Clinical Leadership for Physicians

Christopher P. Bruti, MD, MPH

Dr. Christopher P. Bruti is the division chief of hospital medicine at Rush University and the program director of Rush’s combined Internal Medicine–Pediatrics Residency Program. He is an associate professor of internal medicine and pediatrics and practices as a hospitalist in both departments.

Dr. Bruti always rises to any challenge that comes his way with empathetic, organized, and insightful leadership. Dr. Bruti is known for his innovation in patient care and optimization practices in the hospital setting – from expanding and optimizing the nonteaching service and a high-functioning observation unit to geolocalization and reorganization of medical teams. While his reputation as a leader was well established before the pandemic hit, the way he rose to the many challenges over the past year has been truly remarkable. After he identified one of the first cases of COVID-19 in his hospital, Dr. Bruti’s leadership was evident. He ensured that his staff was wearing proper PPE, reorganized hospitalist staffing, coordinated onboarding of subspecialists, developed algorithms around testing, and created safety-driven patient transfer strategies.

He is a member of the Rush University Medical Center Medical Executive Committee and is the chair of its Medical Records Committee. He has been recognized by both Internal Medicine and Pediatrics clerkships multiple times for excellence in teaching.

Dr. Bruti became a member of SHM in 2014 and has been extremely active with the Chicago chapter. He has also served on the Quality Improvement and Pediatric Medicine Special Interest Groups.
 

Clinical Leadership for NPs & PAs

Krystle D. Apodaca, DNP, FHM

Dr. Krystle D. Apodaca is a nurse practitioner hospitalist at the University of New Mexico Hospital, where she is assistant professor of medicine within the university’s Clinician Education Track.

She was one of the first APPs welcomed into the UNM Hospital Medicine division and has been integral not only in the development of UNM’s APP program, but also its APP Hospital Medicine Fellowship, which she helped to cofound. She is a member of the UNM Hospital Medicine Executive Committee as well as its LGBTQ Collaborative.

She is known for her leadership within Project ECHO at UNM, a worldwide program focused on democratizing medical knowledge. She is the co–medical director of its National Nursing Home COVID-19 Safety and Medicaid Quality Improvement Hospitalization Avoidance efforts, both focused on improving nursing home practices. This program, in partnership with the Agency for Healthcare Research and Quality, UNM’s ECHO Institute, and the Institute for Healthcare Improvement, is now a national initiative dedicated to standardizing COVID-19 best practices at nursing homes across the country. To achieve its goals, more than 15,000 nursing homes have been certified and a community of more than 250 training centers has been built through Project ECHO.

Dr. Apodaca has been a member of SHM since 2015. She has been an active member of SHM’s NP/PA Special Interest Group since she joined and was appointed as the first APP president of SHM’s New Mexico chapter in April 2020. Under her leadership, the chapter achieved Gold and Platinum status as well as the Chapter of the Year Award. She is also a Fellow in Hospital Medicine.
 

Certificate of Leadership in Hospital Medicine

Mihir Patel, MD, MBA, MPH, CLHM, SFHM

The Certificate of Leadership in Hospital Medicine (CLHM) cultivates leadership skills in the context of specific hospital medicine challenges. This designation informs employers – or potential employers – with confidence that a candidate is equipped and ready to lead teams and grow an organization.

Dr. Mihir Patel serves as medical director of virtual medicine and a full-time hospitalist at Ballad Health in Johnson City, Tenn. He also works part time as a telehospitalist with Sound Physicians, covering multiple hospitals in California and Washington State. He has previously served in a number of administrative roles including medical director of hospitalist program, chief of staff, and director of medical informatics committee, in addition to working as hospitalist in both rural and urban hospitals. He is cofounder and president of the Blue Ridge Chapter of the Society of Hospital Medicine.

Dr. Mihir’s research and clinical interests focus on integration of telemedicine, electronic medical records, and principles of lean healthcare to reduce waste and cost of care while improving overall quality and safety.
 

Humanitarian Services

Eileen Barrett, MD, MPH, MACP, SFHM

Dr. Eileen Barrett is an internal medicine hospitalist at the University of New Mexico, where she also serves as associate professor of medicine and the director of Continuing Medical Education in the Office of Continuous Professional Learning.

In addition to current clinical and educational roles at UNM, Dr. Barrett has extensive leadership experience as the former director of Graduate Medical Education Wellness Initiatives, the current District 10 Chair of SHM, as chair of a multiorganizational Diversity Equity and Inclusion (DEI) Collaborative Task Force, and as a former regent of the American College of Physicians.

Her tremendous efforts in humanitarian services are reflected in her dedication to supporting communities in need. In 2015, Dr. Barrett traveled to Sierra Leone, where she served as an Ebola response clinician. There, she helped to develop safer care protocols, including initiating morning huddles, standardizing onboarding, and improving medication administration and documentation. These skills were developed while she worked for the Navajo Area Indian Health Service (including as an infection control consultant) for more than 9 years and in volunteering at the Myanmar-Thai border with refugees. Her work abroad helped support her training for directing UNM hospitalist COVID-19 Operations while also providing direct care.

Dr. Barrett has represented the specialty of hospital medicine both nationally and internationally. She has served on national committees and spoken from the perspective of an academic and community hospitalist leader on issues such as performance management, patient engagement, DEI, and professional fulfillment.

She has been a member of SHM since 2014 and has served as cochair of the three most recent Innovations Poster Competitions. Dr. Barrett is a former president of SHM’s New Mexico chapter where under her leadership the chapter received SHM’s Outstanding Chapter Award in 2018. She is a dedicated member of SHM’s Physicians in Training Committee and Chapter Support Committee. Dr. Barrett is an elected member of the Gold Humanism Honor Society, received a 2019 Exemplary Mentor Award from the American Medical Women’s Association, and is a Senior Fellow in Hospital Medicine.
 

Leadership for Practice Management

Leah Lleras, MS

Leah Lleras is the division administrator for the University of Colorado, Anschutz Medical Campus, and holds a Master of Science Management and Organization degree from the University of Colorado.

Her leadership as a practice manager is exemplified through her efforts in challenges of salary inequity. After joining the Division of Hospital Medicine in 2018, Ms. Lleras was successful in launching and achieving compensation equity and transparency across the department. She has demonstrated an incredible ability to collaborate with clinical leadership to marry the vision of clinical leaders with the administrative support required to turn a vision into a reality. During the COVID-19 pandemic, Ms. Lleras has been instrumental in ensuring that the division was prepared and supported to care for an influx of new patients. She did this by leading emergent onboarding of new practitioners, strategizing financial management of hazard pay for frontline clinicians, and creating a streamlined budget system during rapid change.

Ms. Lleras joined the Society in 2018 and has been an active member of the Rocky Mountain Chapter and the Hospital Medicine Administrator Special Interest Group.
 

Outstanding Service

Robert Zipper, MD, MMM, SFHM

Dr. Robert Zipper is a physician advisor and senior policy advisor for Sound Physicians, with more than 20 years of clinical experience as a hospital medicine leader.

He has a diverse background in quality and patient safety, hospitalist program design, and performance management. He began working as a hospitalist in 1999, in private practice. In 2006, he launched his career at Sound, where he began as a hospitalist but eventually managed Sound’s West Coast programs. In 2017, he was appointed Sound vice president of innovation technology. He later became Sound’s leader for healthcare policy, and now serves as a senior policy advisor for Sound, and physician advisor within the Advisory Services line.

Dr. Zipper has been a longtime supporter and advocate of SHM and the field of hospital medicine since joining in 2005. He attended his first Leadership Academy in 2006 and went on to serve as facilitator four times. His passion for SHM’s conferences is evident, as he has presented at three Annual Conferences alongside notable SHM leaders. He has been active in a variety of committees, including Quality and Safety, Leadership, and Performance Measurement and Reporting.

He is a member of the Society’s Public Policy Committee, and his insight has elevated hospital medicine both in the eyes of peer specialties and in discussions with the Centers for Medicare and Medicaid Services. Dr. Zipper has joined a number of calls with key Capitol Hill and CMS staff to help advocate for issues affecting hospital medicine. His ability to explain issues clearly and eloquently has helped stakeholders better understand the issues and move them forward on lawmakers’ agendas.
 

Research

S. Ryan Greysen, MD, MHS, SFHM

Dr. S. Ryan Greysen is chief of the Section of Hospital Medicine and associate professor at the University of Pennsylvania. He is the executive director for the Center for Evidence-based Practice (CEP) which serves all hospitals in the University of Pennsylvania Health System.

Dr. Greysen’s work comprises more than 80 peer-reviewed publications focused on improving outcomes of care for older adults during and after acute illness. Prior to arriving at Penn, he practiced at the University of California, San Francisco, where the impact of his work was extremely visible on the wards. He helped implement care pathways for an Acute Care for Elders (ACE) unit that uses evidence-based protocols and order sets to prevent functional decline and delirium of vulnerable seniors.

At Penn, he has continued to champion care for seniors and has supported other successful programs focused on vulnerable populations: SOAR (Supporting Older Adults at Risk), STEP (Supporting Transitions and Empowering Patients), and MED (Mental health Engagement navigation & Delivery).

During the COVID-19 pandemic, Dr. Greysen helped to accelerate the synthesis of emerging evidence through CEP and the Hospital Medicine Re-engineering Network (HOMERuN) to produce rapid evidence summaries in record speed. These reports have been broadly disseminated across other networks, such as AHRQ and the VA Evidence Synthesis Program.

Since joining the Society 10 years ago, Dr. Greysen has been an engaged member of SHM’s Greater Philadelphia Chapter and has held leadership roles on SHM’s Research Committee and the JHM Editorial Team as an associate editor. He has presented at multiple SHM annual conferences and is an ambassador of the specialty and of the importance of research in hospital medicine.

He is a Senior Fellow in Hospital Medicine.
 

Teaching

Grace C. Huang, MD

Dr. Grace C. Huang is an educator and hospitalist at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School who epitomizes commitment to education and lifelong learning.

Dr. Huang’s nationally recognized hospitalist expertise spans medical education and innovation, administrative management, and editorial leadership. She was among the early hospitalist pioneers who helped to transform how residents were trained to do procedures. Her early work led to the creation of one of the first procedure rotations for residents in the country – an RCT on central line simulation, the validation of a central line placement instrument, and a systematic review on procedural training for nonsurgeons.

Dr. Huang is vice chair for career development and mentoring in the department of medicine and oversees faculty development at the institutional level. She leads a Harvard Medical School–wide medical education fellowship for faculty and codirects the BIDMC Academy. On a broader scale, her efforts in the field have helped to catalyze the growth of computer-based simulation, define new standards for critical thinking education, and influence high-value care and invasive bedside procedure teaching approaches. Finally, she is editor-in-chief of MedEdPORTAL, an innovative journal of the Association of American Medical Colleges that publishes and disseminates educational resources.

Dr. Huang has been awarded the Gordon J. Strewler Mentoring of Resident Research Award in 2018, the Robert Stone Award for Excellence in Teaching Award, and most recently the A. Clifford Barger Excellence in Mentoring Award at Harvard Medical School, among many others. She is an editorial board member of Academic Medicine.

Dr. Huang joined SHM in 2010. Since then, she has been an engaged member of the Boston Chapter and has regularly participated in SHM’s annual conferences. She was also a member of SHM’s Practice Analysis Committee for 7 years.
 

Teamwork in Quality Improvement

Intermountain Healthcare

Intermountain Healthcare is a not-for-profit health system based in Salt Lake City serving the needs of patients primarily in Utah, Idaho, and Nevada. Intermountain recently reimagined its leadership structure with an integrated approach focused on developing and implementing common goals across its 23-hospital healthcare system, which was previously divided into regions. With key focus areas including communication, best practices, and goal setting, this structure has helped to combat former fragmentation struggles by creating an environment that provides a consistent high-level care experience regardless of the treatment center a patient selects.

Intermountain Healthcare

With this reorganization came improved structure allowing for a unique team-based approach while still promoting clear communication lines across the 23 hospitals. This innovative Med/Surg Operations Lane allowed for flexible adaptation to the rapidly changing landscape of the COVID-19 pandemic. Intermountain Healthcare utilized its new framework to ensure crisis-ready operations by defining best practices through real-time literature review and teaming with ED, ICU, and Nursing to create COVID-19 workflows, order sets, and dashboards. Capacity issues were addressed with a variety of strategies: (1) daily systemwide huddles to facilitate load leveling between hospitals; (2) the use of telehealth for early discharges; and (3) remote patient monitoring and admission to the “Intermountain at Home” program, which preserved the ability to deliver critical surgical services.

This new value model clearly sets Intermountain apart from its peers.
 

Diversity

Lilia Cervantes, MD

Dr. Lilia Cervantes is associate professor in the department of medicine at Denver Health Medical Center and the University of Colorado, where she demonstrates an unparalleled commitment to diversity through her patient care, community service efforts, research, and health policy activism.

Following her internal medicine residency at the University of Colorado in 2008, Dr. Cervantes went on to obtain her master of science degree in clinical science, and became associate professor of medicine and a hospitalist at Denver Health Medical Center. In addition to her patient-centric roles at Denver Health, Dr. Cervantes has held a variety of roles in the health equity space. These include founding Denver Health Medical Center’s Health Equity Learning Series and the Healthcare Interest Program, a pre–health pipeline program for undergraduate students interested in a healthcare career.

Dr. Cervantes attributes her passion for becoming a physician to her background as a bilingual Latina who grew up in poverty. She says that her upbringing allows her to use this unique lens to connect with her diverse patient population and to advocate for marginalized communities and eliminate structural inequities.

Her experience with Hilda, an undocumented immigrant with kidney failure, was the catalyst for further research on marginalized patients without access to healthcare, which earned her interviews with NPR and CNN’s Chief Health Correspondent Dr. Sanjay Gupta. Her research and advocacy led to Colorado Medicaid’s expanding access to scheduled dialysis for undocumented immigrants with kidney failure. Upon announcement of the change, Dr. Cervantes was recognized as the driving force whose research informed the decision.

During the COVID-19 pandemic, Dr. Cervantes has worked diligently to launch research projects and create grant-funded programs to reduce the disproportionate burden of COVID-19 cases and deaths in the Latinx community in Denver. One of her studies centers on the Latinx community – through qualitative interviews of Latinx who had survived a COVID-19 hospitalization, Dr. Cervantes learned about the challenges faced during the pandemic. These findings informed local and national interventions to reduce COVID-19 in the Latinx community.

She has received numerous accolades, including the inaugural Outstanding Service to the Community in 2019 by Denver Health, the Florence Rena Sabin Award from the University of Colorado, and awards from the community – Health Equity Champion Award from the Center for Health Progress and the Unsung Heroine Award from the Latina First Foundation. She serves on several boards including two community-based organizations – the Center for Health Progress and Vuela for Health.

Dr. Cervantes has been an active member of SHM since 2009 and served as keynote speaker for the annual “Summit of the Rockies” Rocky Mountain Chapter SHM conference, “The role of advocacy: Moving the needle towards health equity.”
 

Junior Investigator Award

Matthew Pappas, MD, MPH, FHM

Dr. Matthew Pappas is a staff physician at the Cleveland Clinic, where he serves as assistant professor at the Lerner College of Medicine and Research Investigator at the Center for Value-Based Care Research.

Dr. Pappas completed his residency at the University of Michigan Health System and a postdoctoral fellowship with the VA Ann Arbor Healthcare System in 2016. Currently a hospitalist, he believes in addressing the tension between evidence-based and personal decisions, a fundamental hypothesis of his research career. As a Fellow, he created a model to predict the benefit of bridging anticoagulation for patients with atrial fibrillation. He sees his research mission as addressing the importance of these balanced decisions.

In 2019, Dr. Pappas secured a K08 award from the National Heart, Lung, and Blood Institute, and has turned his attention to preoperative cardiac testing and perioperative outcomes. He has published two manuscripts from this project, with a robust pipeline of others in progress.

He was recognized for his research by the Society of General Internal Medicine in 2018 with the Hamolsky Award for best abstract and had one of his research articles included in the Top 10 Articles of 2019 by the Journal of Hospital Medicine. Dr. Pappas has ongoing research support from the National Heart, Lung and Blood Institute.

He has been a member of SHM since 2015 and currently serves on the Perioperative Special Interest Group and Research Committee.

Clinical Leadership for Physicians

Christopher P. Bruti, MD, MPH

Dr. Christopher P. Bruti is the division chief of hospital medicine at Rush University and the program director of Rush’s combined Internal Medicine–Pediatrics Residency Program. He is an associate professor of internal medicine and pediatrics and practices as a hospitalist in both departments.

Dr. Bruti always rises to any challenge that comes his way with empathetic, organized, and insightful leadership. Dr. Bruti is known for his innovation in patient care and optimization practices in the hospital setting – from expanding and optimizing the nonteaching service and a high-functioning observation unit to geolocalization and reorganization of medical teams. While his reputation as a leader was well established before the pandemic hit, the way he rose to the many challenges over the past year has been truly remarkable. After he identified one of the first cases of COVID-19 in his hospital, Dr. Bruti’s leadership was evident. He ensured that his staff was wearing proper PPE, reorganized hospitalist staffing, coordinated onboarding of subspecialists, developed algorithms around testing, and created safety-driven patient transfer strategies.

He is a member of the Rush University Medical Center Medical Executive Committee and is the chair of its Medical Records Committee. He has been recognized by both Internal Medicine and Pediatrics clerkships multiple times for excellence in teaching.

Dr. Bruti became a member of SHM in 2014 and has been extremely active with the Chicago chapter. He has also served on the Quality Improvement and Pediatric Medicine Special Interest Groups.
 

Clinical Leadership for NPs & PAs

Krystle D. Apodaca, DNP, FHM

Dr. Krystle D. Apodaca is a nurse practitioner hospitalist at the University of New Mexico Hospital, where she is assistant professor of medicine within the university’s Clinician Education Track.

She was one of the first APPs welcomed into the UNM Hospital Medicine division and has been integral not only in the development of UNM’s APP program, but also its APP Hospital Medicine Fellowship, which she helped to cofound. She is a member of the UNM Hospital Medicine Executive Committee as well as its LGBTQ Collaborative.

She is known for her leadership within Project ECHO at UNM, a worldwide program focused on democratizing medical knowledge. She is the co–medical director of its National Nursing Home COVID-19 Safety and Medicaid Quality Improvement Hospitalization Avoidance efforts, both focused on improving nursing home practices. This program, in partnership with the Agency for Healthcare Research and Quality, UNM’s ECHO Institute, and the Institute for Healthcare Improvement, is now a national initiative dedicated to standardizing COVID-19 best practices at nursing homes across the country. To achieve its goals, more than 15,000 nursing homes have been certified and a community of more than 250 training centers has been built through Project ECHO.

Dr. Apodaca has been a member of SHM since 2015. She has been an active member of SHM’s NP/PA Special Interest Group since she joined and was appointed as the first APP president of SHM’s New Mexico chapter in April 2020. Under her leadership, the chapter achieved Gold and Platinum status as well as the Chapter of the Year Award. She is also a Fellow in Hospital Medicine.
 

Certificate of Leadership in Hospital Medicine

Mihir Patel, MD, MBA, MPH, CLHM, SFHM

The Certificate of Leadership in Hospital Medicine (CLHM) cultivates leadership skills in the context of specific hospital medicine challenges. This designation informs employers – or potential employers – with confidence that a candidate is equipped and ready to lead teams and grow an organization.

Dr. Mihir Patel serves as medical director of virtual medicine and a full-time hospitalist at Ballad Health in Johnson City, Tenn. He also works part time as a telehospitalist with Sound Physicians, covering multiple hospitals in California and Washington State. He has previously served in a number of administrative roles including medical director of hospitalist program, chief of staff, and director of medical informatics committee, in addition to working as hospitalist in both rural and urban hospitals. He is cofounder and president of the Blue Ridge Chapter of the Society of Hospital Medicine.

Dr. Mihir’s research and clinical interests focus on integration of telemedicine, electronic medical records, and principles of lean healthcare to reduce waste and cost of care while improving overall quality and safety.
 

Humanitarian Services

Eileen Barrett, MD, MPH, MACP, SFHM

Dr. Eileen Barrett is an internal medicine hospitalist at the University of New Mexico, where she also serves as associate professor of medicine and the director of Continuing Medical Education in the Office of Continuous Professional Learning.

In addition to current clinical and educational roles at UNM, Dr. Barrett has extensive leadership experience as the former director of Graduate Medical Education Wellness Initiatives, the current District 10 Chair of SHM, as chair of a multiorganizational Diversity Equity and Inclusion (DEI) Collaborative Task Force, and as a former regent of the American College of Physicians.

Her tremendous efforts in humanitarian services are reflected in her dedication to supporting communities in need. In 2015, Dr. Barrett traveled to Sierra Leone, where she served as an Ebola response clinician. There, she helped to develop safer care protocols, including initiating morning huddles, standardizing onboarding, and improving medication administration and documentation. These skills were developed while she worked for the Navajo Area Indian Health Service (including as an infection control consultant) for more than 9 years and in volunteering at the Myanmar-Thai border with refugees. Her work abroad helped support her training for directing UNM hospitalist COVID-19 Operations while also providing direct care.

Dr. Barrett has represented the specialty of hospital medicine both nationally and internationally. She has served on national committees and spoken from the perspective of an academic and community hospitalist leader on issues such as performance management, patient engagement, DEI, and professional fulfillment.

She has been a member of SHM since 2014 and has served as cochair of the three most recent Innovations Poster Competitions. Dr. Barrett is a former president of SHM’s New Mexico chapter where under her leadership the chapter received SHM’s Outstanding Chapter Award in 2018. She is a dedicated member of SHM’s Physicians in Training Committee and Chapter Support Committee. Dr. Barrett is an elected member of the Gold Humanism Honor Society, received a 2019 Exemplary Mentor Award from the American Medical Women’s Association, and is a Senior Fellow in Hospital Medicine.
 

Leadership for Practice Management

Leah Lleras, MS

Leah Lleras is the division administrator for the University of Colorado, Anschutz Medical Campus, and holds a Master of Science Management and Organization degree from the University of Colorado.

Her leadership as a practice manager is exemplified through her efforts in challenges of salary inequity. After joining the Division of Hospital Medicine in 2018, Ms. Lleras was successful in launching and achieving compensation equity and transparency across the department. She has demonstrated an incredible ability to collaborate with clinical leadership to marry the vision of clinical leaders with the administrative support required to turn a vision into a reality. During the COVID-19 pandemic, Ms. Lleras has been instrumental in ensuring that the division was prepared and supported to care for an influx of new patients. She did this by leading emergent onboarding of new practitioners, strategizing financial management of hazard pay for frontline clinicians, and creating a streamlined budget system during rapid change.

Ms. Lleras joined the Society in 2018 and has been an active member of the Rocky Mountain Chapter and the Hospital Medicine Administrator Special Interest Group.
 

Outstanding Service

Robert Zipper, MD, MMM, SFHM

Dr. Robert Zipper is a physician advisor and senior policy advisor for Sound Physicians, with more than 20 years of clinical experience as a hospital medicine leader.

He has a diverse background in quality and patient safety, hospitalist program design, and performance management. He began working as a hospitalist in 1999, in private practice. In 2006, he launched his career at Sound, where he began as a hospitalist but eventually managed Sound’s West Coast programs. In 2017, he was appointed Sound vice president of innovation technology. He later became Sound’s leader for healthcare policy, and now serves as a senior policy advisor for Sound, and physician advisor within the Advisory Services line.

Dr. Zipper has been a longtime supporter and advocate of SHM and the field of hospital medicine since joining in 2005. He attended his first Leadership Academy in 2006 and went on to serve as facilitator four times. His passion for SHM’s conferences is evident, as he has presented at three Annual Conferences alongside notable SHM leaders. He has been active in a variety of committees, including Quality and Safety, Leadership, and Performance Measurement and Reporting.

He is a member of the Society’s Public Policy Committee, and his insight has elevated hospital medicine both in the eyes of peer specialties and in discussions with the Centers for Medicare and Medicaid Services. Dr. Zipper has joined a number of calls with key Capitol Hill and CMS staff to help advocate for issues affecting hospital medicine. His ability to explain issues clearly and eloquently has helped stakeholders better understand the issues and move them forward on lawmakers’ agendas.
 

Research

S. Ryan Greysen, MD, MHS, SFHM

Dr. S. Ryan Greysen is chief of the Section of Hospital Medicine and associate professor at the University of Pennsylvania. He is the executive director for the Center for Evidence-based Practice (CEP) which serves all hospitals in the University of Pennsylvania Health System.

Dr. Greysen’s work comprises more than 80 peer-reviewed publications focused on improving outcomes of care for older adults during and after acute illness. Prior to arriving at Penn, he practiced at the University of California, San Francisco, where the impact of his work was extremely visible on the wards. He helped implement care pathways for an Acute Care for Elders (ACE) unit that uses evidence-based protocols and order sets to prevent functional decline and delirium of vulnerable seniors.

At Penn, he has continued to champion care for seniors and has supported other successful programs focused on vulnerable populations: SOAR (Supporting Older Adults at Risk), STEP (Supporting Transitions and Empowering Patients), and MED (Mental health Engagement navigation & Delivery).

During the COVID-19 pandemic, Dr. Greysen helped to accelerate the synthesis of emerging evidence through CEP and the Hospital Medicine Re-engineering Network (HOMERuN) to produce rapid evidence summaries in record speed. These reports have been broadly disseminated across other networks, such as AHRQ and the VA Evidence Synthesis Program.

Since joining the Society 10 years ago, Dr. Greysen has been an engaged member of SHM’s Greater Philadelphia Chapter and has held leadership roles on SHM’s Research Committee and the JHM Editorial Team as an associate editor. He has presented at multiple SHM annual conferences and is an ambassador of the specialty and of the importance of research in hospital medicine.

He is a Senior Fellow in Hospital Medicine.
 

Teaching

Grace C. Huang, MD

Dr. Grace C. Huang is an educator and hospitalist at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School who epitomizes commitment to education and lifelong learning.

Dr. Huang’s nationally recognized hospitalist expertise spans medical education and innovation, administrative management, and editorial leadership. She was among the early hospitalist pioneers who helped to transform how residents were trained to do procedures. Her early work led to the creation of one of the first procedure rotations for residents in the country – an RCT on central line simulation, the validation of a central line placement instrument, and a systematic review on procedural training for nonsurgeons.

Dr. Huang is vice chair for career development and mentoring in the department of medicine and oversees faculty development at the institutional level. She leads a Harvard Medical School–wide medical education fellowship for faculty and codirects the BIDMC Academy. On a broader scale, her efforts in the field have helped to catalyze the growth of computer-based simulation, define new standards for critical thinking education, and influence high-value care and invasive bedside procedure teaching approaches. Finally, she is editor-in-chief of MedEdPORTAL, an innovative journal of the Association of American Medical Colleges that publishes and disseminates educational resources.

Dr. Huang has been awarded the Gordon J. Strewler Mentoring of Resident Research Award in 2018, the Robert Stone Award for Excellence in Teaching Award, and most recently the A. Clifford Barger Excellence in Mentoring Award at Harvard Medical School, among many others. She is an editorial board member of Academic Medicine.

Dr. Huang joined SHM in 2010. Since then, she has been an engaged member of the Boston Chapter and has regularly participated in SHM’s annual conferences. She was also a member of SHM’s Practice Analysis Committee for 7 years.
 

Teamwork in Quality Improvement

Intermountain Healthcare

Intermountain Healthcare is a not-for-profit health system based in Salt Lake City serving the needs of patients primarily in Utah, Idaho, and Nevada. Intermountain recently reimagined its leadership structure with an integrated approach focused on developing and implementing common goals across its 23-hospital healthcare system, which was previously divided into regions. With key focus areas including communication, best practices, and goal setting, this structure has helped to combat former fragmentation struggles by creating an environment that provides a consistent high-level care experience regardless of the treatment center a patient selects.

Intermountain Healthcare

With this reorganization came improved structure allowing for a unique team-based approach while still promoting clear communication lines across the 23 hospitals. This innovative Med/Surg Operations Lane allowed for flexible adaptation to the rapidly changing landscape of the COVID-19 pandemic. Intermountain Healthcare utilized its new framework to ensure crisis-ready operations by defining best practices through real-time literature review and teaming with ED, ICU, and Nursing to create COVID-19 workflows, order sets, and dashboards. Capacity issues were addressed with a variety of strategies: (1) daily systemwide huddles to facilitate load leveling between hospitals; (2) the use of telehealth for early discharges; and (3) remote patient monitoring and admission to the “Intermountain at Home” program, which preserved the ability to deliver critical surgical services.

This new value model clearly sets Intermountain apart from its peers.
 

Diversity

Lilia Cervantes, MD

Dr. Lilia Cervantes is associate professor in the department of medicine at Denver Health Medical Center and the University of Colorado, where she demonstrates an unparalleled commitment to diversity through her patient care, community service efforts, research, and health policy activism.

Following her internal medicine residency at the University of Colorado in 2008, Dr. Cervantes went on to obtain her master of science degree in clinical science, and became associate professor of medicine and a hospitalist at Denver Health Medical Center. In addition to her patient-centric roles at Denver Health, Dr. Cervantes has held a variety of roles in the health equity space. These include founding Denver Health Medical Center’s Health Equity Learning Series and the Healthcare Interest Program, a pre–health pipeline program for undergraduate students interested in a healthcare career.

Dr. Cervantes attributes her passion for becoming a physician to her background as a bilingual Latina who grew up in poverty. She says that her upbringing allows her to use this unique lens to connect with her diverse patient population and to advocate for marginalized communities and eliminate structural inequities.

Her experience with Hilda, an undocumented immigrant with kidney failure, was the catalyst for further research on marginalized patients without access to healthcare, which earned her interviews with NPR and CNN’s Chief Health Correspondent Dr. Sanjay Gupta. Her research and advocacy led to Colorado Medicaid’s expanding access to scheduled dialysis for undocumented immigrants with kidney failure. Upon announcement of the change, Dr. Cervantes was recognized as the driving force whose research informed the decision.

During the COVID-19 pandemic, Dr. Cervantes has worked diligently to launch research projects and create grant-funded programs to reduce the disproportionate burden of COVID-19 cases and deaths in the Latinx community in Denver. One of her studies centers on the Latinx community – through qualitative interviews of Latinx who had survived a COVID-19 hospitalization, Dr. Cervantes learned about the challenges faced during the pandemic. These findings informed local and national interventions to reduce COVID-19 in the Latinx community.

She has received numerous accolades, including the inaugural Outstanding Service to the Community in 2019 by Denver Health, the Florence Rena Sabin Award from the University of Colorado, and awards from the community – Health Equity Champion Award from the Center for Health Progress and the Unsung Heroine Award from the Latina First Foundation. She serves on several boards including two community-based organizations – the Center for Health Progress and Vuela for Health.

Dr. Cervantes has been an active member of SHM since 2009 and served as keynote speaker for the annual “Summit of the Rockies” Rocky Mountain Chapter SHM conference, “The role of advocacy: Moving the needle towards health equity.”
 

Junior Investigator Award

Matthew Pappas, MD, MPH, FHM

Dr. Matthew Pappas is a staff physician at the Cleveland Clinic, where he serves as assistant professor at the Lerner College of Medicine and Research Investigator at the Center for Value-Based Care Research.

Dr. Pappas completed his residency at the University of Michigan Health System and a postdoctoral fellowship with the VA Ann Arbor Healthcare System in 2016. Currently a hospitalist, he believes in addressing the tension between evidence-based and personal decisions, a fundamental hypothesis of his research career. As a Fellow, he created a model to predict the benefit of bridging anticoagulation for patients with atrial fibrillation. He sees his research mission as addressing the importance of these balanced decisions.

In 2019, Dr. Pappas secured a K08 award from the National Heart, Lung, and Blood Institute, and has turned his attention to preoperative cardiac testing and perioperative outcomes. He has published two manuscripts from this project, with a robust pipeline of others in progress.

He was recognized for his research by the Society of General Internal Medicine in 2018 with the Hamolsky Award for best abstract and had one of his research articles included in the Top 10 Articles of 2019 by the Journal of Hospital Medicine. Dr. Pappas has ongoing research support from the National Heart, Lung and Blood Institute.

He has been a member of SHM since 2015 and currently serves on the Perioperative Special Interest Group and Research Committee.

Clinical Leadership for Physicians

Christopher P. Bruti, MD, MPH

Dr. Christopher P. Bruti is the division chief of hospital medicine at Rush University and the program director of Rush’s combined Internal Medicine–Pediatrics Residency Program. He is an associate professor of internal medicine and pediatrics and practices as a hospitalist in both departments.

Dr. Bruti always rises to any challenge that comes his way with empathetic, organized, and insightful leadership. Dr. Bruti is known for his innovation in patient care and optimization practices in the hospital setting – from expanding and optimizing the nonteaching service and a high-functioning observation unit to geolocalization and reorganization of medical teams. While his reputation as a leader was well established before the pandemic hit, the way he rose to the many challenges over the past year has been truly remarkable. After he identified one of the first cases of COVID-19 in his hospital, Dr. Bruti’s leadership was evident. He ensured that his staff was wearing proper PPE, reorganized hospitalist staffing, coordinated onboarding of subspecialists, developed algorithms around testing, and created safety-driven patient transfer strategies.

He is a member of the Rush University Medical Center Medical Executive Committee and is the chair of its Medical Records Committee. He has been recognized by both Internal Medicine and Pediatrics clerkships multiple times for excellence in teaching.

Dr. Bruti became a member of SHM in 2014 and has been extremely active with the Chicago chapter. He has also served on the Quality Improvement and Pediatric Medicine Special Interest Groups.
 

Clinical Leadership for NPs & PAs

Krystle D. Apodaca, DNP, FHM

Dr. Krystle D. Apodaca is a nurse practitioner hospitalist at the University of New Mexico Hospital, where she is assistant professor of medicine within the university’s Clinician Education Track.

She was one of the first APPs welcomed into the UNM Hospital Medicine division and has been integral not only in the development of UNM’s APP program, but also its APP Hospital Medicine Fellowship, which she helped to cofound. She is a member of the UNM Hospital Medicine Executive Committee as well as its LGBTQ Collaborative.

She is known for her leadership within Project ECHO at UNM, a worldwide program focused on democratizing medical knowledge. She is the co–medical director of its National Nursing Home COVID-19 Safety and Medicaid Quality Improvement Hospitalization Avoidance efforts, both focused on improving nursing home practices. This program, in partnership with the Agency for Healthcare Research and Quality, UNM’s ECHO Institute, and the Institute for Healthcare Improvement, is now a national initiative dedicated to standardizing COVID-19 best practices at nursing homes across the country. To achieve its goals, more than 15,000 nursing homes have been certified and a community of more than 250 training centers has been built through Project ECHO.

Dr. Apodaca has been a member of SHM since 2015. She has been an active member of SHM’s NP/PA Special Interest Group since she joined and was appointed as the first APP president of SHM’s New Mexico chapter in April 2020. Under her leadership, the chapter achieved Gold and Platinum status as well as the Chapter of the Year Award. She is also a Fellow in Hospital Medicine.
 

Certificate of Leadership in Hospital Medicine

Mihir Patel, MD, MBA, MPH, CLHM, SFHM

The Certificate of Leadership in Hospital Medicine (CLHM) cultivates leadership skills in the context of specific hospital medicine challenges. This designation informs employers – or potential employers – with confidence that a candidate is equipped and ready to lead teams and grow an organization.

Dr. Mihir Patel serves as medical director of virtual medicine and a full-time hospitalist at Ballad Health in Johnson City, Tenn. He also works part time as a telehospitalist with Sound Physicians, covering multiple hospitals in California and Washington State. He has previously served in a number of administrative roles including medical director of hospitalist program, chief of staff, and director of medical informatics committee, in addition to working as hospitalist in both rural and urban hospitals. He is cofounder and president of the Blue Ridge Chapter of the Society of Hospital Medicine.

Dr. Mihir’s research and clinical interests focus on integration of telemedicine, electronic medical records, and principles of lean healthcare to reduce waste and cost of care while improving overall quality and safety.
 

Humanitarian Services

Eileen Barrett, MD, MPH, MACP, SFHM

Dr. Eileen Barrett is an internal medicine hospitalist at the University of New Mexico, where she also serves as associate professor of medicine and the director of Continuing Medical Education in the Office of Continuous Professional Learning.

In addition to current clinical and educational roles at UNM, Dr. Barrett has extensive leadership experience as the former director of Graduate Medical Education Wellness Initiatives, the current District 10 Chair of SHM, as chair of a multiorganizational Diversity Equity and Inclusion (DEI) Collaborative Task Force, and as a former regent of the American College of Physicians.

Her tremendous efforts in humanitarian services are reflected in her dedication to supporting communities in need. In 2015, Dr. Barrett traveled to Sierra Leone, where she served as an Ebola response clinician. There, she helped to develop safer care protocols, including initiating morning huddles, standardizing onboarding, and improving medication administration and documentation. These skills were developed while she worked for the Navajo Area Indian Health Service (including as an infection control consultant) for more than 9 years and in volunteering at the Myanmar-Thai border with refugees. Her work abroad helped support her training for directing UNM hospitalist COVID-19 Operations while also providing direct care.

Dr. Barrett has represented the specialty of hospital medicine both nationally and internationally. She has served on national committees and spoken from the perspective of an academic and community hospitalist leader on issues such as performance management, patient engagement, DEI, and professional fulfillment.

She has been a member of SHM since 2014 and has served as cochair of the three most recent Innovations Poster Competitions. Dr. Barrett is a former president of SHM’s New Mexico chapter where under her leadership the chapter received SHM’s Outstanding Chapter Award in 2018. She is a dedicated member of SHM’s Physicians in Training Committee and Chapter Support Committee. Dr. Barrett is an elected member of the Gold Humanism Honor Society, received a 2019 Exemplary Mentor Award from the American Medical Women’s Association, and is a Senior Fellow in Hospital Medicine.
 

Leadership for Practice Management

Leah Lleras, MS

Leah Lleras is the division administrator for the University of Colorado, Anschutz Medical Campus, and holds a Master of Science Management and Organization degree from the University of Colorado.

Her leadership as a practice manager is exemplified through her efforts in challenges of salary inequity. After joining the Division of Hospital Medicine in 2018, Ms. Lleras was successful in launching and achieving compensation equity and transparency across the department. She has demonstrated an incredible ability to collaborate with clinical leadership to marry the vision of clinical leaders with the administrative support required to turn a vision into a reality. During the COVID-19 pandemic, Ms. Lleras has been instrumental in ensuring that the division was prepared and supported to care for an influx of new patients. She did this by leading emergent onboarding of new practitioners, strategizing financial management of hazard pay for frontline clinicians, and creating a streamlined budget system during rapid change.

Ms. Lleras joined the Society in 2018 and has been an active member of the Rocky Mountain Chapter and the Hospital Medicine Administrator Special Interest Group.
 

Outstanding Service

Robert Zipper, MD, MMM, SFHM

Dr. Robert Zipper is a physician advisor and senior policy advisor for Sound Physicians, with more than 20 years of clinical experience as a hospital medicine leader.

He has a diverse background in quality and patient safety, hospitalist program design, and performance management. He began working as a hospitalist in 1999, in private practice. In 2006, he launched his career at Sound, where he began as a hospitalist but eventually managed Sound’s West Coast programs. In 2017, he was appointed Sound vice president of innovation technology. He later became Sound’s leader for healthcare policy, and now serves as a senior policy advisor for Sound, and physician advisor within the Advisory Services line.

Dr. Zipper has been a longtime supporter and advocate of SHM and the field of hospital medicine since joining in 2005. He attended his first Leadership Academy in 2006 and went on to serve as facilitator four times. His passion for SHM’s conferences is evident, as he has presented at three Annual Conferences alongside notable SHM leaders. He has been active in a variety of committees, including Quality and Safety, Leadership, and Performance Measurement and Reporting.

He is a member of the Society’s Public Policy Committee, and his insight has elevated hospital medicine both in the eyes of peer specialties and in discussions with the Centers for Medicare and Medicaid Services. Dr. Zipper has joined a number of calls with key Capitol Hill and CMS staff to help advocate for issues affecting hospital medicine. His ability to explain issues clearly and eloquently has helped stakeholders better understand the issues and move them forward on lawmakers’ agendas.
 

Research

S. Ryan Greysen, MD, MHS, SFHM

Dr. S. Ryan Greysen is chief of the Section of Hospital Medicine and associate professor at the University of Pennsylvania. He is the executive director for the Center for Evidence-based Practice (CEP) which serves all hospitals in the University of Pennsylvania Health System.

Dr. Greysen’s work comprises more than 80 peer-reviewed publications focused on improving outcomes of care for older adults during and after acute illness. Prior to arriving at Penn, he practiced at the University of California, San Francisco, where the impact of his work was extremely visible on the wards. He helped implement care pathways for an Acute Care for Elders (ACE) unit that uses evidence-based protocols and order sets to prevent functional decline and delirium of vulnerable seniors.

At Penn, he has continued to champion care for seniors and has supported other successful programs focused on vulnerable populations: SOAR (Supporting Older Adults at Risk), STEP (Supporting Transitions and Empowering Patients), and MED (Mental health Engagement navigation & Delivery).

During the COVID-19 pandemic, Dr. Greysen helped to accelerate the synthesis of emerging evidence through CEP and the Hospital Medicine Re-engineering Network (HOMERuN) to produce rapid evidence summaries in record speed. These reports have been broadly disseminated across other networks, such as AHRQ and the VA Evidence Synthesis Program.

Since joining the Society 10 years ago, Dr. Greysen has been an engaged member of SHM’s Greater Philadelphia Chapter and has held leadership roles on SHM’s Research Committee and the JHM Editorial Team as an associate editor. He has presented at multiple SHM annual conferences and is an ambassador of the specialty and of the importance of research in hospital medicine.

He is a Senior Fellow in Hospital Medicine.
 

Teaching

Grace C. Huang, MD

Dr. Grace C. Huang is an educator and hospitalist at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School who epitomizes commitment to education and lifelong learning.

Dr. Huang’s nationally recognized hospitalist expertise spans medical education and innovation, administrative management, and editorial leadership. She was among the early hospitalist pioneers who helped to transform how residents were trained to do procedures. Her early work led to the creation of one of the first procedure rotations for residents in the country – an RCT on central line simulation, the validation of a central line placement instrument, and a systematic review on procedural training for nonsurgeons.

Dr. Huang is vice chair for career development and mentoring in the department of medicine and oversees faculty development at the institutional level. She leads a Harvard Medical School–wide medical education fellowship for faculty and codirects the BIDMC Academy. On a broader scale, her efforts in the field have helped to catalyze the growth of computer-based simulation, define new standards for critical thinking education, and influence high-value care and invasive bedside procedure teaching approaches. Finally, she is editor-in-chief of MedEdPORTAL, an innovative journal of the Association of American Medical Colleges that publishes and disseminates educational resources.

Dr. Huang has been awarded the Gordon J. Strewler Mentoring of Resident Research Award in 2018, the Robert Stone Award for Excellence in Teaching Award, and most recently the A. Clifford Barger Excellence in Mentoring Award at Harvard Medical School, among many others. She is an editorial board member of Academic Medicine.

Dr. Huang joined SHM in 2010. Since then, she has been an engaged member of the Boston Chapter and has regularly participated in SHM’s annual conferences. She was also a member of SHM’s Practice Analysis Committee for 7 years.
 

Teamwork in Quality Improvement

Intermountain Healthcare

Intermountain Healthcare is a not-for-profit health system based in Salt Lake City serving the needs of patients primarily in Utah, Idaho, and Nevada. Intermountain recently reimagined its leadership structure with an integrated approach focused on developing and implementing common goals across its 23-hospital healthcare system, which was previously divided into regions. With key focus areas including communication, best practices, and goal setting, this structure has helped to combat former fragmentation struggles by creating an environment that provides a consistent high-level care experience regardless of the treatment center a patient selects.

Intermountain Healthcare

With this reorganization came improved structure allowing for a unique team-based approach while still promoting clear communication lines across the 23 hospitals. This innovative Med/Surg Operations Lane allowed for flexible adaptation to the rapidly changing landscape of the COVID-19 pandemic. Intermountain Healthcare utilized its new framework to ensure crisis-ready operations by defining best practices through real-time literature review and teaming with ED, ICU, and Nursing to create COVID-19 workflows, order sets, and dashboards. Capacity issues were addressed with a variety of strategies: (1) daily systemwide huddles to facilitate load leveling between hospitals; (2) the use of telehealth for early discharges; and (3) remote patient monitoring and admission to the “Intermountain at Home” program, which preserved the ability to deliver critical surgical services.

This new value model clearly sets Intermountain apart from its peers.
 

Diversity

Lilia Cervantes, MD

Dr. Lilia Cervantes is associate professor in the department of medicine at Denver Health Medical Center and the University of Colorado, where she demonstrates an unparalleled commitment to diversity through her patient care, community service efforts, research, and health policy activism.

Following her internal medicine residency at the University of Colorado in 2008, Dr. Cervantes went on to obtain her master of science degree in clinical science, and became associate professor of medicine and a hospitalist at Denver Health Medical Center. In addition to her patient-centric roles at Denver Health, Dr. Cervantes has held a variety of roles in the health equity space. These include founding Denver Health Medical Center’s Health Equity Learning Series and the Healthcare Interest Program, a pre–health pipeline program for undergraduate students interested in a healthcare career.

Dr. Cervantes attributes her passion for becoming a physician to her background as a bilingual Latina who grew up in poverty. She says that her upbringing allows her to use this unique lens to connect with her diverse patient population and to advocate for marginalized communities and eliminate structural inequities.

Her experience with Hilda, an undocumented immigrant with kidney failure, was the catalyst for further research on marginalized patients without access to healthcare, which earned her interviews with NPR and CNN’s Chief Health Correspondent Dr. Sanjay Gupta. Her research and advocacy led to Colorado Medicaid’s expanding access to scheduled dialysis for undocumented immigrants with kidney failure. Upon announcement of the change, Dr. Cervantes was recognized as the driving force whose research informed the decision.

During the COVID-19 pandemic, Dr. Cervantes has worked diligently to launch research projects and create grant-funded programs to reduce the disproportionate burden of COVID-19 cases and deaths in the Latinx community in Denver. One of her studies centers on the Latinx community – through qualitative interviews of Latinx who had survived a COVID-19 hospitalization, Dr. Cervantes learned about the challenges faced during the pandemic. These findings informed local and national interventions to reduce COVID-19 in the Latinx community.

She has received numerous accolades, including the inaugural Outstanding Service to the Community in 2019 by Denver Health, the Florence Rena Sabin Award from the University of Colorado, and awards from the community – Health Equity Champion Award from the Center for Health Progress and the Unsung Heroine Award from the Latina First Foundation. She serves on several boards including two community-based organizations – the Center for Health Progress and Vuela for Health.

Dr. Cervantes has been an active member of SHM since 2009 and served as keynote speaker for the annual “Summit of the Rockies” Rocky Mountain Chapter SHM conference, “The role of advocacy: Moving the needle towards health equity.”
 

Junior Investigator Award

Matthew Pappas, MD, MPH, FHM

Dr. Matthew Pappas is a staff physician at the Cleveland Clinic, where he serves as assistant professor at the Lerner College of Medicine and Research Investigator at the Center for Value-Based Care Research.

Dr. Pappas completed his residency at the University of Michigan Health System and a postdoctoral fellowship with the VA Ann Arbor Healthcare System in 2016. Currently a hospitalist, he believes in addressing the tension between evidence-based and personal decisions, a fundamental hypothesis of his research career. As a Fellow, he created a model to predict the benefit of bridging anticoagulation for patients with atrial fibrillation. He sees his research mission as addressing the importance of these balanced decisions.

In 2019, Dr. Pappas secured a K08 award from the National Heart, Lung, and Blood Institute, and has turned his attention to preoperative cardiac testing and perioperative outcomes. He has published two manuscripts from this project, with a robust pipeline of others in progress.

He was recognized for his research by the Society of General Internal Medicine in 2018 with the Hamolsky Award for best abstract and had one of his research articles included in the Top 10 Articles of 2019 by the Journal of Hospital Medicine. Dr. Pappas has ongoing research support from the National Heart, Lung and Blood Institute.

He has been a member of SHM since 2015 and currently serves on the Perioperative Special Interest Group and Research Committee.

More than 11 million individuals in the United States identify as LGBTQ+, and data show that this population has a shorter life expectancy and increased rates of suicide, violence, and cardiovascular disease, according to Keshav Khanijow, MD, of Northwestern University, Chicago, and Nicole Rosendale, MD, of the University of California, San Francisco.

More than half of these individuals report experiencing discrimination, and one in three transgendered individuals have reported prejudice when visiting a doctor or health clinic, they said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

“It is impossible to know how someone identifies by gender just by looking at them,” Dr. Rosendale emphasized.

However, attention to terminology, use of affirming language and documentation, and attention to clinical considerations can help LGBTQ+ patients feel comfortable in the health care setting.
 

Ask, don’t assume

Do ask patients how they identify themselves, Dr. Khanijow said. It is important to ask about sexual orientation as part of a social history. One big “Don’t” in terminology is to avoid the use of the term “homosexual,” he added. Although the description “homosexual” began as a scientific term, it has become associated with pathology, rather than identity, and is often used by hate groups. Also, do not assume sexual orientation based on a patient’s partner.

Always ask about sexual orientation before assuming it, and include that information in documentation. Dr. Khanijow used an example of a “one-liner” case of a 45-year-old male who self-identifies as “queer” and presents with a migraine. The most appropriate version would be “45yoM who identifies as queer with PMHx Migraines presents with Headache,” Dr. Khanijow said. However, as a clinician, consider why you are including sexual orientation in the one-liner. If there isn’t any real reason to include it (such as stress related to coming out, increased risk for other conditions) it may not be necessary in all visits.
 

Transgender considerations

Dr. Khanijow shared some specific considerations for the transgender/nonbinary population.

In terms of gender, “it is most respectful to identify the patient as they would like to be identified,” he said.

Ask how they identify their gender, including their preferred pronouns, and be sure to note this identification in their documents, he said. Be vigilant in addressing a transgender patient correctly. Mistakes happen, and when they do, correct yourself, apologize succinctly and move on.
 

Clinical challenges

Research on LGBTQ+ health is limited, and these individuals are often grouped into a single category despite diverse experiences, Dr. Rosendale said. Another limitation in LGBTQ+ research is that some studies assess based on identity (such as gay, lesbian, bisexual) while others assess behavior (studies of men who have sex with men).

Dr. Rosendale went on to highlight several important clinical concerns for the LGBTQ+ population. Compared with the general population, lesbian women are at higher risk for breast cancer, and gay men are at increased risk for prostate, colon, and testicular cancers. Potential heart disease risk factors of physical inactivity, obesity, and smoking are more prevalent among lesbian women, and tobacco and alcohol use are more prevalent among gay men, and men who have sex with men are at increased risk for STIs.

Clinicians also should be aware that “bisexual individuals face worse health outcomes than their lesbian, gay, and heterosexual counterparts,” Dr. Rosendale said.

LGBTQ+ patients often use hormone therapy, so clinicians should be aware of some potential adverse effects, Dr. Rosendale said. For example, trans women on gender-affirming estrogen therapy may have increased cardiovascular risks including incident MI, ischemic stroke, and cardiovascular mortality, compared with cisgender women.

In trans men, testosterone use has not been definitively linked to cardiovascular risk, although patients may show small changes in systolic blood pressure, lipid profiles, and blood glucose, Dr. Rosendale noted.
 

In-hospital issues

Inpatient and critical care of transgender and LGBTQ+ patients may have unique psychosocial considerations in hospital care, Dr. Rosendale said. To provide some guidance, a document on “Transgender-Affirming Hospital Policies” has been developed jointly by Lamda Legal, the Human Rights Campaign, the law firm of Hogan Lovells, and the New York City Bar.

Best practices noted in the document include rooming transgender individuals according to their identity, and recognizing that these patients may experience additional stress while an inpatient if personal clothing or other means of gender expression are replaced during the hospital stay, Dr. Rosendale noted.

Finally, clinicians seeing LGBTQ+ patients in an acute care setting should keep in mind that socioeconomic disparities may limit access to outpatient care, and that this population has higher rates of unemployment, exacerbated by the ongoing COVID-19 pandemic, Dr. Rosendale said. In addition, she advised clinicians to be aware that LGBTQ+ people may experience discrimination in rehabilitation centers, and their surrogate decision makers may be individuals other than family members.

Dr. Khanijow and Dr. Rosendale had no financial conflicts to disclose.

More than 11 million individuals in the United States identify as LGBTQ+, and data show that this population has a shorter life expectancy and increased rates of suicide, violence, and cardiovascular disease, according to Keshav Khanijow, MD, of Northwestern University, Chicago, and Nicole Rosendale, MD, of the University of California, San Francisco.

More than half of these individuals report experiencing discrimination, and one in three transgendered individuals have reported prejudice when visiting a doctor or health clinic, they said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

“It is impossible to know how someone identifies by gender just by looking at them,” Dr. Rosendale emphasized.

However, attention to terminology, use of affirming language and documentation, and attention to clinical considerations can help LGBTQ+ patients feel comfortable in the health care setting.
 

Ask, don’t assume

Do ask patients how they identify themselves, Dr. Khanijow said. It is important to ask about sexual orientation as part of a social history. One big “Don’t” in terminology is to avoid the use of the term “homosexual,” he added. Although the description “homosexual” began as a scientific term, it has become associated with pathology, rather than identity, and is often used by hate groups. Also, do not assume sexual orientation based on a patient’s partner.

Always ask about sexual orientation before assuming it, and include that information in documentation. Dr. Khanijow used an example of a “one-liner” case of a 45-year-old male who self-identifies as “queer” and presents with a migraine. The most appropriate version would be “45yoM who identifies as queer with PMHx Migraines presents with Headache,” Dr. Khanijow said. However, as a clinician, consider why you are including sexual orientation in the one-liner. If there isn’t any real reason to include it (such as stress related to coming out, increased risk for other conditions) it may not be necessary in all visits.
 

Transgender considerations

Dr. Khanijow shared some specific considerations for the transgender/nonbinary population.

In terms of gender, “it is most respectful to identify the patient as they would like to be identified,” he said.

Ask how they identify their gender, including their preferred pronouns, and be sure to note this identification in their documents, he said. Be vigilant in addressing a transgender patient correctly. Mistakes happen, and when they do, correct yourself, apologize succinctly and move on.
 

Clinical challenges

Research on LGBTQ+ health is limited, and these individuals are often grouped into a single category despite diverse experiences, Dr. Rosendale said. Another limitation in LGBTQ+ research is that some studies assess based on identity (such as gay, lesbian, bisexual) while others assess behavior (studies of men who have sex with men).

Dr. Rosendale went on to highlight several important clinical concerns for the LGBTQ+ population. Compared with the general population, lesbian women are at higher risk for breast cancer, and gay men are at increased risk for prostate, colon, and testicular cancers. Potential heart disease risk factors of physical inactivity, obesity, and smoking are more prevalent among lesbian women, and tobacco and alcohol use are more prevalent among gay men, and men who have sex with men are at increased risk for STIs.

Clinicians also should be aware that “bisexual individuals face worse health outcomes than their lesbian, gay, and heterosexual counterparts,” Dr. Rosendale said.

LGBTQ+ patients often use hormone therapy, so clinicians should be aware of some potential adverse effects, Dr. Rosendale said. For example, trans women on gender-affirming estrogen therapy may have increased cardiovascular risks including incident MI, ischemic stroke, and cardiovascular mortality, compared with cisgender women.

In trans men, testosterone use has not been definitively linked to cardiovascular risk, although patients may show small changes in systolic blood pressure, lipid profiles, and blood glucose, Dr. Rosendale noted.
 

In-hospital issues

Inpatient and critical care of transgender and LGBTQ+ patients may have unique psychosocial considerations in hospital care, Dr. Rosendale said. To provide some guidance, a document on “Transgender-Affirming Hospital Policies” has been developed jointly by Lamda Legal, the Human Rights Campaign, the law firm of Hogan Lovells, and the New York City Bar.

Best practices noted in the document include rooming transgender individuals according to their identity, and recognizing that these patients may experience additional stress while an inpatient if personal clothing or other means of gender expression are replaced during the hospital stay, Dr. Rosendale noted.

Finally, clinicians seeing LGBTQ+ patients in an acute care setting should keep in mind that socioeconomic disparities may limit access to outpatient care, and that this population has higher rates of unemployment, exacerbated by the ongoing COVID-19 pandemic, Dr. Rosendale said. In addition, she advised clinicians to be aware that LGBTQ+ people may experience discrimination in rehabilitation centers, and their surrogate decision makers may be individuals other than family members.

Dr. Khanijow and Dr. Rosendale had no financial conflicts to disclose.

More than 11 million individuals in the United States identify as LGBTQ+, and data show that this population has a shorter life expectancy and increased rates of suicide, violence, and cardiovascular disease, according to Keshav Khanijow, MD, of Northwestern University, Chicago, and Nicole Rosendale, MD, of the University of California, San Francisco.

More than half of these individuals report experiencing discrimination, and one in three transgendered individuals have reported prejudice when visiting a doctor or health clinic, they said in a presentation at SHM Converge, the annual conference of the Society of Hospital Medicine.

“It is impossible to know how someone identifies by gender just by looking at them,” Dr. Rosendale emphasized.

However, attention to terminology, use of affirming language and documentation, and attention to clinical considerations can help LGBTQ+ patients feel comfortable in the health care setting.
 

Ask, don’t assume

Do ask patients how they identify themselves, Dr. Khanijow said. It is important to ask about sexual orientation as part of a social history. One big “Don’t” in terminology is to avoid the use of the term “homosexual,” he added. Although the description “homosexual” began as a scientific term, it has become associated with pathology, rather than identity, and is often used by hate groups. Also, do not assume sexual orientation based on a patient’s partner.

Always ask about sexual orientation before assuming it, and include that information in documentation. Dr. Khanijow used an example of a “one-liner” case of a 45-year-old male who self-identifies as “queer” and presents with a migraine. The most appropriate version would be “45yoM who identifies as queer with PMHx Migraines presents with Headache,” Dr. Khanijow said. However, as a clinician, consider why you are including sexual orientation in the one-liner. If there isn’t any real reason to include it (such as stress related to coming out, increased risk for other conditions) it may not be necessary in all visits.
 

Transgender considerations

Dr. Khanijow shared some specific considerations for the transgender/nonbinary population.

In terms of gender, “it is most respectful to identify the patient as they would like to be identified,” he said.

Ask how they identify their gender, including their preferred pronouns, and be sure to note this identification in their documents, he said. Be vigilant in addressing a transgender patient correctly. Mistakes happen, and when they do, correct yourself, apologize succinctly and move on.
 

Clinical challenges

Research on LGBTQ+ health is limited, and these individuals are often grouped into a single category despite diverse experiences, Dr. Rosendale said. Another limitation in LGBTQ+ research is that some studies assess based on identity (such as gay, lesbian, bisexual) while others assess behavior (studies of men who have sex with men).

Dr. Rosendale went on to highlight several important clinical concerns for the LGBTQ+ population. Compared with the general population, lesbian women are at higher risk for breast cancer, and gay men are at increased risk for prostate, colon, and testicular cancers. Potential heart disease risk factors of physical inactivity, obesity, and smoking are more prevalent among lesbian women, and tobacco and alcohol use are more prevalent among gay men, and men who have sex with men are at increased risk for STIs.

Clinicians also should be aware that “bisexual individuals face worse health outcomes than their lesbian, gay, and heterosexual counterparts,” Dr. Rosendale said.

LGBTQ+ patients often use hormone therapy, so clinicians should be aware of some potential adverse effects, Dr. Rosendale said. For example, trans women on gender-affirming estrogen therapy may have increased cardiovascular risks including incident MI, ischemic stroke, and cardiovascular mortality, compared with cisgender women.

In trans men, testosterone use has not been definitively linked to cardiovascular risk, although patients may show small changes in systolic blood pressure, lipid profiles, and blood glucose, Dr. Rosendale noted.
 

In-hospital issues

Inpatient and critical care of transgender and LGBTQ+ patients may have unique psychosocial considerations in hospital care, Dr. Rosendale said. To provide some guidance, a document on “Transgender-Affirming Hospital Policies” has been developed jointly by Lamda Legal, the Human Rights Campaign, the law firm of Hogan Lovells, and the New York City Bar.

Best practices noted in the document include rooming transgender individuals according to their identity, and recognizing that these patients may experience additional stress while an inpatient if personal clothing or other means of gender expression are replaced during the hospital stay, Dr. Rosendale noted.

Finally, clinicians seeing LGBTQ+ patients in an acute care setting should keep in mind that socioeconomic disparities may limit access to outpatient care, and that this population has higher rates of unemployment, exacerbated by the ongoing COVID-19 pandemic, Dr. Rosendale said. In addition, she advised clinicians to be aware that LGBTQ+ people may experience discrimination in rehabilitation centers, and their surrogate decision makers may be individuals other than family members.

Dr. Khanijow and Dr. Rosendale had no financial conflicts to disclose.

The Moderna SARS-CoV-2 vaccine booster developed specifically with variant B.1.351 in mind shows efficacy against that strain and the P1 variant among people already vaccinated for COVID-19, according to first results released May 5.
 

Furthermore, data from the company’s ongoing phase 2 study show the variant-specific booster, known as mRNA-1273.351, achieved higher antibody titers against the B.1.351 variant than did a booster with the original Moderna vaccine.

“We are encouraged by these new data, which reinforce our confidence that our booster strategy should be protective against these newly detected variants. The strong and rapid boost in titers to levels above primary vaccination also clearly demonstrates the ability of mRNA-1273 to induce immune memory,” Stéphane Bancel, chief executive officer of Moderna, said in a statement.

The phase 2 study researchers also are evaluating a multivariant booster that is a 50/50 mix of mRNA-1273.351 and mRNA-1273, the initial vaccine given Food and Drug Administration emergency use authorization, in a single vial.

Unlike the two-dose regimen with the original vaccine, the boosters are administered as a single dose immunization.

The trial participants received a booster 6-8 months after primary vaccination. Titers to the wild-type SARS-CoV-2 virus remained high and detectable in 37 out of 40 participants. However, prior to the booster, titers against the two variants of concern, B.1.351 and P.1, were lower, with about half of participants showing undetectable levels.

In contrast, 2 weeks after a booster with the original vaccine or the B.1.351 strain-specific product, pseudovirus neutralizing titers were boosted in all participants and all variants tested.

“Following [the] boost, geometric mean titers against the wild-type, B.1.351, and P.1 variants increased to levels similar to or higher than the previously reported peak titers against the ancestral (D614G) strain following primary vaccination,” the company stated.

Both mRNA-1273.351 and mRNA-1273 booster doses were generally well tolerated, the company reported. Safety and tolerability were generally comparable to those reported after the second dose of the original vaccine. Most adverse events were mild to moderate, with injection site pain most common in both groups. Participants also reported fatigue, headache, myalgia, and arthralgia.

The company plans to release data shortly on the booster efficacy at additional time points beyond 2 weeks for mRNA-1273.351, a lower-dose booster with mRNA-1272/351, as well as data on the multivariant mRNA vaccine booster.

In addition to the company’s phase 2 study, the National Institute of Allergy and Infectious Diseases is conducting a separate phase 1 study of mRNA-1273.351.

A version of this article first appeared on Medscape.com.

The Moderna SARS-CoV-2 vaccine booster developed specifically with variant B.1.351 in mind shows efficacy against that strain and the P1 variant among people already vaccinated for COVID-19, according to first results released May 5.
 

Furthermore, data from the company’s ongoing phase 2 study show the variant-specific booster, known as mRNA-1273.351, achieved higher antibody titers against the B.1.351 variant than did a booster with the original Moderna vaccine.

“We are encouraged by these new data, which reinforce our confidence that our booster strategy should be protective against these newly detected variants. The strong and rapid boost in titers to levels above primary vaccination also clearly demonstrates the ability of mRNA-1273 to induce immune memory,” Stéphane Bancel, chief executive officer of Moderna, said in a statement.

The phase 2 study researchers also are evaluating a multivariant booster that is a 50/50 mix of mRNA-1273.351 and mRNA-1273, the initial vaccine given Food and Drug Administration emergency use authorization, in a single vial.

Unlike the two-dose regimen with the original vaccine, the boosters are administered as a single dose immunization.

The trial participants received a booster 6-8 months after primary vaccination. Titers to the wild-type SARS-CoV-2 virus remained high and detectable in 37 out of 40 participants. However, prior to the booster, titers against the two variants of concern, B.1.351 and P.1, were lower, with about half of participants showing undetectable levels.

In contrast, 2 weeks after a booster with the original vaccine or the B.1.351 strain-specific product, pseudovirus neutralizing titers were boosted in all participants and all variants tested.

“Following [the] boost, geometric mean titers against the wild-type, B.1.351, and P.1 variants increased to levels similar to or higher than the previously reported peak titers against the ancestral (D614G) strain following primary vaccination,” the company stated.

Both mRNA-1273.351 and mRNA-1273 booster doses were generally well tolerated, the company reported. Safety and tolerability were generally comparable to those reported after the second dose of the original vaccine. Most adverse events were mild to moderate, with injection site pain most common in both groups. Participants also reported fatigue, headache, myalgia, and arthralgia.

The company plans to release data shortly on the booster efficacy at additional time points beyond 2 weeks for mRNA-1273.351, a lower-dose booster with mRNA-1272/351, as well as data on the multivariant mRNA vaccine booster.

In addition to the company’s phase 2 study, the National Institute of Allergy and Infectious Diseases is conducting a separate phase 1 study of mRNA-1273.351.

A version of this article first appeared on Medscape.com.

The Moderna SARS-CoV-2 vaccine booster developed specifically with variant B.1.351 in mind shows efficacy against that strain and the P1 variant among people already vaccinated for COVID-19, according to first results released May 5.
 

Furthermore, data from the company’s ongoing phase 2 study show the variant-specific booster, known as mRNA-1273.351, achieved higher antibody titers against the B.1.351 variant than did a booster with the original Moderna vaccine.

“We are encouraged by these new data, which reinforce our confidence that our booster strategy should be protective against these newly detected variants. The strong and rapid boost in titers to levels above primary vaccination also clearly demonstrates the ability of mRNA-1273 to induce immune memory,” Stéphane Bancel, chief executive officer of Moderna, said in a statement.

The phase 2 study researchers also are evaluating a multivariant booster that is a 50/50 mix of mRNA-1273.351 and mRNA-1273, the initial vaccine given Food and Drug Administration emergency use authorization, in a single vial.

Unlike the two-dose regimen with the original vaccine, the boosters are administered as a single dose immunization.

The trial participants received a booster 6-8 months after primary vaccination. Titers to the wild-type SARS-CoV-2 virus remained high and detectable in 37 out of 40 participants. However, prior to the booster, titers against the two variants of concern, B.1.351 and P.1, were lower, with about half of participants showing undetectable levels.

In contrast, 2 weeks after a booster with the original vaccine or the B.1.351 strain-specific product, pseudovirus neutralizing titers were boosted in all participants and all variants tested.

“Following [the] boost, geometric mean titers against the wild-type, B.1.351, and P.1 variants increased to levels similar to or higher than the previously reported peak titers against the ancestral (D614G) strain following primary vaccination,” the company stated.

Both mRNA-1273.351 and mRNA-1273 booster doses were generally well tolerated, the company reported. Safety and tolerability were generally comparable to those reported after the second dose of the original vaccine. Most adverse events were mild to moderate, with injection site pain most common in both groups. Participants also reported fatigue, headache, myalgia, and arthralgia.

The company plans to release data shortly on the booster efficacy at additional time points beyond 2 weeks for mRNA-1273.351, a lower-dose booster with mRNA-1272/351, as well as data on the multivariant mRNA vaccine booster.

In addition to the company’s phase 2 study, the National Institute of Allergy and Infectious Diseases is conducting a separate phase 1 study of mRNA-1273.351.

A version of this article first appeared on Medscape.com.

Nearly one out of five American adults with hypertension is on a prescription drug known to raise blood pressure, based on analysis of more than 27,000 people included in recent reports from the recurring National Health and Nutrition Examination Survey (NHANES).

Nearly half of these American adults had hypertension, and in this subgroup, 18.5% reported using a prescription drug known to increase blood pressure. The most widely used class of agents with this effect was antidepressants, used by 8.7%; followed by nonsteroidal anti-inflammatory drugs (NSAIDs), used by 6.5%; steroids, 1.9%; estrogens, 1.7%; and several other agents each used by fewer than 1% of the study cohort, John Vitarello, MD, said during a press briefing on reports from the upcoming annual scientific sessions of the American College of Cardiology.

He and his associates estimated that this use of prescription drugs known to raise blood pressure could be what stands in the way of some 560,000-2.2 million Americans from having their hypertension under control, depending on the exact blood pressure impact that various pressure-increasing drugs have and presuming that half of those on blood pressure increasing agents could stop them and switch to alternative agents, said Dr. Vitarello, a researcher at Beth Israel Deaconess Medical Center in Boston.

He also highlighted that the study assessed only prescription drugs and did not examine OTC drug use, which may be especially relevant for the many people who regularly take NSAIDs.

“Clinicians should review the prescription and OTC drug use of patients with hypertension and consider stopping drugs that increase blood pressure or switching the patient to alternatives” that are blood pressure neutral, Dr. Vitarello said during the briefing. He cautioned that maintaining hypertensive patients on agents that raise their blood pressure can result in “prescribing cascades” where taking drugs that boost blood pressure results in need for intensified antihypertensive treatment.
 

An opportunity for NSAID alternatives

“This study hopefully raises awareness that there is a very high use of medications that increase blood pressure, and use of OTC agents could increase the rate even higher” said Eugene Yang, MD, a cardiologist and codirector of the Cardiovascular Wellness and Prevention Program of the University of Washington, Seattle. Substituting for certain antidepressant agents may often not be realistic, but an opportunity exists for reducing NSAID use, a class also linked with an increased risk for bleeding and other adverse effects, Dr. Yang said during the briefing. Minimizing use of NSAIDs including ibuprofen and naproxen use “is something to think about,” he suggested.

“The effect of NSAIDs on blood pressure is not well studied and can vary from person to person” noted Dr. Vitarello, who added that higher NSAID dosages and more prolonged use likely increase the risk for an adverse effect on blood pressure. One reasonable option is to encourage patients to use an alternative class of pain reliever such as acetaminophen.

It remains “a challenge” to discern differences in adverse blood pressure effects, and in all adverse cardiovascular effects among different NSAIDs, said Dr. Yang. Results from “some studies show that certain NSAIDs may be safer, but other studies did not. We need to be very careful using NSAIDs because, on average, they increase blood pressure by about 3 mm Hg. We need to be mindful to try to prescribe alternative agents, like acetaminophen.”
 

A decade of data from NHANES

The analysis run by Dr. Vitarello and associates used data from 27,599 American adults included in the NHANES during 2009-2018, and focused on the 44% who either had an average blood pressure measurement of at least 130/80 mm Hg or reported having ever been told by a clinician that they had hypertension. The NHANES assessments included the prescription medications taken by each participant. The prevalence of using at least one prescription drug known to raise blood pressure was 24% among women and 14% among men, and 4% of those with hypertension were on two or more pressure-increasing agents.

The researchers based their identification of pressure-increasing prescription drugs on the list included in the 2017 guideline for managing high blood pressure from the American College of Cardiology and American Heart Association. This list specifies that the antidepressants that raise blood pressure are the monoamine oxidase inhibitors, serotonin norepinephrine reuptake inhibitors, and tricyclic antidepressants.

Dr. Vitarello and Dr. Yang had no disclosures.

[email protected]

Nearly one out of five American adults with hypertension is on a prescription drug known to raise blood pressure, based on analysis of more than 27,000 people included in recent reports from the recurring National Health and Nutrition Examination Survey (NHANES).

Nearly half of these American adults had hypertension, and in this subgroup, 18.5% reported using a prescription drug known to increase blood pressure. The most widely used class of agents with this effect was antidepressants, used by 8.7%; followed by nonsteroidal anti-inflammatory drugs (NSAIDs), used by 6.5%; steroids, 1.9%; estrogens, 1.7%; and several other agents each used by fewer than 1% of the study cohort, John Vitarello, MD, said during a press briefing on reports from the upcoming annual scientific sessions of the American College of Cardiology.

He and his associates estimated that this use of prescription drugs known to raise blood pressure could be what stands in the way of some 560,000-2.2 million Americans from having their hypertension under control, depending on the exact blood pressure impact that various pressure-increasing drugs have and presuming that half of those on blood pressure increasing agents could stop them and switch to alternative agents, said Dr. Vitarello, a researcher at Beth Israel Deaconess Medical Center in Boston.

He also highlighted that the study assessed only prescription drugs and did not examine OTC drug use, which may be especially relevant for the many people who regularly take NSAIDs.

“Clinicians should review the prescription and OTC drug use of patients with hypertension and consider stopping drugs that increase blood pressure or switching the patient to alternatives” that are blood pressure neutral, Dr. Vitarello said during the briefing. He cautioned that maintaining hypertensive patients on agents that raise their blood pressure can result in “prescribing cascades” where taking drugs that boost blood pressure results in need for intensified antihypertensive treatment.
 

An opportunity for NSAID alternatives

“This study hopefully raises awareness that there is a very high use of medications that increase blood pressure, and use of OTC agents could increase the rate even higher” said Eugene Yang, MD, a cardiologist and codirector of the Cardiovascular Wellness and Prevention Program of the University of Washington, Seattle. Substituting for certain antidepressant agents may often not be realistic, but an opportunity exists for reducing NSAID use, a class also linked with an increased risk for bleeding and other adverse effects, Dr. Yang said during the briefing. Minimizing use of NSAIDs including ibuprofen and naproxen use “is something to think about,” he suggested.

“The effect of NSAIDs on blood pressure is not well studied and can vary from person to person” noted Dr. Vitarello, who added that higher NSAID dosages and more prolonged use likely increase the risk for an adverse effect on blood pressure. One reasonable option is to encourage patients to use an alternative class of pain reliever such as acetaminophen.

It remains “a challenge” to discern differences in adverse blood pressure effects, and in all adverse cardiovascular effects among different NSAIDs, said Dr. Yang. Results from “some studies show that certain NSAIDs may be safer, but other studies did not. We need to be very careful using NSAIDs because, on average, they increase blood pressure by about 3 mm Hg. We need to be mindful to try to prescribe alternative agents, like acetaminophen.”
 

A decade of data from NHANES

The analysis run by Dr. Vitarello and associates used data from 27,599 American adults included in the NHANES during 2009-2018, and focused on the 44% who either had an average blood pressure measurement of at least 130/80 mm Hg or reported having ever been told by a clinician that they had hypertension. The NHANES assessments included the prescription medications taken by each participant. The prevalence of using at least one prescription drug known to raise blood pressure was 24% among women and 14% among men, and 4% of those with hypertension were on two or more pressure-increasing agents.

The researchers based their identification of pressure-increasing prescription drugs on the list included in the 2017 guideline for managing high blood pressure from the American College of Cardiology and American Heart Association. This list specifies that the antidepressants that raise blood pressure are the monoamine oxidase inhibitors, serotonin norepinephrine reuptake inhibitors, and tricyclic antidepressants.

Dr. Vitarello and Dr. Yang had no disclosures.

[email protected]

Nearly one out of five American adults with hypertension is on a prescription drug known to raise blood pressure, based on analysis of more than 27,000 people included in recent reports from the recurring National Health and Nutrition Examination Survey (NHANES).

Nearly half of these American adults had hypertension, and in this subgroup, 18.5% reported using a prescription drug known to increase blood pressure. The most widely used class of agents with this effect was antidepressants, used by 8.7%; followed by nonsteroidal anti-inflammatory drugs (NSAIDs), used by 6.5%; steroids, 1.9%; estrogens, 1.7%; and several other agents each used by fewer than 1% of the study cohort, John Vitarello, MD, said during a press briefing on reports from the upcoming annual scientific sessions of the American College of Cardiology.

He and his associates estimated that this use of prescription drugs known to raise blood pressure could be what stands in the way of some 560,000-2.2 million Americans from having their hypertension under control, depending on the exact blood pressure impact that various pressure-increasing drugs have and presuming that half of those on blood pressure increasing agents could stop them and switch to alternative agents, said Dr. Vitarello, a researcher at Beth Israel Deaconess Medical Center in Boston.

He also highlighted that the study assessed only prescription drugs and did not examine OTC drug use, which may be especially relevant for the many people who regularly take NSAIDs.

“Clinicians should review the prescription and OTC drug use of patients with hypertension and consider stopping drugs that increase blood pressure or switching the patient to alternatives” that are blood pressure neutral, Dr. Vitarello said during the briefing. He cautioned that maintaining hypertensive patients on agents that raise their blood pressure can result in “prescribing cascades” where taking drugs that boost blood pressure results in need for intensified antihypertensive treatment.
 

An opportunity for NSAID alternatives

“This study hopefully raises awareness that there is a very high use of medications that increase blood pressure, and use of OTC agents could increase the rate even higher” said Eugene Yang, MD, a cardiologist and codirector of the Cardiovascular Wellness and Prevention Program of the University of Washington, Seattle. Substituting for certain antidepressant agents may often not be realistic, but an opportunity exists for reducing NSAID use, a class also linked with an increased risk for bleeding and other adverse effects, Dr. Yang said during the briefing. Minimizing use of NSAIDs including ibuprofen and naproxen use “is something to think about,” he suggested.

“The effect of NSAIDs on blood pressure is not well studied and can vary from person to person” noted Dr. Vitarello, who added that higher NSAID dosages and more prolonged use likely increase the risk for an adverse effect on blood pressure. One reasonable option is to encourage patients to use an alternative class of pain reliever such as acetaminophen.

It remains “a challenge” to discern differences in adverse blood pressure effects, and in all adverse cardiovascular effects among different NSAIDs, said Dr. Yang. Results from “some studies show that certain NSAIDs may be safer, but other studies did not. We need to be very careful using NSAIDs because, on average, they increase blood pressure by about 3 mm Hg. We need to be mindful to try to prescribe alternative agents, like acetaminophen.”
 

A decade of data from NHANES

The analysis run by Dr. Vitarello and associates used data from 27,599 American adults included in the NHANES during 2009-2018, and focused on the 44% who either had an average blood pressure measurement of at least 130/80 mm Hg or reported having ever been told by a clinician that they had hypertension. The NHANES assessments included the prescription medications taken by each participant. The prevalence of using at least one prescription drug known to raise blood pressure was 24% among women and 14% among men, and 4% of those with hypertension were on two or more pressure-increasing agents.

The researchers based their identification of pressure-increasing prescription drugs on the list included in the 2017 guideline for managing high blood pressure from the American College of Cardiology and American Heart Association. This list specifies that the antidepressants that raise blood pressure are the monoamine oxidase inhibitors, serotonin norepinephrine reuptake inhibitors, and tricyclic antidepressants.

Dr. Vitarello and Dr. Yang had no disclosures.

[email protected]

For persons with obesity who lost a substantial amount of weight on a low-calorie diet, the combination of exercise and medication significantly improved weight-loss maintenance, and more so than either strategy alone, according to results of a randomized, head-to-head trial.

A year after starting moderate to vigorous exercise coupled with liraglutide treatment, study participants had a weight loss 9.5 kg more than those who received placebo and usual activity, study results show.

Reductions in both weight and fat loss seen with exercise and liraglutide was roughly twice as much as what was achieved at 1 year with the strategies of liraglutide or exercise alone, according to authors of the study, which appears in the New England Journal of Medicine .

Although the findings may not apply to those who can’t or won’t perform moderate to vigorous exercise, the intervention in this study was nevertheless feasible in this group of persons with obesity who had a very low level of fitness, according to the authors.
 

Hope for healthy weight loss maintenance

Investigator Signe S. Torekov, PhD, said in an interview that these results provide hope that more-intensive exercise regimens, with or without medication, can be useful and well accepted among individuals struggling with obesity.

“When we started our study, we were told, ‘you are never going to have people with obesity exercising that much, and for that long’ – but people were actually very happy about the exercise,” said Dr. Torekov, a professor in the department of biomedical sciences at the University of Copenhagen.

“If you actually set up a program where people are monitored and you have a feedback system, then exercise is an excellent component in obesity treatment that should be much more actively used – not only for its weight-lowering component, but also for improving health and quality of life,” she said in an interview.

Weight-management specialist John D. Clark, MD, PhD, said results of this study can be used to help inform patients about how successful different strategies incorporating exercise and medication may be following initial weight loss.

“When patients plateau on a consistent, calorie-restricted dietary plan, we can educate them and manage expectations about what options may be available to them after their initial weight loss,” said Dr. Clark, of the University of Texas, Dallas.

“If the patient’s goal specifically is weight loss at all costs, then I may suggest, ‘let’s consider liraglutide or liraglutide in combination with exercise,’ ” he said in an interview. “Exercise improves body composition, even if it may not on its own be as successful in the next phase of their weight-loss journey, as shown in this study.”
 

Obesity and weight-loss challenges

Although it’s not uncommon for obese patients to lose a large amount of weight, keeping the weight off is frequently a challenge unless the patient follows a structured weight maintenance program, according to Dr. Torekov and coauthors.

The rapid weight regain seen in many obese patients could be a result of reductions in total energy expenditure or increased appetite. Exercise is one strategy to sustain weight loss, though according to the authors, very few studies have looked at exercise in isolation to quantify its contribution to maintenance.

Accordingly, the present study sought to determine whether exercise, medication, or the combination thereof works best to keep weight off.

The study incorporated liraglutide, a GLP-1 receptor agonist indicated for chronic weight management, along with a reduced-calorie diet and increased physical activity, in adults with elevated body mass index and at least one weight-related comorbidity.

The investigator-initiated phase 3 trial included 215 adults with a body mass index of 32-43. Individuals with type 2 diabetes were excluded. All participants followed an 8-week, low-calorie diet comprising 800 calories per day.

Participants who lost 5% or more of their body weight were then randomized to 1 year of exercise plus liraglutide, exercise plus placebo, usual activity plus liraglutide, or usual activity plus placebo.

The exercise program – which was structured but flexible, according to investigators – included group exercise sessions that incorporated 30 minutes of indoor cycling and 15 minutes of circuit training 2 days each week. Participants wore heart rate monitors during exercise to make sure they reached targets for moderate to vigorous intensity.

Instructors trained in exercise physiology planned and monitored individualized exercise programs for each participant in the exercise-medication or exercise-only arms of the study.

Participants in all groups attended 12 one-on-one consultations where body weight was measured and dietetic support was provided.
 

Weight loss with exercise and medication

Out of 215 individuals enrolled in the study, 195 lost at least 5% of body weight and continued on to the randomized portion, the investigators reported. During the diet phase, they lost a mean of 13.1 kg, translating into a 12% mean reduction in body weight.

The mean frequency of exercise was 2.4 times per week in the exercise-plus-medication group and 2.5 times per week in the exercise-only group. About one-third of the exercise took place in the group sessions, and there was no difference in relative intensity between group and individual exercise regimens, the investigators said.

Individuals in the exercise plus medication group continued to lose more weight, such that, at the end of 1 year, the weight loss decreased even further, by a mean of –3.4 kg. By contrast, weight increased by a mean of 6.1 kg for the placebo group, adding up to a treatment difference of –9.5 kg (95% confidence interval, –13.1 to –5.9; P < .001), according to the report.

That treatment effect was also seen, but more muted, in the exercise- and liraglutide-only groups, at –4.1 kg and –6.8 kg, respectively.

A significant treatment effect was observed for exercise plus liraglutide, compared with exercise alone, at –5.4 kg (P = .004), while the treatment effect for the combination versus liraglutide alone was not significant at –2.7 kg (P = .13), the data show.

Body-fat reduction at 52 weeks was –3.9 percentage points for exercise plus liraglutide as compared with placebo, or roughly twice the reductions seen in the exercise- and liraglutide-alone groups, the investigators said, adding that the combination preserved lean mass.

Reductions in hemoglobin A1c, which are generally thought to reduce diabetes risk, were reduced in both the liraglutide and liraglutide-exercise combination group, according to their report.

The research was supported in part by grants from the Novo Nordisk Foundation.

For persons with obesity who lost a substantial amount of weight on a low-calorie diet, the combination of exercise and medication significantly improved weight-loss maintenance, and more so than either strategy alone, according to results of a randomized, head-to-head trial.

A year after starting moderate to vigorous exercise coupled with liraglutide treatment, study participants had a weight loss 9.5 kg more than those who received placebo and usual activity, study results show.

Reductions in both weight and fat loss seen with exercise and liraglutide was roughly twice as much as what was achieved at 1 year with the strategies of liraglutide or exercise alone, according to authors of the study, which appears in the New England Journal of Medicine .

Although the findings may not apply to those who can’t or won’t perform moderate to vigorous exercise, the intervention in this study was nevertheless feasible in this group of persons with obesity who had a very low level of fitness, according to the authors.
 

Hope for healthy weight loss maintenance

Investigator Signe S. Torekov, PhD, said in an interview that these results provide hope that more-intensive exercise regimens, with or without medication, can be useful and well accepted among individuals struggling with obesity.

“When we started our study, we were told, ‘you are never going to have people with obesity exercising that much, and for that long’ – but people were actually very happy about the exercise,” said Dr. Torekov, a professor in the department of biomedical sciences at the University of Copenhagen.

“If you actually set up a program where people are monitored and you have a feedback system, then exercise is an excellent component in obesity treatment that should be much more actively used – not only for its weight-lowering component, but also for improving health and quality of life,” she said in an interview.

Weight-management specialist John D. Clark, MD, PhD, said results of this study can be used to help inform patients about how successful different strategies incorporating exercise and medication may be following initial weight loss.

“When patients plateau on a consistent, calorie-restricted dietary plan, we can educate them and manage expectations about what options may be available to them after their initial weight loss,” said Dr. Clark, of the University of Texas, Dallas.

“If the patient’s goal specifically is weight loss at all costs, then I may suggest, ‘let’s consider liraglutide or liraglutide in combination with exercise,’ ” he said in an interview. “Exercise improves body composition, even if it may not on its own be as successful in the next phase of their weight-loss journey, as shown in this study.”
 

Obesity and weight-loss challenges

Although it’s not uncommon for obese patients to lose a large amount of weight, keeping the weight off is frequently a challenge unless the patient follows a structured weight maintenance program, according to Dr. Torekov and coauthors.

The rapid weight regain seen in many obese patients could be a result of reductions in total energy expenditure or increased appetite. Exercise is one strategy to sustain weight loss, though according to the authors, very few studies have looked at exercise in isolation to quantify its contribution to maintenance.

Accordingly, the present study sought to determine whether exercise, medication, or the combination thereof works best to keep weight off.

The study incorporated liraglutide, a GLP-1 receptor agonist indicated for chronic weight management, along with a reduced-calorie diet and increased physical activity, in adults with elevated body mass index and at least one weight-related comorbidity.

The investigator-initiated phase 3 trial included 215 adults with a body mass index of 32-43. Individuals with type 2 diabetes were excluded. All participants followed an 8-week, low-calorie diet comprising 800 calories per day.

Participants who lost 5% or more of their body weight were then randomized to 1 year of exercise plus liraglutide, exercise plus placebo, usual activity plus liraglutide, or usual activity plus placebo.

The exercise program – which was structured but flexible, according to investigators – included group exercise sessions that incorporated 30 minutes of indoor cycling and 15 minutes of circuit training 2 days each week. Participants wore heart rate monitors during exercise to make sure they reached targets for moderate to vigorous intensity.

Instructors trained in exercise physiology planned and monitored individualized exercise programs for each participant in the exercise-medication or exercise-only arms of the study.

Participants in all groups attended 12 one-on-one consultations where body weight was measured and dietetic support was provided.
 

Weight loss with exercise and medication

Out of 215 individuals enrolled in the study, 195 lost at least 5% of body weight and continued on to the randomized portion, the investigators reported. During the diet phase, they lost a mean of 13.1 kg, translating into a 12% mean reduction in body weight.

The mean frequency of exercise was 2.4 times per week in the exercise-plus-medication group and 2.5 times per week in the exercise-only group. About one-third of the exercise took place in the group sessions, and there was no difference in relative intensity between group and individual exercise regimens, the investigators said.

Individuals in the exercise plus medication group continued to lose more weight, such that, at the end of 1 year, the weight loss decreased even further, by a mean of –3.4 kg. By contrast, weight increased by a mean of 6.1 kg for the placebo group, adding up to a treatment difference of –9.5 kg (95% confidence interval, –13.1 to –5.9; P < .001), according to the report.

That treatment effect was also seen, but more muted, in the exercise- and liraglutide-only groups, at –4.1 kg and –6.8 kg, respectively.

A significant treatment effect was observed for exercise plus liraglutide, compared with exercise alone, at –5.4 kg (P = .004), while the treatment effect for the combination versus liraglutide alone was not significant at –2.7 kg (P = .13), the data show.

Body-fat reduction at 52 weeks was –3.9 percentage points for exercise plus liraglutide as compared with placebo, or roughly twice the reductions seen in the exercise- and liraglutide-alone groups, the investigators said, adding that the combination preserved lean mass.

Reductions in hemoglobin A1c, which are generally thought to reduce diabetes risk, were reduced in both the liraglutide and liraglutide-exercise combination group, according to their report.

The research was supported in part by grants from the Novo Nordisk Foundation.

For persons with obesity who lost a substantial amount of weight on a low-calorie diet, the combination of exercise and medication significantly improved weight-loss maintenance, and more so than either strategy alone, according to results of a randomized, head-to-head trial.

A year after starting moderate to vigorous exercise coupled with liraglutide treatment, study participants had a weight loss 9.5 kg more than those who received placebo and usual activity, study results show.

Reductions in both weight and fat loss seen with exercise and liraglutide was roughly twice as much as what was achieved at 1 year with the strategies of liraglutide or exercise alone, according to authors of the study, which appears in the New England Journal of Medicine .

Although the findings may not apply to those who can’t or won’t perform moderate to vigorous exercise, the intervention in this study was nevertheless feasible in this group of persons with obesity who had a very low level of fitness, according to the authors.
 

Hope for healthy weight loss maintenance

Investigator Signe S. Torekov, PhD, said in an interview that these results provide hope that more-intensive exercise regimens, with or without medication, can be useful and well accepted among individuals struggling with obesity.

“When we started our study, we were told, ‘you are never going to have people with obesity exercising that much, and for that long’ – but people were actually very happy about the exercise,” said Dr. Torekov, a professor in the department of biomedical sciences at the University of Copenhagen.

“If you actually set up a program where people are monitored and you have a feedback system, then exercise is an excellent component in obesity treatment that should be much more actively used – not only for its weight-lowering component, but also for improving health and quality of life,” she said in an interview.

Weight-management specialist John D. Clark, MD, PhD, said results of this study can be used to help inform patients about how successful different strategies incorporating exercise and medication may be following initial weight loss.

“When patients plateau on a consistent, calorie-restricted dietary plan, we can educate them and manage expectations about what options may be available to them after their initial weight loss,” said Dr. Clark, of the University of Texas, Dallas.

“If the patient’s goal specifically is weight loss at all costs, then I may suggest, ‘let’s consider liraglutide or liraglutide in combination with exercise,’ ” he said in an interview. “Exercise improves body composition, even if it may not on its own be as successful in the next phase of their weight-loss journey, as shown in this study.”
 

Obesity and weight-loss challenges

Although it’s not uncommon for obese patients to lose a large amount of weight, keeping the weight off is frequently a challenge unless the patient follows a structured weight maintenance program, according to Dr. Torekov and coauthors.

The rapid weight regain seen in many obese patients could be a result of reductions in total energy expenditure or increased appetite. Exercise is one strategy to sustain weight loss, though according to the authors, very few studies have looked at exercise in isolation to quantify its contribution to maintenance.

Accordingly, the present study sought to determine whether exercise, medication, or the combination thereof works best to keep weight off.

The study incorporated liraglutide, a GLP-1 receptor agonist indicated for chronic weight management, along with a reduced-calorie diet and increased physical activity, in adults with elevated body mass index and at least one weight-related comorbidity.

The investigator-initiated phase 3 trial included 215 adults with a body mass index of 32-43. Individuals with type 2 diabetes were excluded. All participants followed an 8-week, low-calorie diet comprising 800 calories per day.

Participants who lost 5% or more of their body weight were then randomized to 1 year of exercise plus liraglutide, exercise plus placebo, usual activity plus liraglutide, or usual activity plus placebo.

The exercise program – which was structured but flexible, according to investigators – included group exercise sessions that incorporated 30 minutes of indoor cycling and 15 minutes of circuit training 2 days each week. Participants wore heart rate monitors during exercise to make sure they reached targets for moderate to vigorous intensity.

Instructors trained in exercise physiology planned and monitored individualized exercise programs for each participant in the exercise-medication or exercise-only arms of the study.

Participants in all groups attended 12 one-on-one consultations where body weight was measured and dietetic support was provided.
 

Weight loss with exercise and medication

Out of 215 individuals enrolled in the study, 195 lost at least 5% of body weight and continued on to the randomized portion, the investigators reported. During the diet phase, they lost a mean of 13.1 kg, translating into a 12% mean reduction in body weight.

The mean frequency of exercise was 2.4 times per week in the exercise-plus-medication group and 2.5 times per week in the exercise-only group. About one-third of the exercise took place in the group sessions, and there was no difference in relative intensity between group and individual exercise regimens, the investigators said.

Individuals in the exercise plus medication group continued to lose more weight, such that, at the end of 1 year, the weight loss decreased even further, by a mean of –3.4 kg. By contrast, weight increased by a mean of 6.1 kg for the placebo group, adding up to a treatment difference of –9.5 kg (95% confidence interval, –13.1 to –5.9; P < .001), according to the report.

That treatment effect was also seen, but more muted, in the exercise- and liraglutide-only groups, at –4.1 kg and –6.8 kg, respectively.

A significant treatment effect was observed for exercise plus liraglutide, compared with exercise alone, at –5.4 kg (P = .004), while the treatment effect for the combination versus liraglutide alone was not significant at –2.7 kg (P = .13), the data show.

Body-fat reduction at 52 weeks was –3.9 percentage points for exercise plus liraglutide as compared with placebo, or roughly twice the reductions seen in the exercise- and liraglutide-alone groups, the investigators said, adding that the combination preserved lean mass.

Reductions in hemoglobin A1c, which are generally thought to reduce diabetes risk, were reduced in both the liraglutide and liraglutide-exercise combination group, according to their report.

The research was supported in part by grants from the Novo Nordisk Foundation.

In 2017-2018, only one in three U.S. adults with diabetes received five basic elements of care recommended by the American Diabetes Association, new research indicates.

BakiBG

The proportions of patients who visited a physician for diabetes care and received hemoglobin A1c testing, foot and eye exams, and cholesterol testing increased from 2005 to 2018. However, this increase was primarily among those aged 65 years and older, and therefore eligible for Medicare.

“Our study suggests that providing affordable health care coverage can help ensure people with diabetes get recommended care. We also found that patients who were not receiving recommended care were more likely to be younger, newly diagnosed with diabetes, and not on diabetes medication. Clinicians can pay more attention to these patient populations to improve recommended care delivery and prevent diabetes-related complications,” lead author Jung-Im Shin, MD, said in an interview.

The data predate the COVID-19 pandemic, which has also had major effects on delivery of diabetes care, added Dr. Shin of Johns Hopkins University, Baltimore.

“Routine visits to the doctor and important screenings for retinopathy or foot examination have been postponed. People with diabetes have had to reschedule or cancel nonurgent visits, some have lost ... insurance following unemployment, and many have avoided health care facilities out of fear. We are only just beginning to understand the consequences of the pandemic on the health of people with diabetes,” Dr. Shin noted.
 

Overall improvements seen only in those aged 65 and older

The data, from 4,069 adults aged 20 years and older from the 2005-2018 National Health and Nutrition and Examination Survey (NHANES), were published online April 16, 2021, in Diabetes Care.

Dr. Shin and colleagues defined receipt of diabetes care as meeting all of the following five criteria in the past 12 months, based on the ADA Standards of Care and NHANES data availability: seeing a primary doctor for diabetes care, receiving A1c testing, receiving a foot examination, receiving an eye examination, and receiving cholesterol testing.

Over the entire 13-year period, 29.2% of respondents reported having received all five components.

That proportion increased significantly over time, from 25.0% in 2005-2006 to 34.1% in 2017-2018 (P = .004). However, among the individual components, only receiving A1c testing increased significantly over time, from 64.4% to 85.3%, in all age groups (P < .001).

Moreover, when stratified by age, receipt of all five components only increased significantly among participants aged 65 and older, from 29.3% in 2005-2006 to 44.2% in 2017-2018 (P = .001).

The proportion remained unchanged among those aged 40-64 (25.2% to 25.8%; P =  .457) and showed a nonsignificant increase in those aged 20-39 (9.9% to 26.0%; P = .401).

In adjusted analyses, older age, higher income and education, health insurance, longer duration of diabetes, use of diabetes medications, and hypercholesterolemia were significantly associated with receipt of ADA guideline–recommended diabetes care.

Factors not found to be associated with care receipt included sex, race/ethnicity, body mass index, smoking status, A1c, hypertension, cardiovascular disease, chronic kidney disease, and depressive symptoms.

Participants who received ADA guideline–recommended care were significantly more likely to achieve A1c below 7.5% (adjusted odds ratio, 1.52), blood pressure less than 140/90 mm Hg (aOR, 1.47), and LDL cholesterol below 100 mg/dL (aOR, 1.47), and to receive cholesterol-lowering medication (aOR, 1.79).

Dr. Shin said that it will be “important to study the impact of COVID-19 on diabetes care when new data are available.”

The project was supported by a research grant from Merck to Johns Hopkins University. Shin has reported receiving a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. Two coauthors are Merck employees.

A version of this article first appeared on Medscape.com.

In 2017-2018, only one in three U.S. adults with diabetes received five basic elements of care recommended by the American Diabetes Association, new research indicates.

BakiBG

The proportions of patients who visited a physician for diabetes care and received hemoglobin A1c testing, foot and eye exams, and cholesterol testing increased from 2005 to 2018. However, this increase was primarily among those aged 65 years and older, and therefore eligible for Medicare.

“Our study suggests that providing affordable health care coverage can help ensure people with diabetes get recommended care. We also found that patients who were not receiving recommended care were more likely to be younger, newly diagnosed with diabetes, and not on diabetes medication. Clinicians can pay more attention to these patient populations to improve recommended care delivery and prevent diabetes-related complications,” lead author Jung-Im Shin, MD, said in an interview.

The data predate the COVID-19 pandemic, which has also had major effects on delivery of diabetes care, added Dr. Shin of Johns Hopkins University, Baltimore.

“Routine visits to the doctor and important screenings for retinopathy or foot examination have been postponed. People with diabetes have had to reschedule or cancel nonurgent visits, some have lost ... insurance following unemployment, and many have avoided health care facilities out of fear. We are only just beginning to understand the consequences of the pandemic on the health of people with diabetes,” Dr. Shin noted.
 

Overall improvements seen only in those aged 65 and older

The data, from 4,069 adults aged 20 years and older from the 2005-2018 National Health and Nutrition and Examination Survey (NHANES), were published online April 16, 2021, in Diabetes Care.

Dr. Shin and colleagues defined receipt of diabetes care as meeting all of the following five criteria in the past 12 months, based on the ADA Standards of Care and NHANES data availability: seeing a primary doctor for diabetes care, receiving A1c testing, receiving a foot examination, receiving an eye examination, and receiving cholesterol testing.

Over the entire 13-year period, 29.2% of respondents reported having received all five components.

That proportion increased significantly over time, from 25.0% in 2005-2006 to 34.1% in 2017-2018 (P = .004). However, among the individual components, only receiving A1c testing increased significantly over time, from 64.4% to 85.3%, in all age groups (P < .001).

Moreover, when stratified by age, receipt of all five components only increased significantly among participants aged 65 and older, from 29.3% in 2005-2006 to 44.2% in 2017-2018 (P = .001).

The proportion remained unchanged among those aged 40-64 (25.2% to 25.8%; P =  .457) and showed a nonsignificant increase in those aged 20-39 (9.9% to 26.0%; P = .401).

In adjusted analyses, older age, higher income and education, health insurance, longer duration of diabetes, use of diabetes medications, and hypercholesterolemia were significantly associated with receipt of ADA guideline–recommended diabetes care.

Factors not found to be associated with care receipt included sex, race/ethnicity, body mass index, smoking status, A1c, hypertension, cardiovascular disease, chronic kidney disease, and depressive symptoms.

Participants who received ADA guideline–recommended care were significantly more likely to achieve A1c below 7.5% (adjusted odds ratio, 1.52), blood pressure less than 140/90 mm Hg (aOR, 1.47), and LDL cholesterol below 100 mg/dL (aOR, 1.47), and to receive cholesterol-lowering medication (aOR, 1.79).

Dr. Shin said that it will be “important to study the impact of COVID-19 on diabetes care when new data are available.”

The project was supported by a research grant from Merck to Johns Hopkins University. Shin has reported receiving a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. Two coauthors are Merck employees.

A version of this article first appeared on Medscape.com.

In 2017-2018, only one in three U.S. adults with diabetes received five basic elements of care recommended by the American Diabetes Association, new research indicates.

BakiBG

The proportions of patients who visited a physician for diabetes care and received hemoglobin A1c testing, foot and eye exams, and cholesterol testing increased from 2005 to 2018. However, this increase was primarily among those aged 65 years and older, and therefore eligible for Medicare.

“Our study suggests that providing affordable health care coverage can help ensure people with diabetes get recommended care. We also found that patients who were not receiving recommended care were more likely to be younger, newly diagnosed with diabetes, and not on diabetes medication. Clinicians can pay more attention to these patient populations to improve recommended care delivery and prevent diabetes-related complications,” lead author Jung-Im Shin, MD, said in an interview.

The data predate the COVID-19 pandemic, which has also had major effects on delivery of diabetes care, added Dr. Shin of Johns Hopkins University, Baltimore.

“Routine visits to the doctor and important screenings for retinopathy or foot examination have been postponed. People with diabetes have had to reschedule or cancel nonurgent visits, some have lost ... insurance following unemployment, and many have avoided health care facilities out of fear. We are only just beginning to understand the consequences of the pandemic on the health of people with diabetes,” Dr. Shin noted.
 

Overall improvements seen only in those aged 65 and older

The data, from 4,069 adults aged 20 years and older from the 2005-2018 National Health and Nutrition and Examination Survey (NHANES), were published online April 16, 2021, in Diabetes Care.

Dr. Shin and colleagues defined receipt of diabetes care as meeting all of the following five criteria in the past 12 months, based on the ADA Standards of Care and NHANES data availability: seeing a primary doctor for diabetes care, receiving A1c testing, receiving a foot examination, receiving an eye examination, and receiving cholesterol testing.

Over the entire 13-year period, 29.2% of respondents reported having received all five components.

That proportion increased significantly over time, from 25.0% in 2005-2006 to 34.1% in 2017-2018 (P = .004). However, among the individual components, only receiving A1c testing increased significantly over time, from 64.4% to 85.3%, in all age groups (P < .001).

Moreover, when stratified by age, receipt of all five components only increased significantly among participants aged 65 and older, from 29.3% in 2005-2006 to 44.2% in 2017-2018 (P = .001).

The proportion remained unchanged among those aged 40-64 (25.2% to 25.8%; P =  .457) and showed a nonsignificant increase in those aged 20-39 (9.9% to 26.0%; P = .401).

In adjusted analyses, older age, higher income and education, health insurance, longer duration of diabetes, use of diabetes medications, and hypercholesterolemia were significantly associated with receipt of ADA guideline–recommended diabetes care.

Factors not found to be associated with care receipt included sex, race/ethnicity, body mass index, smoking status, A1c, hypertension, cardiovascular disease, chronic kidney disease, and depressive symptoms.

Participants who received ADA guideline–recommended care were significantly more likely to achieve A1c below 7.5% (adjusted odds ratio, 1.52), blood pressure less than 140/90 mm Hg (aOR, 1.47), and LDL cholesterol below 100 mg/dL (aOR, 1.47), and to receive cholesterol-lowering medication (aOR, 1.79).

Dr. Shin said that it will be “important to study the impact of COVID-19 on diabetes care when new data are available.”

The project was supported by a research grant from Merck to Johns Hopkins University. Shin has reported receiving a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. Two coauthors are Merck employees.

A version of this article first appeared on Medscape.com.

For patients with postural tachycardia syndrome (POTS), dietary sodium intake can be increased more confidently, suggests the first study to yield solid evidence to support this treatment strategy.

The results showed that high dietary sodium intake can lower plasma norepinephrine levels and ameliorate standing and orthostatic tachycardia for patients with POTS.

“These results suggest that increasing dietary salt is a good rationale for treatment of this condition, and this study gives reassurance we are doing the right thing for POTS patients by increasing their sodium intake,” senior author Satish R. Raj, MD, said in an interview.

The study, with lead author Emily M. Garland, PhD, was published online April 26, 2021, in the Journal of the American College of Cardiology.

Dr. Raj, who is professor of cardiac science at the University of Calgary (Alta.), explained that POTS includes a spectrum of disorders that affect the automatic nervous system, which regulates heart rate and blood pressure.

“It is a disorder of orthostatic intolerance – patients feel better when they lie down. It differs from orthostatic hypotension in that, when a POTS patient stands up, the blood pressure does not necessarily drop, but the heart rate increases excessively.”

Although it is normal for the heart rate to increase somewhat on standing, among patients with POTS, the heart rate increases excessively. The condition is defined as an orthostatic heart rate increase of at least 30 beats/min (or 40 beats/min among individuals aged 12-19 years ) in the absence of orthostatic hypotension.

The disorder is characterized by a range of symptoms, including lightheadedness, shortness of breath, palpitations, and exertional intolerance, that are worse when in an upright position. Patients also experience chronic fatigue and perceived cognitive impairment, Dr. Raj noted.

The typical demographic for POTS is young women; the condition often starts during the teenage years.

Patients often have low blood volume, so one approach to treatment is to increase the intake of salt and water so as to increase blood volume.

“This is one of the mainstays of treatment, but it has never really been properly studied,” Dr. Raj commented. Increasing salt intake “is an unusual message from a cardiologist, and there have been concerns that we are making recommendations against traditional advice, so we urgently need evidence to support this recommendation.”

The current crossover study enrolled 14 patients with POTS and 13 healthy control persons who, over a period of 6 days, underwent treatment with a low-sodium diet (10 mEq sodium per day) or a high-sodium diet (300 mEq sodium per day).

Supine and standing heart rate, blood pressure, serum aldosterone level, plasma renin activity, blood volume, and plasma norepinephrine and epinephrine levels were measured.

Results showed that, among the POTS patients, the high-sodium diet reduced upright heart rate and the change in heart rate on standing, compared with the low-sodium diet.

Heart rate increased by 46 beats/min with the high-sodium diet versus 60 beats/min with the low-sodium diet.

Total blood volume and plasma volume increased, and standing norepinephrine levels decreased with the high-sodium diet, compared with the low-sodium diet.

However, upright heart rate, change in heart rate, and upright norepinephrine levels remained higher among POTS patients than among control persons receiving the high-sodium diet.

There was a nonsignificant trend for a lower symptom burden score among the POTS patients who received the high-sodium diet in comparison with those taking the low-sodium diet. Scores for mental confusion, palpitations, lightheadedness, and headache trending downward on the high-sodium diet.

“We found that high levels of dietary salt did what we hoped, with increased blood volume and reduced norepinephrine levels on standing and reduced excessive increase in heart rate. While it didn’t completely normalize heart rate, this was reduced significantly,” Dr. Raj said.

Another observation from the study was that the increased salt intake seemed to be beneficial across the whole spectrum of patients.

“There are some patients who have very high levels of sympathetic activation, and there have been anecdotal reports that increasing salt may not work so well in this group,” he said. “In this study, we didn’t differentiate, but average norepinephrine levels were very high, and many patients would be considered to be hyperadrenergic. Our results suggest this treatment will help these patients too.”

He noted that sodium intake was increased in this study just through diet. “We had a special metabolic kitchen. In clinical practice, we advise patients to add regular table salt to their food, and we only use salt tablets when they cannot tolerate so much salt in their diet.”

Recognizing that there may be concerns about hypertension with long-term use of such a treatment, Dr. Raj said there were no signs of an increase in blood pressure in this study. “But this should be considered a short-term therapy for the time being, and patients need to be reassessed every few years as their physiology changes.”

The authors estimated that POTS affects up to 1% of the population. Because there is no diagnostic code for the condition at present, all incidence data are estimates.

Dr. Raj pointed out that potentially a lot of people are affected, but there is little recognition of the condition among patients and physicians.

“Many family doctors are unaware of POTS,” he noted. “Patients often have to research their symptoms themselves and inform their doctor of the condition. Many patients wait years and often see many different doctors before getting a correct diagnosis.”

He explained that patients with POTS are often diagnosed as having a psychiatric illness. “They are mainly young women with palpitations, heart pounding, shakiness, which is often labeled as anxiety.”

Dr. Raj urged clinicians to consider POTS if patients have symptoms that are worse when standing up. The diagnosis is confirmed if their blood pressure doesn’t fall when standing up but their heart rate increases by at least 30 beats/min.

He noted that not enough specialists treat this condition, so family doctors need to be able to diagnose and initiate treatment. If more aggressive treatment is required, patients can be referred to a specialist.

“One of the problems is that this condition pans across different medical specialties. No one field owns it, so it tends to get ignored. But there are clinicians who are interested in POTS, and the key is finding one of these,” he said.

“We have finally established that this high-sodium diet works as treatment for POTS,” he concluded. “We have been using it for some time, but now we have evidence for its use across the whole spectrum of patients.”

In an accompanying editorial (J Am Coll Cardiol. 2021 May 4;77[17]:2185-2186), Blair P. Grubb, MD, University of Toledo (Ohio) Medical Center, wrote that this “superb study by Garland et al. helps better establish our understanding of the pathophysiologic process taking place in POTS while at the same time providing good evidence for the augmentation of dietary sodium as one of the cornerstones of treatment.”

He added that the field needs more such studies “in our quest to better understand POTS and to elaborate therapeutic modalities to help those suffering from this debilitating illness.”

The study was supported in part by the National Heart, Lung, and Blood Institute; the National Center for Advancing Translational Sciences; and the Vanderbilt Hormone and Analytical Services Core. Dr. Raj has served as a consultant for Lundbeck NA and Theravance; has served as chair of the data safety and monitoring board for Arena Pharmaceuticals and as Cardiac Arrhythmia Network of Canada network investigator; and has served on the medical advisory board of Dysautonomia International and PoTS UK, both without financial compensation.

A version of this article first appeared on Medscape.com.

For patients with postural tachycardia syndrome (POTS), dietary sodium intake can be increased more confidently, suggests the first study to yield solid evidence to support this treatment strategy.

The results showed that high dietary sodium intake can lower plasma norepinephrine levels and ameliorate standing and orthostatic tachycardia for patients with POTS.

“These results suggest that increasing dietary salt is a good rationale for treatment of this condition, and this study gives reassurance we are doing the right thing for POTS patients by increasing their sodium intake,” senior author Satish R. Raj, MD, said in an interview.

The study, with lead author Emily M. Garland, PhD, was published online April 26, 2021, in the Journal of the American College of Cardiology.

Dr. Raj, who is professor of cardiac science at the University of Calgary (Alta.), explained that POTS includes a spectrum of disorders that affect the automatic nervous system, which regulates heart rate and blood pressure.

“It is a disorder of orthostatic intolerance – patients feel better when they lie down. It differs from orthostatic hypotension in that, when a POTS patient stands up, the blood pressure does not necessarily drop, but the heart rate increases excessively.”

Although it is normal for the heart rate to increase somewhat on standing, among patients with POTS, the heart rate increases excessively. The condition is defined as an orthostatic heart rate increase of at least 30 beats/min (or 40 beats/min among individuals aged 12-19 years ) in the absence of orthostatic hypotension.

The disorder is characterized by a range of symptoms, including lightheadedness, shortness of breath, palpitations, and exertional intolerance, that are worse when in an upright position. Patients also experience chronic fatigue and perceived cognitive impairment, Dr. Raj noted.

The typical demographic for POTS is young women; the condition often starts during the teenage years.

Patients often have low blood volume, so one approach to treatment is to increase the intake of salt and water so as to increase blood volume.

“This is one of the mainstays of treatment, but it has never really been properly studied,” Dr. Raj commented. Increasing salt intake “is an unusual message from a cardiologist, and there have been concerns that we are making recommendations against traditional advice, so we urgently need evidence to support this recommendation.”

The current crossover study enrolled 14 patients with POTS and 13 healthy control persons who, over a period of 6 days, underwent treatment with a low-sodium diet (10 mEq sodium per day) or a high-sodium diet (300 mEq sodium per day).

Supine and standing heart rate, blood pressure, serum aldosterone level, plasma renin activity, blood volume, and plasma norepinephrine and epinephrine levels were measured.

Results showed that, among the POTS patients, the high-sodium diet reduced upright heart rate and the change in heart rate on standing, compared with the low-sodium diet.

Heart rate increased by 46 beats/min with the high-sodium diet versus 60 beats/min with the low-sodium diet.

Total blood volume and plasma volume increased, and standing norepinephrine levels decreased with the high-sodium diet, compared with the low-sodium diet.

However, upright heart rate, change in heart rate, and upright norepinephrine levels remained higher among POTS patients than among control persons receiving the high-sodium diet.

There was a nonsignificant trend for a lower symptom burden score among the POTS patients who received the high-sodium diet in comparison with those taking the low-sodium diet. Scores for mental confusion, palpitations, lightheadedness, and headache trending downward on the high-sodium diet.

“We found that high levels of dietary salt did what we hoped, with increased blood volume and reduced norepinephrine levels on standing and reduced excessive increase in heart rate. While it didn’t completely normalize heart rate, this was reduced significantly,” Dr. Raj said.

Another observation from the study was that the increased salt intake seemed to be beneficial across the whole spectrum of patients.

“There are some patients who have very high levels of sympathetic activation, and there have been anecdotal reports that increasing salt may not work so well in this group,” he said. “In this study, we didn’t differentiate, but average norepinephrine levels were very high, and many patients would be considered to be hyperadrenergic. Our results suggest this treatment will help these patients too.”

He noted that sodium intake was increased in this study just through diet. “We had a special metabolic kitchen. In clinical practice, we advise patients to add regular table salt to their food, and we only use salt tablets when they cannot tolerate so much salt in their diet.”

Recognizing that there may be concerns about hypertension with long-term use of such a treatment, Dr. Raj said there were no signs of an increase in blood pressure in this study. “But this should be considered a short-term therapy for the time being, and patients need to be reassessed every few years as their physiology changes.”

The authors estimated that POTS affects up to 1% of the population. Because there is no diagnostic code for the condition at present, all incidence data are estimates.

Dr. Raj pointed out that potentially a lot of people are affected, but there is little recognition of the condition among patients and physicians.

“Many family doctors are unaware of POTS,” he noted. “Patients often have to research their symptoms themselves and inform their doctor of the condition. Many patients wait years and often see many different doctors before getting a correct diagnosis.”

He explained that patients with POTS are often diagnosed as having a psychiatric illness. “They are mainly young women with palpitations, heart pounding, shakiness, which is often labeled as anxiety.”

Dr. Raj urged clinicians to consider POTS if patients have symptoms that are worse when standing up. The diagnosis is confirmed if their blood pressure doesn’t fall when standing up but their heart rate increases by at least 30 beats/min.

He noted that not enough specialists treat this condition, so family doctors need to be able to diagnose and initiate treatment. If more aggressive treatment is required, patients can be referred to a specialist.

“One of the problems is that this condition pans across different medical specialties. No one field owns it, so it tends to get ignored. But there are clinicians who are interested in POTS, and the key is finding one of these,” he said.

“We have finally established that this high-sodium diet works as treatment for POTS,” he concluded. “We have been using it for some time, but now we have evidence for its use across the whole spectrum of patients.”

In an accompanying editorial (J Am Coll Cardiol. 2021 May 4;77[17]:2185-2186), Blair P. Grubb, MD, University of Toledo (Ohio) Medical Center, wrote that this “superb study by Garland et al. helps better establish our understanding of the pathophysiologic process taking place in POTS while at the same time providing good evidence for the augmentation of dietary sodium as one of the cornerstones of treatment.”

He added that the field needs more such studies “in our quest to better understand POTS and to elaborate therapeutic modalities to help those suffering from this debilitating illness.”

The study was supported in part by the National Heart, Lung, and Blood Institute; the National Center for Advancing Translational Sciences; and the Vanderbilt Hormone and Analytical Services Core. Dr. Raj has served as a consultant for Lundbeck NA and Theravance; has served as chair of the data safety and monitoring board for Arena Pharmaceuticals and as Cardiac Arrhythmia Network of Canada network investigator; and has served on the medical advisory board of Dysautonomia International and PoTS UK, both without financial compensation.

A version of this article first appeared on Medscape.com.

For patients with postural tachycardia syndrome (POTS), dietary sodium intake can be increased more confidently, suggests the first study to yield solid evidence to support this treatment strategy.

The results showed that high dietary sodium intake can lower plasma norepinephrine levels and ameliorate standing and orthostatic tachycardia for patients with POTS.

“These results suggest that increasing dietary salt is a good rationale for treatment of this condition, and this study gives reassurance we are doing the right thing for POTS patients by increasing their sodium intake,” senior author Satish R. Raj, MD, said in an interview.

The study, with lead author Emily M. Garland, PhD, was published online April 26, 2021, in the Journal of the American College of Cardiology.

Dr. Raj, who is professor of cardiac science at the University of Calgary (Alta.), explained that POTS includes a spectrum of disorders that affect the automatic nervous system, which regulates heart rate and blood pressure.

“It is a disorder of orthostatic intolerance – patients feel better when they lie down. It differs from orthostatic hypotension in that, when a POTS patient stands up, the blood pressure does not necessarily drop, but the heart rate increases excessively.”

Although it is normal for the heart rate to increase somewhat on standing, among patients with POTS, the heart rate increases excessively. The condition is defined as an orthostatic heart rate increase of at least 30 beats/min (or 40 beats/min among individuals aged 12-19 years ) in the absence of orthostatic hypotension.

The disorder is characterized by a range of symptoms, including lightheadedness, shortness of breath, palpitations, and exertional intolerance, that are worse when in an upright position. Patients also experience chronic fatigue and perceived cognitive impairment, Dr. Raj noted.

The typical demographic for POTS is young women; the condition often starts during the teenage years.

Patients often have low blood volume, so one approach to treatment is to increase the intake of salt and water so as to increase blood volume.

“This is one of the mainstays of treatment, but it has never really been properly studied,” Dr. Raj commented. Increasing salt intake “is an unusual message from a cardiologist, and there have been concerns that we are making recommendations against traditional advice, so we urgently need evidence to support this recommendation.”

The current crossover study enrolled 14 patients with POTS and 13 healthy control persons who, over a period of 6 days, underwent treatment with a low-sodium diet (10 mEq sodium per day) or a high-sodium diet (300 mEq sodium per day).

Supine and standing heart rate, blood pressure, serum aldosterone level, plasma renin activity, blood volume, and plasma norepinephrine and epinephrine levels were measured.

Results showed that, among the POTS patients, the high-sodium diet reduced upright heart rate and the change in heart rate on standing, compared with the low-sodium diet.

Heart rate increased by 46 beats/min with the high-sodium diet versus 60 beats/min with the low-sodium diet.

Total blood volume and plasma volume increased, and standing norepinephrine levels decreased with the high-sodium diet, compared with the low-sodium diet.

However, upright heart rate, change in heart rate, and upright norepinephrine levels remained higher among POTS patients than among control persons receiving the high-sodium diet.

There was a nonsignificant trend for a lower symptom burden score among the POTS patients who received the high-sodium diet in comparison with those taking the low-sodium diet. Scores for mental confusion, palpitations, lightheadedness, and headache trending downward on the high-sodium diet.

“We found that high levels of dietary salt did what we hoped, with increased blood volume and reduced norepinephrine levels on standing and reduced excessive increase in heart rate. While it didn’t completely normalize heart rate, this was reduced significantly,” Dr. Raj said.

Another observation from the study was that the increased salt intake seemed to be beneficial across the whole spectrum of patients.

“There are some patients who have very high levels of sympathetic activation, and there have been anecdotal reports that increasing salt may not work so well in this group,” he said. “In this study, we didn’t differentiate, but average norepinephrine levels were very high, and many patients would be considered to be hyperadrenergic. Our results suggest this treatment will help these patients too.”

He noted that sodium intake was increased in this study just through diet. “We had a special metabolic kitchen. In clinical practice, we advise patients to add regular table salt to their food, and we only use salt tablets when they cannot tolerate so much salt in their diet.”

Recognizing that there may be concerns about hypertension with long-term use of such a treatment, Dr. Raj said there were no signs of an increase in blood pressure in this study. “But this should be considered a short-term therapy for the time being, and patients need to be reassessed every few years as their physiology changes.”

The authors estimated that POTS affects up to 1% of the population. Because there is no diagnostic code for the condition at present, all incidence data are estimates.

Dr. Raj pointed out that potentially a lot of people are affected, but there is little recognition of the condition among patients and physicians.

“Many family doctors are unaware of POTS,” he noted. “Patients often have to research their symptoms themselves and inform their doctor of the condition. Many patients wait years and often see many different doctors before getting a correct diagnosis.”

He explained that patients with POTS are often diagnosed as having a psychiatric illness. “They are mainly young women with palpitations, heart pounding, shakiness, which is often labeled as anxiety.”

Dr. Raj urged clinicians to consider POTS if patients have symptoms that are worse when standing up. The diagnosis is confirmed if their blood pressure doesn’t fall when standing up but their heart rate increases by at least 30 beats/min.

He noted that not enough specialists treat this condition, so family doctors need to be able to diagnose and initiate treatment. If more aggressive treatment is required, patients can be referred to a specialist.

“One of the problems is that this condition pans across different medical specialties. No one field owns it, so it tends to get ignored. But there are clinicians who are interested in POTS, and the key is finding one of these,” he said.

“We have finally established that this high-sodium diet works as treatment for POTS,” he concluded. “We have been using it for some time, but now we have evidence for its use across the whole spectrum of patients.”

In an accompanying editorial (J Am Coll Cardiol. 2021 May 4;77[17]:2185-2186), Blair P. Grubb, MD, University of Toledo (Ohio) Medical Center, wrote that this “superb study by Garland et al. helps better establish our understanding of the pathophysiologic process taking place in POTS while at the same time providing good evidence for the augmentation of dietary sodium as one of the cornerstones of treatment.”

He added that the field needs more such studies “in our quest to better understand POTS and to elaborate therapeutic modalities to help those suffering from this debilitating illness.”

The study was supported in part by the National Heart, Lung, and Blood Institute; the National Center for Advancing Translational Sciences; and the Vanderbilt Hormone and Analytical Services Core. Dr. Raj has served as a consultant for Lundbeck NA and Theravance; has served as chair of the data safety and monitoring board for Arena Pharmaceuticals and as Cardiac Arrhythmia Network of Canada network investigator; and has served on the medical advisory board of Dysautonomia International and PoTS UK, both without financial compensation.

A version of this article first appeared on Medscape.com.

Due to its size, 2 shave biopsies targeting the most concerning portions of the lesion were performed; the results were consistent with a lichenoid keratosis (LK), also known as lichen planus-like keratosis.

LK is a benign solitary lesion that mimics basal cell carcinoma, squamous cell carcinoma, and superficial spreading or amelanotic melanoma.¹ One theory suggests that LK is a solar lentigo or actinic keratosis undergoing attack from the immune system. Lesions most often manifest as a pink, gray, or brown macule to thin papule on the trunk or extremities. Itching or mild pain may be present. Dermoscopy can help distinguish an LK from malignancy but overlapping features of fine dark regression structures (called peppering, as seen in this case) should prompt further evaluation.

LKs are great mimics and biopsy is key to distinguishing them from cancer. In this case, shave biopsies were performed in the thickest and most characteristic portions of the lesion. Punch or incisional biopsies also would have been appropriate, but any result would have been a partial result. If the result had come back as an atypical melanocytic lesion, a complete excision would have been necessary to make sure the pathology reflected the entirety of the lesion.

Armed with the knowledge that the LK was benign, the patient in this case was scheduled for a follow-up visit for cryotherapy to remove the residual lesion.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

Due to its size, 2 shave biopsies targeting the most concerning portions of the lesion were performed; the results were consistent with a lichenoid keratosis (LK), also known as lichen planus-like keratosis.

LK is a benign solitary lesion that mimics basal cell carcinoma, squamous cell carcinoma, and superficial spreading or amelanotic melanoma.¹ One theory suggests that LK is a solar lentigo or actinic keratosis undergoing attack from the immune system. Lesions most often manifest as a pink, gray, or brown macule to thin papule on the trunk or extremities. Itching or mild pain may be present. Dermoscopy can help distinguish an LK from malignancy but overlapping features of fine dark regression structures (called peppering, as seen in this case) should prompt further evaluation.

LKs are great mimics and biopsy is key to distinguishing them from cancer. In this case, shave biopsies were performed in the thickest and most characteristic portions of the lesion. Punch or incisional biopsies also would have been appropriate, but any result would have been a partial result. If the result had come back as an atypical melanocytic lesion, a complete excision would have been necessary to make sure the pathology reflected the entirety of the lesion.

Armed with the knowledge that the LK was benign, the patient in this case was scheduled for a follow-up visit for cryotherapy to remove the residual lesion.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

Due to its size, 2 shave biopsies targeting the most concerning portions of the lesion were performed; the results were consistent with a lichenoid keratosis (LK), also known as lichen planus-like keratosis.

LK is a benign solitary lesion that mimics basal cell carcinoma, squamous cell carcinoma, and superficial spreading or amelanotic melanoma.¹ One theory suggests that LK is a solar lentigo or actinic keratosis undergoing attack from the immune system. Lesions most often manifest as a pink, gray, or brown macule to thin papule on the trunk or extremities. Itching or mild pain may be present. Dermoscopy can help distinguish an LK from malignancy but overlapping features of fine dark regression structures (called peppering, as seen in this case) should prompt further evaluation.

LKs are great mimics and biopsy is key to distinguishing them from cancer. In this case, shave biopsies were performed in the thickest and most characteristic portions of the lesion. Punch or incisional biopsies also would have been appropriate, but any result would have been a partial result. If the result had come back as an atypical melanocytic lesion, a complete excision would have been necessary to make sure the pathology reflected the entirety of the lesion.

Armed with the knowledge that the LK was benign, the patient in this case was scheduled for a follow-up visit for cryotherapy to remove the residual lesion.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

When caring for older adults with multiple chronic conditions, prioritizing patient goals is more effective and efficient than trying to address each condition in isolation, said Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine and Public Health and chief of geriatrics at Yale University, New Haven, Conn.

During a virtual presentation at the American College of Physicians annual Internal Medicine meeting, the gerontologist noted that primary care providers face a number of challenges when managing elderly patients with multimorbidity. These challenges include a lack of representative data in clinical trials, conflicting guideline recommendations, patient nonadherence, and decreased benefit from therapies due to competing conditions, she said.

“Trying to follow multiple guidelines can result in unintentional harms to these people with multiple conditions,” Dr. Tinetti said. She gave examples of the wide-ranging goals patients can have.

“Some [patients] will maximize the focus on function, regardless of how long they are likely to live,” Dr. Tinetti said. “Others will say symptom burden management is most important to them. And others will say they want to live as long as possible, and survival is most important, even if that means a reduction in their function. These individuals also vary in the care they are willing and able to receive to achieve the outcomes that matter most to them.”

For these reasons, Dr. Tinetti recommended patient priorities care, which she and her colleagues have been developing and implementing over the past 5-6 years.

“If the benefits and harms of addressing each condition in isolation is of uncertain benefit and potentially burdensome to both clinician and patient, and we know that patients vary in their health priorities ... then what else would you want to focus on in your 20-minute visit ... except each patient’s priorities?” Dr. Tinetti asked. “This is one solution to the challenge.”


 

What is patient priorities care?

Patient priorities care is a multidisciplinary, cyclical approach to clinical decision-making composed of three steps, Dr. Tinetti explained. First, a clinician identifies the patient’s health priorities. Second, this information is transmitted to comanaging providers, who decide which of their respective treatments are consistent with the patient’s priorities. And third, those decisions are disseminated to everyone involved in the patient’s care, both within and outside of the health care system, allowing all care providers to align with the patient’s priorities, she noted.

“Each person does that from their own expertise,” Dr. Tinetti said. “The social worker will do something different than the cardiologist, the physical therapist, the endocrinologist – but everybody is aiming at the same outcome – the patient’s priorities.”

In 2019, Dr. Tinetti led a nonrandomized clinical trial to test the feasibility of patient priorities care. The study involved 366 older adults with multimorbidity, among whom 203 received usual care, while 163 received this type of care. Patients in the latter group were twice as likely to have medications stopped, and significantly less likely to have self-management tasks added and diagnostic tests ordered.
 

How electronic health records can help

In an interview, Dr. Tinetti suggested that comanaging physicians communicate through electronic health records (EHRs), first to ensure that all care providers understand a patient’s goals, then to determine if recommended therapies align with those goals.

“It would be a little bit of a culture change to do that,” Dr. Tinetti said, “but the technology is there and it isn’t too terribly time consuming.”

She went on to suggest that primary care providers are typically best suited to coordinate this process; however, if a patient receives the majority of their care from a particular specialist, then that clinician may be the most suitable coordinator.
 

Systemic obstacles and solutions

According to Cynthia Boyd, MD, interim director of the division of geriatric medicine and gerontology, Johns Hopkins University, Baltimore, clinicians may encounter obstacles when implementing patient priorities care.

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Click here for the Thursday issue of the SHM Converge Daily News newsletter.

Click here for the Thursday issue of the SHM Converge Daily News newsletter.