in maternal health at the community and systems levels. Inadequate health insurance coverage was described as a strong driver of the disparities. Service providers suggested strategies for Alabama should be community focused, evidence based, and culturally sensitive. These should include Medicaid expansion, expanded parental leave, and removal of laws restricting choice. Community- and systems-level interventions should include community infrastructure improvements, choice in maternity services, and provision of digital communication options. Conclusions: Providers shared perspectives on community and structural areas of intervention to reduce racial inequities in SMM. These results can inform discussions with health system and community partners about Alabama and other Deep South initiatives to improve maternal health outcomes in black communities.

Reported Clinical and Financial Performance of Hospitals With Physician CEOs Compared to Those With Nonphysician CEOs.

EXECUTIVE SUMMARY: Little work has been done comparing the performance of hospitals with physician CEOs versus nonphysician CEOs, despite the ease of identifying this characteristic and extant leadership theories suggesting a relationship between technical expertise and success in leading highly technical organizations. We performed a detailed analysis of several widely accepted measures of clinical and financial performance across a randomly selected group of U.S. acute care hospitals with more than 40 beds and found no statistically significant differences between the two groups. The 30-day acute myocardial infarction mortality rate showed a positive statistically significant difference in the bivariate analysis (p < .001), but the effect was nullified in the multivariable regression analysis.

Elective Induction of Labor in the 39th Week of Gestation Compared With Expectant Management of Low-Risk Multiparous Women.

OBJECTIVE: To compare perinatal and maternal outcomes in low-risk multiparous women who underwent elective induction of labor in the 39th week of gestation with those who were expectantly managed. METHODS: We performed a single center retrospective cohort study of low-risk multiparous women delivering nonanomalous singletons between 39 and 42 completed weeks of gestation from 2014 to 2018. The primary outcome was a perinatal composite of death, neonatal respiratory support, a 5-minute Apgar score of 3 or less, and shoulder dystocia. Groups were compared using χ, Fisher exact, two sample t-test, and Wilcoxon rank sum tests, as appropriate. Multivariable logistic regression models were used to adjust for potential confounders. RESULTS: Of the 3,703 low-risk multiparous women meeting inclusion criteria, 453 (12%) delivered between 39 0/7 and 39 4/7 after an elective induction of labor. Women who underwent elective induction of labor were more likely to be privately insured, non-Hispanic, and weigh more at their first prenatal visit (all P<.01) compared with expectant management. An elective induction of labor was associated with decreased frequency of the perinatal composite morbidity (4.0% vs 7.1%; adjusted odds ratio [aOR] 0.57, 95% CI 0.34-0.96) compared with expectant management. Fewer cesarean deliveries occurred among women in the elective induction of labor group (5.1% vs 6.6%; aOR 0.60, 95% CI 0.37-0.97). Other maternal outcomes (hypertensive disorders, chorioamnionitis, and operative vaginal deliveries) as well as neonatal intensive care unit admissions were not different between groups. CONCLUSION: Elective induction of labor in low-risk multiparous women in the 39th week of gestation was associated with decreased perinatal morbidity and a lower frequency of cesarean delivery compared with expectant management.

Economic Evaluation of Adjunctive Azithromycin Prophylaxis for Cesarean Delivery.

OBJECTIVE: To compare the costs associated with adjunctive azithromycin compared with standard cefazolin antibiotic prophylaxis alone for unscheduled and scheduled cesarean deliveries. METHODS: A decision analytic model was created to compare cefazolin alone with azithromycin plus cefazolin. Published incidences of surgical site infection after cesarean delivery were used to estimate the baseline incidence of surgical site infection in scheduled and unscheduled cesarean delivery using standard antibiotic prophylaxis. The effectiveness of adjunctive azithromycin prophylaxis was obtained from published randomized controlled trials for unscheduled cesarean deliveries. No randomized study of its use in scheduled procedures has been completed. Cost estimates were obtained from published literature, hospital estimates, and the Healthcare Cost and Utilization Project and considered costs of azithromycin and surgical site infections. A series of sensitivity analyses were conducted by varying parameters in the model based on observed distributions for probabilities and costs. The outcome was cost per cesarean delivery from a health system perspective. RESULTS: For unscheduled cesarean deliveries, cefazolin prophylaxis alone would cost $695 compared with $335 for adjunctive azithromycin prophylaxis, resulting in a savings of $360 (95% CI $155-451) per cesarean delivery. In scheduled cesarean deliveries, cefazolin prophylaxis alone would cost $254 compared with $111 for adjunctive azithromycin prophylaxis, resulting in a savings of $143 (95% CI 98-157) per cesarean delivery, if proven effective. These findings were robust to a multitude of inputs; as long as adjunctive azithromycin prevented as few as seven additional surgical site infections per 1,000 unscheduled cesarean deliveries and nine additional surgical site infections per 10,000 scheduled cesarean deliveries, adjunctive azithromycin prophylaxis was cost-saving. CONCLUSION: Adjunctive azithromycin prophylaxis is a cost-saving strategy in both unscheduled and scheduled cesarean deliveries.

A randomized clinical trial testing the anti-inflammatory effects of preemptive inhaled nitric oxide in human liver transplantation.

Decreases in endothelial nitric oxide synthase derived nitric oxide (NO) production during liver transplantation promotes injury. We hypothesized that preemptive inhaled NO (iNO) would improve allograft function (primary) and reduce complications post-transplantation (secondary). Patients at two university centers (Center A and B) were randomized to receive placebo (n = 20/center) or iNO (80 ppm, n = 20/center) during the operative phase of liver transplantation. Data were analyzed at set intervals for up to 9-months post-transplantation and compared between groups. Patient characteristics and outcomes were examined with the Mann-Whitney U test, Student t-test, logistic regression, repeated measures ANOVA, and Cox proportional hazards models. Combined and site stratified analyses were performed. MELD scores were significantly higher at Center B (22.5 vs. 19.5, p<0.0001), surgical times were greater at Center B (7.7 vs. 4.5 hrs, p<0.001) and warm ischemia times were greater at Center B (95.4 vs. 69.7 min, p<0.0001). No adverse metabolic or hematologic effects from iNO occurred. iNO enhanced allograft function indexed by liver function tests (Center B, p<0.05; and p<0.03 for ALT with center data combined) and reduced complications at 9-months (Center A and B, p = 0.0062, OR = 0.15, 95% CI (0.04, 0.59)). ICU (p = 0.47) and hospital length of stay (p = 0.49) were not decreased. iNO increased concentrations of nitrate (p<0.001), nitrite (p<0.001) and nitrosylhemoglobin (p<0.001), with nitrite being postulated as a protective mechanism. Mean costs of iNO were $1,020 per transplant. iNO was safe and improved allograft function at one center and trended toward improving allograft function at the other. ClinicalTrials.gov with registry number 00582010 and the following URL:http://clinicaltrials.gov/show/NCT00582010.

Testing and validation of a low-cost cystoscopy teaching model: a randomized controlled trial.

OBJECTIVE: To estimate whether the use of a low-cost cystoscopy model effectively trains residents in cystourethroscopy and to validate the model as a teaching tool. METHODS: A randomized, controlled, and evaluator-blinded study was performed. Twenty-nine obstetrician-gynecologist residents had access to fresh-frozen cadavers on which baseline cystoscopic skills were assessed using the validated Objective Structured Assessment of Technical Skills checklists for cystourethroscopy. Subsequently, residents were randomized to one of two arms, a didactic study arm using the cystoscopy model and a control arm. Repeated technical skills testing was performed. RESULTS: The study group demonstrated statistically significant decreases in cystoscope assembly time (128.8 seconds at baseline to 54.9 seconds postintervention; P=.005), and increases in task-specific checklist scores (from 59.3 at baseline to 92.9 postintervention; P<.001) and in global rating scale scores (from 61.0 at baseline to 87.8 postintervention; P<.001). Further, there was a significant improvement in task-specific checklist (P<.001), global rating scale (P=.002), and knowledge quiz scores (P=.011) in the study arm compared with the control arm. CONCLUSION: Use of the bladder model exhibited validity in enhancing performance and knowledge of cystourethroscopy among ob-gyn residents. LEVEL OF EVIDENCE: I.

Patient death as a censoring event or competing risk event in models of nursing home placement.

Participant death is often observed in studies that examine predictors of events, such as hospitalization or institutionalization, in older adult populations. The Cox proportional hazards modeling of the target event, whereby death is treated as a censoring event, is the standard analysis in this competing risks situation. However, the assumption of noninformative censoring applied to a frequently occurring competing event like death may be invalid and complicate interpretation in terms of the probability of the event. Multiple cause-specific hazard (CSH) models can be estimated, but ambiguities may arise when interpreting covariate effects across multiple CSH models and in terms of the cumulative incidence function (CIF). Alternatively, one can model the proportional hazards of the subdistribution of the CIF and evaluate the covariate effects on the CIF directly. We examine and compare these two approaches with nursing home (NH) placement data from a randomized controlled trial of a counseling and support intervention for spouse-caregivers of patients with Alzheimer's disease. CSHs for NH placement (where death is treated as a censoring event) and death (where NH placement is treated as a censoring event) and subdistribution hazards of the CIF for NH placement are modeled separately. In the presence of multiple covariates, the intervention effect is significant in both approaches, but the interpretation of the covariate effects requires joint evaluation of all estimated models.