Abstract
Background
Complementary and integrative health (CIH) services enhance physiological and psychological wellbeing, while potentially reducing medical costs. Despite these benefits, use of inpatient CIH services remains poorly characterized, impeding efforts to develop equitable and effective healthcare.
Objective
This retrospective case-control study examined characteristics of patients likely to receive CIH referrals and consults.
Method
Electronic health records were analyzed from patients hospitalized at a large metropolitan academic medical center from September 2022 to February 2024.
Results
Referred patients (n = 3491) were less frequently male, Asian American, non-English-speaking, and more medically complex compared to non-referred patients (n = 6982, P values <0.001). Among those referred, 72% received at least one CIH consult, with lower odds of completing a consult for male patients.
Conclusion
Disparities underscore the need for equitable CIH services access in healthcare systems. Future research will test how to broaden services to male patients, those with non-English language preference, and less medical complexity, to ensure greater benefit from holistic healthcare.
Keywords
Background
Complementary and integrative health (CIH) combines conventional medical approaches (eg, medication) with complementary therapies (eg, massage therapy, meditation) to address people’s physical, behavioral, spiritual, and socioeconomic wellbeing holistically. 1 Over the past twenty years, leading academic medical centers and Veterans Affairs facilities have increasingly offered CIH services via a consultative model to hospitalized patients, 2 typically at no cost to the patient. Increased utilization in healthcare settings mirrors an upward trend in the public’s adoption of non-pharmacological strategies for health promotion and disease prevention. 3 CIH research in the United States has expanded rapidly, with congressional funding for the National Center for Complementary and Integrative Health tripling between 1999 to 2024, reaching over $170 million in 2024. 4 These trends indicate that interest for CIH is high and growing among donors, healthcare systems, and the public.
Of 5858 hospitals surveyed in 2010, 299 or 42% reported that they offer inpatient CIH services alongside conventional medical approaches. 5 Services are typically provided to manage patient distress, anxiety, fear, and frustration that often accompany diagnosis and hospitalization 6 ; and targeting mental health with behavioral interventions can reduce risk of infection and readmission. 7 Significant gaps remain in understanding optimal delivery and implementation of CIH services, particularly in hospitals. Characterizing which patients receive services, including referral patterns and consult completion rates, is essential for identifying care gaps, developing equitable care models, enhancing patient education, and establishing efficacious treatment protocols. The following study, conducted at Tisch Hospital/Kimmel Pavilion, NYU Langone Health, a 650+ bed hospital, compared demographic and health profiles across patient groups: patients who received or did not receive a referral for CIH services, and among referred patients, those who completed a CIH intervention vs those who did not.
Method
Study Population
NYU Langone Health’s Department of Integrative Health (DIH) at Tisch/Kimmel in Manhattan has operated as a bedside consultative service since 1992. Services are ordered in the Electronic Health Record (EHR) by the attending physician, physician assistant, nurse practitioner or nurse, at no cost to patients. Thirteen DIH nurses respond to referrals by attempting a bedside consult, usually within 48 hours of receiving the order. DIH nurses are trained in multiple CIH modalities (eg, Reiki, light touch massage therapy, aromatherapy, meditation, focused breathing, guided imagery) and typically administer a combination of these to approximately 200 patients monthly. In this study, the majority (56%) of referred patients were admitted from the Emergency Department.
Study Design
This retrospective case-control study analyzed patient EHRs from hospitalizations between September 1, 2022 and February 29, 2024. To examine differences in demographic and health profiles, two main analyses were conducted comparing (1) patients who received a referral for CIH services [CIH] vs those who did not receive a referral [NR], and (2) of the referred patients, those who completed at least 1 CIH intervention vs those who did not complete any. Not all referred patients completed a CIH session due to screen outs (eg, patients with active psychosis and/or severe behavioral health symptoms, and substance use/abuse), patient unavailability (eg, asleep, with a provider, undergoing tests), or patient refusal or lack of interest.
Data Extraction
Data extraction included demographic variables (age, sex, race, preferred language) and clinical characteristics (number of comorbidities and medications, length of stay) and referral/consult outcomes. Analyses were conducted in R (v4.4.3). Duplicate patient encounters and entries lacking unique patient identifiers or admission/discharge dates were removed. Self-reported race and language variables were standardized to ensure consistency. Patients who identified as more than one race over multiple encounters were grouped as “Multiracial.” Responses to ‘preferred language’ were categorized as “English” or “Not English.”
Data Analysis
Demographic and Clinical Characteristics of Referred and Non-referred Patients for Complementary and Integrative Health Services on Admission
aBonferroni-corrected P < 0.0001. Uncorrected P-values shown in table.
Demographic characteristics are reported at the patient-level (ie, patient only counted once, even if they have multiple hospital encounters), while clinical characteristics are reported at encounter-level (ie, patient may have multiple hospital encounters). Final sample sizes for consult data (due to screenouts and/or missing data) were as follows: Demographic (Referred [n = 3491], Not Referred [n = 6982], Total [n = 10 451]), Clinical (Referred [n = 3966], Not Referred [n = 7932], Total [n = 11 898]), Medications (Referred [n = 3966], Not Referred [n = 6912], Total [n = 10 878]), Comorbidities (Referred [n = 3652], Not Referred [n = 6810], Total [n = 10 462]), Length of stay (Referred [n = 3966], Not Referred [n = 7932], Total [n = 11 898]); Q1-Q3 = 25th percentile - 75th percentile; aOR = AdjustedOdds Ratio; CI = Confidence Interval.
Demographic and Clinical Characteristics of Referred Patients for Completed and Attempted Complementary and Integrative Health Consults
# Excluded from the logistic regression model due to separation.
aBonferonni-corrected P < 0.01.
Final sample sizes for consult data (due to screenouts and/or missing values) were as follows: Demographic (Completed [n = 2530], Attempted [n = 727], Total [n = 3257]), Clinical (Completed [n = 2904], Attempted [n = 824], Total [n = 3728]), Medications (Completed [n = 2767], Attempted [n = 764], Total [n = 3531]), Comorbidities (Completed [n = 2582], Attempted [n = 709], Total [n = 3291]), Length of stay (Completed [n = 2904], Attempted [n = 824], Total [n = 3728]); Q1-Q3 = 25th percentile - 75th percentile; aOR = Adjusted Odds Ratio; CI = Confidence Interval.
Ethical Considerations
This study was approved by the Institutional Review Board at NYU Langone Health (study number: 23-01271).
Results
Mean age was 56 years old for referred (CIH, n = 3491) and non-referred (NR, n = 6982) groups, reflecting the age-matched study design. Multiple logistic regression identified significant associations between patient demographics and receiving a CIH referral. Male (aOR: 0.76, CI: 0.70-0.82; relative to female); Asian or Asian American (aOR: 0.55, CI: 0.46-0.66) and those who did not report their race (aOR: 0.65, CI: 0.21-2.07; relative to White or European); and non-English speaking patients (aOR: 0.59, CI: 0.49-0.70; relative to English speaking) had significantly lower odds of receiving a CIH referral (Table 1; all Bonferroni-corrected P values < 0.0001).
Relative to non-referred patients, increased medication use (aOR: 1.08, 1.07-1.09) and longer hospital stays (aOR: 1.79, CI: 1.71-1.87; Bonferroni-corrected P values < 0.0001) were also associated with significantly higher odds of receiving a referral. The median number of comorbidities was higher in referred patients (vs NR), but this difference was not statistically significant.
Among referred patients (n = 3491), 2530 (73%) received at least one CIH consult. Median time to a completed consult was 4 days (IQR: 2-8 days). The mean age for patients with completed consults was 55 years, and 57 years for those with attempted but not completed consults. Significant differences were observed only in gender between groups after correcting for multiple comparisons (Table 2). Compared to females, males had significantly lower odds of completing at least one CIH consultat (aOR: 0.72, CI: 0.61-0.86, Bonferroni-corrected P < 0.0001). Multiple logistic regression revealed that longer length of stay was associated with CIH consult completion (aOR: 1.04, CI: 1.01-1.06, Bonferroni-corrected P < 0.01), indicating that each additional day of hospitalization increased the odds of completing a CIH consult by 4%.
Discussion
This study provides a comprehensive characterization of CIH services at a large metropolitan academic medical center. Our findings reveal important demographic and clinical differences among hospitalized patients who were referred for and received CIH services. Namely, male, Asian American (and patients who did not report their race), non-English speaking patients, and those with less medical complexity were less likely to receive a referral for CIH services. While the majority (73%) of referred patients received at least 1 consult, male patients were also less likely to have completed a CIH intervention.
The gender, race, and language disparities underscore the need for more equitable access to CIH services across diverse patient populations. Similar patterns have been reported in both outpatient and inpatient settings, where the historic underrepresentation of racially/ethnically and linguistically diverse patients in CIH service access and utilization remains a recognized challenge in the field. 8 These findings imply potential systemic barriers related to cultural, linguistic, or educational factors that might impact referrals, in addition to potential implicit bias among providers. 9 Of note, music therapy has been successfully delivered to socioeconomically-diverse patient groups where 44% self-identified as Black and 69% reported being on Medicare/Medicaid. 10 Thus, successfully integrating a wider range of therapies may aid providers in reaching more patients. Patients’ preferences undoubtedly influence their receptivity to CIH interventions, and thus, consult completion rates. A person’s familiarity with these interventions, not to mention their cultural beliefs or background, likely impacts whether they accept, refuse, or express an interest in receiving services. Though patient receptivity was not directly tested in this study, these attitudes are an important topic for future research. Addressing these gaps will require targeted provider education, improved communication, and culturally responsive care models.
Demographic characteristics among referred patients in this study mirrored that of the medical center at large, which serves a majority English-speaking patient population. However, the greater number of women who were referred and received consults cannot be explained by the medical center’s population demographics, as it serves equal numbers of men and women. Therefore, these findings reinforce the need to target men and racially and linguistically diverse groups, with potentially more robust care models that address demographic disparities in CIH access and utilization. Suggested enhancements include improving provider-patient communication, fostering peer support, and addressing biopsychosocial factors that account for social determinants of health. 11 Future studies also should closely examine the referral process to identify how clinical workflows can be improved to optimize equitable service delivery. As CIH services at the medical center in this study were delivered at no cost to patients, it serves as a key entry point to facilitate education on CIH for various patient groups, where otherwise in the community, patients might not have access to CIH services as readily.
With respect to clinical characteristics, more medically complex patients with significantly more medications and longer stays were more likely to be referred. Given these patients were quite ill, comorbidities, medications and length of stays were substantially high. Although patients of all medical severity types could benefit from CIH, these data suggest that services are being directed toward those with greater clinical complexity. These findings align with previous research suggesting CIH services are often utilized for chronically ill patients when conventional treatments are limited. 12 Importantly, delivering these interventions to patients with less severe presentations and early in the course of care (so-called upstream interventions) 13 might improve their longer-term outcomes; and ideally, non-pharmacological approaches should be provided alongside established and effective conventional treatments.
Overall, this study provides a comprehensive examination of hospitalized patient characteristics throughout the referral and service delivery process from a long-established CIH program within a large metropolitan academic medical center. Limitations and barriers in the consult process have been assessed elsewhere (Millon et al, manuscript under review). This study highlighted that additional factors related to provider bias should be systematically evaluated to determine how they are impacting the ability of patients to receive these types of services. Knowledge of barriers will assist with developing targeted strategies to address disparities in access, potentially through provider education, multilingual service delivery, and culturally sensitive approaches. Even still, the fact that almost three-quarters of referred patients were visited by DIH clinicians demonstrates strong program utilization and positive reception by referring clinicians and patients. The high utilization rates suggest that nurse-led CIH services can be successfully incorporated into standard hospital care. These data provide a foundation for future research examining the effectiveness of CIH interventions for specific patient populations and clinical conditions.
Study limitations include the focus on a single institution design, which may affect generalizability. Multi-site studies and practice-based research networks like BraveNet are needed to compare patient utilization of CIH services across institutions and to examine areas of alignment and key differences in consult models. 14 Future prospective studies should examine patient-reported outcomes following CIH interventions across multiple sites and explore implementation strategies to enhance equitable access to care. Nevertheless, our findings offer valuable insights for health systems seeking to implement CIH services that address the physiological and psychological needs of diverse patient populations.
Conclusion
This study characterized referral patterns and consult rates for CIH services delivered through a consultative model, providing essential insights for advancing high-quality clinical care and patient wellbeing. Female, English speaking, and medically complex patients were more likely to be referred, highlighting persistent disparities in access and utilization. Addressing these disparities is critical to ensuring equitable delivery of care. Findings lay the groundwork for improving CIH utilization and may inform the development of inpatient models at other institutions. Future research should explore how cultural, educational, and operational factors influence referral and consult patterns to optimize equitable access to CIH services.
Footnotes
Ethical Considerations
This study was approved by the Institutional Review Board at NYU Langone Health (study number: 23-01271).
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Thank you to the Lerner family for their continued support of the Lerner Health Promotion program.
Declaration of conflicting interests
The authors declared no conflicts of interest regarding the research, authorship, and/or publication of this article.