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OBJECTIVE: We determine whether racial concordance between postpartum patients and obstetric providers (dyads) impacts the perception of quality of care among people undergoing intrapartum obstetrical procedures. STUDY DESIGN: This is a prospective cohort study of postpartum people who underwent operative vaginal or cesarean deliveries in the second stage of labor. Participants were asked to identify the race of their primary provider and complete the Interpersonal Processes of Care (IPC) survey, which assesses communication, patient-centered decision-making, and interpersonal style. The association of participant-identified patient-provider racial concordance with IPC scores was determined. The primary outcome was the IPC subdomain related to discrimination, and secondary outcomes included other IPC subdomains and IPC results by participant racial identity (Black, LatinX vs. White). Sociodemographic and biomedical data were extracted from the medical record. Bivariable analyses were performed. RESULTS: Of 168 patients who were approached, 107 (63.6%) agreed to participate and 87 (81.3%) completed the survey. The majority (n=49) identified a racially discordant provider. Participants in racially concordant dyads were more likely to be older, White, use English as a primary language, complete a higher degree of education, and have a higher household income when compared with racially discordant dyads. Intrapartum outcomes were not significantly different between groups. Median IPC subtest scores were not significantly different between groups or between racial/ethnic identities. CONCLUSION: There were no significant differences in perceptions of IPC between racially concordant versus discordant dyads. However, there is an ongoing need to further clarify measures of quality of care in high-acuity obstetrical situations to remediate ongoing racial and ethnic disparities in adverse health outcomes. KEY POINTS: · Racial concordance between patient and clinician has been associated with improved quality of care.. · There are limited data on racial concordance and perceptions of operative obstetrical care (e.g., operative vaginal delivery).. · Racial concordance was not associated with differences in patient-perceived quality of care associated with operative obstetrics..
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BACKGROUND: Antiretroviral (ARV) management in pediatrics is a challenging process in which multiple barriers to optimal therapy can lead to poor clinical outcomes. In a pediatric HIV clinic, we implemented a systematic ARV stewardship program to evaluate ARV regimens and make recommendations for optimization when indicated. METHODS: A comprehensive assessment tool was used to screen for issues related to genotypic resistance, virologic/immunologic response, drug-drug interactions, side effects and potential for regimen simplification. The ARV stewardship team (AST) made recommendations to the HIV clinic provider, and followed patients prospectively to assess clinical outcomes at 6 and 12 months. RESULTS: The most common interventions made by the AST included regimen optimization in patients on suboptimal regimens based on resistance mutations (35.4%), switching to safer ARVs (33.3%) and averting significant drug-drug interactions (10.4%). In patients anticipated to have a change in viral load (VL) as a result of the AST recommendations, we identified a significant benefit in virologic outcomes at 6 and 12 months when recommendations were implemented within 6 months of ARV review. Patients who had recommendations implemented within 6 months had a 7-fold higher probability of achieving a 0.7 log10 reduction in VL by 6 months, and this benefit remained significant after controlling for adherence [adjusted odds ratio: 6.8 (95% confidence interval: 1.03-44.9; P <0.05)]. CONCLUSIONS: A systematic ARV stewardship program implemented at a pediatric HIV clinic significantly improved clinical outcomes. ARV stewardship programs can be considered a core strategy for continuous quality improvement in the management of HIV-infected children and adolescents.
