Arthur Blank

Palliative care consultation improves quality of care through symptom management, communication, care coordination, and earlier hospice referral, and it may decrease burdensome hospital readmissions at the end of life. To compare 30-day readmission rates for patients admitted with exacerbation of congestive heart failure (CHF) receiving palliative care consultation services compared with controls. Retrospective cohort study using propensity score matching. A secondary, subgroup analysis compared patients with palliative care consults and patients with an incomplete consult order. Settings/Subjects: Single-center study in an academic acute inpatient setting. Of a pool of 8215 admissions from January 1, 2011 to April 6, 2014, 356 included a palliative care consultation, and 356 matched controls were found. The 30-day readmission rate was 50.8% for admissions including a palliative care consult and 36.0% for controls (OR 1.8, 95% CI 1.4-2.5). Those with a completed consult had fewer re...

This article has reviewed the detection, diagnosis, and differential diagnosis of PTSD. Recognition of particular effects of traumatic stress on patients' communications and adjustments in interviewing technique facilitate the expression and detection of PTSD when it is present. The phenomenologic boundaries between PTSD and a number of clinical syndromes and disorders are explored in detail. Delineation of PTSD from other disorders even when they co-occur with PTSD is almost always possible with effective rapport and knowledge from clinical research. An understanding of the role of traumatic stress in the origin of several disorders aside from PTSD assists in differential diagnosis, particularly when PTSD is present along with another trauma disorder. To avoid an undue, misleading proliferation of diagnoses (illusory comorbidity), the clinician should move beyond simply a cross-sectional enumeration of symptoms, to conduct a careful exploration of the patient's longitudinal history and thus understand fully which features are secondary to traumatic stress.

The authors assessed DSM-III-R disorders among American former prisoners of war. Comorbidity, time of onset, and the relationship of trauma severity to complicated versus uncomplicated posttraumatic stress disorder (PTSD) were examined. A community sample (N=262) of men exposed to combat and imprisonment was assessed by clinicians using the Structured Clinical Interview for DSM-III-R. The rates of comorbidity among the men with PTSD were lower than rates from community samples assessed by lay interviewers. Over one-third of the cases of lifetime PTSD were uncomplicated by another axis I disorder; over one-half of the cases of current PTSD were uncomplicated. PTSD almost always emerged soon after exposure to trauma. Lifetime PTSD was associated with increased risk of lifetime panic disorder, major depression, alcohol abuse/dependence, and social phobia. Current PTSD was associated with increased risk of current panic disorder, dysthymia, social phobia, major depression, and generaliz...

Agency and altruism theory are combined to develop a framework for explaining expected returns on informal investments in 35 countries that participated in the Global Entrepreneurship Monitor (GEM) in 2004 and 2005. 1 The principal finding is that altruism affects expected returns. Expected returns increase as the relationship distance between the investor and the entrepreneur increases; men expect higher returns

The National Institutes of Health (NIH) Roadmap for Medical Research initiative, funded by the NIH Common Fund and offered through the Clinical and Translational Science Award (CTSA) program, developed more than 60 unique models for achieving the NIH goal of accelerating discoveries toward better public health. The variety of these models enabled participating academic centers to experiment with different approaches to fit their research environment. A central challenge related to the diversity of approaches is the ability to determine the success and contribution of each model. This paper describes the effort by the Evaluation Key Function Committee to develop and test a methodology for identifying a set of common metrics to assess the efficiency of clinical research processes and for pilot testing these processes for collecting and analyzing metrics. The project involved more than one-fourth of all CTSAs and resulted in useful information regarding the challenges in developing common metrics, the complexity and costs of acquiring data for the metrics, and limitations on the utility of the metrics in assessing clinical research performance. The results of this process led to the identification of lessons learned and recommendations for development and use of common metrics to evaluate the CTSA effort. Clin Trans Sci 2015; Volume #: 1-9.

Previous research and theory suggest that a person's anxiety level plays a functional role in determining his responsiveness to and appreciation of humor. Based upon the theoretical view that humor serves to dissipate anxiety, it was proposed that highly anxious individuals would respond more favourably to a therapist's use of humor than low trait-anxiety individuals. To test the hypothesis 87 undergraduate students in psychology were classified according to their measured level of trait anxiety (high or low, on the Spielberger Trait-Anxiety Inventory). Subjects evaluated a therapist who used humor in a written therapist-client dialogue. Results were contrary to prediction; an inverse relation between anxiety and appreciation of humor obtained.

To determine the effectiveness of an educational video entitled Syphilis and Men to increase syphilis knowledge among at-risk Black and Hispanic male patients. In this randomized controlled trial, participants were randomly assigned to one of four groups and completed a pre-test survey, viewed the video (intervention group) and/or completed a post-test knowledge survey. Our analysis assessed whether the intervention group in comparison to the control group had an increase in syphilis knowledge, regardless of self-reported socio-demographic and sexual behavior characteristics associated with increased risk for syphilis infection. Two hundred and six (206) males were studied. The intervention group participants scored on average 24.8 percentage points higher than the control group participants (p<.001) on the post-test survey after viewing the video. This difference was present regardless of certain self-reported socio-demographic and sexual behavior characteristics associated with increased risk for syphilis infection. The Syphilis and Men video is a five-minute, low-cost tool that increased syphilis knowledge among Black and Hispanic male patients and could have similar effects in other settings.

In September 2009, the Health Resources and Services Administration, (HRSA) HIV-AIDS Bureau funded 11 programs to engage and retain women of color (WoC) living with HIV in care. This field report describes the rationale for this Special Project of National Significance (SPNS) initiative, the 11 programs in terms of their theoretical frameworks as well as the contexts and mechanism of care, and outlines some factors that may influence engaging and retaining WoC in care.

We proposed and tested a theoretical framework for how use of Teach-back could influence communication during the pediatric clinical encounter. Audio-taped pediatric primary care encounters with 44 children with asthma were coded using the Roter Interaction Analysis System to measure patient-centered communication and affective engagement of the parent. A newly created Teach-back Loop Score measured the extent to which Teach-back occurred during the clinical encounter; parental health literacy was measured by Newest Vital Sign. Logistic regression was used to test the relationship between Teach-back and features of communication. Focus groups held separately with clinicians and parents elicited perceptions of Teach-back usefulness. Teach-back was used in 39% of encounters. Visits with Teach-back had more patient centered communication (p=0.01). Adjusting for parent health literacy, parent age, and child age, Teach-back increased the odds of both patient centered communication [propo...

Inadequate or poor quality sleep in early childhood impairs social-emotional and cognitive function via effects on the developing brain and increases obesity risk via hormonal and endocrine effects. The prevalence of short sleep duration, behavioral sleep problems, and sleep-disordered breathing among children aged 3 to 5 years is 20% to 50%. Healthy sleep habits increase sleep duration and prevent behavioral sleep problems. Awareness of sleep-disordered breathing symptoms leads to its timely treatment. We designed a study that aims to empower families whose children are in early childhood programs with the knowledge and skills needed to obtain healthy sleep and to recognize a sleep problem. We used the social-ecological framework to guide individual, interpersonal, organizational, community, and policy interventions. This study builds on the Sweet Dreamzzz, Inc, Early Childhood Sleep Education Program (ECSEP) in Head Start. A stepped-wedge-cluster randomized trial will test effects on child, parent, and classroom outcomes; a policy evaluation will assess the impact of knowledge-translation strategies. The study has 3 aims. The first is to adapt educational materials into multimedia formats and build the capacity of Head Start agencies to implement the study. The second aim is to enroll 540 parent-child dyads in a primary prevention trial of sleep health promotion in Head Start and to analyze effects on children's sleep duration (primary outcome); parents' knowledge, attitudes, self-efficacy, and behavior; and children's sleep difficulties. The third aim is to conduct a secondary prevention feasibility study of screening and guidance for sleep problems. Secondary outcomes are changes in classroom behaviors and policies. Integrating sleep health literacy into early childhood programs could affect the life-course development of millions of children.

Pain is highly prevalent among HIV-positive individuals, with women representing a large subset of those with pain. However, little is known about the relationship between pain and retention in HIV medical care. Among a cohort of HIV-positive women of color, we evaluated the association between pain and retention in care, as measured by missed clinic visits. The Health Resources and Services Administration's Women of Color Initiative was a multi-site observational cohort study evaluating demonstration projects to engage HIV-positive women in medical care. From November 2010 to July 2013, 921 women were enrolled in the study across nine U.S. sites; baseline interviews collected data on socio-demographic, clinical, and risk behavior characteristics. Pain was assessed at baseline based on number of days in pain over the last 30 days and was categorized as no pain (0 days), infrequent pain (1-13 days), and frequent pain (14-30 days), with 14 days being the median. Missed visits over the one-year follow-up period, evaluated by chart abstraction, were dichotomized as ≤1 missed visit versus >1 missed visit. We conducted multivariate logistic regression to assess the association between pain at baseline and missed visits, adjusting for pertinent covariates. Among our sample (N = 862), 52.2 % of women reported no pain, 23.7 % reported infrequent pain and 24.1 % reported frequent pain. Forty-five percent had >1 missed visit during the one-year follow-up period. Overall, we did not find a significant association between pain and missed visits (aOR 2.30; 95 % CI 1.00-5.25). However, in planned stratified analyses, among women reporting current substance use at baseline, reporting frequent pain was associated with a higher odds of missed visits as compared with reporting no pain (aOR 15.14; 95 % CI 1.78-128.88). In our overall sample, pain was not significantly associated with missed visits. However, frequent pain was associated with missed visits among HIV-positive women of color who reported substance use at baseline. A better understanding of the relationship between pain and missed visits could guide efforts to improve retention in care in this population.

In response to the current CDC recommendations for routine HIV testing in clinical settings, the Adolescent AIDS Program at Montefiore Medical Center in the Bronx, New York, developed the Advise, Consent, Test, Support routine HIV testing model (ACTS) in 2003. ACTS was piloted in 10 community health centers operated by Montefiore because they serve populations most at risk for HIV/AIDS. ACTS streamlined and codified the counseling and testing process, provided a routine HIV testing practice change plan, and provided training and communication materials that promoted routine HIV testing. To determine program success, we measured the number of patients seen at the clinics, the number of HIV test-eligible patients (those aged 13-64 years and not pregnant), the number and percent of patients receiving HIV testing, HIV test results, and the number of patients linked to care. HIV testing in the 10 sites increased nearly threefold during the pilot period (2003-2007), from 3,944 of 49,125 e...

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. 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. 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. 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.

Background: Project TEETH, a 5-year HRSA-SPNS funded grant, was designed to increase the number of HIV+ patients referred to and utilizing dental services at ten Montefiore Medical Group (MMG2) sites. To accomplish this we delineate three objectives: Design and implement an integrative model of oral health (OH) care; Increase usage rates of OH services in an HIV+ population; and Using a QI orientation and the RE-AIM framework to evaluate our model of dental care with regards to reach, effectiveness, acceptance, implementation and maintenance. Methods: Three of the MMG2 sites have existing dental facilities on/near site, while seven are being serviced by mobile dental unit (MDU). Patient Navigators (PNs) have been integrated at the three sites to act as liaisons between medical care and OH services, assist with the dental appointment process and perform educational and follow-up functions. The MDU has integrated a Dental Hygienist (DH) to act as its liaison/link between medical and d...

Issues: Project TEETH, a 5-year HRSA-SPNS funded grant, was designed to increase the number of HIV+ patients referred to and utilizing dental services at ten Montefiore Medical Group (MMG2) sites. One objective is to design and implement an integrative model of oral health (OH) care by integrating Patient Navigators (PNs) into three sites with existing dental facilities on/near site. Description: The bilingual PNs are liaisons between medical and dental care. They educate HIV+ patients on the essentials of maintaining good OH, assist with the dental appointment process, and perform follow-up activities. The PNs create an environment in which the patient may feel more comfortable speaking to someone who can relay the information in layman's terms. Patients receive services which makes them feel like they're receiving client services and educational tools unlike that of routine clinical visits thus improving their perceptions of the facility. PNs prompt patients to initiate co...

Introduction: The prevalence of childhood overweight/obesity has grown three-fold since the early 1990's, and today's children face increased health burdens and shortened life spans. Objective: NYCRING -a practice based research network (PBRN) in Montefiore Medical Center's Department of Family and Social Medicine - introduced a simple clinic based intervention to: (1) increase screening in primary care for young children at risk of obesity, and (2) influence short-term parent and child activity and nutrition. Intervention: The Family Lifestyle Assessment of Initial Risk (FLAIR) project encouraged primary care providers (PCP) to help families set behavior change goals. There were 3 intervention and 3 control sites. At the intervention sites, the 2-to-3 year old well child visit was reframed to focus on family lifestyle risk assessment and behavior change. Clinician counseling was augmented by contact with a health educator. At the control sites families received usual ca...

Research Objective: To evaluate the impact of a learning collaborative model on ability of primary care practices to demonstrate decreased time in achieving quality improvement outcomes. Background: Bronx Ongoing Pediatric Screening in the Medical Home (BOPS) is incorporates evidence-based medical home screening strategies across the pediatric lifespan in 13 pediatric, family medicine, and school health practices in Bronx, NY. BOPS combines a modified learning collaborative, using multidisciplinary onsite teams, coupled with real-time clinical data feedback to practitioners, quality improvement coaching and a pay-for-quality monetary incentive. The four-year project targets four screening domains: 1) newborn screening for genetic, metabolic and infectious diseases, 2) infant and toddler screening for developmental, behavioral and social/emotional disorders, 3) school age and adolescent mental health screening, and 4) screening of sexually active adolescents for sexually transmitted ...

Background and Methods: In September 2009, the Health Resources and Services Administration, (HRSA) HIVAIDS Bureau funded 10 programs to engage and retain women of color (WoC) living with HIV in care and a National Evaluation and Technical Assistance Center. The Center developed a standardized multi-site survey. The data come from WoC enrolled in 9 programs between January, 2010 - December, 2012, 6 urban and 3 rural, with high HIV prevalence. Baseline sociodemographic, risk behaviors, barriers to care, and HIV care status were compared between urban/rural sites. Specific barriers were compared to risk behaviors, education, and HIV care status. Findings: The 633 women enrolling from urban areas (N=415) were different from rural areas (N=218). Most were Non-Hispanic Black (68.8%), but in urban areas, there were significantly more Latinas (30.0%/5.0%), foreign-born (10.0%/4.6%), currently single (86.5%/78.0%), less than HS education (43.9%/32.6%), unemployed (62.2%/40.8%), and domestic...

Background: In 9/2009, the Health Resources and Services Administration, HIV/AIDS Bureau funded 10 programs to engage and retain HIV+ women of color (WoC) in care and a National Evaluation and Technical Assistance Center. The Center developed a standardized multi-site survey. Methods: Data come from 9/10 programs between 1/2010-12/2012. Part of a larger survey, the Dynamics of Care, administered 3-months post-baseline, allowed women to self-identify and prioritize areas of concern (AoCs) that could influence care seeking behaviors and health status. Prioritized AoC were followed to see if problems were being resolved/changed. Results: The 435 WoC were x=40.7 years (11.42); African-American/Black (67.7%), Hispanic/Latina (22.8%); US-born (85.1%); no HS diploma (39.8%); unemployed (52.9%); no insurance (33.4%). WoC ranked the top 5 concerns into 3 dominant areas life circumstances (44.5%), medical problems (23.1%), and psychological symptoms (12.4%). For 64.5%, the concern arose in th...

Background and Methods: In 2009, the HIV/AIDS Bureau funded a multi-site initiative to engage and retain in care women of color living with HIV. Data were collected from 633 HIV-infected WOC at 3 rural, 6 urban sites using standardized multi-site surveys that included demographics, general health status, HIV health status, HIV-related illnesses, and women's health issues. Significance of differences in percentages between groups was assessed using Chi-square tests, or exact statistics at P <0.05 (**). Results. In contrast to rural women (R), more urban (U) women reported a history of AIDS ** (22%U vs. 13%R), and more days with a depressed mood in the last month**(72%U vs. 63%R), compared with rural (R) women. More rural women reported having excellent/very good general health** (23%U vs. 30%R) and reported having very healthy days in the last month (76%U vs. 84%R)**. Rural women also reported more vaginal yeast infections** (46%U vs. 63%R), sexually transmitted infections** (...