The Society of Hospital Medicine’s 2012 State of Hospital Medicine report (SOHM) offers new insights about physician practice leaders.

Physician Leader Presence

“Choose a hospitalist leader with the right skills and experience. Selecting the right leader is fundamental to a successful hospitalist practice. These individuals are hard to find. They must be excellent clinically and have superb communication skills.”¹

The SOHM survey shows that the vast majority (97%) of hospital medicine groups (HMGs) in the U.S. now have a designated physician leader (see Figure 1). Given this high percentage, examining the outliers is intriguing. Of the 13 adult medicine HMGs that reported not having a physician leader, the large majority were hospital-owned, located in the South region, and situated in non-teaching hospitals. The size of the HMG impacted the presence of a physician leader: 100% of groups with 20 or more full-time equivalents had physician leaders.

click for large version

Dedicated Leadership Time

“The medical director of the hospitalist program needs sufficient, non-clinical time to address administrative and leadership issues.”¹

The 2007/2008 SOHM survey reported a median of 20% administrative time for physician leaders. In the 2012 survey, the median amount of time was 25% for adult medicine HMGs. The percentages were higher in the East and West regions, in hospital-owned programs, and in non- academic programs. The percentage of protected time also went up with group size.

Dr. Lovins

Compensation

The 2012 SOHM shows median compensation premiums for physician leaders of 20%; that is, leader compensation is 120% of the average salary in their group. The numbers across regions and sizes were remarkably consistent. Overall, it seems that a 15% to 20% compensation premium for hospitalist leaders is standard.

Key Takeaways

No. 1, hospitalist groups need physician hospitalist leaders with protected leadership, but who also work clinically as a hospitalist. Why? Because hospitalists need a leader they respect, someone that they believe understands their specific issues. Unless the physician in charge has worked those 12-hour overnight shifts, argued with the consultants, tried to discharge an ornery patient, received 20 pages in an hour about medication reconciliation, or disagreed with an ED doc about the appropriateness of an admission, it would be hard for that leader to fully understand the stresses hospitalists encounter on a daily basis.

Hospitalist leaders are taking on increasingly important roles to help their organizations realize key performance improvement goals.

Additionally, the roles of outpatient doctors are changing: “Many physicians are no longer able or willing to serve on hospital committees or play a leadership role for the medical staff. Hospitalists have the potential to step in and help address these key issues”¹

No. 2, size matters. Given increased responsibilities that include handling focused and ongoing professional practice evaluations, designing pathways to reduce adverse events, counseling, mentoring, disciplining, conducting yearly reviews, and investigating patient and staff complaints, it makes sense that larger programs also have leaders with more protected time and commensurate compensation.

As our healthcare systems ask hospitalists to offer higher reliability and to champion more administrative, safety, and quality projects, HM leaders—who are perfectly placed to organize and manage those projects—need the time and the compensation to do so. To borrow from hospitalist pioneer Bob Wachter, MD, MHM, our future C-suite leaders are percolating in hospitalist programs, learning the skills we will need to participate in the high reliability hospitals of our present and future.

Dr. Lovins is chief of hospital medicine at Middlesex Hospital in Middletown, Conn., and assistant clinical professor of medicine at Yale University School of Medicine. She is a member of SHM’s Practice Analysis Committee.

Reference

1. American Medical Association. Principles for a sustainable and successful hospitalist program. AMA website. Available at: http://www.ama-assn.org/resources/doc/omss/sustainable-hospitalist-program.pdf. Accessed September 18, 2013.

The Society of Hospital Medicine’s 2012 State of Hospital Medicine report (SOHM) offers new insights about physician practice leaders.

Physician Leader Presence

“Choose a hospitalist leader with the right skills and experience. Selecting the right leader is fundamental to a successful hospitalist practice. These individuals are hard to find. They must be excellent clinically and have superb communication skills.”¹

The SOHM survey shows that the vast majority (97%) of hospital medicine groups (HMGs) in the U.S. now have a designated physician leader (see Figure 1). Given this high percentage, examining the outliers is intriguing. Of the 13 adult medicine HMGs that reported not having a physician leader, the large majority were hospital-owned, located in the South region, and situated in non-teaching hospitals. The size of the HMG impacted the presence of a physician leader: 100% of groups with 20 or more full-time equivalents had physician leaders.

click for large version

Dedicated Leadership Time

“The medical director of the hospitalist program needs sufficient, non-clinical time to address administrative and leadership issues.”¹

The 2007/2008 SOHM survey reported a median of 20% administrative time for physician leaders. In the 2012 survey, the median amount of time was 25% for adult medicine HMGs. The percentages were higher in the East and West regions, in hospital-owned programs, and in non- academic programs. The percentage of protected time also went up with group size.

Dr. Lovins

Compensation

The 2012 SOHM shows median compensation premiums for physician leaders of 20%; that is, leader compensation is 120% of the average salary in their group. The numbers across regions and sizes were remarkably consistent. Overall, it seems that a 15% to 20% compensation premium for hospitalist leaders is standard.

Key Takeaways

No. 1, hospitalist groups need physician hospitalist leaders with protected leadership, but who also work clinically as a hospitalist. Why? Because hospitalists need a leader they respect, someone that they believe understands their specific issues. Unless the physician in charge has worked those 12-hour overnight shifts, argued with the consultants, tried to discharge an ornery patient, received 20 pages in an hour about medication reconciliation, or disagreed with an ED doc about the appropriateness of an admission, it would be hard for that leader to fully understand the stresses hospitalists encounter on a daily basis.

Hospitalist leaders are taking on increasingly important roles to help their organizations realize key performance improvement goals.

Additionally, the roles of outpatient doctors are changing: “Many physicians are no longer able or willing to serve on hospital committees or play a leadership role for the medical staff. Hospitalists have the potential to step in and help address these key issues”¹

No. 2, size matters. Given increased responsibilities that include handling focused and ongoing professional practice evaluations, designing pathways to reduce adverse events, counseling, mentoring, disciplining, conducting yearly reviews, and investigating patient and staff complaints, it makes sense that larger programs also have leaders with more protected time and commensurate compensation.

As our healthcare systems ask hospitalists to offer higher reliability and to champion more administrative, safety, and quality projects, HM leaders—who are perfectly placed to organize and manage those projects—need the time and the compensation to do so. To borrow from hospitalist pioneer Bob Wachter, MD, MHM, our future C-suite leaders are percolating in hospitalist programs, learning the skills we will need to participate in the high reliability hospitals of our present and future.

Dr. Lovins is chief of hospital medicine at Middlesex Hospital in Middletown, Conn., and assistant clinical professor of medicine at Yale University School of Medicine. She is a member of SHM’s Practice Analysis Committee.

Reference

1. American Medical Association. Principles for a sustainable and successful hospitalist program. AMA website. Available at: http://www.ama-assn.org/resources/doc/omss/sustainable-hospitalist-program.pdf. Accessed September 18, 2013.

The Society of Hospital Medicine’s 2012 State of Hospital Medicine report (SOHM) offers new insights about physician practice leaders.

Physician Leader Presence

“Choose a hospitalist leader with the right skills and experience. Selecting the right leader is fundamental to a successful hospitalist practice. These individuals are hard to find. They must be excellent clinically and have superb communication skills.”¹

The SOHM survey shows that the vast majority (97%) of hospital medicine groups (HMGs) in the U.S. now have a designated physician leader (see Figure 1). Given this high percentage, examining the outliers is intriguing. Of the 13 adult medicine HMGs that reported not having a physician leader, the large majority were hospital-owned, located in the South region, and situated in non-teaching hospitals. The size of the HMG impacted the presence of a physician leader: 100% of groups with 20 or more full-time equivalents had physician leaders.

click for large version

Dedicated Leadership Time

“The medical director of the hospitalist program needs sufficient, non-clinical time to address administrative and leadership issues.”¹

The 2007/2008 SOHM survey reported a median of 20% administrative time for physician leaders. In the 2012 survey, the median amount of time was 25% for adult medicine HMGs. The percentages were higher in the East and West regions, in hospital-owned programs, and in non- academic programs. The percentage of protected time also went up with group size.

Dr. Lovins

Compensation

The 2012 SOHM shows median compensation premiums for physician leaders of 20%; that is, leader compensation is 120% of the average salary in their group. The numbers across regions and sizes were remarkably consistent. Overall, it seems that a 15% to 20% compensation premium for hospitalist leaders is standard.

Key Takeaways

No. 1, hospitalist groups need physician hospitalist leaders with protected leadership, but who also work clinically as a hospitalist. Why? Because hospitalists need a leader they respect, someone that they believe understands their specific issues. Unless the physician in charge has worked those 12-hour overnight shifts, argued with the consultants, tried to discharge an ornery patient, received 20 pages in an hour about medication reconciliation, or disagreed with an ED doc about the appropriateness of an admission, it would be hard for that leader to fully understand the stresses hospitalists encounter on a daily basis.

Hospitalist leaders are taking on increasingly important roles to help their organizations realize key performance improvement goals.

Additionally, the roles of outpatient doctors are changing: “Many physicians are no longer able or willing to serve on hospital committees or play a leadership role for the medical staff. Hospitalists have the potential to step in and help address these key issues”¹

No. 2, size matters. Given increased responsibilities that include handling focused and ongoing professional practice evaluations, designing pathways to reduce adverse events, counseling, mentoring, disciplining, conducting yearly reviews, and investigating patient and staff complaints, it makes sense that larger programs also have leaders with more protected time and commensurate compensation.

As our healthcare systems ask hospitalists to offer higher reliability and to champion more administrative, safety, and quality projects, HM leaders—who are perfectly placed to organize and manage those projects—need the time and the compensation to do so. To borrow from hospitalist pioneer Bob Wachter, MD, MHM, our future C-suite leaders are percolating in hospitalist programs, learning the skills we will need to participate in the high reliability hospitals of our present and future.

Dr. Lovins is chief of hospital medicine at Middlesex Hospital in Middletown, Conn., and assistant clinical professor of medicine at Yale University School of Medicine. She is a member of SHM’s Practice Analysis Committee.

Reference

1. American Medical Association. Principles for a sustainable and successful hospitalist program. AMA website. Available at: http://www.ama-assn.org/resources/doc/omss/sustainable-hospitalist-program.pdf. Accessed September 18, 2013.

For more information, visit www.hospitalmedicine.org/leadership.

This issue of The Hospitalist features many hospitalists who have honed their leadership skills and ascended to leadership levels within their hospitals. Now is the time for aspiring hospitalists everywhere to make plans for the 2014 Leadership Academy.

SHM’s intensive series of four-day courses in effective leadership sold out early in 2013, and next year’s Leadership Academy will be presented in Honolulu in November, so it’s not too early to register and make travel arrangements.

The three courses presented in SHM’s Leadership Academy are:

• Foundations of Effective Leadership
• Advanced Leadership: Personal Leadership Excellence
• Advanced Leadership: Strengthening Your Organization

For more information, visit www.hospitalmedicine.org/leadership.

This issue of The Hospitalist features many hospitalists who have honed their leadership skills and ascended to leadership levels within their hospitals. Now is the time for aspiring hospitalists everywhere to make plans for the 2014 Leadership Academy.

SHM’s intensive series of four-day courses in effective leadership sold out early in 2013, and next year’s Leadership Academy will be presented in Honolulu in November, so it’s not too early to register and make travel arrangements.

The three courses presented in SHM’s Leadership Academy are:

• Foundations of Effective Leadership
• Advanced Leadership: Personal Leadership Excellence
• Advanced Leadership: Strengthening Your Organization

For more information, visit www.hospitalmedicine.org/leadership.

This issue of The Hospitalist features many hospitalists who have honed their leadership skills and ascended to leadership levels within their hospitals. Now is the time for aspiring hospitalists everywhere to make plans for the 2014 Leadership Academy.

SHM’s intensive series of four-day courses in effective leadership sold out early in 2013, and next year’s Leadership Academy will be presented in Honolulu in November, so it’s not too early to register and make travel arrangements.

The three courses presented in SHM’s Leadership Academy are:

• Foundations of Effective Leadership
• Advanced Leadership: Personal Leadership Excellence
• Advanced Leadership: Strengthening Your Organization

HMX: Two New Communities, Lots of New Conversations

More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.

The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.

And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.

Brendon Shank is SHM’s associate vice president of communications.

HMX: Two New Communities, Lots of New Conversations

More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.

The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.

And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.

Brendon Shank is SHM’s associate vice president of communications.

HMX: Two New Communities, Lots of New Conversations

More than 2,500 hospitalists have logged in to HMX (www.hmxchange.org) to share their experiences and learn from the experiences of other hospitalists. And now, two other groups of hospitalists have a new reason to check out HMX.

The first community, for family medicine hospitalists, was launched in October. Approximately 10% of SHM’s active members are hospitalists trained in family medicine (HTFM), many of whom are very active within SHM. More than 60 hospitalists trained in family medicine are either Fellows in Hospital Medicine or Senior Fellows in Hospital Medicine.

And, in December, hospitalists who work in post-acute care can work together to tackle the challenges unique to post-acute care. This new community was an outgrowth of SHM’s Post-Acute Care Task Force.

Brendon Shank is SHM’s associate vice president of communications.

Fellows Deadline Is Jan. 10, 2014

Thousands of hospitalists across the country have earned the Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM) designation to set themselves apart in the specialty—and among other hospital-based caregivers.

For the second year, nurse practitioners and physician assistants can also earn the FHM and SFHM designations.

Candidates for FHM and SFHM can now apply online. For more information or to apply, visit www.hospitalmedicine.org/fellows.

Fellows Deadline Is Jan. 10, 2014

Thousands of hospitalists across the country have earned the Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM) designation to set themselves apart in the specialty—and among other hospital-based caregivers.

For the second year, nurse practitioners and physician assistants can also earn the FHM and SFHM designations.

Candidates for FHM and SFHM can now apply online. For more information or to apply, visit www.hospitalmedicine.org/fellows.

Fellows Deadline Is Jan. 10, 2014

Thousands of hospitalists across the country have earned the Fellow in Hospital Medicine (FHM) and Senior Fellow in Hospital Medicine (SFHM) designation to set themselves apart in the specialty—and among other hospital-based caregivers.

For the second year, nurse practitioners and physician assistants can also earn the FHM and SFHM designations.

Candidates for FHM and SFHM can now apply online. For more information or to apply, visit www.hospitalmedicine.org/fellows.

HM14: Submit Your Scientific Abstracts Soon

Abstracts are being accepted for SHM’s scientific poster and oral abstract competition, known as Research, Innovations, and Clinical Vignettes (RIV), until Sunday, Dec. 1. Visit the Academic Community page on the SHM website, or, for a full suite of resources for submitting your abstract, go directly to the abstract submission site (https://shm.confex.com/shm/HM14/cfp.cgi) to submit your abstract today.

For more on HM14, the biggest meeting in hospital medicine, visit www.hospitalmedicine2014.org.

Brendon Shank is SHM’s associate vice president of communications.

HM14: Submit Your Scientific Abstracts Soon

Abstracts are being accepted for SHM’s scientific poster and oral abstract competition, known as Research, Innovations, and Clinical Vignettes (RIV), until Sunday, Dec. 1. Visit the Academic Community page on the SHM website, or, for a full suite of resources for submitting your abstract, go directly to the abstract submission site (https://shm.confex.com/shm/HM14/cfp.cgi) to submit your abstract today.

For more on HM14, the biggest meeting in hospital medicine, visit www.hospitalmedicine2014.org.

Brendon Shank is SHM’s associate vice president of communications.

HM14: Submit Your Scientific Abstracts Soon

Abstracts are being accepted for SHM’s scientific poster and oral abstract competition, known as Research, Innovations, and Clinical Vignettes (RIV), until Sunday, Dec. 1. Visit the Academic Community page on the SHM website, or, for a full suite of resources for submitting your abstract, go directly to the abstract submission site (https://shm.confex.com/shm/HM14/cfp.cgi) to submit your abstract today.

For more on HM14, the biggest meeting in hospital medicine, visit www.hospitalmedicine2014.org.

Brendon Shank is SHM’s associate vice president of communications.

Xavier Perez, MD

Xavier Perez, MD, is the 2013 Hospitalist Medical Director of the Year at TeamHealth. Dr. Perez oversees the hospital medicine program at Sutter Solano Medical Center, a 102-bed acute care center in Vallejo, Calif. Knoxville, Tenn.-based TeamHealth has been partnering with hospital-based providers to provide hospitalist, emergency, and anesthesia staffing since 1979.

Christopher Sharp, MD

Christopher Sharp, MD, has been named the new chief medical information officer at Stanford Hospital and Clinics in Stanford, Calif. Dr. Sharp is hospitalist at Stanford University Medical Center, clinical associate professor of medicine at Stanford University School of Medicine, and chair of the Medical Staff Health Information Management (HIM) Committee.

Business Moves

Xavier Perez, MD

Hospitalists of Northern Michigan (HNM), based in Traverse City, Mich., has been recognized as one of Modern Healthcare’s 2013 Best Places to Work in Healthcare. The award has honored healthcare employers for economic development, employee satisfaction, and retention for the last six years. HNM provides hospitalist services to six hospitals in four different healthcare systems throughout Northern Michigan.

Xavier Perez, MD

IPC The Hospitalist Company, based in North Hollywood, Calif., recently announced that it will oversee hospitalist services at Metropolitan Pulmonary and Hospital Medicine, P.C. (MPHM), in Kansas City, Mo. This new agreement will place IPC management into two new Kansas City hospitals. IPC provides hospitalist services to over 350 hospitals in 28 states throughout the country.

WakeMed Health and Hospitals, a Raleigh, N.C.-based healthcare system, now provides pediatric hospitalist services to Central Carolina Hospital (CCH) in Sanford, N.C. WakeMed will begin by staffing three pediatric hospitalists at CCH to establish 24-hour pediatric inpatient care. Central Carolina Hospital is an acute care community hospital that already offers hospitalist services to its adult patients.

Xavier Perez, MD

Tacoma, Wash.-based Sound Inpatient Physicians has partnered with CHRISTUS Health to provide hospitalist services at seven of its hospitals in Texas and Louisiana. The seven hospitals are CHRISTUS Spohn Hospital Corpus Christi-Shoreline and CHRISTUS Spohn Hospital Corpus Christi-South in Corpus Christi, Texas; CHRISTUS Santa Rosa Hospital-Medical Center and CHRISTUS Santa Rosa Hospital-Westover Hills, both in San Antonio, Texas; CHRISTUS St. Frances Cabrini Hospital in Alexandria, La.; CHRISTUS St. Patrick Hospital in Lake Charles, La.; and CHRISTUS Highland Medical Center in Shreveport, La. Sound now provides hospitalist services to over 70 hospitals throughout the country. CHRISTUS Health is a Catholic hospital system made up of more than 40 hospitals throughout seven U.S. states and six Mexican states.

Xavier Perez, MD

Carolinas Medical Center–Union in Monroe, N.C., will staff three 24-hour pediatric hospitalists thanks to an agreement with Levine Children’s Hospital in Charlotte, N.C. Both hospitals are part of Carolinas HealthCare System, which is the largest public, non-profit hospital system in North and South Carolina.

Curry General Hospital in Gold Beach, Ore., is offering hospitalist services to inpatients at the flagship hospital of Curry Health Network, which is made up of seven hospitals and outpatient clinics serving the Wild Rivers Coast area of southwestern Oregon.

Xavier Perez, MD

Xavier Perez, MD, is the 2013 Hospitalist Medical Director of the Year at TeamHealth. Dr. Perez oversees the hospital medicine program at Sutter Solano Medical Center, a 102-bed acute care center in Vallejo, Calif. Knoxville, Tenn.-based TeamHealth has been partnering with hospital-based providers to provide hospitalist, emergency, and anesthesia staffing since 1979.

Christopher Sharp, MD

Christopher Sharp, MD, has been named the new chief medical information officer at Stanford Hospital and Clinics in Stanford, Calif. Dr. Sharp is hospitalist at Stanford University Medical Center, clinical associate professor of medicine at Stanford University School of Medicine, and chair of the Medical Staff Health Information Management (HIM) Committee.

Business Moves

Xavier Perez, MD

Hospitalists of Northern Michigan (HNM), based in Traverse City, Mich., has been recognized as one of Modern Healthcare’s 2013 Best Places to Work in Healthcare. The award has honored healthcare employers for economic development, employee satisfaction, and retention for the last six years. HNM provides hospitalist services to six hospitals in four different healthcare systems throughout Northern Michigan.

Xavier Perez, MD

IPC The Hospitalist Company, based in North Hollywood, Calif., recently announced that it will oversee hospitalist services at Metropolitan Pulmonary and Hospital Medicine, P.C. (MPHM), in Kansas City, Mo. This new agreement will place IPC management into two new Kansas City hospitals. IPC provides hospitalist services to over 350 hospitals in 28 states throughout the country.

WakeMed Health and Hospitals, a Raleigh, N.C.-based healthcare system, now provides pediatric hospitalist services to Central Carolina Hospital (CCH) in Sanford, N.C. WakeMed will begin by staffing three pediatric hospitalists at CCH to establish 24-hour pediatric inpatient care. Central Carolina Hospital is an acute care community hospital that already offers hospitalist services to its adult patients.

Xavier Perez, MD

Tacoma, Wash.-based Sound Inpatient Physicians has partnered with CHRISTUS Health to provide hospitalist services at seven of its hospitals in Texas and Louisiana. The seven hospitals are CHRISTUS Spohn Hospital Corpus Christi-Shoreline and CHRISTUS Spohn Hospital Corpus Christi-South in Corpus Christi, Texas; CHRISTUS Santa Rosa Hospital-Medical Center and CHRISTUS Santa Rosa Hospital-Westover Hills, both in San Antonio, Texas; CHRISTUS St. Frances Cabrini Hospital in Alexandria, La.; CHRISTUS St. Patrick Hospital in Lake Charles, La.; and CHRISTUS Highland Medical Center in Shreveport, La. Sound now provides hospitalist services to over 70 hospitals throughout the country. CHRISTUS Health is a Catholic hospital system made up of more than 40 hospitals throughout seven U.S. states and six Mexican states.

Xavier Perez, MD

Carolinas Medical Center–Union in Monroe, N.C., will staff three 24-hour pediatric hospitalists thanks to an agreement with Levine Children’s Hospital in Charlotte, N.C. Both hospitals are part of Carolinas HealthCare System, which is the largest public, non-profit hospital system in North and South Carolina.

Curry General Hospital in Gold Beach, Ore., is offering hospitalist services to inpatients at the flagship hospital of Curry Health Network, which is made up of seven hospitals and outpatient clinics serving the Wild Rivers Coast area of southwestern Oregon.

Xavier Perez, MD

Xavier Perez, MD, is the 2013 Hospitalist Medical Director of the Year at TeamHealth. Dr. Perez oversees the hospital medicine program at Sutter Solano Medical Center, a 102-bed acute care center in Vallejo, Calif. Knoxville, Tenn.-based TeamHealth has been partnering with hospital-based providers to provide hospitalist, emergency, and anesthesia staffing since 1979.

Christopher Sharp, MD

Christopher Sharp, MD, has been named the new chief medical information officer at Stanford Hospital and Clinics in Stanford, Calif. Dr. Sharp is hospitalist at Stanford University Medical Center, clinical associate professor of medicine at Stanford University School of Medicine, and chair of the Medical Staff Health Information Management (HIM) Committee.

Business Moves

Xavier Perez, MD

Hospitalists of Northern Michigan (HNM), based in Traverse City, Mich., has been recognized as one of Modern Healthcare’s 2013 Best Places to Work in Healthcare. The award has honored healthcare employers for economic development, employee satisfaction, and retention for the last six years. HNM provides hospitalist services to six hospitals in four different healthcare systems throughout Northern Michigan.

Xavier Perez, MD

IPC The Hospitalist Company, based in North Hollywood, Calif., recently announced that it will oversee hospitalist services at Metropolitan Pulmonary and Hospital Medicine, P.C. (MPHM), in Kansas City, Mo. This new agreement will place IPC management into two new Kansas City hospitals. IPC provides hospitalist services to over 350 hospitals in 28 states throughout the country.

WakeMed Health and Hospitals, a Raleigh, N.C.-based healthcare system, now provides pediatric hospitalist services to Central Carolina Hospital (CCH) in Sanford, N.C. WakeMed will begin by staffing three pediatric hospitalists at CCH to establish 24-hour pediatric inpatient care. Central Carolina Hospital is an acute care community hospital that already offers hospitalist services to its adult patients.

Xavier Perez, MD

Tacoma, Wash.-based Sound Inpatient Physicians has partnered with CHRISTUS Health to provide hospitalist services at seven of its hospitals in Texas and Louisiana. The seven hospitals are CHRISTUS Spohn Hospital Corpus Christi-Shoreline and CHRISTUS Spohn Hospital Corpus Christi-South in Corpus Christi, Texas; CHRISTUS Santa Rosa Hospital-Medical Center and CHRISTUS Santa Rosa Hospital-Westover Hills, both in San Antonio, Texas; CHRISTUS St. Frances Cabrini Hospital in Alexandria, La.; CHRISTUS St. Patrick Hospital in Lake Charles, La.; and CHRISTUS Highland Medical Center in Shreveport, La. Sound now provides hospitalist services to over 70 hospitals throughout the country. CHRISTUS Health is a Catholic hospital system made up of more than 40 hospitals throughout seven U.S. states and six Mexican states.

Xavier Perez, MD

Carolinas Medical Center–Union in Monroe, N.C., will staff three 24-hour pediatric hospitalists thanks to an agreement with Levine Children’s Hospital in Charlotte, N.C. Both hospitals are part of Carolinas HealthCare System, which is the largest public, non-profit hospital system in North and South Carolina.

Curry General Hospital in Gold Beach, Ore., is offering hospitalist services to inpatients at the flagship hospital of Curry Health Network, which is made up of seven hospitals and outpatient clinics serving the Wild Rivers Coast area of southwestern Oregon.

Karen Appold’s cover story, “Copper,” in the September 2013 issue, offers an exciting and encouraging development in the struggle to prevent hospital-acquired infections, but I have two concerns. As copper tarnishes, it forms a surface patina of copper hydroxide and copper carbonate. Would this patina act as a physical barrier, preventing bacteria from coming into contact with elemental copper and inhibiting the antimicrobial effect? If so, the obvious solution is to polish the surface frequently enough to prevent tarnishing.

The second concern regards the use of copper-nickel alloys. Many people are sensitive to nickel, [with reactions that] usually manifest as contact dermatitis. A study by the North American Contact Dermatitis Group (NACDG), conducted between 1992-2004 and involving 25,626 patients who were patch-tested, showed a prevalence of nickel sensitivity of 18.8% in 2004, increased from 14.5% in 1992.¹

With a current U.S. population of approximately 317 million, a prevalence of 18.8% would mean nearly 60 million people with nickel sensitivity. Extrapolating from the NACDG study, the rate is probably actually higher. Medical devices made with copper-nickel alloys that contact the patient’s skin would cause contact dermatitis, and implanted devices would have the potential for more severe allergic reactions.

I simply urge foresight and caution in the use of various copper alloys for medical applications.

Rod Duraski, MD, MBA, FACP, medical director, WGH Hospital Medicine, LaGrange, Ga.

Reference

1. Rietschel R, Fowler JF, Warshaw EM, et al. Detection of nickel sensitivity has increased in North American patch-test patients. Dermatitis. 2008;19(1):16-19.

Karen Appold’s cover story, “Copper,” in the September 2013 issue, offers an exciting and encouraging development in the struggle to prevent hospital-acquired infections, but I have two concerns. As copper tarnishes, it forms a surface patina of copper hydroxide and copper carbonate. Would this patina act as a physical barrier, preventing bacteria from coming into contact with elemental copper and inhibiting the antimicrobial effect? If so, the obvious solution is to polish the surface frequently enough to prevent tarnishing.

The second concern regards the use of copper-nickel alloys. Many people are sensitive to nickel, [with reactions that] usually manifest as contact dermatitis. A study by the North American Contact Dermatitis Group (NACDG), conducted between 1992-2004 and involving 25,626 patients who were patch-tested, showed a prevalence of nickel sensitivity of 18.8% in 2004, increased from 14.5% in 1992.¹

With a current U.S. population of approximately 317 million, a prevalence of 18.8% would mean nearly 60 million people with nickel sensitivity. Extrapolating from the NACDG study, the rate is probably actually higher. Medical devices made with copper-nickel alloys that contact the patient’s skin would cause contact dermatitis, and implanted devices would have the potential for more severe allergic reactions.

I simply urge foresight and caution in the use of various copper alloys for medical applications.

Rod Duraski, MD, MBA, FACP, medical director, WGH Hospital Medicine, LaGrange, Ga.

Reference

1. Rietschel R, Fowler JF, Warshaw EM, et al. Detection of nickel sensitivity has increased in North American patch-test patients. Dermatitis. 2008;19(1):16-19.

Karen Appold’s cover story, “Copper,” in the September 2013 issue, offers an exciting and encouraging development in the struggle to prevent hospital-acquired infections, but I have two concerns. As copper tarnishes, it forms a surface patina of copper hydroxide and copper carbonate. Would this patina act as a physical barrier, preventing bacteria from coming into contact with elemental copper and inhibiting the antimicrobial effect? If so, the obvious solution is to polish the surface frequently enough to prevent tarnishing.

The second concern regards the use of copper-nickel alloys. Many people are sensitive to nickel, [with reactions that] usually manifest as contact dermatitis. A study by the North American Contact Dermatitis Group (NACDG), conducted between 1992-2004 and involving 25,626 patients who were patch-tested, showed a prevalence of nickel sensitivity of 18.8% in 2004, increased from 14.5% in 1992.¹

With a current U.S. population of approximately 317 million, a prevalence of 18.8% would mean nearly 60 million people with nickel sensitivity. Extrapolating from the NACDG study, the rate is probably actually higher. Medical devices made with copper-nickel alloys that contact the patient’s skin would cause contact dermatitis, and implanted devices would have the potential for more severe allergic reactions.

I simply urge foresight and caution in the use of various copper alloys for medical applications.

Rod Duraski, MD, MBA, FACP, medical director, WGH Hospital Medicine, LaGrange, Ga.

Reference

1. Rietschel R, Fowler JF, Warshaw EM, et al. Detection of nickel sensitivity has increased in North American patch-test patients. Dermatitis. 2008;19(1):16-19.

Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.

Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.

The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.

“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”

Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.

The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.

“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.

New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.

Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.

Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.

The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.

“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”

Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.

The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.

“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.

New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.

Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.

Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.

The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.

“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”

Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.

The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.

“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.

New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.

Illustrative case

A 62-year-old patient with diabetes, obesity, and a family history of early onset coronary artery disease is motivated to make significant lifestyle changes. You recommend moderate aerobic exercise for 30 minutes 5 times a week, but wonder whether a low-fat diet or a Mediterranean diet would be more effective in lowering her risk.

Cardiovascular disease (CVD), including heart disease and stroke, is the leading cause of mortality in the United States. CVD accounts for one in every 3 deaths,² and stroke is a leading cause of long-term disability.² The direct cost of treating CVD is estimated at $312.6 billion annually.²

Many modifiable risk factors contribute to CVD, including smoking, sedentary lifestyle, obesity, alcohol consumption, and poorly controlled chronic disease, as well as an unhealthy diet. A recent report from the American Heart Association suggests that 13% of deaths from CVD can be attributed to poor diet.²

Focus counseling on patients at risk
Primary care providers (PCPs) often struggle to effectively counsel patients on behavior change strategies, but face many barriers. Chief among them are the lack of time, training, and confidence in their counseling techniques, as well as a lack of patient motivation and readiness to change.³ In recognition of these barriers, the US Preventive Services Task Force recently recommended that PCPs focus behavioral counseling efforts on patients at high risk for heart disease.⁴

Large observational studies have found an association between trans fat and an increased risk of CVD, as well as a decreased risk of CVD in patients adhering to a Mediterranean diet.^5-11 This type of diet typically includes a high intake of olive oil, fruit, nuts, vegetables, and cereals; moderate intake of fish and poultry; and low intake of dairy products, red meat, processed meats, and sweets. It also includes wine in moderation, consumed with meals.

Data on the physiologic properties of olive oil, including its antioxidant, vasodilating, and antiplatelet effects—as well as its effects on low-density lipoprotein cholesterol (LDL-C) that may inhibit atherogenesis—support the link between a Mediterranean diet and a decreased risk of CVD found in the observational studies.^12,13 Until recently, however, no RCT had compared the effect of a Mediterranean diet with that of a low-fat diet for primary prevention of CVD.

STUDY SUMMARY: Mediterranean diet significantly lowers risk

Prevencion con Dieta Mediterranea (PREDIMED) was a large RCT (N=7447) comparing 2 variations of a Mediterranean diet with a low-fat diet for primary prevention of CVD. This Spanish study enrolled men 55 to 80 years of age and women ages 60 to 80 at high risk for developing CVD. The risk was based on either a diagnosis of type 2 diabetes or the presence of ≥3 major risk factors, including smoking, hypertension, elevated LDL-C, low high-density lipoprotein cholesterol, overweight or obese, and a family history of early heart disease.

A Mediterranean diet, with increased intake of either olive oil or mixed nuts, is more protective against CVD than a recommended low-fat diet.Participants were randomly assigned to one of 3 dietary groups: One group was assigned to a Mediterranean diet supplemented with ≥4 tablespoons per day of extra virgin olive oil; a second group was put on a Mediterranean diet supplemented by 30 grams (about 1/3 cup) of mixed nuts daily; a third group (the controls) was advised to follow a low-fat diet. The majority of baseline characteristics and medications taken throughout the study were similar among all 3 groups.

Those in both Mediterranean diet groups were followed for a median of 4.8 years, during which time they received quarterly dietary classes and individual and group counseling. The controls received baseline training, plus a leaflet about low-fat diets annually. In year 3, however, the researchers began giving the control group the same level of counseling as those in the Mediterranean diet groups to avoid confounding results.

Adherence to the diets was determined by a self-reported 14-item dietary screening questionnaire, plus urinary hydroxytyrosol and serum alpha-linoleic acid levels to assess for olive oil and mixed nut compliance. Self-reporting⁵ and biometric data indicated good compliance with the Mediterranean diets, and there was no difference found in levels of exercise among the groups.

After 5 years, those in the Mediterranean diet groups had consumed significantly more olive oil, nuts, vegetables, fruits, wine, legumes, fish, seafood, and sofrito sauce (a popular tomato-based sauce) than the control group. Participants in the low-fat diet group had decreased their fat intake by 2%, while those in the Mediterranean groups had increased fat intake (by 2.03% for the olive oil group and 2.1% for the nut group). Overall, 37% of energy intake by those in the low-fat diet group came from fat (exceeding the <30% of calories derived from fat intake that defines a low-fat diet) vs 39% fat intake for those in both Mediterranean diet groups.

The primary outcome was a composite of myocardial infarction (MI), stroke, and death from cardiovascular causes, and there were clinically meaningful and statistically significant differences between the Mediterranean diet groups and the controls. The primary outcome rate for the supplemental olive oil group was 3.8%; 3.4% for the extra nuts group; and 4.4% for the controls. This represents a 30% reduction in risk for combined stroke, MI, and death due to cardiovascular causes for the Mediterranean diet groups (hazard ratio [HR]=0.7; 95% confidence interval [CI], 0.53-0.91; P=.009; number needed to treat [NNT]=148 for the olive oil group and HR=0.7; 95% CI, 0.53-0.94; P=.02; NNT=100 for the group consuming extra nuts). Similar benefits were found in the multivariable adjusted analyses. The results correspond to 3 fewer events (stroke, MI, or cardiovascular death) per 1000 person-years for this high-risk population.

The only individual outcome that showed a significant decrease was stroke, with an NNT of 125 in both Mediterranean diet groups. Outcomes for the controls were similar before and after they began receiving quarterly counseling.

WHAT'S NEW?: Mediterranean diet is better than a lower-fat regimen

Rates of CVD are higher in the United States than in Spain, so implementing a Mediterranean diet on a large scale in this country has the potential to produce a greater response than that seen in this study. This study indicates that a Mediterranean diet, with increased intake of either olive oil or mixed nuts, is more protective against CVD than a recommended low-fat diet. It also shows that advising patients at high risk to follow a Mediterranean diet, providing dietary counseling, and monitoring them for adherence, rather than simply recommending a low-fat diet, can significantly decrease the risk of stroke.

Rates of CVD are higher in the United States than in Spain, so implementing a Mediterranean diet on a large scale in this country has the potential to produce a greater response than that seen in this study.

CAVEATS: Would a true low-fat diet be a better comparison?

Although the control group’s diet was meant to be low fat, the participants did not achieve this, possibly due to the relatively low level of dietary education and personalized counseling at the start of the study. Their inability to reach the <30% fat target could also reflect the difficulty patients have, in general, in decreasing fat content in their diet, which may mean the diet they maintained was a more realistic comparison.

This study used one brand of olive oil and a particular mixture of nuts (walnuts, hazelnuts, and almonds); it is possible that variations on either of these could affect the benefits of the diet.

CHALLENGES TO IMPLEMENTATION: Fitting a Mediterranean diet into an American lifestyle

The typical US diet is significantly different from that of most Spaniards. Americans may find it difficult to add either ≥4 tablespoons of olive oil or 30 g (1/3 cup) of nuts daily, for example, due to both cost and availability. Limited access to both individual and group counseling could be a barrier, as well.

On the other hand, this practice changer has the potential to simplify dietary counseling by allowing clinicians to focus on just one type of diet, for which there are many resources available both online and in print. We believe it makes sense to recommend a Mediterranean diet, while continuing to recommend increased exercise, smoking cessation, and improved control of chronic disease to lower patients’ risk of poor outcomes from CVD.

Acknowledgement

The PURLs Surveillance System was supported in part by Grant Number UL 1RR 024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

Illustrative case

A 62-year-old patient with diabetes, obesity, and a family history of early onset coronary artery disease is motivated to make significant lifestyle changes. You recommend moderate aerobic exercise for 30 minutes 5 times a week, but wonder whether a low-fat diet or a Mediterranean diet would be more effective in lowering her risk.

Cardiovascular disease (CVD), including heart disease and stroke, is the leading cause of mortality in the United States. CVD accounts for one in every 3 deaths,² and stroke is a leading cause of long-term disability.² The direct cost of treating CVD is estimated at $312.6 billion annually.²

Many modifiable risk factors contribute to CVD, including smoking, sedentary lifestyle, obesity, alcohol consumption, and poorly controlled chronic disease, as well as an unhealthy diet. A recent report from the American Heart Association suggests that 13% of deaths from CVD can be attributed to poor diet.²

Focus counseling on patients at risk
Primary care providers (PCPs) often struggle to effectively counsel patients on behavior change strategies, but face many barriers. Chief among them are the lack of time, training, and confidence in their counseling techniques, as well as a lack of patient motivation and readiness to change.³ In recognition of these barriers, the US Preventive Services Task Force recently recommended that PCPs focus behavioral counseling efforts on patients at high risk for heart disease.⁴

Large observational studies have found an association between trans fat and an increased risk of CVD, as well as a decreased risk of CVD in patients adhering to a Mediterranean diet.^5-11 This type of diet typically includes a high intake of olive oil, fruit, nuts, vegetables, and cereals; moderate intake of fish and poultry; and low intake of dairy products, red meat, processed meats, and sweets. It also includes wine in moderation, consumed with meals.

Data on the physiologic properties of olive oil, including its antioxidant, vasodilating, and antiplatelet effects—as well as its effects on low-density lipoprotein cholesterol (LDL-C) that may inhibit atherogenesis—support the link between a Mediterranean diet and a decreased risk of CVD found in the observational studies.^12,13 Until recently, however, no RCT had compared the effect of a Mediterranean diet with that of a low-fat diet for primary prevention of CVD.

STUDY SUMMARY: Mediterranean diet significantly lowers risk

Prevencion con Dieta Mediterranea (PREDIMED) was a large RCT (N=7447) comparing 2 variations of a Mediterranean diet with a low-fat diet for primary prevention of CVD. This Spanish study enrolled men 55 to 80 years of age and women ages 60 to 80 at high risk for developing CVD. The risk was based on either a diagnosis of type 2 diabetes or the presence of ≥3 major risk factors, including smoking, hypertension, elevated LDL-C, low high-density lipoprotein cholesterol, overweight or obese, and a family history of early heart disease.

A Mediterranean diet, with increased intake of either olive oil or mixed nuts, is more protective against CVD than a recommended low-fat diet.Participants were randomly assigned to one of 3 dietary groups: One group was assigned to a Mediterranean diet supplemented with ≥4 tablespoons per day of extra virgin olive oil; a second group was put on a Mediterranean diet supplemented by 30 grams (about 1/3 cup) of mixed nuts daily; a third group (the controls) was advised to follow a low-fat diet. The majority of baseline characteristics and medications taken throughout the study were similar among all 3 groups.

Those in both Mediterranean diet groups were followed for a median of 4.8 years, during which time they received quarterly dietary classes and individual and group counseling. The controls received baseline training, plus a leaflet about low-fat diets annually. In year 3, however, the researchers began giving the control group the same level of counseling as those in the Mediterranean diet groups to avoid confounding results.

Adherence to the diets was determined by a self-reported 14-item dietary screening questionnaire, plus urinary hydroxytyrosol and serum alpha-linoleic acid levels to assess for olive oil and mixed nut compliance. Self-reporting⁵ and biometric data indicated good compliance with the Mediterranean diets, and there was no difference found in levels of exercise among the groups.

After 5 years, those in the Mediterranean diet groups had consumed significantly more olive oil, nuts, vegetables, fruits, wine, legumes, fish, seafood, and sofrito sauce (a popular tomato-based sauce) than the control group. Participants in the low-fat diet group had decreased their fat intake by 2%, while those in the Mediterranean groups had increased fat intake (by 2.03% for the olive oil group and 2.1% for the nut group). Overall, 37% of energy intake by those in the low-fat diet group came from fat (exceeding the <30% of calories derived from fat intake that defines a low-fat diet) vs 39% fat intake for those in both Mediterranean diet groups.

The primary outcome was a composite of myocardial infarction (MI), stroke, and death from cardiovascular causes, and there were clinically meaningful and statistically significant differences between the Mediterranean diet groups and the controls. The primary outcome rate for the supplemental olive oil group was 3.8%; 3.4% for the extra nuts group; and 4.4% for the controls. This represents a 30% reduction in risk for combined stroke, MI, and death due to cardiovascular causes for the Mediterranean diet groups (hazard ratio [HR]=0.7; 95% confidence interval [CI], 0.53-0.91; P=.009; number needed to treat [NNT]=148 for the olive oil group and HR=0.7; 95% CI, 0.53-0.94; P=.02; NNT=100 for the group consuming extra nuts). Similar benefits were found in the multivariable adjusted analyses. The results correspond to 3 fewer events (stroke, MI, or cardiovascular death) per 1000 person-years for this high-risk population.

The only individual outcome that showed a significant decrease was stroke, with an NNT of 125 in both Mediterranean diet groups. Outcomes for the controls were similar before and after they began receiving quarterly counseling.

WHAT'S NEW?: Mediterranean diet is better than a lower-fat regimen

Rates of CVD are higher in the United States than in Spain, so implementing a Mediterranean diet on a large scale in this country has the potential to produce a greater response than that seen in this study. This study indicates that a Mediterranean diet, with increased intake of either olive oil or mixed nuts, is more protective against CVD than a recommended low-fat diet. It also shows that advising patients at high risk to follow a Mediterranean diet, providing dietary counseling, and monitoring them for adherence, rather than simply recommending a low-fat diet, can significantly decrease the risk of stroke.

Rates of CVD are higher in the United States than in Spain, so implementing a Mediterranean diet on a large scale in this country has the potential to produce a greater response than that seen in this study.

CAVEATS: Would a true low-fat diet be a better comparison?

Although the control group’s diet was meant to be low fat, the participants did not achieve this, possibly due to the relatively low level of dietary education and personalized counseling at the start of the study. Their inability to reach the <30% fat target could also reflect the difficulty patients have, in general, in decreasing fat content in their diet, which may mean the diet they maintained was a more realistic comparison.

This study used one brand of olive oil and a particular mixture of nuts (walnuts, hazelnuts, and almonds); it is possible that variations on either of these could affect the benefits of the diet.

CHALLENGES TO IMPLEMENTATION: Fitting a Mediterranean diet into an American lifestyle

The typical US diet is significantly different from that of most Spaniards. Americans may find it difficult to add either ≥4 tablespoons of olive oil or 30 g (1/3 cup) of nuts daily, for example, due to both cost and availability. Limited access to both individual and group counseling could be a barrier, as well.

On the other hand, this practice changer has the potential to simplify dietary counseling by allowing clinicians to focus on just one type of diet, for which there are many resources available both online and in print. We believe it makes sense to recommend a Mediterranean diet, while continuing to recommend increased exercise, smoking cessation, and improved control of chronic disease to lower patients’ risk of poor outcomes from CVD.

Acknowledgement

The PURLs Surveillance System was supported in part by Grant Number UL 1RR 024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

Illustrative case

A 62-year-old patient with diabetes, obesity, and a family history of early onset coronary artery disease is motivated to make significant lifestyle changes. You recommend moderate aerobic exercise for 30 minutes 5 times a week, but wonder whether a low-fat diet or a Mediterranean diet would be more effective in lowering her risk.

Cardiovascular disease (CVD), including heart disease and stroke, is the leading cause of mortality in the United States. CVD accounts for one in every 3 deaths,² and stroke is a leading cause of long-term disability.² The direct cost of treating CVD is estimated at $312.6 billion annually.²

Many modifiable risk factors contribute to CVD, including smoking, sedentary lifestyle, obesity, alcohol consumption, and poorly controlled chronic disease, as well as an unhealthy diet. A recent report from the American Heart Association suggests that 13% of deaths from CVD can be attributed to poor diet.²

Focus counseling on patients at risk
Primary care providers (PCPs) often struggle to effectively counsel patients on behavior change strategies, but face many barriers. Chief among them are the lack of time, training, and confidence in their counseling techniques, as well as a lack of patient motivation and readiness to change.³ In recognition of these barriers, the US Preventive Services Task Force recently recommended that PCPs focus behavioral counseling efforts on patients at high risk for heart disease.⁴

Large observational studies have found an association between trans fat and an increased risk of CVD, as well as a decreased risk of CVD in patients adhering to a Mediterranean diet.^5-11 This type of diet typically includes a high intake of olive oil, fruit, nuts, vegetables, and cereals; moderate intake of fish and poultry; and low intake of dairy products, red meat, processed meats, and sweets. It also includes wine in moderation, consumed with meals.

Data on the physiologic properties of olive oil, including its antioxidant, vasodilating, and antiplatelet effects—as well as its effects on low-density lipoprotein cholesterol (LDL-C) that may inhibit atherogenesis—support the link between a Mediterranean diet and a decreased risk of CVD found in the observational studies.^12,13 Until recently, however, no RCT had compared the effect of a Mediterranean diet with that of a low-fat diet for primary prevention of CVD.

STUDY SUMMARY: Mediterranean diet significantly lowers risk

Prevencion con Dieta Mediterranea (PREDIMED) was a large RCT (N=7447) comparing 2 variations of a Mediterranean diet with a low-fat diet for primary prevention of CVD. This Spanish study enrolled men 55 to 80 years of age and women ages 60 to 80 at high risk for developing CVD. The risk was based on either a diagnosis of type 2 diabetes or the presence of ≥3 major risk factors, including smoking, hypertension, elevated LDL-C, low high-density lipoprotein cholesterol, overweight or obese, and a family history of early heart disease.

A Mediterranean diet, with increased intake of either olive oil or mixed nuts, is more protective against CVD than a recommended low-fat diet.Participants were randomly assigned to one of 3 dietary groups: One group was assigned to a Mediterranean diet supplemented with ≥4 tablespoons per day of extra virgin olive oil; a second group was put on a Mediterranean diet supplemented by 30 grams (about 1/3 cup) of mixed nuts daily; a third group (the controls) was advised to follow a low-fat diet. The majority of baseline characteristics and medications taken throughout the study were similar among all 3 groups.

Those in both Mediterranean diet groups were followed for a median of 4.8 years, during which time they received quarterly dietary classes and individual and group counseling. The controls received baseline training, plus a leaflet about low-fat diets annually. In year 3, however, the researchers began giving the control group the same level of counseling as those in the Mediterranean diet groups to avoid confounding results.

Adherence to the diets was determined by a self-reported 14-item dietary screening questionnaire, plus urinary hydroxytyrosol and serum alpha-linoleic acid levels to assess for olive oil and mixed nut compliance. Self-reporting⁵ and biometric data indicated good compliance with the Mediterranean diets, and there was no difference found in levels of exercise among the groups.

After 5 years, those in the Mediterranean diet groups had consumed significantly more olive oil, nuts, vegetables, fruits, wine, legumes, fish, seafood, and sofrito sauce (a popular tomato-based sauce) than the control group. Participants in the low-fat diet group had decreased their fat intake by 2%, while those in the Mediterranean groups had increased fat intake (by 2.03% for the olive oil group and 2.1% for the nut group). Overall, 37% of energy intake by those in the low-fat diet group came from fat (exceeding the <30% of calories derived from fat intake that defines a low-fat diet) vs 39% fat intake for those in both Mediterranean diet groups.

The primary outcome was a composite of myocardial infarction (MI), stroke, and death from cardiovascular causes, and there were clinically meaningful and statistically significant differences between the Mediterranean diet groups and the controls. The primary outcome rate for the supplemental olive oil group was 3.8%; 3.4% for the extra nuts group; and 4.4% for the controls. This represents a 30% reduction in risk for combined stroke, MI, and death due to cardiovascular causes for the Mediterranean diet groups (hazard ratio [HR]=0.7; 95% confidence interval [CI], 0.53-0.91; P=.009; number needed to treat [NNT]=148 for the olive oil group and HR=0.7; 95% CI, 0.53-0.94; P=.02; NNT=100 for the group consuming extra nuts). Similar benefits were found in the multivariable adjusted analyses. The results correspond to 3 fewer events (stroke, MI, or cardiovascular death) per 1000 person-years for this high-risk population.

The only individual outcome that showed a significant decrease was stroke, with an NNT of 125 in both Mediterranean diet groups. Outcomes for the controls were similar before and after they began receiving quarterly counseling.

WHAT'S NEW?: Mediterranean diet is better than a lower-fat regimen

Rates of CVD are higher in the United States than in Spain, so implementing a Mediterranean diet on a large scale in this country has the potential to produce a greater response than that seen in this study. This study indicates that a Mediterranean diet, with increased intake of either olive oil or mixed nuts, is more protective against CVD than a recommended low-fat diet. It also shows that advising patients at high risk to follow a Mediterranean diet, providing dietary counseling, and monitoring them for adherence, rather than simply recommending a low-fat diet, can significantly decrease the risk of stroke.

Rates of CVD are higher in the United States than in Spain, so implementing a Mediterranean diet on a large scale in this country has the potential to produce a greater response than that seen in this study.

CAVEATS: Would a true low-fat diet be a better comparison?

Although the control group’s diet was meant to be low fat, the participants did not achieve this, possibly due to the relatively low level of dietary education and personalized counseling at the start of the study. Their inability to reach the <30% fat target could also reflect the difficulty patients have, in general, in decreasing fat content in their diet, which may mean the diet they maintained was a more realistic comparison.

This study used one brand of olive oil and a particular mixture of nuts (walnuts, hazelnuts, and almonds); it is possible that variations on either of these could affect the benefits of the diet.

CHALLENGES TO IMPLEMENTATION: Fitting a Mediterranean diet into an American lifestyle

The typical US diet is significantly different from that of most Spaniards. Americans may find it difficult to add either ≥4 tablespoons of olive oil or 30 g (1/3 cup) of nuts daily, for example, due to both cost and availability. Limited access to both individual and group counseling could be a barrier, as well.

On the other hand, this practice changer has the potential to simplify dietary counseling by allowing clinicians to focus on just one type of diet, for which there are many resources available both online and in print. We believe it makes sense to recommend a Mediterranean diet, while continuing to recommend increased exercise, smoking cessation, and improved control of chronic disease to lower patients’ risk of poor outcomes from CVD.

Acknowledgement

The PURLs Surveillance System was supported in part by Grant Number UL 1RR 024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

Describing formally for the first time the enormity of the problem of antibiotic resistance and warning of the “potentially catastrophic consequences of inaction,” the Centers for Disease Control and Prevention (CDC) announced in September that more than two million people a year are sickened by infections that are resistant to treatment with antibiotics.

Moreover, the CDC says 23,000 people die as a result.

And because those numbers are based only on the data available—and the agency assumes that many infections are not captured—the CDC says its estimate is a conservative one and the real number is probably higher.

The report is a call to action for hospitalists, who are in an almost ideal position to participate in efforts to prevent infections and control their spread once they’re discovered, says Jean Patel, PhD, deputy director of the office of antimicrobial resistance at the CDC.

“I think it’s a sobering number, and it indicates how far we have to go in combating this problem of antimicrobial resistance,” Dr. Patel says.

The medical community, she adds, cannot expect that new treatments will become available to fight all of these new infections.

“All of the drugs also are going to have some gaps in their range of activity, so there’s no drug coming that’s going to be effective against all the antimicrobial-resistant drugs that we face today,” Dr. Patel explains. “For that reason, we’re sounding the alarm that it’s important to pay attention to infection control and antibiotic stewardship practices.”

The report, “Antibiotic Resistance Threats to the United States, 2013,” creates three categories of antibiotic-resistant pathogens. In the “urgent” tier are Clostridium difficile, which the CDC estimates is responsible for 250,000 infections a year and 14,000 deaths; carbapenem-resistant Enterobacteriaceae, estimated to be responsible for 9,000 drug-resistant infections a year and 600 deaths; and drug-resistant Neisseria gonorrhoeae, at 246,000 drug-resistant infections.

These bacteria are considered an “immediate public health threat that requires urgent and aggressive action.”

There are 12 pathogens in the second category, described as “a serious concern” requiring “prompt and sustained action to ensure the problem does not grow.”

Of particular interest to hospitalists in this group, Dr. Patel says, is methicillin-resistant Staphylococcus aureus (MRSA). The CDC estimates that more than 80,000 severe MRSA infections and more than 11,000 deaths occur in the U.S. every year.

MRSA was not ranked as an “urgent” threat only because the number of infections is actually decreasing, especially in healthcare institutions, and because there are antibiotics that still work on MRSA.

“If either of those things were to change—for example, if the rate of infections were to increase, or if these isolates were to become more resistant—then we would have to think about changing this from a serious threat to an urgent threat,” Dr. Patel says.

Another infection in the serious category that should be on hospitalists’ radar is drug-resistant Streptococcus pneumoniae. A new vaccine is helping to decrease the number of these infections, but hospitalists should be vigilant about infections that could escape the vaccine and become resistant, Dr. Patel says.

The report estimates as much as $20 billion in excess healthcare costs due to antimicrobial-resistant infections, with $35 billion in lost productivity in 2008 dollars.1

Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious disease control committees at Emory University Hospital Midtown, says the sheer numbers are sure to get people to take notice.

“Two million is lots of patients,” she says. “It’s eye-opening, really, for many doctors and patients and society.”

The silver lining, she says, is that the field is moving toward diagnostic tools that will provide quick feedback on the type of infection at work.

It may be that hospitalists have no choice but to give an antibiotic to a patient because of the risk involved in not giving one; however, providers should quickly tailor that treatment to target the specific pathogen when more information is available.

“The most important thing, I think, for hospital medicine and medicine anywhere, is to follow up with whatever you’re ordering and notice right away what happens with these tests. If it’s positive or negative, redirect your care,” Dr. Kobaidze says. “Time is really an important issue here.

“As hospitalists, we need to be extremely cautious not to give them something they don’t need.”

Dr. Kobaidze was particularly struck by gonorrhea being listed in the “urgent” threat category.

“It was so easy to treat before,” she says. “It was nothing, piece of cake. This makes me a little bit concerned.”

Robert Orenstein, DO, an infectious disease expert at Mayo Clinic, praises the report and says hospitalists have a key role to play.

“I think this has a clear impact on hospitalists, who are the primary caregivers of many of these ill patients,” he says. “We need to educate them and build systems that target antimicrobials to the infecting agents and limit their use. Hospitalists are also the people who can help protect patients from the spread of these in the hospital by following appropriate infection prevention guidelines and educating their colleagues of the importance of this.”

He also stresses the importance of being aware of threats within your specific region.

“Many of these MDROs [multi-drug resistant organisms] have regional prevalence,” he says. “And it’s important to know which bugs are in your region so you can work with your institution and public health to tackle these.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Roberts RR, Hota B, Ahmed I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009;49(8):1175-1184.

Describing formally for the first time the enormity of the problem of antibiotic resistance and warning of the “potentially catastrophic consequences of inaction,” the Centers for Disease Control and Prevention (CDC) announced in September that more than two million people a year are sickened by infections that are resistant to treatment with antibiotics.

Moreover, the CDC says 23,000 people die as a result.

And because those numbers are based only on the data available—and the agency assumes that many infections are not captured—the CDC says its estimate is a conservative one and the real number is probably higher.

The report is a call to action for hospitalists, who are in an almost ideal position to participate in efforts to prevent infections and control their spread once they’re discovered, says Jean Patel, PhD, deputy director of the office of antimicrobial resistance at the CDC.

“I think it’s a sobering number, and it indicates how far we have to go in combating this problem of antimicrobial resistance,” Dr. Patel says.

The medical community, she adds, cannot expect that new treatments will become available to fight all of these new infections.

“All of the drugs also are going to have some gaps in their range of activity, so there’s no drug coming that’s going to be effective against all the antimicrobial-resistant drugs that we face today,” Dr. Patel explains. “For that reason, we’re sounding the alarm that it’s important to pay attention to infection control and antibiotic stewardship practices.”

The report, “Antibiotic Resistance Threats to the United States, 2013,” creates three categories of antibiotic-resistant pathogens. In the “urgent” tier are Clostridium difficile, which the CDC estimates is responsible for 250,000 infections a year and 14,000 deaths; carbapenem-resistant Enterobacteriaceae, estimated to be responsible for 9,000 drug-resistant infections a year and 600 deaths; and drug-resistant Neisseria gonorrhoeae, at 246,000 drug-resistant infections.

These bacteria are considered an “immediate public health threat that requires urgent and aggressive action.”

There are 12 pathogens in the second category, described as “a serious concern” requiring “prompt and sustained action to ensure the problem does not grow.”

Of particular interest to hospitalists in this group, Dr. Patel says, is methicillin-resistant Staphylococcus aureus (MRSA). The CDC estimates that more than 80,000 severe MRSA infections and more than 11,000 deaths occur in the U.S. every year.

MRSA was not ranked as an “urgent” threat only because the number of infections is actually decreasing, especially in healthcare institutions, and because there are antibiotics that still work on MRSA.

“If either of those things were to change—for example, if the rate of infections were to increase, or if these isolates were to become more resistant—then we would have to think about changing this from a serious threat to an urgent threat,” Dr. Patel says.

Another infection in the serious category that should be on hospitalists’ radar is drug-resistant Streptococcus pneumoniae. A new vaccine is helping to decrease the number of these infections, but hospitalists should be vigilant about infections that could escape the vaccine and become resistant, Dr. Patel says.

The report estimates as much as $20 billion in excess healthcare costs due to antimicrobial-resistant infections, with $35 billion in lost productivity in 2008 dollars.1

Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious disease control committees at Emory University Hospital Midtown, says the sheer numbers are sure to get people to take notice.

“Two million is lots of patients,” she says. “It’s eye-opening, really, for many doctors and patients and society.”

The silver lining, she says, is that the field is moving toward diagnostic tools that will provide quick feedback on the type of infection at work.

It may be that hospitalists have no choice but to give an antibiotic to a patient because of the risk involved in not giving one; however, providers should quickly tailor that treatment to target the specific pathogen when more information is available.

“The most important thing, I think, for hospital medicine and medicine anywhere, is to follow up with whatever you’re ordering and notice right away what happens with these tests. If it’s positive or negative, redirect your care,” Dr. Kobaidze says. “Time is really an important issue here.

“As hospitalists, we need to be extremely cautious not to give them something they don’t need.”

Dr. Kobaidze was particularly struck by gonorrhea being listed in the “urgent” threat category.

“It was so easy to treat before,” she says. “It was nothing, piece of cake. This makes me a little bit concerned.”

Robert Orenstein, DO, an infectious disease expert at Mayo Clinic, praises the report and says hospitalists have a key role to play.

“I think this has a clear impact on hospitalists, who are the primary caregivers of many of these ill patients,” he says. “We need to educate them and build systems that target antimicrobials to the infecting agents and limit their use. Hospitalists are also the people who can help protect patients from the spread of these in the hospital by following appropriate infection prevention guidelines and educating their colleagues of the importance of this.”

He also stresses the importance of being aware of threats within your specific region.

“Many of these MDROs [multi-drug resistant organisms] have regional prevalence,” he says. “And it’s important to know which bugs are in your region so you can work with your institution and public health to tackle these.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Roberts RR, Hota B, Ahmed I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009;49(8):1175-1184.

Describing formally for the first time the enormity of the problem of antibiotic resistance and warning of the “potentially catastrophic consequences of inaction,” the Centers for Disease Control and Prevention (CDC) announced in September that more than two million people a year are sickened by infections that are resistant to treatment with antibiotics.

Moreover, the CDC says 23,000 people die as a result.

And because those numbers are based only on the data available—and the agency assumes that many infections are not captured—the CDC says its estimate is a conservative one and the real number is probably higher.

The report is a call to action for hospitalists, who are in an almost ideal position to participate in efforts to prevent infections and control their spread once they’re discovered, says Jean Patel, PhD, deputy director of the office of antimicrobial resistance at the CDC.

“I think it’s a sobering number, and it indicates how far we have to go in combating this problem of antimicrobial resistance,” Dr. Patel says.

The medical community, she adds, cannot expect that new treatments will become available to fight all of these new infections.

“All of the drugs also are going to have some gaps in their range of activity, so there’s no drug coming that’s going to be effective against all the antimicrobial-resistant drugs that we face today,” Dr. Patel explains. “For that reason, we’re sounding the alarm that it’s important to pay attention to infection control and antibiotic stewardship practices.”

The report, “Antibiotic Resistance Threats to the United States, 2013,” creates three categories of antibiotic-resistant pathogens. In the “urgent” tier are Clostridium difficile, which the CDC estimates is responsible for 250,000 infections a year and 14,000 deaths; carbapenem-resistant Enterobacteriaceae, estimated to be responsible for 9,000 drug-resistant infections a year and 600 deaths; and drug-resistant Neisseria gonorrhoeae, at 246,000 drug-resistant infections.

These bacteria are considered an “immediate public health threat that requires urgent and aggressive action.”

There are 12 pathogens in the second category, described as “a serious concern” requiring “prompt and sustained action to ensure the problem does not grow.”

Of particular interest to hospitalists in this group, Dr. Patel says, is methicillin-resistant Staphylococcus aureus (MRSA). The CDC estimates that more than 80,000 severe MRSA infections and more than 11,000 deaths occur in the U.S. every year.

MRSA was not ranked as an “urgent” threat only because the number of infections is actually decreasing, especially in healthcare institutions, and because there are antibiotics that still work on MRSA.

“If either of those things were to change—for example, if the rate of infections were to increase, or if these isolates were to become more resistant—then we would have to think about changing this from a serious threat to an urgent threat,” Dr. Patel says.

Another infection in the serious category that should be on hospitalists’ radar is drug-resistant Streptococcus pneumoniae. A new vaccine is helping to decrease the number of these infections, but hospitalists should be vigilant about infections that could escape the vaccine and become resistant, Dr. Patel says.

The report estimates as much as $20 billion in excess healthcare costs due to antimicrobial-resistant infections, with $35 billion in lost productivity in 2008 dollars.1

Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine in Atlanta and a member of the antimicrobial stewardship and infectious disease control committees at Emory University Hospital Midtown, says the sheer numbers are sure to get people to take notice.

“Two million is lots of patients,” she says. “It’s eye-opening, really, for many doctors and patients and society.”

The silver lining, she says, is that the field is moving toward diagnostic tools that will provide quick feedback on the type of infection at work.

It may be that hospitalists have no choice but to give an antibiotic to a patient because of the risk involved in not giving one; however, providers should quickly tailor that treatment to target the specific pathogen when more information is available.

“The most important thing, I think, for hospital medicine and medicine anywhere, is to follow up with whatever you’re ordering and notice right away what happens with these tests. If it’s positive or negative, redirect your care,” Dr. Kobaidze says. “Time is really an important issue here.

“As hospitalists, we need to be extremely cautious not to give them something they don’t need.”

Dr. Kobaidze was particularly struck by gonorrhea being listed in the “urgent” threat category.

“It was so easy to treat before,” she says. “It was nothing, piece of cake. This makes me a little bit concerned.”

Robert Orenstein, DO, an infectious disease expert at Mayo Clinic, praises the report and says hospitalists have a key role to play.

“I think this has a clear impact on hospitalists, who are the primary caregivers of many of these ill patients,” he says. “We need to educate them and build systems that target antimicrobials to the infecting agents and limit their use. Hospitalists are also the people who can help protect patients from the spread of these in the hospital by following appropriate infection prevention guidelines and educating their colleagues of the importance of this.”

He also stresses the importance of being aware of threats within your specific region.

“Many of these MDROs [multi-drug resistant organisms] have regional prevalence,” he says. “And it’s important to know which bugs are in your region so you can work with your institution and public health to tackle these.”

Tom Collins is a freelance writer in South Florida.

Reference

1. Roberts RR, Hota B, Ahmed I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009;49(8):1175-1184.