Addressing racial disparities in perinatal care for African American/Black individuals in the Chicago community health setting: a qualitative study.

BACKGROUND: There are persistent disparities in maternal and infant perinatal outcomes experienced by Black birthing persons compared with non-Hispanic white (NHW) individuals in the US. The differences in outcomes arise from not only socioeconomic factors and individual health behaviors but also structural racism. Recent research is beginning to elucidate the benefits of patient navigation to support underserved minoritized individuals who experience this constellation of barriers to equitable care. Qualitative research that utilizes both the experiences of Black birthing individuals and the expert opinion of healthcare providers working with them can serve to guide a patient navigation intervention to further decrease disparities in perinatal outcomes. METHODS: We conducted 30 interviews between August and December 2020 with Black birthing individuals in the Chicago metropolitan area and healthcare providers who care for this population both in Chicago and across the nation to explore their experiences, perceptions of barriers to care and ways to decrease inequities. RESULTS: Clinical care team members acknowledged the presence of health disparities experienced by Black pregnant individuals compared with their NHW counterparts stemming from racism, discrimination, and lack of resources. Patients similarly reported personal experiences with these disparities and barriers to care. The successful methods used by clinical care teams to help decrease these differences in the past included patient education on important topics such as breastfeeding and the use of patient advocates. Effectively screening for social determinants of health by someone the patient trusts was also cited as important. Regarding perinatal care practices, clinical care team members described the importance of patient education needs and care team cultural competency. Patients' reported positive and negative experiences corroborated these findings, emphasizing the importance of trust, listening, education, access to care, support, and patient advocacy. Finally, the care team members and patients agreed that active trust-building can help the provider/patient relationship and ultimately improve outcomes. CONCLUSIONS: These qualitative research findings improve the understanding of barriers to care and will help guide development of an intervention to reduce the health disparities experienced by Black pregnant persons.

Race/Ethnicity and Perception of Care: Does Patient-Provider Concordance Matter?

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..

Medical Spanish in US Medical Schools: a National Survey to Examine Existing Programs.

BACKGROUND: Most medical schools offer medical Spanish education to teach patient-physician communication skills with the growing Spanish-speaking population. Medical Spanish courses that lack basic standards of curricular structure, faculty educators, learner assessment, and institutional credit may increase student confidence without sufficiently improving skills, inadvertently exacerbating communication problems with linguistic minority patients. OBJECTIVE: To conduct a national environmental scan of US medical schools' medical Spanish educational efforts, examine to what extent existing efforts meet basic standards, and identify next steps in improving the quality of medical Spanish education. DESIGN: Data were collected from March to November 2019 using an IRB-exempt online 6-item primary and 14-item secondary survey. PARTICIPANTS: All deans of the Association of American Medical Colleges member US medical schools were invited to complete the primary survey. If a medical Spanish educator or leader was identified, that person was sent the secondary survey. MAIN MEASURES: The presence of medical Spanish educational programs and, when present, whether the programs met four basic standards: formal curricular structure, faculty educator, learner assessment, and course credit. KEY RESULTS: Seventy-nine percent of medical schools (125 out of 158) responded to either or both the primary and/or secondary surveys. Among participating schools, 78% (98/125) of medical schools offered medical Spanish programming; of those, 21% (21/98) met all basic standards. Likelihood of meeting all basic standards did not significantly differ by location, school size, or funding type. Fifty-four percent (53/98) report formal medical Spanish curricula, 69% (68/98) have faculty instructors, 57% (56/98) include post-course assessment, and 31% (30/98) provide course credit. CONCLUSIONS: Recommended next steps for medical schools include formalizing medical Spanish courses as electives or required curricula; hiring and/or training faculty educators; incorporating learner assessment; and granting credit for student course completion. Future studies should evaluate implementation strategies to establish best practice recommendations beyond basic standards.

Patients' perceptions of a culturally targeted Hispanic Kidney Transplant Program: A mixed methods study.

Disproportionately fewer waitlisted Hispanics receive living donor kidney transplants (LDKTs) compared to non-Hispanic whites. Northwestern Medicine's® culturally targeted Hispanic Kidney Transplant Program (HKTP) is associated with a significant increase in LDKTs among Hispanics. This multisite study assessed potential kidney recipients' and donors' and/or family members' perceptions of the HKTP's cultural components through semi-structured interviews and validated surveys. Qualitative thematic analysis and descriptive statistics were performed. Thirty-six individuals participated (62% participation rate) comprising 21 potential recipients and 15 potential donors/family (mean age: 51 years, 50% female, 72% preferred Spanish). Participants felt confident about the educational information because a transplant physician delivered the education and viewed the group format as effective. Participants felt that education sessions addressed myths about transplantation shared by Hispanics. Primary use of Spanish enhanced participants' understanding of transplantation. While few knew about living donation before attending the HKTP, most were "more in favor of" kidney transplantation (97%) and living donation (97%) afterward. Few reported learning about the HKTP from outreach staff and suggested leveraging community leaders to promote HKTP awareness. Our findings suggest the HKTP's cultural components were viewed favorably and positively influenced perceptions of kidney transplantation and living donation, which may help reduce transplant disparities in Hispanics. (Clinicaltrial.gov registration # NCT03276390, date of registration: 9-7-17, retrospectively registered).

Contemporary Management of the Patient with Polycystic Ovary Syndrome.

Polycystic ovary syndrome (PCOS) is a complex syndrome that affects menstrual regularity, causes hyperandrogenism, increases the risk of metabolic dysfunction and infertility, and is associated with higher rates of mental health disorders. The symptoms of PCOS are unique to each individual and will evolve throughout their reproductive lifespan and beyond. Thus, care should be personalized and provided by an appropriate team of multidisciplinary physicians and clinicians, such as dieticians and psychologists.

How Should Representation of Subjects With LEP Become More Equitable in Clinical Trials?

Underrepresentation of individuals with limited English proficiency (LEP) who speak Spanish is ongoing in phase 3 biomedical clinical trials and exacerbates health inequity. This article suggests strategies for increasing representation of Spanish speakers in clinical rials by emphasizing the importance of early engagement with Spanish language communities, inclusive participant recruitment, and collaborative trial design and implementation. Although investigators and institutions administering government-funded research must meet federal requirements for language assistance, journal editors, peer reviewers, institutional review board members, academic health centers, and all beneficiaries of the biomedical and behavioral research enterprise in the United States must motivate linguistic inclusion.

Todavía continúa la subrepresentación de personas con un dominio limitado del inglés (LEP, por sus siglas en inglés) que hablan español en los ensayos clínicos biomédicos de fase 3 y esto exacerba la inequidad sanitaria. Este artículo propone estrategias para aumentar la representación de los hispanohablantes en los ensayos clínicos al resaltar la importancia del compromiso temprano con las comunidades de habla hispana, el reclutamiento inclusivo de participantes y el diseño e implementación de ensayos colaborativos. Aunque los investigadores y las instituciones que realizan las investigaciones financiadas por el gobierno deben cumplir con los requisitos federales respecto de la asistencia lingüística, los editores de revistas, los revisores inter pares, los miembros de las juntas de revisión institucionales, los centros académicos de salud y todos los beneficiarios de las empresas de investigación biomédica y conductual en los Estados Unidos deben motivar la inclusión lingüística.

Exploring Race and Ethnicity Representational Inequities in Illinois Medical Schools.

Purpose: Efforts to increase U.S. medical school student diversity have lagged behind the continued growth of racial/ethnic minorities in the population. A targeted, local approach may catalyze actionable change that holds schools accountable for addressing community needs through representation. The aims of our study are to (1) analyze the student racial/ethnic profiles of allopathic and osteopathic medical schools in the diverse state of Illinois and (2) compare student race/ethnicity with that of schools' local county and primary teaching hospital patient populations. Methods: Data from the Association of American Medical Colleges and American Association of College of Osteopathic Medicine were used to gather matriculated student race/ethnicity from the eight allopathic schools and one osteopathic medical school in Illinois. Representational inequity quotients (RIQs) were calculated to determine the proportion of Hispanic/Latinx, black/African American, and total underrepresented in medicine (UIM) individuals in three reference populations (U.S., county, and primary teaching hospital patient populations) relative to each medical school's student racial/ethnic profile. Results: Across Illinois schools, mean RIQs were highest (showed greater inequity) when county demographics were used as the reference population as opposed to U.S. or hospital populations. For all schools individually, Hispanic county-student RIQs were higher than RIQs based on hospital population. For a majority of schools with primary teaching hospital in Cook County, hospital-student RIQs magnified representational inequity for the black population. Conclusions: Using county data to evaluate medical school representation inequities may better reflect UIM representation goals than the U.S. population. Examining hospital demographics may further reveal other structural inequities relevant to medical education, such as primary teaching hospitals that are not adequately serving their surrounding communities. By evaluating RIQs on a local and hospital-population level, schools can periodically assess to what degree their student body and hospital populations represent their communities and adjust recruitment, retention, and service efforts.

Student and Faculty Diversity is Insufficient to Ensure High-Quality Medical Spanish Education in US Medical Schools.

Medical Spanish education aims to reduce linguistic barriers in healthcare and has historically been led by Hispanic/Latinx students and faculty, often without formal training or institutional support. We surveyed 158 US medical schools about their medical Spanish programs. We then examined national trends in Underrepresented in Medicine and Hispanic/Latinx faculty and students as factors associated with meeting medical Spanish basic standards for curricula, educators, assessment, and course credit. We received responses from 125 schools (79%), of which 98 (78%) reported offering some form of medical Spanish. Schools with greater racial/ethnic diversity were more likely to have medical Spanish required courses (P-values < 0.01) but not curricular electives. Overall, likelihood of meeting all basic standards did not differ by diversity characteristics. High-quality medical Spanish requires more than recruitment of diverse students and faculty. Institutions should prioritize meaningful inclusion by supporting evidence-based curricula and faculty educators.

The Complex Interplay of Communication and Trust in Healthcare Delivery.

Effective communication in clinician-patient relationships is an essential part of improving health outcomes. Ineffective communication in clinical settings leaves patients feeling undervalued and unheard. Breakdowns in communication can have particularly profound effects on minority or underserved populations, where health disparities already exist. Effective communication is critical for establishing trust, which allows individuals to feel they can share their concerns and questions. Distrust is a particularly important issue in maternal health, where current US rates of maternal mortality and morbidity are 3.1 times higher in Black and African American (AA) pregnant and birthing persons than their non-Hispanic white counterparts. To address the widespread issue of medical distrust and its connection with maternal health outcomes, the OPTIMIZE study is currently implementing an innovative intervention aimed at improving perinatal care for Black/AA pregnant persons. This intervention prompts clinician-patient conversations to enhance communication and repair trust, including a focus on patients' goals, concerns, social determinants of health, and safety. The implications of this intervention are broad, including the potential to improve trust and communication in other clinical specialties.

ApoA-I-Mediated Lipoprotein Remodeling Monitored with a Fluorescent Phospholipid.

We describe simple, sensitive and robust methods to monitor lipoprotein remodeling and cholesterol and apolipoprotein exchange, using fluorescent Lissamine Rhodamine B head-group tagged phosphatidylethanolamine (*PE) as a lipoprotein reference marker. Fluorescent Bodipy cholesterol (*Chol) and *PE directly incorporated into whole plasma lipoproteins in proportion to lipoprotein cholesterol and phospholipid mass, respectively. *Chol, but not *PE, passively exchanged between isolated plasma lipoproteins. Fluorescent apoA-I (*apoA-I) specifically bound to high-density lipoprotein (HDL) and remodeled *PE- and *Chol-labeled synthetic lipoprotein-X multilamellar vesicles (MLV) into a pre-ß HDL-like particle containing *PE, *Chol, and *apoA-I. Fluorescent MLV-derived *PE specifically incorporated into plasma HDL, whereas MLV-derived *Chol incorporation into plasma lipoproteins was similar to direct *Chol incorporation, consistent with apoA-I-mediated remodeling of fluorescent MLV to HDL with concomitant exchange of *Chol between lipoproteins. Based on these findings, we developed a model system to study lipid transfer by depositing fluorescent *PE and *Chol-labeled on calcium silicate hydrate crystals, forming dense lipid-coated donor particles that are readily separated from acceptor lipoprotein particles by low-speed centrifugation. Transfer of *PE from donor particles to mouse plasma lipoproteins was shown to be HDL-specific and apoA-I-dependent. Transfer of donor particle *PE and *Chol to HDL in whole human plasma was highly correlated. Taken together, these studies suggest that cell-free *PE efflux monitors apoA-I functionality.

Lipoprotein X Causes Renal Disease in LCAT Deficiency.

Human familial lecithin:cholesterol acyltransferase (LCAT) deficiency (FLD) is characterized by low HDL, accumulation of an abnormal cholesterol-rich multilamellar particle called lipoprotein-X (LpX) in plasma, and renal disease. The aim of our study was to determine if LpX is nephrotoxic and to gain insight into the pathogenesis of FLD renal disease. We administered a synthetic LpX, nearly identical to endogenous LpX in its physical, chemical and biologic characteristics, to wild-type and Lcat-/- mice. Our in vitro and in vivo studies demonstrated an apoA-I and LCAT-dependent pathway for LpX conversion to HDL-like particles, which likely mediates normal plasma clearance of LpX. Plasma clearance of exogenous LpX was markedly delayed in Lcat-/- mice, which have low HDL, but only minimal amounts of endogenous LpX and do not spontaneously develop renal disease. Chronically administered exogenous LpX deposited in all renal glomerular cellular and matrical compartments of Lcat-/- mice, and induced proteinuria and nephrotoxic gene changes, as well as all of the hallmarks of FLD renal disease as assessed by histological, TEM, and SEM analyses. Extensive in vivo EM studies revealed LpX uptake by macropinocytosis into mouse glomerular endothelial cells, podocytes, and mesangial cells and delivery to lysosomes where it was degraded. Endocytosed LpX appeared to be degraded by both human podocyte and mesangial cell lysosomal PLA2 and induced podocyte secretion of pro-inflammatory IL-6 in vitro and renal Cxl10 expression in Lcat-/- mice. In conclusion, LpX is a nephrotoxic particle that in the absence of Lcat induces all of the histological and functional hallmarks of FLD and hence may serve as a biomarker for monitoring recombinant LCAT therapy. In addition, our studies suggest that LpX-induced loss of endothelial barrier function and release of cytokines by renal glomerular cells likely plays a role in the initiation and progression of FLD nephrosis.