Soothing the heart with music: A feasibility study of a bedside music therapy intervention for critically ill patients in an urban hospital setting.

OBJECTIVES: Music therapy has been shown to be effective for reducing anxiety and pain in people with a serious illness. Few studies have investigated the feasibility of integrating music therapy into general inpatient care of the seriously ill, including the care of diverse, multiethnic patients. This leaves a deficit in knowledge for intervention planning. This study investigated the feasibility and effectiveness of introducing music therapy for patients on 4 inpatient units in a large urban medical center. Capacitated and incapacitated patients on palliative care, transplantation, medical intensive care, and general medicine units received a single bedside session led by a music therapist. METHODS: A mixed-methods, pre-post design was used to assess clinical indicators and the acceptability and feasibility of the intervention. Multiple regression modeling was used to evaluate the effect of music therapy on anxiety, pain, pulse, and respiratory rate. Process evaluation data and qualitative analysis of observational data recorded by the music therapists were used to assess the feasibility of providing music therapy on the units and patients' interest, receptivity, and satisfaction. RESULTS: Music therapy was delivered to 150 patients over a 6-month period. Controlling for gender, age, and session length, regression modeling showed that patients reported reduced anxiety post-session. Music therapy was found to be an accessible and adaptable intervention, with patients expressing high interest, receptivity, and satisfaction. SIGNIFICANCE OF RESULTS: This study found it feasible and effective to introduce bedside music therapy for seriously ill patients in a large urban medical center. Lessons learned and recommendations for future investigation are discussed.

Decisional Control Preferences in the Hispanic Population in the Bronx.

Hispanic Americans are among the fastest growing minority groups in the USA, and understanding their preferences for medical decision-making and information sharing is imperative to provide high quality end of life care. Studies exploring these decision control preferences (DCPs) are limited and found inconsistent results. (1) To measure DCPs of Hispanic patients in the Bronx. (2) To measure disclosure of information preferences of Hispanic patients in the Bronx. This is a cross-sectional survey. One hundred nineteen cancer patients who self-identified as Hispanic and were waiting at the oncology clinic at Montefiore Medical Center Cancer Center. Proportions of patients endorsing DCPs and disclosure of information preferences are reported. The relationship between patient characteristics and DCPs was tested using chi-squared tests of homogeneity. The majority (63, 52.9%) preferred shared decision-making with their doctors, families or both, while 46 (38.7%) had an active decision-making style. A minority (9, 7.6%) had a passive decision-making style, deferring to their families, and only 1 (0.8%) deferring to the physician. No demographic characteristics significantly predicted DCPs. The majority of patients agreed or strongly agreed that they wanted to hear all of the information regarding their diagnosis (94%), treatment options (94%), treatment expectations (92%), and treatment risks and benefits (96%). These results confirm our hypothesis that most Hispanic patients prefer either an active or shared decision-making process rather than a passive decision-making process. Most patients prefer disclosure of diagnosis, prognosis, and plan.

2017 HIV Medicine Association of Infectious Diseases Society of America Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With Human Immunodeficiency Virus.

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV.

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

HIV-Associated Complications: A Systems-Based Approach.

Persons with human immunodeficiency virus (HIV) infection often develop complications related directly to the infection, as well as to treatment. Aging, lifestyle factors, and comorbidities increase the risk of developing chronic conditions such as diabetes mellitus and chronic kidney disease. HIV-associated neurologic complications encompass a wide spectrum of pathophysiology and symptomatology. Cardiovascular and pulmonary conditions are common among persons with HIV infection. Although some specific antiretroviral medications have been linked to disease development, traditional risk factors (e.g., smoking) have major roles. Prevention and management of viral hepatitis coinfection are important to reduce morbidity and mortality, and new anti-hepatitis C agents produce high rates of sustained virologic response. Antiretroviral-associated metabolic complications include dyslipidemia, hyperglycemia, and loss of bone mineral density. Newer options generally pose less risk of significant systemic toxicity and are better tolerated. Family physicians who care for patients with HIV infection have a key role in identifying and managing many of these chronic complications.

Missing the mark: ongoing missed opportunities for HIV diagnosis at an urban medical center despite universal screening recommendations.

BACKGROUND: Despite established recommendations from the Centers for Disease Control (CDC) to scale up testing efforts in the USA, this study shows full scale implementation of these recommendations may still be lacking. We hypothesize that patients experience ongoing missed opportunities for earlier diagnosis of HIV, despite frequent encounters to Montefiore Medical Center (MMC), an integrated hospital system in the Bronx, NY. METHODS: Retrospective chart review via electronic medical records of patients newly diagnosed with HIV in 2012 and 2013 at varied MMC clinical sites. Missed opportunities were defined as > 1 prior health care encounter at MMC within three calendar years of diagnosis, in which HIV testing was not offered for those who had a prior negative test or no prior test. RESULTS: There were 218 patients newly diagnosed with HIV at MMC during the study period; 31% presented with a CD4 <200 cells/mm3; 22% were asymptomatic at diagnosis. Patients (56%) without a prior HIV test had an average 4.72 clinical encounters at MMC within the 3 years prior to their HIV diagnosis. Over 95% of visits prior to diagnosis occurred in emergency departments (EDs) or primary care outpatient department (OPDs) and accounted for the vast majority of missed opportunities. CONCLUSIONS: HIV infected patients continue to present late to care, with low CD4 and commonly utilize OPDs and EDs, where missed opportunities for earlier diagnosis are common. Practices that address augmentation of current HIV testing strategies are needed, especially in outpatient and first-contact acute care settings.

Combining clinical and population-level data to understand the health of neighborhoods.

From February through December 2012, we examined responses to health behavior questions integrated into the electronic medical record of primary care centers in the Bronx, New York in the context of New York City Community Health Survey data. We saw a higher proportion of unhealthy behaviors among patients than among the neighborhood population. Analyzing clinical data in the neighborhood context can better target at-risk populations.

Openings.

Reviewing his clinic patient schedule for the day, a physician reflects on the history of a young woman he has been caring for over the past 9 years. What starts out as a routine visit then turns into a unique opening for communication and connection. A chance glimpse out the window of the exam room leads to a deeper meditation on parenthood, survival, and healing, not only for the patient but also for the physician. How many missed opportunities have we all had, without even realizing it, to allow this kind of fleeting but profound opening?

Factors associated with daily consumption of sugar-sweetened beverages among adult patients at four federally qualified health centers, Bronx, New York, 2013.

INTRODUCTION: Consumption of sugar-sweetened beverages (SSBs) is associated with cardiovascular disease risk factors. This study examined the relationships between SSB consumption and demographic, health behavior, health service, and health condition characteristics of adult patients of a network of federally qualified health centers (FQHCs) in a low-income, urban setting. METHODS: Validated, standardized self-reported health behavior questions were incorporated into the electronic health record (EHR) and asked of patients yearly, at 4 FQHCs. We conducted cross-sectional analysis of EHR data collected in 2013 from 12,214 adult patients by using logistic regression. RESULTS: Forty percent of adult patients consumed 1 or more SSBs daily. The adjusted odds ratios indicated that patients who consumed more than 1 SSB daily were more likely to be aged 18 to 29 years versus age 70 or older, current smokers versus never smoking, eating no servings of fruits and/or vegetables daily or 1 to 4 servings daily versus 5 or more servings daily, and not walking or biking more than 10 blocks in the past 30 days. Patients consuming 1 or more servings of SSBs daily were less likely to speak Spanish than English, be women than men, be diagnosed with type 2 diabetes versus no diabetes, and be diagnosed with hypertension versus no hypertension. CONCLUSION: SSB consumption differed by certain demographic characteristics, health behaviors, and health conditions. Recording SSB intake and other health behaviors data in the EHR could help clinicians in identifying and counseling patients to promote health behavior changes. Future studies should investigate how EHR data on patient health behavior can be used to improve the health of patients and communities.

Increasing Referrals to a YMCA-Based Diabetes Prevention Program: Effects of Electronic Referral System Modification and Provider Education in Federally Qualified Health Centers.

INTRODUCTION: The Diabetes Prevention Program has been translated to community settings with varying success. Although primary care referrals are used for identifying and enrolling eligible patients in the Diabetes Prevention Program, little is known about the effects of strategies to facilitate and sustain eligible patient referrals using electronic health record systems. METHODS: To facilitate and sustain patient referrals, a modification to the electronic health record system was made and combined with provider education in 6 federally qualified health centers in the Bronx, New York. Referral data from April 2012 through November 2014 were analyzed using segmented regression analysis. RESULTS: Patient referrals increased significantly after the modification of the electronic health record system and implementation of the provider education intervention. Before the electronic system modification, 0 to 2 patients were referred per month. During the following year (September 2013 through August 2014), which included the provider education intervention, referrals increased to 1 to 9 per month and continued to increase to 5 to 11 per month from September through November 2014. CONCLUSIONS: Modification of an electronic health record system coupled with a provider education intervention shows promise as a strategy to identify and refer eligible patients to community-based Diabetes Prevention Programs. Further refinement of the electronic system for facilitating referrals and follow-up of eligible patients should be explored.

Results of a voter registration project at 2 family medicine residency clinics in the Bronx, New York.

PURPOSE: Federally qualified health centers provide care to medically underserved populations, the same individuals often underrepresented in the electoral process. These centers are unique venues to access patients for voter registration services. METHODS: We undertook a clinician-led, nonpartisan voter registration drive within 2 university-affiliated federally qualified health centers in the Bronx, New York. Patients were approached by voter registration volunteers in clinic waiting areas during a 12-week period. RESULTS: Volunteers directly engaged with 304 patients. Of the 128 patients who were eligible and not currently registered, 114 (89%) registered to vote through this project. This number corresponded to 38% of all patients engaged. Sixty-five percent of new registrants were aged younger than 40 years. CONCLUSIONS: This project was successful in registering clinic patients to vote. Clinics are not only health centers, but also powerful vehicles for bringing a voice to civically disenfranchised communities.

Hospital-Based Interventions to Address Provider Grief: A Narrative Review.

CONTEXT: Provider grief, i.e., grief related to the death of patients, often forms an ongoing and profound stressor impacting healthcare providers' ability to maintain their sense of well-being, avoid feeling overwhelmed, and sustain quality and compassionate patient care over time. OBJECTIVES: This narrative review presents findings on the types of interventions hospitals have offered to physicians and nurses to address provider grief. METHODS: Searches of PubMed and PsycINFO were conducted for articles (e.g., research studies, program descriptions and evaluations) focused on hospital-based interventions to help physicians and nurses cope with their own grief. RESULTS: Twenty-nine articles met inclusion criteria. The most common adult clinical areas were oncology (n = 6), intensive care (n = 6), and internal medicine (n = 3), while eight articles focused on pediatric settings. Nine articles featured education interventions, including instructional education programs and critical incident debriefing sessions. Twenty articles discussed psychosocial support interventions, including emotional processing debriefing sessions, creative arts interventions, support groups, and retreats. A majority of participants reported that interventions were helpful in facilitating reflection, grieving, closure, stress relief, team cohesion, and improved end-of-life care, yet mixed results were found related to interventions' effects on reducing provider grief to a statistically significant degree. CONCLUSION: Providers largely reported benefits from grief-focused interventions, yet research was sparse and evaluation methodologies were heterogenous, making it difficult to generalize findings. Given the known impact provider grief can have on the individual and organizational levels, it is important to expand providers' access to grief-focused services and to increase evidence-based research in this field.

Essential components of effective HIV care: a policy paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition.

Human immunodeficiency virus (HIV) antiretroviral agents and effective HIV care management transformed HIV disease from a death sentence to a chronic condition for many in the United States. A comprehensive HIV care model was developed to meet the complex needs of HIV patients, with support from the Ryan White program, the Veterans Administration, and others. This paper identifies the essential components of an effective HIV care model. As access to health care expands under the National HIV/AIDS Strategy and the Patient Protection and Affordable Care Act, it will be critical to build upon the HIV care model to realize positive health outcomes for people with HIV infection.

An epidemic in evolution: the need for new models of HIV care in the chronic disease era.

Since the beginning of the AIDS epidemic, models of HIV care have needed to be invented or modified as the needs of patients and communities evolved. Early in the epidemic, primary care and palliative care predominated; subsequently, the emergence of effective therapy for HIV infection led to further specialization and a focus on increasingly complex antiretroviral therapy as the cornerstone of effective HIV care. Over the past decade, factors including (1) an aging, long-surviving population; (2) multiple co-morbidities; (3) polypharmacy; and (4) the need for chronic disease management have led to a need for further evolution of HIV care models. Moreover, geographic diffusion; persistent disparities in timely HIV diagnosis, treatment access, and outcomes; and the aging of the HIV provider workforce also suggest the importance of reincorporating primary care providers into the spectrum of HIV care in the current era. Although some HIV-dedicated treatment centers offer comprehensive medical services, other models of HIV care potentially exist and should be developed and evaluated. In particular, primary care- and community-based collaborative practices-where HIV experts or specialists are incorporated into existing health centers-are one approach that combines the benefits of HIV-specific expertise and comprehensive primary care using an integrated, patient-centered approach.

Comorbidity-related treatment outcomes among HIV-infected adults in the Bronx, NY.

Aging, HIV infection, and antiretroviral therapy have been associated with increasing rates of chronic comorbidities in patients with HIV. Urban minority populations in particular are affected by both the HIV/AIDS and chronic disease epidemics. Our objectives were to estimate the prevalence of and risk factors for hypertension, dyslipidemia, and diabetes among HIV-infected adults in the Bronx and describe comorbidity-related treatment outcomes. This was a cross-sectional study of 854 HIV-positive adults receiving care at 11 clinics which provide HIV primary care services; clinics were affiliated with a large urban academic medical center. Data on blood pressure (BP), cholesterol, and glycemic control were collected through standardized chart review of outpatient medical records. We found prevalence rates of 26%, 48%, and 13% for hypertension, dyslipidemia, and diabetes, respectively. Older age, obesity, family history, and current protease inhibitor use were consistently associated with comorbidity. Diabetes treatment goals were achieved less often than BP and lipid goals, and concurrent diabetes was a significant predictor for BP and lipid control. In conclusion, major cardiovascular-related comorbidities are prevalent among HIV-positive adults in the Bronx, especially older and obese individuals. Differences exist in comorbidity-related treatment outcomes, especially for patients with concurrent diabetes. Because cardiovascular risk is modifiable, effective treatment of related comorbidities may improve morbidity and mortality in HIV-infected patients.

Complications of HIV infection: a systems-based approach.

Patients with human immunodeficiency virus (HIV) infection often develop multiple complications and comorbidities. Opportunistic infections should always be considered in the evaluation of symptomatic patients with advanced HIV/AIDS, although the overall incidence of these infections has decreased. Primary care of HIV infection includes the early detection of some complications through screening at-risk and symptomatic patients with routine laboratory monitoring (e.g., comprehensive metabolic and lipid panels) and validated tools (e.g., the HIV Dementia Scale). Treatment of many chronic complications is similar for patients with HIV infection and those without infection; however, combination antiretroviral therapy has shown benefit for some conditions, such as HIV-associated nephropathy. For other complications, such as cardiovascular disease and lipoatrophy, management may include switching antiretroviral regimens to reduce exposure to HIV medications known to cause toxicity.

Clinical Redeployment of an Academic Family Medicine Department in an Early, Severe COVID-19 Pandemic in the Bronx, NY.

INTRODUCTION: A severe surge of the COVID-19 pandemic in spring 2020 infected 33% of the population and caused more than 7000 deaths in the Bronx, NY. The Department of Family and Social Medicine at Montefiore Medical Center rapidly and strategically reconfigured clinical services to meet the needs of patients, communities, and the health system. CLINICAL RECONFIGURATION: Family medicine hospitalist services tripled in size within 2 weeks to cover 71 beds and cared for 447 patients between March 24 and June 10, 2020, of whom 279 (62.4%) had COVID-19. Community health centers reorganized to maintain primary care services, shifting abruptly to telemedicine while maintaining 95% of the previous year's visit volume, and address intensified patient needs related to viral infection and mental health impacts. Core principles for redeployment included role flexibility, communication, responsiveness, and safety and wellness. DISCUSSION: During a pandemic surge, academic family medicine departments have an important role in expanding hospitalist services and redesigning primary care services. The ability to reconfigure work to meet unprecedented demands on health care was facilitated by family medicine's broad scope of practice including training in hospital medicine, interpersonal communication, behavioral health, care across settings, collaborative partnerships with specialists, and adaptability to communities' needs.

Early Use of the Palliative Approach to Improve Patient Outcomes in HIV Disease: Insights and Findings From the Care and Support Access (CASA) Study 2013-2019.

Young men of color who have sex with men (yMSM) living with human immunodeficiency virus (HIV) in syndemic environments have been difficult-to-retain in care resulting in their being at-risk for poor health outcomes despite availability of effective once-daily antiretroviral treatment (ART). Multiple methods have been implemented to improve outcomes for this cohort; none with sustainable results. Outpatient HIV staff themselves may be a contributing factor. We introduced multidisciplinary staff to the concept of using a palliative approach early (ePA) in outpatient HIV care management to enable them to consider the patient-level complexity of these young men. Young MSM (18-35 years of age) enrolled in and cared for at the intervention site of the Care and Support Access Study (CASA), completed serial surveys over 18 months. Patients' Global and Summary quality of life (QoL) increased during the study at the intervention site (IS) where staff learned about ePA, compared with patients attending the control site (CS) (p=.021 and p=.018, respectively). Using serial surveys of staff members, we found that in the era of HIV disease control, outpatient staff are stressed more by environmental factors than by patients' disease status seen historically in the HIV epidemic. A Community Advisory Panel of HIV stakeholders contributed to all phases of this study and altered language used in educational activities with staff members to describe the patient cohort.

Preliminary report of the integration of a palliative care team into an intensive care unit.

Nearly half of Americans who die in hospitals spend time in the intensive care unit (ICU) in the last 3 days of life. Minority patients who die in the ICU are less likely to formalize advance directives and surviving family members report lower satisfaction with the provision of information and sensitivity to their cultural traditions at the end-of-life. This is a descriptive report of a convenience sample of 157 consecutive patients served by a palliative care team which was integrated into the operations of an ICU at Montefiore Medical Center in the Bronx, New York, from August 2005 until August 2007. The team included an advance practice nurse (APN) and social worker. A separate case-control study was conducted comparing the length of hospital stay for persons who died in the ICU during the final 6 months of the project, prior to and post-palliative care consultation for 22 patients at the hospital campus where the project team was located versus 24 patients at the other campus. Pharmaco-economic data were evaluated for 22 persons who died with and 43 who died without a palliative care consultation at the intervention campus ICU to evaluate whether the project intervention was associated with an increase in the use of pain medications or alterations in the use of potentially non-beneficial life-prolonging treatments in persons dying in the ICU. Data was abstracted from the medical record with a standardized chart abstraction instrument by an unblinded research assistant. Interviews were conducted with a sample of family members and ICU nurses rating the quality of end-of-life care in the ICU with the Quality of Dying and Death in the ICU instrument (ICUQODD), and a family focus group was also conducted. Forty percent of patients were Caucasian, 35% were African American or Afro-Caribbean, 22% Hispanic and 3% were Asian or other. Exploration of the patients' and families' needs identified significant spiritual needs in 62.4% of cases. Education on the death process was provided to 85% of families by the project team. Twenty-nine percent of patients were disconnected from mechanical ventilators following consultation with the Palliative Care Service (PCS), 15.9% of patients discontinued the use of inotropic support, 15.3% stopped artificial nutrition, 6.4% stopped dialysis and 2.5% discontinued artificial hydration. Recommendations on pain management were made for 51% of the project's patients and symptom management for 52% of patients. The project was associated with an increase in the rate of the formalization of advance directives. Thirty-three percent of the patients who received PCS consultations had 'do not resuscitate' orders in place prior to consultation and 83.4% had 'do not resuscitate' orders after the intervention. The project team referred 80 (51%) of the project patients to hospice and 55 (35%) patients were enrolled on hospice, primarily at the medical center. The mean time from admission to palliative care consultation at the project site was 2.8 days versus 15.5 days at the other campus (p = 0.0184). Median survival times from admission to the medical center were not significantly different when stratified by palliative care consultation status: 12 days for the control group (95% CI 8-18) and 13.5 days for the intervention group (95% CI 8-20). Median charges for the use of opioid medications were higher (p = 0.01) for the intervention group but lower for use of laboratory (p = 0.004) and radiology tests (p = 0.027). We conclude that the integration of palliative care experts into the operation of critical care units is of benefit to patients, families and critical care clinicians. Preliminary evidence suggest that such models may be associated with improved quality of life, higher rates of formalization of advance directives and utilization of hospices, as well as lower use of certain non-beneficial life-prolonging treatments for critically ill patients who are at the end of life.

Diagnosis and initial management of acute HIV infection.

Recognition and diagnosis of acute human immunodeficiency virus (HIV) infection in the primary care setting presents an opportunity for patient education and health promotion. Symptoms of acute HIV infection are nonspecific (e.g., fever, malaise, myalgias, rash), making misdiagnosis common. Because a wide range of conditions may produce similar symptoms, the diagnosis of acute HIV infection involves a high index of suspicion, a thorough assessment of HIV exposure risk, and appropriate HIV-related laboratory tests. HIV RNA viral load testing is the most useful diagnostic test for acute HIV infection because HIV antibody testing results are generally negative or indeterminate during acute HIV infection. After the diagnosis of acute HIV infection is confirmed, physicians should discuss effective transmission risk reduction strategies with patients. The decision to initiate antiretroviral therapy should be guided by consultation with an HIV specialist.