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Major takeaways from the seventh world symposium on PH
Pulmonary Vascular and Cardiovascular Network
Pulmonary Vascular Disease Section
The core definition of pulmonary hypertension (PH) remains a mean pulmonary arterial pressure (mPAP) > 20 mm Hg, with precapillary PH defined by a pulmonary arterial wedge pressure (PCWP) ≤ 15 mm Hg and pulmonary vascular resistance (PVR) > 2 Wood units (WU), similar to the 2022 European guidelines.1,2 There was recognition of uncertainty in patients with borderline PAWP (12-18 mm Hg) for postcapillary PH.
It’s crucial to phenotype patients, especially those with valvular heart disease, hypertrophic cardiomyopathy, or amyloid cardiomyopathy, and to be cautious when using PAH medications for this PH group.3
Group 3 PH is often underrecognized and associated with poor outcomes, so screening in clinically stable patients is recommended using a multimodal assessment before hemodynamic evaluation. Inhaled treprostinil is recommended for PH associated with interstitial lung disease (ILD). However, the PERFECT trial on PH therapy in COPD was stopped due to safety concerns, highlighting the need for careful evaluation in chronic lung disease (CLD) patients.4 For risk stratification, further emphasis was made on cardiac imaging and hemodynamic data.
Significant progress was made in understanding four key pathways, including bone morphogenetic protein (BMP)/activin signaling. A treatment algorithm based on risk stratification was reinforced, recommending initial triple therapy with parenteral prostacyclin analogs for high-risk patients.5 Follow-up reassessment may include adding an activin-signaling inhibitor for all risk groups except low risk, as well as oral or inhaled prostacyclin for intermediate-low risk groups.
References
1. Kovacs G, Bartolome S, Denton CP, et al. Definition, classification and diagnosis of pulmonary hypertension. Eur Respir J. 2024;2401324. (Online ahead of print.)
2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2024;61(1):2200879.
3. Maron BA, Bortman G, De Marco T, et al. Pulmonary hypertension associated with left heart disease. Eur Respir J. 2024;2401344. (Online ahead of print.)
4. Shlobin OA, Adir Y, Barbera JA, et al. Pulmonary hypertension associated with lung diseases. Eur Respir J. 2024;2401200. (Online ahead of print.)
5. Chin KM, Gaine SP, Gerges C, et al. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J. 2024;2401325. (Online ahead of print.)
Pulmonary Vascular and Cardiovascular Network
Pulmonary Vascular Disease Section
The core definition of pulmonary hypertension (PH) remains a mean pulmonary arterial pressure (mPAP) > 20 mm Hg, with precapillary PH defined by a pulmonary arterial wedge pressure (PCWP) ≤ 15 mm Hg and pulmonary vascular resistance (PVR) > 2 Wood units (WU), similar to the 2022 European guidelines.1,2 There was recognition of uncertainty in patients with borderline PAWP (12-18 mm Hg) for postcapillary PH.
It’s crucial to phenotype patients, especially those with valvular heart disease, hypertrophic cardiomyopathy, or amyloid cardiomyopathy, and to be cautious when using PAH medications for this PH group.3
Group 3 PH is often underrecognized and associated with poor outcomes, so screening in clinically stable patients is recommended using a multimodal assessment before hemodynamic evaluation. Inhaled treprostinil is recommended for PH associated with interstitial lung disease (ILD). However, the PERFECT trial on PH therapy in COPD was stopped due to safety concerns, highlighting the need for careful evaluation in chronic lung disease (CLD) patients.4 For risk stratification, further emphasis was made on cardiac imaging and hemodynamic data.
Significant progress was made in understanding four key pathways, including bone morphogenetic protein (BMP)/activin signaling. A treatment algorithm based on risk stratification was reinforced, recommending initial triple therapy with parenteral prostacyclin analogs for high-risk patients.5 Follow-up reassessment may include adding an activin-signaling inhibitor for all risk groups except low risk, as well as oral or inhaled prostacyclin for intermediate-low risk groups.
References
1. Kovacs G, Bartolome S, Denton CP, et al. Definition, classification and diagnosis of pulmonary hypertension. Eur Respir J. 2024;2401324. (Online ahead of print.)
2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2024;61(1):2200879.
3. Maron BA, Bortman G, De Marco T, et al. Pulmonary hypertension associated with left heart disease. Eur Respir J. 2024;2401344. (Online ahead of print.)
4. Shlobin OA, Adir Y, Barbera JA, et al. Pulmonary hypertension associated with lung diseases. Eur Respir J. 2024;2401200. (Online ahead of print.)
5. Chin KM, Gaine SP, Gerges C, et al. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J. 2024;2401325. (Online ahead of print.)
Pulmonary Vascular and Cardiovascular Network
Pulmonary Vascular Disease Section
The core definition of pulmonary hypertension (PH) remains a mean pulmonary arterial pressure (mPAP) > 20 mm Hg, with precapillary PH defined by a pulmonary arterial wedge pressure (PCWP) ≤ 15 mm Hg and pulmonary vascular resistance (PVR) > 2 Wood units (WU), similar to the 2022 European guidelines.1,2 There was recognition of uncertainty in patients with borderline PAWP (12-18 mm Hg) for postcapillary PH.
It’s crucial to phenotype patients, especially those with valvular heart disease, hypertrophic cardiomyopathy, or amyloid cardiomyopathy, and to be cautious when using PAH medications for this PH group.3
Group 3 PH is often underrecognized and associated with poor outcomes, so screening in clinically stable patients is recommended using a multimodal assessment before hemodynamic evaluation. Inhaled treprostinil is recommended for PH associated with interstitial lung disease (ILD). However, the PERFECT trial on PH therapy in COPD was stopped due to safety concerns, highlighting the need for careful evaluation in chronic lung disease (CLD) patients.4 For risk stratification, further emphasis was made on cardiac imaging and hemodynamic data.
Significant progress was made in understanding four key pathways, including bone morphogenetic protein (BMP)/activin signaling. A treatment algorithm based on risk stratification was reinforced, recommending initial triple therapy with parenteral prostacyclin analogs for high-risk patients.5 Follow-up reassessment may include adding an activin-signaling inhibitor for all risk groups except low risk, as well as oral or inhaled prostacyclin for intermediate-low risk groups.
References
1. Kovacs G, Bartolome S, Denton CP, et al. Definition, classification and diagnosis of pulmonary hypertension. Eur Respir J. 2024;2401324. (Online ahead of print.)
2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2024;61(1):2200879.
3. Maron BA, Bortman G, De Marco T, et al. Pulmonary hypertension associated with left heart disease. Eur Respir J. 2024;2401344. (Online ahead of print.)
4. Shlobin OA, Adir Y, Barbera JA, et al. Pulmonary hypertension associated with lung diseases. Eur Respir J. 2024;2401200. (Online ahead of print.)
5. Chin KM, Gaine SP, Gerges C, et al. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J. 2024;2401325. (Online ahead of print.)
Extending exercise testing using telehealth monitoring in patients with ILD
Diffuse Lung Disease and Lung Transplant Network
Pulmonary Physiology and Rehabilitation Section
The COVID-19 pandemic revolutionized the use of monitoring equipment in general and oxygen saturation monitoring devices as pulse oximeters in specific. The increasing adoption of activity trackers is geared toward promoting an active lifestyle through real-time feedback and continuous monitoring. Patients with interstitial lung diseases (ILDs) suffer from different symptoms; one of the most disabling is dyspnea. Primarily associated with oxygen desaturation, it initiates a detrimental cycle of decreased physical activity, ultimately compromising the overall quality of life.
The use of activity trackers has shown to enhance exercise capacity among ILD and sarcoidosis patients.1
Implementing continuous monitor activity by activity trackers coupled with continuous oxygen saturation can provide a comprehensive tool to follow up with ILD patients efficiently and accurately based on established use of a six-minute walk test (6MWT) and desaturation screen. Combined 6MWT and desaturation screens remain the principal predictors to assess the disease progression and treatment response in a variety of lung diseases, mainly pulmonary hypertension and ILD and serve as a prognostic indicator of those patients.2 One of the test limitations is that the distance walked in six minutes reflects fluctuations in quality of life.3 Also, the test measures submaximal exercise performance rather than maximal exercise capacity.4
Associations have been found in that the amplitude of oxygen desaturation at the end of exercise was poorly reproducible in 6MWT in idiopathic Interstitial pneumonia.5
Considering the mentioned limitations of the classic 6MWT, an alternative approach involves extended desaturation screen using telehealth and involving different activity levels. However, further validation across a diverse spectrum of ILDs remains essential.
References
1. Cho PSP, Vasudevan S, Maddocks M, et al. Physical inactivity in pulmonary sarcoidosis. Lung. 2019;197(3):285-293.
2. Flaherty KR, Andrei AC, Murray S, et al. Idiopathic pulmonary fibrosis: prognostic value of changes in physiology and six-minute-walk test. Am J Respir Crit Care Med. 2006;174(7), 803-809.
3. Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG. Six-minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review. Eur Heart J. 2005;26(8):778-793.
4. Ingle L, Wilkinson M, Carroll S, et al. Cardiorespiratory requirements of the 6-min walk test in older patients with left ventricular systolic dysfunction and no major structural heart disease. Int J Sports Med. 2007;28(8):678-684. https://doi.org/10.1055/s-2007-964886
5. Eaton T, Young P, Milne D, Wells AU. Six-minute walk, maximal exercise tests: reproducibility in fibrotic interstitial pneumonia. Am J Respir Crit Care Med. 2005;171(10):1150-1157.
Diffuse Lung Disease and Lung Transplant Network
Pulmonary Physiology and Rehabilitation Section
The COVID-19 pandemic revolutionized the use of monitoring equipment in general and oxygen saturation monitoring devices as pulse oximeters in specific. The increasing adoption of activity trackers is geared toward promoting an active lifestyle through real-time feedback and continuous monitoring. Patients with interstitial lung diseases (ILDs) suffer from different symptoms; one of the most disabling is dyspnea. Primarily associated with oxygen desaturation, it initiates a detrimental cycle of decreased physical activity, ultimately compromising the overall quality of life.
The use of activity trackers has shown to enhance exercise capacity among ILD and sarcoidosis patients.1
Implementing continuous monitor activity by activity trackers coupled with continuous oxygen saturation can provide a comprehensive tool to follow up with ILD patients efficiently and accurately based on established use of a six-minute walk test (6MWT) and desaturation screen. Combined 6MWT and desaturation screens remain the principal predictors to assess the disease progression and treatment response in a variety of lung diseases, mainly pulmonary hypertension and ILD and serve as a prognostic indicator of those patients.2 One of the test limitations is that the distance walked in six minutes reflects fluctuations in quality of life.3 Also, the test measures submaximal exercise performance rather than maximal exercise capacity.4
Associations have been found in that the amplitude of oxygen desaturation at the end of exercise was poorly reproducible in 6MWT in idiopathic Interstitial pneumonia.5
Considering the mentioned limitations of the classic 6MWT, an alternative approach involves extended desaturation screen using telehealth and involving different activity levels. However, further validation across a diverse spectrum of ILDs remains essential.
References
1. Cho PSP, Vasudevan S, Maddocks M, et al. Physical inactivity in pulmonary sarcoidosis. Lung. 2019;197(3):285-293.
2. Flaherty KR, Andrei AC, Murray S, et al. Idiopathic pulmonary fibrosis: prognostic value of changes in physiology and six-minute-walk test. Am J Respir Crit Care Med. 2006;174(7), 803-809.
3. Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG. Six-minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review. Eur Heart J. 2005;26(8):778-793.
4. Ingle L, Wilkinson M, Carroll S, et al. Cardiorespiratory requirements of the 6-min walk test in older patients with left ventricular systolic dysfunction and no major structural heart disease. Int J Sports Med. 2007;28(8):678-684. https://doi.org/10.1055/s-2007-964886
5. Eaton T, Young P, Milne D, Wells AU. Six-minute walk, maximal exercise tests: reproducibility in fibrotic interstitial pneumonia. Am J Respir Crit Care Med. 2005;171(10):1150-1157.
Diffuse Lung Disease and Lung Transplant Network
Pulmonary Physiology and Rehabilitation Section
The COVID-19 pandemic revolutionized the use of monitoring equipment in general and oxygen saturation monitoring devices as pulse oximeters in specific. The increasing adoption of activity trackers is geared toward promoting an active lifestyle through real-time feedback and continuous monitoring. Patients with interstitial lung diseases (ILDs) suffer from different symptoms; one of the most disabling is dyspnea. Primarily associated with oxygen desaturation, it initiates a detrimental cycle of decreased physical activity, ultimately compromising the overall quality of life.
The use of activity trackers has shown to enhance exercise capacity among ILD and sarcoidosis patients.1
Implementing continuous monitor activity by activity trackers coupled with continuous oxygen saturation can provide a comprehensive tool to follow up with ILD patients efficiently and accurately based on established use of a six-minute walk test (6MWT) and desaturation screen. Combined 6MWT and desaturation screens remain the principal predictors to assess the disease progression and treatment response in a variety of lung diseases, mainly pulmonary hypertension and ILD and serve as a prognostic indicator of those patients.2 One of the test limitations is that the distance walked in six minutes reflects fluctuations in quality of life.3 Also, the test measures submaximal exercise performance rather than maximal exercise capacity.4
Associations have been found in that the amplitude of oxygen desaturation at the end of exercise was poorly reproducible in 6MWT in idiopathic Interstitial pneumonia.5
Considering the mentioned limitations of the classic 6MWT, an alternative approach involves extended desaturation screen using telehealth and involving different activity levels. However, further validation across a diverse spectrum of ILDs remains essential.
References
1. Cho PSP, Vasudevan S, Maddocks M, et al. Physical inactivity in pulmonary sarcoidosis. Lung. 2019;197(3):285-293.
2. Flaherty KR, Andrei AC, Murray S, et al. Idiopathic pulmonary fibrosis: prognostic value of changes in physiology and six-minute-walk test. Am J Respir Crit Care Med. 2006;174(7), 803-809.
3. Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG. Six-minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review. Eur Heart J. 2005;26(8):778-793.
4. Ingle L, Wilkinson M, Carroll S, et al. Cardiorespiratory requirements of the 6-min walk test in older patients with left ventricular systolic dysfunction and no major structural heart disease. Int J Sports Med. 2007;28(8):678-684. https://doi.org/10.1055/s-2007-964886
5. Eaton T, Young P, Milne D, Wells AU. Six-minute walk, maximal exercise tests: reproducibility in fibrotic interstitial pneumonia. Am J Respir Crit Care Med. 2005;171(10):1150-1157.
Exciting opportunities for tobacco treatment
FROM THE CHEST TOBACCO/VAPING WORK GROUP –
The recent changes enacted by the Centers for Medicare & Medicaid Services (CMS) are creating unprecedented opportunities for pulmonologists and medical centers to help treat people with tobacco use disorder. As we face a critical moment in the fight against tobacco-related morbidity and mortality, it is essential that we leverage these changes. In doing so, CHEST aims to serve as an active bridge, informing health care providers of this unique federal opportunity that benefits both patients and clinicians.
A quick primer on “incident to” services
These CMS changes create an important shift in how “incident to” services can be billed. These are any services that are incident to (occur because of) a provider evaluation. These previously required direct supervision of the provider (in the same building) to be billed at the provider rate. Now “general supervision” suffices, which means the physician can be available by phone/video call. These services can then often be billed at a higher rate. In the case of treating dependence on tobacco products, any tobacco treatment specialist (TTS) employed by a practice who cares for the patient subsequent to the initial encounter can now be reimbursed in an increased manner. Better reimbursement for this vital service will ideally lead to better utilization of these resources and better public health.
The Medicare solution is here
With the CMS rule changes in 2023 and their reaffirmation in 2024, the structure has been put in place to allow physicians, medical centers, and TTSs to create contractual relationships that can significantly improve patient care. TTSs are health care professionals from a wide variety of disciplines who have received specialized training in tobacco and nicotine addiction and treatment strategies. By expanding billing and, thus, service opportunities, these CMS modifications empower health care providers to leverage the existing fee-for-service model, translating to better care and sustainable revenue streams.
Key changes in the CMS 2023 rule
One of the most notable changes involves the supervision requirements for auxiliary personnel, which now permit general supervision. Specifically, physicians are not required to be physically present during clinical encounters but can supervise TTSs virtually through real-time audio/video technology. This is a vital shift that enhances flexibility in patient care and expands the capabilities of health care teams.
According to 42 CFR § 410.26, TTSs qualify as auxiliary health care providers, meaning that they can operate under the supervision of a physician or other designated providers. This revised framework gives practices maximum autonomy in their staffing models and enhances their ability to offer comprehensive care. For example, TTSs can function as patient navigators, ensuring patients using tobacco receive medically appropriate early lung cancer screening and other related medical services.
Expanding access to behavioral health services
The changes aim not only to increase the efficiency of health care delivery but also to reflect a commitment to expanding access to vital behavioral health services. Key takeaways from a summary of the CMS 2023 rule include:
- The goal of these changes is to enhance access to behavioral health services across the board.
- The change in supervision requirements applies to auxiliary personnel offering behavioral health services incident to a physician’s services.
- Both patients and physicians will benefit from an expanded clinical team and improved reimbursement options for the services provided.
By leveraging these opportunities, physicians and their teams can collaborate with TTSs to make significant strides in helping patients address and overcome their dependence on tobacco and nicotine.
The outlook: CMS 2024 rule
The current outlook for 2024 and beyond promises even more opportunities as part of CMS’ ongoing Behavioral Health Strategy. This includes enabling mental health counselors (MHCs) and marriage and family therapists (MFTs) to bill Medicare independently, initiating vital coverage for mental health services that align with tobacco cessation efforts.
Physicians and medical centers can contract with MFTs and MHCs who are TTSs to provide tobacco addiction services. TTSs will serve as essential partners in multidisciplinary care teams, enhancing the overall health care landscape while ensuring that patients receive comprehensive support tailored to their needs.
Telehealth policy changes: Making services accessible
The White House also recently reinforced the importance of telehealth services, providing further avenues for TTSs to reach patients effectively. With expanded geographic locations for service delivery, care can be provided from virtually anywhere, including when the patient is at home.
Key telehealth provisions include:
- Extended telehealth services through 2024
- Elimination of in-person requirements for mental health services
- Expanded eligibility for providers qualified to provide telehealth services
Practical implications for providers
These developments not only simplify the establishment of tobacco treatment programs but also create better avenues to develop partnerships between physicians, hospitals, medical centers, multidisciplinary practices, and TTSs. Importantly, these clinicians will be compensated directly for the tobacco treatment services they provide.
Conclusion
This is a pivotal moment for pulmonologists and TTSs to meaningfully claim their place within the health care space. As we strive to “make smoking history,” we must act on these CMS opportunities. As providers, we must be proactive, collaborate across disciplines, and serve as advocates for our patients.
Together, we can turn the tide against tobacco use and improve health outcomes nationwide.
Call to action
CHEST encourages all health care professionals to engage with the available resources, collaborate with TTSs, and take appropriate advantage of these new policies for the benefit of our patients. Let’s work together to ensure that we seize this moment and make a real difference in the lives of those affected by tobacco addiction.
Those interested in more information—or to access additional resources and assistance in locating TTSs—please contact Matthew Bars at matt@IntelliQuit.org or +1 (800) 45-SMOKE.
FROM THE CHEST TOBACCO/VAPING WORK GROUP –
The recent changes enacted by the Centers for Medicare & Medicaid Services (CMS) are creating unprecedented opportunities for pulmonologists and medical centers to help treat people with tobacco use disorder. As we face a critical moment in the fight against tobacco-related morbidity and mortality, it is essential that we leverage these changes. In doing so, CHEST aims to serve as an active bridge, informing health care providers of this unique federal opportunity that benefits both patients and clinicians.
A quick primer on “incident to” services
These CMS changes create an important shift in how “incident to” services can be billed. These are any services that are incident to (occur because of) a provider evaluation. These previously required direct supervision of the provider (in the same building) to be billed at the provider rate. Now “general supervision” suffices, which means the physician can be available by phone/video call. These services can then often be billed at a higher rate. In the case of treating dependence on tobacco products, any tobacco treatment specialist (TTS) employed by a practice who cares for the patient subsequent to the initial encounter can now be reimbursed in an increased manner. Better reimbursement for this vital service will ideally lead to better utilization of these resources and better public health.
The Medicare solution is here
With the CMS rule changes in 2023 and their reaffirmation in 2024, the structure has been put in place to allow physicians, medical centers, and TTSs to create contractual relationships that can significantly improve patient care. TTSs are health care professionals from a wide variety of disciplines who have received specialized training in tobacco and nicotine addiction and treatment strategies. By expanding billing and, thus, service opportunities, these CMS modifications empower health care providers to leverage the existing fee-for-service model, translating to better care and sustainable revenue streams.
Key changes in the CMS 2023 rule
One of the most notable changes involves the supervision requirements for auxiliary personnel, which now permit general supervision. Specifically, physicians are not required to be physically present during clinical encounters but can supervise TTSs virtually through real-time audio/video technology. This is a vital shift that enhances flexibility in patient care and expands the capabilities of health care teams.
According to 42 CFR § 410.26, TTSs qualify as auxiliary health care providers, meaning that they can operate under the supervision of a physician or other designated providers. This revised framework gives practices maximum autonomy in their staffing models and enhances their ability to offer comprehensive care. For example, TTSs can function as patient navigators, ensuring patients using tobacco receive medically appropriate early lung cancer screening and other related medical services.
Expanding access to behavioral health services
The changes aim not only to increase the efficiency of health care delivery but also to reflect a commitment to expanding access to vital behavioral health services. Key takeaways from a summary of the CMS 2023 rule include:
- The goal of these changes is to enhance access to behavioral health services across the board.
- The change in supervision requirements applies to auxiliary personnel offering behavioral health services incident to a physician’s services.
- Both patients and physicians will benefit from an expanded clinical team and improved reimbursement options for the services provided.
By leveraging these opportunities, physicians and their teams can collaborate with TTSs to make significant strides in helping patients address and overcome their dependence on tobacco and nicotine.
The outlook: CMS 2024 rule
The current outlook for 2024 and beyond promises even more opportunities as part of CMS’ ongoing Behavioral Health Strategy. This includes enabling mental health counselors (MHCs) and marriage and family therapists (MFTs) to bill Medicare independently, initiating vital coverage for mental health services that align with tobacco cessation efforts.
Physicians and medical centers can contract with MFTs and MHCs who are TTSs to provide tobacco addiction services. TTSs will serve as essential partners in multidisciplinary care teams, enhancing the overall health care landscape while ensuring that patients receive comprehensive support tailored to their needs.
Telehealth policy changes: Making services accessible
The White House also recently reinforced the importance of telehealth services, providing further avenues for TTSs to reach patients effectively. With expanded geographic locations for service delivery, care can be provided from virtually anywhere, including when the patient is at home.
Key telehealth provisions include:
- Extended telehealth services through 2024
- Elimination of in-person requirements for mental health services
- Expanded eligibility for providers qualified to provide telehealth services
Practical implications for providers
These developments not only simplify the establishment of tobacco treatment programs but also create better avenues to develop partnerships between physicians, hospitals, medical centers, multidisciplinary practices, and TTSs. Importantly, these clinicians will be compensated directly for the tobacco treatment services they provide.
Conclusion
This is a pivotal moment for pulmonologists and TTSs to meaningfully claim their place within the health care space. As we strive to “make smoking history,” we must act on these CMS opportunities. As providers, we must be proactive, collaborate across disciplines, and serve as advocates for our patients.
Together, we can turn the tide against tobacco use and improve health outcomes nationwide.
Call to action
CHEST encourages all health care professionals to engage with the available resources, collaborate with TTSs, and take appropriate advantage of these new policies for the benefit of our patients. Let’s work together to ensure that we seize this moment and make a real difference in the lives of those affected by tobacco addiction.
Those interested in more information—or to access additional resources and assistance in locating TTSs—please contact Matthew Bars at matt@IntelliQuit.org or +1 (800) 45-SMOKE.
FROM THE CHEST TOBACCO/VAPING WORK GROUP –
The recent changes enacted by the Centers for Medicare & Medicaid Services (CMS) are creating unprecedented opportunities for pulmonologists and medical centers to help treat people with tobacco use disorder. As we face a critical moment in the fight against tobacco-related morbidity and mortality, it is essential that we leverage these changes. In doing so, CHEST aims to serve as an active bridge, informing health care providers of this unique federal opportunity that benefits both patients and clinicians.
A quick primer on “incident to” services
These CMS changes create an important shift in how “incident to” services can be billed. These are any services that are incident to (occur because of) a provider evaluation. These previously required direct supervision of the provider (in the same building) to be billed at the provider rate. Now “general supervision” suffices, which means the physician can be available by phone/video call. These services can then often be billed at a higher rate. In the case of treating dependence on tobacco products, any tobacco treatment specialist (TTS) employed by a practice who cares for the patient subsequent to the initial encounter can now be reimbursed in an increased manner. Better reimbursement for this vital service will ideally lead to better utilization of these resources and better public health.
The Medicare solution is here
With the CMS rule changes in 2023 and their reaffirmation in 2024, the structure has been put in place to allow physicians, medical centers, and TTSs to create contractual relationships that can significantly improve patient care. TTSs are health care professionals from a wide variety of disciplines who have received specialized training in tobacco and nicotine addiction and treatment strategies. By expanding billing and, thus, service opportunities, these CMS modifications empower health care providers to leverage the existing fee-for-service model, translating to better care and sustainable revenue streams.
Key changes in the CMS 2023 rule
One of the most notable changes involves the supervision requirements for auxiliary personnel, which now permit general supervision. Specifically, physicians are not required to be physically present during clinical encounters but can supervise TTSs virtually through real-time audio/video technology. This is a vital shift that enhances flexibility in patient care and expands the capabilities of health care teams.
According to 42 CFR § 410.26, TTSs qualify as auxiliary health care providers, meaning that they can operate under the supervision of a physician or other designated providers. This revised framework gives practices maximum autonomy in their staffing models and enhances their ability to offer comprehensive care. For example, TTSs can function as patient navigators, ensuring patients using tobacco receive medically appropriate early lung cancer screening and other related medical services.
Expanding access to behavioral health services
The changes aim not only to increase the efficiency of health care delivery but also to reflect a commitment to expanding access to vital behavioral health services. Key takeaways from a summary of the CMS 2023 rule include:
- The goal of these changes is to enhance access to behavioral health services across the board.
- The change in supervision requirements applies to auxiliary personnel offering behavioral health services incident to a physician’s services.
- Both patients and physicians will benefit from an expanded clinical team and improved reimbursement options for the services provided.
By leveraging these opportunities, physicians and their teams can collaborate with TTSs to make significant strides in helping patients address and overcome their dependence on tobacco and nicotine.
The outlook: CMS 2024 rule
The current outlook for 2024 and beyond promises even more opportunities as part of CMS’ ongoing Behavioral Health Strategy. This includes enabling mental health counselors (MHCs) and marriage and family therapists (MFTs) to bill Medicare independently, initiating vital coverage for mental health services that align with tobacco cessation efforts.
Physicians and medical centers can contract with MFTs and MHCs who are TTSs to provide tobacco addiction services. TTSs will serve as essential partners in multidisciplinary care teams, enhancing the overall health care landscape while ensuring that patients receive comprehensive support tailored to their needs.
Telehealth policy changes: Making services accessible
The White House also recently reinforced the importance of telehealth services, providing further avenues for TTSs to reach patients effectively. With expanded geographic locations for service delivery, care can be provided from virtually anywhere, including when the patient is at home.
Key telehealth provisions include:
- Extended telehealth services through 2024
- Elimination of in-person requirements for mental health services
- Expanded eligibility for providers qualified to provide telehealth services
Practical implications for providers
These developments not only simplify the establishment of tobacco treatment programs but also create better avenues to develop partnerships between physicians, hospitals, medical centers, multidisciplinary practices, and TTSs. Importantly, these clinicians will be compensated directly for the tobacco treatment services they provide.
Conclusion
This is a pivotal moment for pulmonologists and TTSs to meaningfully claim their place within the health care space. As we strive to “make smoking history,” we must act on these CMS opportunities. As providers, we must be proactive, collaborate across disciplines, and serve as advocates for our patients.
Together, we can turn the tide against tobacco use and improve health outcomes nationwide.
Call to action
CHEST encourages all health care professionals to engage with the available resources, collaborate with TTSs, and take appropriate advantage of these new policies for the benefit of our patients. Let’s work together to ensure that we seize this moment and make a real difference in the lives of those affected by tobacco addiction.
Those interested in more information—or to access additional resources and assistance in locating TTSs—please contact Matthew Bars at matt@IntelliQuit.org or +1 (800) 45-SMOKE.
Top reads from the CHEST journal portfolio
Journal CHEST®
By Claire Launois, MD, PhD, and colleagues
It has long been a critique of studies that evaluate the impact of positive airway pressure (PAP) adherence on positive health outcomes that patients who are more adherent to PAP may also be more adherent to other health behaviors that contribute to those positive outcomes, such as incident cardiac events in patients with OSA. An association was found between multiple proxies of the healthy adherer effect and later PAP adherence in patients with OSA, the highest being related to proxies of cardiovascular health. A preceding reduction in health care costs was also found in these patients. These findings may help contribute to interpretation and validation of new studies to help us better understand the impact of PAP treatment of OSA.
– Commentary by Sreelatha Naik, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
By Burton H. Shen, MD, and colleagues
Asthma is a common reason for hospital admission. Between 5% and 35% of patients who are admitted due to asthma are also admitted to the ICU during their hospital stay. For adolescents and young adults, there is variability in admission to the PICU vs adult ICU. This study specifically evaluated patients aged 12 to 26 years old and included hospitals with both a PICU and an adult ICU. The results show us that age, rather than specific clinical characteristics, is the strongest predictor for PICU admission. Patients aged 18 years and younger were more likely to be admitted to the PICU. This is an important consideration, as hospital bedspace is often more limited during viral season in pediatric hospitals and PICUs. This information is also important for outpatient asthma providers to consider as they counsel their patients and provide long-term management before and after these hospital stays.
– Commentary by Lisa Ulrich, MD, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
Short-Acting Beta-Agonists, Antibiotics, Oral Corticosteroids, and the Associated Burden of COPD
By Mohit Bhutani, MD, FCCP, and colleagues
This study notably highlights the fact that high frequency use of short-acting beta-agonists, antibiotics, and oral corticosteroids may not directly raise the likelihood of an exacerbation but rather may be a sign of worsening disease or poorly managed COPD.
Future studies should investigate the factors that contribute to patients’ frequent prescription use, such as understanding the underlying causes of their exacerbations and other pertinent factors. Additionally, details about patient adherence, a complete clinical history, and the treatment of any further chronic disorders are pivotal for a more complete picture. Enhanced methods for recognizing mild/moderate and severe exacerbations, including patient-reported outcomes, in order to have a better understanding of the influence on drug use and outcomes will be extremely helpful as well. To understand how medications impact results, further studies should look for causal links between medication use and exacerbations.
Lastly, Canadian research on COPD definitely offers insightful information, but when extrapolating these results to the United States, one must take into account variations in the health care system, demographics, and regional patterns along with social determinants of health.
– Commentary by Humayun Anjum, MD, FCCP, Member of the CHEST Physician Editorial Board
Journal CHEST®
By Claire Launois, MD, PhD, and colleagues
It has long been a critique of studies that evaluate the impact of positive airway pressure (PAP) adherence on positive health outcomes that patients who are more adherent to PAP may also be more adherent to other health behaviors that contribute to those positive outcomes, such as incident cardiac events in patients with OSA. An association was found between multiple proxies of the healthy adherer effect and later PAP adherence in patients with OSA, the highest being related to proxies of cardiovascular health. A preceding reduction in health care costs was also found in these patients. These findings may help contribute to interpretation and validation of new studies to help us better understand the impact of PAP treatment of OSA.
– Commentary by Sreelatha Naik, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
By Burton H. Shen, MD, and colleagues
Asthma is a common reason for hospital admission. Between 5% and 35% of patients who are admitted due to asthma are also admitted to the ICU during their hospital stay. For adolescents and young adults, there is variability in admission to the PICU vs adult ICU. This study specifically evaluated patients aged 12 to 26 years old and included hospitals with both a PICU and an adult ICU. The results show us that age, rather than specific clinical characteristics, is the strongest predictor for PICU admission. Patients aged 18 years and younger were more likely to be admitted to the PICU. This is an important consideration, as hospital bedspace is often more limited during viral season in pediatric hospitals and PICUs. This information is also important for outpatient asthma providers to consider as they counsel their patients and provide long-term management before and after these hospital stays.
– Commentary by Lisa Ulrich, MD, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
Short-Acting Beta-Agonists, Antibiotics, Oral Corticosteroids, and the Associated Burden of COPD
By Mohit Bhutani, MD, FCCP, and colleagues
This study notably highlights the fact that high frequency use of short-acting beta-agonists, antibiotics, and oral corticosteroids may not directly raise the likelihood of an exacerbation but rather may be a sign of worsening disease or poorly managed COPD.
Future studies should investigate the factors that contribute to patients’ frequent prescription use, such as understanding the underlying causes of their exacerbations and other pertinent factors. Additionally, details about patient adherence, a complete clinical history, and the treatment of any further chronic disorders are pivotal for a more complete picture. Enhanced methods for recognizing mild/moderate and severe exacerbations, including patient-reported outcomes, in order to have a better understanding of the influence on drug use and outcomes will be extremely helpful as well. To understand how medications impact results, further studies should look for causal links between medication use and exacerbations.
Lastly, Canadian research on COPD definitely offers insightful information, but when extrapolating these results to the United States, one must take into account variations in the health care system, demographics, and regional patterns along with social determinants of health.
– Commentary by Humayun Anjum, MD, FCCP, Member of the CHEST Physician Editorial Board
Journal CHEST®
By Claire Launois, MD, PhD, and colleagues
It has long been a critique of studies that evaluate the impact of positive airway pressure (PAP) adherence on positive health outcomes that patients who are more adherent to PAP may also be more adherent to other health behaviors that contribute to those positive outcomes, such as incident cardiac events in patients with OSA. An association was found between multiple proxies of the healthy adherer effect and later PAP adherence in patients with OSA, the highest being related to proxies of cardiovascular health. A preceding reduction in health care costs was also found in these patients. These findings may help contribute to interpretation and validation of new studies to help us better understand the impact of PAP treatment of OSA.
– Commentary by Sreelatha Naik, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
By Burton H. Shen, MD, and colleagues
Asthma is a common reason for hospital admission. Between 5% and 35% of patients who are admitted due to asthma are also admitted to the ICU during their hospital stay. For adolescents and young adults, there is variability in admission to the PICU vs adult ICU. This study specifically evaluated patients aged 12 to 26 years old and included hospitals with both a PICU and an adult ICU. The results show us that age, rather than specific clinical characteristics, is the strongest predictor for PICU admission. Patients aged 18 years and younger were more likely to be admitted to the PICU. This is an important consideration, as hospital bedspace is often more limited during viral season in pediatric hospitals and PICUs. This information is also important for outpatient asthma providers to consider as they counsel their patients and provide long-term management before and after these hospital stays.
– Commentary by Lisa Ulrich, MD, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
Short-Acting Beta-Agonists, Antibiotics, Oral Corticosteroids, and the Associated Burden of COPD
By Mohit Bhutani, MD, FCCP, and colleagues
This study notably highlights the fact that high frequency use of short-acting beta-agonists, antibiotics, and oral corticosteroids may not directly raise the likelihood of an exacerbation but rather may be a sign of worsening disease or poorly managed COPD.
Future studies should investigate the factors that contribute to patients’ frequent prescription use, such as understanding the underlying causes of their exacerbations and other pertinent factors. Additionally, details about patient adherence, a complete clinical history, and the treatment of any further chronic disorders are pivotal for a more complete picture. Enhanced methods for recognizing mild/moderate and severe exacerbations, including patient-reported outcomes, in order to have a better understanding of the influence on drug use and outcomes will be extremely helpful as well. To understand how medications impact results, further studies should look for causal links between medication use and exacerbations.
Lastly, Canadian research on COPD definitely offers insightful information, but when extrapolating these results to the United States, one must take into account variations in the health care system, demographics, and regional patterns along with social determinants of health.
– Commentary by Humayun Anjum, MD, FCCP, Member of the CHEST Physician Editorial Board
Improved CHEST Physician® coming in 2025
FROM THE CHEST PHYSICIAN EDITORIAL BOARD – There will be some exciting changes happening at the CHEST Physician publication in 2025. We’re building on nearly three decades as a leading source of news and clinical commentary in pulmonary and critical care medicine to roll out several notable improvements.
First, the CHEST Physician website, chestphysician.org, will undergo a complete transformation. With an improved user experience, you’ll be able to more easily find content relevant to your interests and specialties.
Second, a brand-new email newsletter will hit your inbox twice a month, starting in January 2025. These emails will give you a quick look into timely content that may interest you and affect your daily practice. Additionally, this digital-first approach will get you the news and research you rely on sooner.
Lastly, the redesigned CHEST Physician print issue will now be produced and delivered on a quarterly basis. The first issue will arrive in March 2025. These special issues will feature print-exclusive content and graphics, as well as offer a deeper dive into the most relevant news stories from recent months.
Notably, all new CHEST Physician content published in the new year will be tailored to our audience and readership, and it will address the issues and topics that matter to you most as health care providers.
As the CHEST Physician publication undergoes this transformation, we want to hear from you. What topics do you want more of? How can CHEST continue to best serve the chest medicine community? Email chestphysiciannews@chestnet.org to share your ideas.
Thank you for being a loyal CHEST Physician reader. We look forward to bringing you elevated content and an enhanced reader experience in the new year.
FROM THE CHEST PHYSICIAN EDITORIAL BOARD – There will be some exciting changes happening at the CHEST Physician publication in 2025. We’re building on nearly three decades as a leading source of news and clinical commentary in pulmonary and critical care medicine to roll out several notable improvements.
First, the CHEST Physician website, chestphysician.org, will undergo a complete transformation. With an improved user experience, you’ll be able to more easily find content relevant to your interests and specialties.
Second, a brand-new email newsletter will hit your inbox twice a month, starting in January 2025. These emails will give you a quick look into timely content that may interest you and affect your daily practice. Additionally, this digital-first approach will get you the news and research you rely on sooner.
Lastly, the redesigned CHEST Physician print issue will now be produced and delivered on a quarterly basis. The first issue will arrive in March 2025. These special issues will feature print-exclusive content and graphics, as well as offer a deeper dive into the most relevant news stories from recent months.
Notably, all new CHEST Physician content published in the new year will be tailored to our audience and readership, and it will address the issues and topics that matter to you most as health care providers.
As the CHEST Physician publication undergoes this transformation, we want to hear from you. What topics do you want more of? How can CHEST continue to best serve the chest medicine community? Email chestphysiciannews@chestnet.org to share your ideas.
Thank you for being a loyal CHEST Physician reader. We look forward to bringing you elevated content and an enhanced reader experience in the new year.
FROM THE CHEST PHYSICIAN EDITORIAL BOARD – There will be some exciting changes happening at the CHEST Physician publication in 2025. We’re building on nearly three decades as a leading source of news and clinical commentary in pulmonary and critical care medicine to roll out several notable improvements.
First, the CHEST Physician website, chestphysician.org, will undergo a complete transformation. With an improved user experience, you’ll be able to more easily find content relevant to your interests and specialties.
Second, a brand-new email newsletter will hit your inbox twice a month, starting in January 2025. These emails will give you a quick look into timely content that may interest you and affect your daily practice. Additionally, this digital-first approach will get you the news and research you rely on sooner.
Lastly, the redesigned CHEST Physician print issue will now be produced and delivered on a quarterly basis. The first issue will arrive in March 2025. These special issues will feature print-exclusive content and graphics, as well as offer a deeper dive into the most relevant news stories from recent months.
Notably, all new CHEST Physician content published in the new year will be tailored to our audience and readership, and it will address the issues and topics that matter to you most as health care providers.
As the CHEST Physician publication undergoes this transformation, we want to hear from you. What topics do you want more of? How can CHEST continue to best serve the chest medicine community? Email chestphysiciannews@chestnet.org to share your ideas.
Thank you for being a loyal CHEST Physician reader. We look forward to bringing you elevated content and an enhanced reader experience in the new year.
Top reads from the CHEST journal portfolio
Explore articles on PAP adherence, plasma biomarkers in ARDS, and airways disorders hospitalizations during wildfire season
Journal CHEST®
Association Between Healthy Behaviors and Health Care Resource Use With Subsequent Positive Airway Pressure Therapy Adherence in OSA
By Launois, MD, PhD, and colleagues
One of the pitfalls in the interpretation of the effect of treatment adherence on health outcomes is the healthy-adherer effect (HAE) bias. Healthy-adherer bias occurs when patients who are treatment-adherent tend to actively seek out preventative care and engage in other healthy behaviors. Incomplete adjustment for such behaviors can lead to spurious inferences regarding study outcomes because healthy behaviors are associated with a reduced risk of many poor health outcomes.
This study demonstrates that HAE proxies (adherence to CV active drugs, no history of smoking, or sleepiness-related car accidents) were associated with subsequent PAP adherence after adjustment for confounders. PAP-adherent patients used less health care resources before PAP initiation. Unfortunately, the study did not measure other healthy behaviors (nutrition, physical activity, psychosocial support) that could also potentially explain HAE. Until the HAE associated with PAP adherence is better understood, clinicians should use caution when interpreting the association of PAP adherence with CV health outcomes and health care resource use.
– Commentary by Sai Venkateshiah, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Circulating Biomarkers of Endothelial Dysfunction Associated With Ventilatory Ratio and Mortality in ARDS Resulting From SARS-CoV-2 Infection Treated With Anti-inflammatory Therapies
By Alladina, MD, and colleagues
Practitioners in the intensive care unit have become increasingly aware that the population of patients with ARDS is highly heterogenous not only in terms of the inciting factors of their condition but also in terms of their respiratory physiology. Calfee and co-workers opened new horizons for us with their 2014 descriptions of two phenotypes of ARDS based upon biological markers that had different clinical outcome profiles. The work by Alladina et al adds to this body of knowledge by studying biomarkers from patients with COVID-ARDS who were receiving anti-inflammatory therapies. These researchers demonstrated that in such patients, endothelial biomarkers, particularly NEDD9, were associated with 60-day mortality. Increased understanding of biologic phenotypes in ARDS patients may facilitate the application of precision medicine to patients with this condition, improving outcome prediction and allowing practitioners to target specific treatments to selected patients.
– Commentary by Daniel R. Ouellette, MD, FCCP, Critical Care Commentary Editor of CHEST Physician
CHEST® Pulmonary
Association of Short-Term Increases in Ambient Fine Particulate Matter With Hospitalization for Asthma or COPD During Wildfire Season and Other Time Periods
By Horne, PhD, MStat, MPH, and colleagues
Trigger avoidance is one the most important interventions in the control of symptoms and prevention of exacerbations in chronic airways diseases. Nevertheless, trigger avoidance is at times not possible. This is the case with wildfire smoke and other environmental irritants—an increasing global health problem. Using data from 11 hospitals along the Utah’s Wasatch Front, the study by Horne and colleagues shows a clear association between a short-term increase in ambient fine particulate matter exposure resulting from wildfires and a surge in asthma exacerbations. This effect was also seen in patients with COPD but to a lesser degree. The study is limited by its observational design and because measurements of pollution levels were performed regionally and not at individual patient level. Yet this study offers valuable insights on the effects of environmental exposures in patients with chronic airways diseases and the consequences to our health care systems. Futures studies are still needed to assess the long-term consequences of sustained exposures to these irritants in patients with respiratory conditions.
– Commentary by Diego J. Maselli, MD, FCCP, Member of the CHEST Physician Editorial Board
Explore articles on PAP adherence, plasma biomarkers in ARDS, and airways disorders hospitalizations during wildfire season
Explore articles on PAP adherence, plasma biomarkers in ARDS, and airways disorders hospitalizations during wildfire season
Journal CHEST®
Association Between Healthy Behaviors and Health Care Resource Use With Subsequent Positive Airway Pressure Therapy Adherence in OSA
By Launois, MD, PhD, and colleagues
One of the pitfalls in the interpretation of the effect of treatment adherence on health outcomes is the healthy-adherer effect (HAE) bias. Healthy-adherer bias occurs when patients who are treatment-adherent tend to actively seek out preventative care and engage in other healthy behaviors. Incomplete adjustment for such behaviors can lead to spurious inferences regarding study outcomes because healthy behaviors are associated with a reduced risk of many poor health outcomes.
This study demonstrates that HAE proxies (adherence to CV active drugs, no history of smoking, or sleepiness-related car accidents) were associated with subsequent PAP adherence after adjustment for confounders. PAP-adherent patients used less health care resources before PAP initiation. Unfortunately, the study did not measure other healthy behaviors (nutrition, physical activity, psychosocial support) that could also potentially explain HAE. Until the HAE associated with PAP adherence is better understood, clinicians should use caution when interpreting the association of PAP adherence with CV health outcomes and health care resource use.
– Commentary by Sai Venkateshiah, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Circulating Biomarkers of Endothelial Dysfunction Associated With Ventilatory Ratio and Mortality in ARDS Resulting From SARS-CoV-2 Infection Treated With Anti-inflammatory Therapies
By Alladina, MD, and colleagues
Practitioners in the intensive care unit have become increasingly aware that the population of patients with ARDS is highly heterogenous not only in terms of the inciting factors of their condition but also in terms of their respiratory physiology. Calfee and co-workers opened new horizons for us with their 2014 descriptions of two phenotypes of ARDS based upon biological markers that had different clinical outcome profiles. The work by Alladina et al adds to this body of knowledge by studying biomarkers from patients with COVID-ARDS who were receiving anti-inflammatory therapies. These researchers demonstrated that in such patients, endothelial biomarkers, particularly NEDD9, were associated with 60-day mortality. Increased understanding of biologic phenotypes in ARDS patients may facilitate the application of precision medicine to patients with this condition, improving outcome prediction and allowing practitioners to target specific treatments to selected patients.
– Commentary by Daniel R. Ouellette, MD, FCCP, Critical Care Commentary Editor of CHEST Physician
CHEST® Pulmonary
Association of Short-Term Increases in Ambient Fine Particulate Matter With Hospitalization for Asthma or COPD During Wildfire Season and Other Time Periods
By Horne, PhD, MStat, MPH, and colleagues
Trigger avoidance is one the most important interventions in the control of symptoms and prevention of exacerbations in chronic airways diseases. Nevertheless, trigger avoidance is at times not possible. This is the case with wildfire smoke and other environmental irritants—an increasing global health problem. Using data from 11 hospitals along the Utah’s Wasatch Front, the study by Horne and colleagues shows a clear association between a short-term increase in ambient fine particulate matter exposure resulting from wildfires and a surge in asthma exacerbations. This effect was also seen in patients with COPD but to a lesser degree. The study is limited by its observational design and because measurements of pollution levels were performed regionally and not at individual patient level. Yet this study offers valuable insights on the effects of environmental exposures in patients with chronic airways diseases and the consequences to our health care systems. Futures studies are still needed to assess the long-term consequences of sustained exposures to these irritants in patients with respiratory conditions.
– Commentary by Diego J. Maselli, MD, FCCP, Member of the CHEST Physician Editorial Board
Journal CHEST®
Association Between Healthy Behaviors and Health Care Resource Use With Subsequent Positive Airway Pressure Therapy Adherence in OSA
By Launois, MD, PhD, and colleagues
One of the pitfalls in the interpretation of the effect of treatment adherence on health outcomes is the healthy-adherer effect (HAE) bias. Healthy-adherer bias occurs when patients who are treatment-adherent tend to actively seek out preventative care and engage in other healthy behaviors. Incomplete adjustment for such behaviors can lead to spurious inferences regarding study outcomes because healthy behaviors are associated with a reduced risk of many poor health outcomes.
This study demonstrates that HAE proxies (adherence to CV active drugs, no history of smoking, or sleepiness-related car accidents) were associated with subsequent PAP adherence after adjustment for confounders. PAP-adherent patients used less health care resources before PAP initiation. Unfortunately, the study did not measure other healthy behaviors (nutrition, physical activity, psychosocial support) that could also potentially explain HAE. Until the HAE associated with PAP adherence is better understood, clinicians should use caution when interpreting the association of PAP adherence with CV health outcomes and health care resource use.
– Commentary by Sai Venkateshiah, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Circulating Biomarkers of Endothelial Dysfunction Associated With Ventilatory Ratio and Mortality in ARDS Resulting From SARS-CoV-2 Infection Treated With Anti-inflammatory Therapies
By Alladina, MD, and colleagues
Practitioners in the intensive care unit have become increasingly aware that the population of patients with ARDS is highly heterogenous not only in terms of the inciting factors of their condition but also in terms of their respiratory physiology. Calfee and co-workers opened new horizons for us with their 2014 descriptions of two phenotypes of ARDS based upon biological markers that had different clinical outcome profiles. The work by Alladina et al adds to this body of knowledge by studying biomarkers from patients with COVID-ARDS who were receiving anti-inflammatory therapies. These researchers demonstrated that in such patients, endothelial biomarkers, particularly NEDD9, were associated with 60-day mortality. Increased understanding of biologic phenotypes in ARDS patients may facilitate the application of precision medicine to patients with this condition, improving outcome prediction and allowing practitioners to target specific treatments to selected patients.
– Commentary by Daniel R. Ouellette, MD, FCCP, Critical Care Commentary Editor of CHEST Physician
CHEST® Pulmonary
Association of Short-Term Increases in Ambient Fine Particulate Matter With Hospitalization for Asthma or COPD During Wildfire Season and Other Time Periods
By Horne, PhD, MStat, MPH, and colleagues
Trigger avoidance is one the most important interventions in the control of symptoms and prevention of exacerbations in chronic airways diseases. Nevertheless, trigger avoidance is at times not possible. This is the case with wildfire smoke and other environmental irritants—an increasing global health problem. Using data from 11 hospitals along the Utah’s Wasatch Front, the study by Horne and colleagues shows a clear association between a short-term increase in ambient fine particulate matter exposure resulting from wildfires and a surge in asthma exacerbations. This effect was also seen in patients with COPD but to a lesser degree. The study is limited by its observational design and because measurements of pollution levels were performed regionally and not at individual patient level. Yet this study offers valuable insights on the effects of environmental exposures in patients with chronic airways diseases and the consequences to our health care systems. Futures studies are still needed to assess the long-term consequences of sustained exposures to these irritants in patients with respiratory conditions.
– Commentary by Diego J. Maselli, MD, FCCP, Member of the CHEST Physician Editorial Board
Advocating for diversity in medical education
Earlier this year,
If enacted, the EDUCATE Act would cut off federal funding to medical schools that force students or faculty to adopt specific beliefs; discriminate based on race or ethnicity; or have diversity, equity, and inclusion (DEI) offices or any functional equivalent. The bill would also require accreditation agencies to check that their standards do not push these practices, while still allowing instruction about health issues tied to race or collecting data for research.
In response to the introduction of this act, CHEST published a statement in support of DEI practices and their necessary role within the practice of health care and medical training programs.
It is our belief that health care requires a solid patient-provider therapeutic alliance to achieve successful outcomes, and decades of scientific research have shown that a lack of clinician diversity worsens health disparities. For patients from historically underserved communities, having clinicians who share similar lived experiences almost always leads to significant improvements in patient outcomes. If identity concordance is not feasible, clinicians with considerable exposure to diverse patient populations, equitable approaches to care, and inclusive perspectives on health gained through continuing, comprehensive medical education and professional training can also positively impact outcomes.
Research indicates that a diverse medical workforce improves cultural competence and can help clinicians better meet the needs of patients from diverse backgrounds and ethnicities and that the benefits of diverse learning environments enhance the educational experience of all participants. Racial and ethnic health inequities illuminate the greatest gaps and worst patient outcomes, especially when compounded by disparities related to gender identity, ability, language, immigration status, sexual orientation, age, socioeconomics, and other social drivers of health. Research also shows that nearly one-fifth of Latine Americans avoid medical care due to concern about experiencing discrimination, Black Americans have significantly lower life expectancies, and Asian Americans are the only racial group to experience cancer as a leading cause of death. It is also well documented that communities experiencing disproportionately high rates of COVID-19 infection, hospitalization, and mortality when compared with White Americans include Black, Latine, Asian, Native Hawaiian, and Native Americans.
“In 2023, the CHEST organization shared its organizational values: community, inclusivity, innovation, advocacy, and integrity,” said CHEST President, Jack D. Buckley, MD, MPH, FCCP. “In strong accordance with these values and with our mission to champion the prevention, diagnosis, and treatment of chest diseases and advance the best patient outcomes, CHEST is firmly committed to the necessity of diversity, equity, and inclusion in health care research, education, and delivery.”
Guided by our core values, CHEST is relentlessly committed to improving the professional’s experience and patient outcomes equally. This commitment compels us to work toward eliminating disparities in the medical field. According to the most recent US Census projections, by 2045, White Americans will no longer be considered a racial majority, with Black, Latine, and Asian Americans continuing to rise. It is incumbent upon us to ensure that our clinician workforce reflects the diversity of its local and national communities.
The underrepresentation of physicians from racially diverse backgrounds is factually clear. Black physicians comprise 5% of the current physician workforce despite Black Americans representing 13% of the population.1 Similarly, while Native Americans comprise 3% of the United States population, Native American physicians account for less than 1% of the physician workforce, with less than 10% of medical schools reporting total enrollment of more than four Native American students.2 Where gender is concerned, women make up about 36% of the physician workforce, a professional disparity that is further exacerbated given the intersections of race and gender, resulting in a significant impact on the current workforce.3 Allowing disinformation to influence the future of medical education and patient care directly contradicts our mission as clinicians dedicated to improving the health of all people.
If physician representation and patient outcomes are linked, as research shows, the lack of diverse medical school representation has dire consequences for matriculation, job recruitment, retention, and promotion. Without supportive policies, programs, and equity-focused curriculums in medical education, we will never close the gap on professional disparities, which means we will similarly never close the gap on health disparities.
Our commitment to our members, all health care professionals, and the field of medicine means that we will stand firm in our defense of DEI today and every day until we have achieved optimal, equitable health for all people in all places. CHEST is committed to an intersectional approach to equitable health care education and delivery. We strive to design solutions that center the most impacted and radiate support outward, ensuring our interventions benefit all others experiencing discrimination.
Read more about CHEST’s commitment to diversity and other advocacy work on the CHEST website.
References
1. AAMC. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC; 2019. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018#:~:text=Diversity%20in%20Medicine%3A%20Facts%20and%20Figures%202019,-Diversity%20in%20Medicine&text=Among%20active%20physicians%2C%2056.2%25%20identified,as%20Black%20or%20African%20American
2. Murphy B. New effort to help Native American pre-meds pursue physician dreams. AMA. January 13, 2022. https://www.ama-assn.org/education/medical-school-diversity/new-effort-help-native-american-pre-meds-pursue-physician-dreams
3. AAMC. U.S. Physician Workforce Data Dashboard. AAMC; 2023. https://www.aamc.org/data-reports/report/us-physician-workforce-data-dashboard
Earlier this year,
If enacted, the EDUCATE Act would cut off federal funding to medical schools that force students or faculty to adopt specific beliefs; discriminate based on race or ethnicity; or have diversity, equity, and inclusion (DEI) offices or any functional equivalent. The bill would also require accreditation agencies to check that their standards do not push these practices, while still allowing instruction about health issues tied to race or collecting data for research.
In response to the introduction of this act, CHEST published a statement in support of DEI practices and their necessary role within the practice of health care and medical training programs.
It is our belief that health care requires a solid patient-provider therapeutic alliance to achieve successful outcomes, and decades of scientific research have shown that a lack of clinician diversity worsens health disparities. For patients from historically underserved communities, having clinicians who share similar lived experiences almost always leads to significant improvements in patient outcomes. If identity concordance is not feasible, clinicians with considerable exposure to diverse patient populations, equitable approaches to care, and inclusive perspectives on health gained through continuing, comprehensive medical education and professional training can also positively impact outcomes.
Research indicates that a diverse medical workforce improves cultural competence and can help clinicians better meet the needs of patients from diverse backgrounds and ethnicities and that the benefits of diverse learning environments enhance the educational experience of all participants. Racial and ethnic health inequities illuminate the greatest gaps and worst patient outcomes, especially when compounded by disparities related to gender identity, ability, language, immigration status, sexual orientation, age, socioeconomics, and other social drivers of health. Research also shows that nearly one-fifth of Latine Americans avoid medical care due to concern about experiencing discrimination, Black Americans have significantly lower life expectancies, and Asian Americans are the only racial group to experience cancer as a leading cause of death. It is also well documented that communities experiencing disproportionately high rates of COVID-19 infection, hospitalization, and mortality when compared with White Americans include Black, Latine, Asian, Native Hawaiian, and Native Americans.
“In 2023, the CHEST organization shared its organizational values: community, inclusivity, innovation, advocacy, and integrity,” said CHEST President, Jack D. Buckley, MD, MPH, FCCP. “In strong accordance with these values and with our mission to champion the prevention, diagnosis, and treatment of chest diseases and advance the best patient outcomes, CHEST is firmly committed to the necessity of diversity, equity, and inclusion in health care research, education, and delivery.”
Guided by our core values, CHEST is relentlessly committed to improving the professional’s experience and patient outcomes equally. This commitment compels us to work toward eliminating disparities in the medical field. According to the most recent US Census projections, by 2045, White Americans will no longer be considered a racial majority, with Black, Latine, and Asian Americans continuing to rise. It is incumbent upon us to ensure that our clinician workforce reflects the diversity of its local and national communities.
The underrepresentation of physicians from racially diverse backgrounds is factually clear. Black physicians comprise 5% of the current physician workforce despite Black Americans representing 13% of the population.1 Similarly, while Native Americans comprise 3% of the United States population, Native American physicians account for less than 1% of the physician workforce, with less than 10% of medical schools reporting total enrollment of more than four Native American students.2 Where gender is concerned, women make up about 36% of the physician workforce, a professional disparity that is further exacerbated given the intersections of race and gender, resulting in a significant impact on the current workforce.3 Allowing disinformation to influence the future of medical education and patient care directly contradicts our mission as clinicians dedicated to improving the health of all people.
If physician representation and patient outcomes are linked, as research shows, the lack of diverse medical school representation has dire consequences for matriculation, job recruitment, retention, and promotion. Without supportive policies, programs, and equity-focused curriculums in medical education, we will never close the gap on professional disparities, which means we will similarly never close the gap on health disparities.
Our commitment to our members, all health care professionals, and the field of medicine means that we will stand firm in our defense of DEI today and every day until we have achieved optimal, equitable health for all people in all places. CHEST is committed to an intersectional approach to equitable health care education and delivery. We strive to design solutions that center the most impacted and radiate support outward, ensuring our interventions benefit all others experiencing discrimination.
Read more about CHEST’s commitment to diversity and other advocacy work on the CHEST website.
References
1. AAMC. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC; 2019. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018#:~:text=Diversity%20in%20Medicine%3A%20Facts%20and%20Figures%202019,-Diversity%20in%20Medicine&text=Among%20active%20physicians%2C%2056.2%25%20identified,as%20Black%20or%20African%20American
2. Murphy B. New effort to help Native American pre-meds pursue physician dreams. AMA. January 13, 2022. https://www.ama-assn.org/education/medical-school-diversity/new-effort-help-native-american-pre-meds-pursue-physician-dreams
3. AAMC. U.S. Physician Workforce Data Dashboard. AAMC; 2023. https://www.aamc.org/data-reports/report/us-physician-workforce-data-dashboard
Earlier this year,
If enacted, the EDUCATE Act would cut off federal funding to medical schools that force students or faculty to adopt specific beliefs; discriminate based on race or ethnicity; or have diversity, equity, and inclusion (DEI) offices or any functional equivalent. The bill would also require accreditation agencies to check that their standards do not push these practices, while still allowing instruction about health issues tied to race or collecting data for research.
In response to the introduction of this act, CHEST published a statement in support of DEI practices and their necessary role within the practice of health care and medical training programs.
It is our belief that health care requires a solid patient-provider therapeutic alliance to achieve successful outcomes, and decades of scientific research have shown that a lack of clinician diversity worsens health disparities. For patients from historically underserved communities, having clinicians who share similar lived experiences almost always leads to significant improvements in patient outcomes. If identity concordance is not feasible, clinicians with considerable exposure to diverse patient populations, equitable approaches to care, and inclusive perspectives on health gained through continuing, comprehensive medical education and professional training can also positively impact outcomes.
Research indicates that a diverse medical workforce improves cultural competence and can help clinicians better meet the needs of patients from diverse backgrounds and ethnicities and that the benefits of diverse learning environments enhance the educational experience of all participants. Racial and ethnic health inequities illuminate the greatest gaps and worst patient outcomes, especially when compounded by disparities related to gender identity, ability, language, immigration status, sexual orientation, age, socioeconomics, and other social drivers of health. Research also shows that nearly one-fifth of Latine Americans avoid medical care due to concern about experiencing discrimination, Black Americans have significantly lower life expectancies, and Asian Americans are the only racial group to experience cancer as a leading cause of death. It is also well documented that communities experiencing disproportionately high rates of COVID-19 infection, hospitalization, and mortality when compared with White Americans include Black, Latine, Asian, Native Hawaiian, and Native Americans.
“In 2023, the CHEST organization shared its organizational values: community, inclusivity, innovation, advocacy, and integrity,” said CHEST President, Jack D. Buckley, MD, MPH, FCCP. “In strong accordance with these values and with our mission to champion the prevention, diagnosis, and treatment of chest diseases and advance the best patient outcomes, CHEST is firmly committed to the necessity of diversity, equity, and inclusion in health care research, education, and delivery.”
Guided by our core values, CHEST is relentlessly committed to improving the professional’s experience and patient outcomes equally. This commitment compels us to work toward eliminating disparities in the medical field. According to the most recent US Census projections, by 2045, White Americans will no longer be considered a racial majority, with Black, Latine, and Asian Americans continuing to rise. It is incumbent upon us to ensure that our clinician workforce reflects the diversity of its local and national communities.
The underrepresentation of physicians from racially diverse backgrounds is factually clear. Black physicians comprise 5% of the current physician workforce despite Black Americans representing 13% of the population.1 Similarly, while Native Americans comprise 3% of the United States population, Native American physicians account for less than 1% of the physician workforce, with less than 10% of medical schools reporting total enrollment of more than four Native American students.2 Where gender is concerned, women make up about 36% of the physician workforce, a professional disparity that is further exacerbated given the intersections of race and gender, resulting in a significant impact on the current workforce.3 Allowing disinformation to influence the future of medical education and patient care directly contradicts our mission as clinicians dedicated to improving the health of all people.
If physician representation and patient outcomes are linked, as research shows, the lack of diverse medical school representation has dire consequences for matriculation, job recruitment, retention, and promotion. Without supportive policies, programs, and equity-focused curriculums in medical education, we will never close the gap on professional disparities, which means we will similarly never close the gap on health disparities.
Our commitment to our members, all health care professionals, and the field of medicine means that we will stand firm in our defense of DEI today and every day until we have achieved optimal, equitable health for all people in all places. CHEST is committed to an intersectional approach to equitable health care education and delivery. We strive to design solutions that center the most impacted and radiate support outward, ensuring our interventions benefit all others experiencing discrimination.
Read more about CHEST’s commitment to diversity and other advocacy work on the CHEST website.
References
1. AAMC. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC; 2019. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018#:~:text=Diversity%20in%20Medicine%3A%20Facts%20and%20Figures%202019,-Diversity%20in%20Medicine&text=Among%20active%20physicians%2C%2056.2%25%20identified,as%20Black%20or%20African%20American
2. Murphy B. New effort to help Native American pre-meds pursue physician dreams. AMA. January 13, 2022. https://www.ama-assn.org/education/medical-school-diversity/new-effort-help-native-american-pre-meds-pursue-physician-dreams
3. AAMC. U.S. Physician Workforce Data Dashboard. AAMC; 2023. https://www.aamc.org/data-reports/report/us-physician-workforce-data-dashboard
The countdown to CHEST 2024 begins
As we find ourselves in September, I cannot help but dedicate my column to the upcoming CHEST Annual Meeting quickly approaching, October 6 to 9, in Boston.
If you haven’t yet been to a CHEST Annual Meeting, it’s an unmatched experience.
For those who have attended, there’s always something new to see. Every year is different, with the culture of the location guiding the way and new opportunities to network while engaging in activity. No matter how many times you have been, attending the CHEST Annual Meeting never gets old.
Leveraging CHEST 2024’s location, we’ll be hosting a Grand Rounds event days before the meeting starts with pulmonary and critical care medicine fellows from the regional Boston programs to learn from visiting CHEST leadership on a variety of influential topics. These fellowship programs held events like this prepandemic, so I’m truly excited we could help restart the tradition and give the local fellows an opportunity to interact with each other from both an academic and social perspective. Personally, I am very much looking forward to meeting and getting to know the fellows from the Boston area.
The meeting has a lot of notable opportunities lined up (see my official “President’s checklist”), including the third year of CHEST After Hours (Monday, October 7)—a unique storytelling event focusing on the humanities of medicine in partnership with The Nocturnists podcast. And for the first time in recent years, CHEST 2024 will feature a 5K run/walk (Tuesday, October 8) in support of CHEST philanthropy and its work to fuel breakthroughs, empower innovation, and drive toward a future where every patient’s well-being is safeguarded. I encourage you to register in advance of the meeting to secure your space and snag a souvenir T-shirt.
First thing Sunday morning (October 6), the meeting kicks off with the Opening Session where we will be celebrating the new fellows of the college (FCCP), honoring trailblazers in chest medicine, and welcoming this year’s keynote speaker.
This year’s keynote address will come from Vanessa Kerry, MD, who will speak on environmental issues and her work to raise awareness of the impact of climate change on health.
With so many things to look forward to, this meeting will be one to remember for all in attendance.
I look forward to seeing you in Boston,
Jack
As we find ourselves in September, I cannot help but dedicate my column to the upcoming CHEST Annual Meeting quickly approaching, October 6 to 9, in Boston.
If you haven’t yet been to a CHEST Annual Meeting, it’s an unmatched experience.
For those who have attended, there’s always something new to see. Every year is different, with the culture of the location guiding the way and new opportunities to network while engaging in activity. No matter how many times you have been, attending the CHEST Annual Meeting never gets old.
Leveraging CHEST 2024’s location, we’ll be hosting a Grand Rounds event days before the meeting starts with pulmonary and critical care medicine fellows from the regional Boston programs to learn from visiting CHEST leadership on a variety of influential topics. These fellowship programs held events like this prepandemic, so I’m truly excited we could help restart the tradition and give the local fellows an opportunity to interact with each other from both an academic and social perspective. Personally, I am very much looking forward to meeting and getting to know the fellows from the Boston area.
The meeting has a lot of notable opportunities lined up (see my official “President’s checklist”), including the third year of CHEST After Hours (Monday, October 7)—a unique storytelling event focusing on the humanities of medicine in partnership with The Nocturnists podcast. And for the first time in recent years, CHEST 2024 will feature a 5K run/walk (Tuesday, October 8) in support of CHEST philanthropy and its work to fuel breakthroughs, empower innovation, and drive toward a future where every patient’s well-being is safeguarded. I encourage you to register in advance of the meeting to secure your space and snag a souvenir T-shirt.
First thing Sunday morning (October 6), the meeting kicks off with the Opening Session where we will be celebrating the new fellows of the college (FCCP), honoring trailblazers in chest medicine, and welcoming this year’s keynote speaker.
This year’s keynote address will come from Vanessa Kerry, MD, who will speak on environmental issues and her work to raise awareness of the impact of climate change on health.
With so many things to look forward to, this meeting will be one to remember for all in attendance.
I look forward to seeing you in Boston,
Jack
As we find ourselves in September, I cannot help but dedicate my column to the upcoming CHEST Annual Meeting quickly approaching, October 6 to 9, in Boston.
If you haven’t yet been to a CHEST Annual Meeting, it’s an unmatched experience.
For those who have attended, there’s always something new to see. Every year is different, with the culture of the location guiding the way and new opportunities to network while engaging in activity. No matter how many times you have been, attending the CHEST Annual Meeting never gets old.
Leveraging CHEST 2024’s location, we’ll be hosting a Grand Rounds event days before the meeting starts with pulmonary and critical care medicine fellows from the regional Boston programs to learn from visiting CHEST leadership on a variety of influential topics. These fellowship programs held events like this prepandemic, so I’m truly excited we could help restart the tradition and give the local fellows an opportunity to interact with each other from both an academic and social perspective. Personally, I am very much looking forward to meeting and getting to know the fellows from the Boston area.
The meeting has a lot of notable opportunities lined up (see my official “President’s checklist”), including the third year of CHEST After Hours (Monday, October 7)—a unique storytelling event focusing on the humanities of medicine in partnership with The Nocturnists podcast. And for the first time in recent years, CHEST 2024 will feature a 5K run/walk (Tuesday, October 8) in support of CHEST philanthropy and its work to fuel breakthroughs, empower innovation, and drive toward a future where every patient’s well-being is safeguarded. I encourage you to register in advance of the meeting to secure your space and snag a souvenir T-shirt.
First thing Sunday morning (October 6), the meeting kicks off with the Opening Session where we will be celebrating the new fellows of the college (FCCP), honoring trailblazers in chest medicine, and welcoming this year’s keynote speaker.
This year’s keynote address will come from Vanessa Kerry, MD, who will speak on environmental issues and her work to raise awareness of the impact of climate change on health.
With so many things to look forward to, this meeting will be one to remember for all in attendance.
I look forward to seeing you in Boston,
Jack
Top reads from the CHEST journal portfolio
Covering the frailty scale in ILD, diagnosis of peripheral pulmonary nodules, and platelet mitochondrial function in sepsis.
Journal CHEST®
By Guler, MD, and colleagues
Life expectancy is a very important factor for patients with interstitial lung disease (ILD) and their caregivers. The discussion surrounding prognosis is often wrought with uncertainty and is inherently painful for both patients and clinicians when faced with nonmodifiable traits. This study illustrates the significance of employing a method that succinctly and systematically communicates the degree of functional impairment in patients with fibrotic lung disease. The authors have highlighted the importance of identifying and improving health factors associated with frailty to enhance the survival and quality of life of patients with chronic noncurable fibrotic lung disease. It also presents hope that interventions aimed at improving functional capacity may improve frailty and thus modify prognosis. In the future, longitudinal trends of frailty assessments following interventions aimed at improving both exercise and functional capacity, like pulmonary rehab, should be explored.
– Commentary by Priya Balakrishnan, MD, MS, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
By Michael V. Brown, MD, and colleagues
Brown and colleagues provide a systemic review and meta-analysis of the diagnostic yield of cone beam computed tomography (CBCT) scan combined with radial-endobronchial ultrasound (r-EBUS) for the diagnosis of peripheral pulmonary nodules. They included 14 studies (865 patients with 882 lesions) with pooled diagnostic yield from CBCT scan and r-EBUS for peripheral pulmonary nodules of 80% (95% CI, 76% to 84%) with complication rates of 2.01% for pneumothorax and 1.08% for bleeding. Amongst the studies selected, confounders (including study design, definition of diagnostic yield, use of ROSE, additional equipment, etc) existed. The important takeaway is that 3D imaging guidance with CBCT scan can corroborate “tool in lesion” and thus potentially improve the outcomes of the different bronchoscopic modalities utilized to diagnose peripheral pulmonary nodules. Future prospective investigations with less heterogeneity in study design and outcomes, as well as comparison with newer technologies such as robotic bronchoscopy, are necessary to corroborate these findings.
– Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Platelet Bioenergetics and Associations With Delirium and Coma in Patients With Sepsis
By Chukwudi A. Onyemekwu, DO, and colleagues
The study by Onyemekwu and colleagues explores the link between platelet mitochondrial function and acute brain dysfunction (delirium and coma) in patients with sepsis. The investigators measured various parameters of platelet mitochondrial respiratory bioenergetics and found that increased spare respiratory capacity was significantly associated with coma but not delirium. These findings suggest that systemic mitochondrial function could influence brain health and indicate a potential link between mitochondrial bioenergetics and coma during sepsis. The study did not find a significant association between platelet bioenergetics and delirium, suggesting that coma and delirium may have different underlying pathophysiologic mechanisms. We must interpret the results with caution, as the associations identified in this observational study do not prove causation. It is possible that the changes seen in platelet mitochondria may be a result of coma rather than a mechanism. Nonetheless, the study provides a foundation for future research to explore the mechanistic role of mitochondria in acute brain dysfunction during sepsis and the potential for developing mitochondrial-targeted therapies as a possible treatment approach for patients with sepsis-induced coma.
– Commentary by Angel O. Coz, MD, FCCP, Editor in Chief of CHEST Physician
Covering the frailty scale in ILD, diagnosis of peripheral pulmonary nodules, and platelet mitochondrial function in sepsis.
Covering the frailty scale in ILD, diagnosis of peripheral pulmonary nodules, and platelet mitochondrial function in sepsis.
Journal CHEST®
By Guler, MD, and colleagues
Life expectancy is a very important factor for patients with interstitial lung disease (ILD) and their caregivers. The discussion surrounding prognosis is often wrought with uncertainty and is inherently painful for both patients and clinicians when faced with nonmodifiable traits. This study illustrates the significance of employing a method that succinctly and systematically communicates the degree of functional impairment in patients with fibrotic lung disease. The authors have highlighted the importance of identifying and improving health factors associated with frailty to enhance the survival and quality of life of patients with chronic noncurable fibrotic lung disease. It also presents hope that interventions aimed at improving functional capacity may improve frailty and thus modify prognosis. In the future, longitudinal trends of frailty assessments following interventions aimed at improving both exercise and functional capacity, like pulmonary rehab, should be explored.
– Commentary by Priya Balakrishnan, MD, MS, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
By Michael V. Brown, MD, and colleagues
Brown and colleagues provide a systemic review and meta-analysis of the diagnostic yield of cone beam computed tomography (CBCT) scan combined with radial-endobronchial ultrasound (r-EBUS) for the diagnosis of peripheral pulmonary nodules. They included 14 studies (865 patients with 882 lesions) with pooled diagnostic yield from CBCT scan and r-EBUS for peripheral pulmonary nodules of 80% (95% CI, 76% to 84%) with complication rates of 2.01% for pneumothorax and 1.08% for bleeding. Amongst the studies selected, confounders (including study design, definition of diagnostic yield, use of ROSE, additional equipment, etc) existed. The important takeaway is that 3D imaging guidance with CBCT scan can corroborate “tool in lesion” and thus potentially improve the outcomes of the different bronchoscopic modalities utilized to diagnose peripheral pulmonary nodules. Future prospective investigations with less heterogeneity in study design and outcomes, as well as comparison with newer technologies such as robotic bronchoscopy, are necessary to corroborate these findings.
– Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Platelet Bioenergetics and Associations With Delirium and Coma in Patients With Sepsis
By Chukwudi A. Onyemekwu, DO, and colleagues
The study by Onyemekwu and colleagues explores the link between platelet mitochondrial function and acute brain dysfunction (delirium and coma) in patients with sepsis. The investigators measured various parameters of platelet mitochondrial respiratory bioenergetics and found that increased spare respiratory capacity was significantly associated with coma but not delirium. These findings suggest that systemic mitochondrial function could influence brain health and indicate a potential link between mitochondrial bioenergetics and coma during sepsis. The study did not find a significant association between platelet bioenergetics and delirium, suggesting that coma and delirium may have different underlying pathophysiologic mechanisms. We must interpret the results with caution, as the associations identified in this observational study do not prove causation. It is possible that the changes seen in platelet mitochondria may be a result of coma rather than a mechanism. Nonetheless, the study provides a foundation for future research to explore the mechanistic role of mitochondria in acute brain dysfunction during sepsis and the potential for developing mitochondrial-targeted therapies as a possible treatment approach for patients with sepsis-induced coma.
– Commentary by Angel O. Coz, MD, FCCP, Editor in Chief of CHEST Physician
Journal CHEST®
By Guler, MD, and colleagues
Life expectancy is a very important factor for patients with interstitial lung disease (ILD) and their caregivers. The discussion surrounding prognosis is often wrought with uncertainty and is inherently painful for both patients and clinicians when faced with nonmodifiable traits. This study illustrates the significance of employing a method that succinctly and systematically communicates the degree of functional impairment in patients with fibrotic lung disease. The authors have highlighted the importance of identifying and improving health factors associated with frailty to enhance the survival and quality of life of patients with chronic noncurable fibrotic lung disease. It also presents hope that interventions aimed at improving functional capacity may improve frailty and thus modify prognosis. In the future, longitudinal trends of frailty assessments following interventions aimed at improving both exercise and functional capacity, like pulmonary rehab, should be explored.
– Commentary by Priya Balakrishnan, MD, MS, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
By Michael V. Brown, MD, and colleagues
Brown and colleagues provide a systemic review and meta-analysis of the diagnostic yield of cone beam computed tomography (CBCT) scan combined with radial-endobronchial ultrasound (r-EBUS) for the diagnosis of peripheral pulmonary nodules. They included 14 studies (865 patients with 882 lesions) with pooled diagnostic yield from CBCT scan and r-EBUS for peripheral pulmonary nodules of 80% (95% CI, 76% to 84%) with complication rates of 2.01% for pneumothorax and 1.08% for bleeding. Amongst the studies selected, confounders (including study design, definition of diagnostic yield, use of ROSE, additional equipment, etc) existed. The important takeaway is that 3D imaging guidance with CBCT scan can corroborate “tool in lesion” and thus potentially improve the outcomes of the different bronchoscopic modalities utilized to diagnose peripheral pulmonary nodules. Future prospective investigations with less heterogeneity in study design and outcomes, as well as comparison with newer technologies such as robotic bronchoscopy, are necessary to corroborate these findings.
– Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Platelet Bioenergetics and Associations With Delirium and Coma in Patients With Sepsis
By Chukwudi A. Onyemekwu, DO, and colleagues
The study by Onyemekwu and colleagues explores the link between platelet mitochondrial function and acute brain dysfunction (delirium and coma) in patients with sepsis. The investigators measured various parameters of platelet mitochondrial respiratory bioenergetics and found that increased spare respiratory capacity was significantly associated with coma but not delirium. These findings suggest that systemic mitochondrial function could influence brain health and indicate a potential link between mitochondrial bioenergetics and coma during sepsis. The study did not find a significant association between platelet bioenergetics and delirium, suggesting that coma and delirium may have different underlying pathophysiologic mechanisms. We must interpret the results with caution, as the associations identified in this observational study do not prove causation. It is possible that the changes seen in platelet mitochondria may be a result of coma rather than a mechanism. Nonetheless, the study provides a foundation for future research to explore the mechanistic role of mitochondria in acute brain dysfunction during sepsis and the potential for developing mitochondrial-targeted therapies as a possible treatment approach for patients with sepsis-induced coma.
– Commentary by Angel O. Coz, MD, FCCP, Editor in Chief of CHEST Physician
Improving ILD diagnosis in primary care settings
Interstitial lung diseases (ILDs), with their many ubiquitous symptoms, are often hard to diagnose in patients. That’s why Amirahwaty Abdullah, MBBS, and Kavitha Selvan, MD, see value in educating clinicians on how to identify and diagnose ILD.
Both Dr. Abdullah and Dr. Selvan received quality improvement grants from CHEST in October 2023 to do just that. Their projects put the ILD Clinician Toolkit into practice, created as a part of CHEST’s Bridging Specialties™: Timely Diagnosis for ILD initiative aimed at shortening the time to diagnosis.
Recently, CHEST caught up with the two grant recipients to see how their projects were progressing.
Combating the prevalence of ILDs in West Virginia
Dr. Abdullah and Co-Principal Investigator, Haroon Ahmed, MD, are two of the staff members supporting West Virginia University ILD Clinic, where the ILD Clinician Toolkit is being utilized.
“ILD is so prevalent here, so we thought it would be an excellent opportunity to do the quality improvement project here because we really do need the resources to improve the care of our [patients with ILD],” Dr. Abdullah said. “For the entire state of West Virginia, we’re the only ILD center.”
In West Virginia, many factors are at play making ILD prevalent, with a recent study showing that the state has the second highest rate of interstitial pulmonary fibrosis, Dr. Abdullah said. This is all due to the economy of the state, the rurality of the population, and the occupational hazards with common jobs like coal mining and farming.
“This topic about bridging the gap and early diagnosis really resonated with us because we see all these patients who end up seeing us after they’ve been on oxygen for years, when they can’t do anything else,” Dr. Ahmed said. “There was a big gap here, and we saw that every day in our clinical practice.”
Since implementing the ILD Clinician Toolkit into their program, the two have started providing these resources to primary care physicians in an effort to help expedite their workups when they see patients with common ILD symptoms. This was done through grand rounds and educational conferences for those practicing in family medicine, internal medicine, and pediatric medicine. And more education is planned for the future.
They have also created working relationships with these departments and have encouraged them to send patients to the ILD Clinic, so patients don’t have to be referred to multiple different physicians.
The next step for the project is to implement telemedicine capabilities, which will allow the team to roll out the patient questionnaire from the toolkit. The questionnaire helps physicians gather a detailed history about their patients, including their past and current medications, surgeries, occupational and environmental exposures, and known comorbidities.
“We definitely want to reach out via telemedicine to patients because, at this point in time, some of our patients travel 3, 4 hours one way just to come see us. So, if we can make it more accessible, we will,” Dr. Abdullah said.
Their plan is to provide iPads that are equipped with the questionnaire and other toolkit resources to the providers. Through this method, the team will be able to see how often the questionnaire is used.
“We are very thankful for this grant because I do think we are saving lives,” Dr. Abdullah said. “Any little thing that we can do to improve the outcomes of these patients who have a rare but difficult-to-treat disease—it’s crucial. This gives us the ability to reach out and help patients who are out of our physical bounds.”
Diagnosing ILD among underrepresented minority populations in Chicago
Dr. Kavitha Selvan is conducting her quality improvement research project at the University of Chicago, alongside her team.
“The community we serve in South Chicago houses a significant number of underrepresented [minority populations],” she said.
“We know that Black patients with ILD experience higher rates of hospitalization, compared with White patients,” she said. “And they are hospitalized, require lung transplants, and die at a younger age too.”
In clinical practice, Dr. Selvan has noticed a trend of patients being referred for evaluation of possible ILD later and later. In some cases, several years go by before the appropriate work for ILD is initiated, and that valuable time lost leads to irreversible loss of lung function.
Dr. Selvan’s plan is to partner with primary care providers who are seeing these patients first in order to expedite the work-up and referral of ILD when appropriate and, ultimately, reduce the amount of time that passes between symptom onset and definitive diagnosis.
“To me, this grant and the resources it provided represented an important opportunity to improve outcomes in the high-risk patients we care for through early disease recognition and treatment,” she said.
Dr. Selvan’s project began with educating members of the Primary Care Group at UChicago on risk factors and exam findings that may suggest ILD in patients coming to clinic with nonspecific respiratory complaints. Then they had to equip providers with the ILD Clinician Toolkit and reach patients by handing out the patient questionnaire in primary care clinic.
The next step for this project is going to be dissecting the answers to a postintervention survey that was sent out to understand the practices and comfort of primary care providers in evaluating suspected ILD and the utility of the additional resources created by Dr. Selvan’s team.
“My hope is that we can utilize this partnership with the Primary Care Group to provide the education that’s needed both on the patient side and the provider side, like knowing not to ignore respiratory symptoms, knowing which patients warrant ILD-specific testing, and knowing what the appropriate tests are. In doing so, we can get patients into ILD clinic earlier, confirm their diagnosis, and get them initiated on the appropriate therapies sooner,” she said.
Dr. Selvan credits the quality improvement grant as being fundamental in her success as a fellow and early faculty at UChicago Medicine and believes that this project has created a culture of awareness that wouldn’t have been possible without funding.
“I truly believe that early detection and risk factor modification is the most critical aspect of interstitial lung disease care, and the mechanism for how we’re going to actually improve patient outcomes in our community,” Dr. Selvan said. “Building the infrastructure to accomplish that requires time, resources, and support from institutions and philanthropic foundations that believe in that mission too."
Opportunities like this are made possible by generous contributions from our donors. Make a gift to CHEST and select “Clinical Research” to help aid future research into interstitial lung disease and much more.
Interstitial lung diseases (ILDs), with their many ubiquitous symptoms, are often hard to diagnose in patients. That’s why Amirahwaty Abdullah, MBBS, and Kavitha Selvan, MD, see value in educating clinicians on how to identify and diagnose ILD.
Both Dr. Abdullah and Dr. Selvan received quality improvement grants from CHEST in October 2023 to do just that. Their projects put the ILD Clinician Toolkit into practice, created as a part of CHEST’s Bridging Specialties™: Timely Diagnosis for ILD initiative aimed at shortening the time to diagnosis.
Recently, CHEST caught up with the two grant recipients to see how their projects were progressing.
Combating the prevalence of ILDs in West Virginia
Dr. Abdullah and Co-Principal Investigator, Haroon Ahmed, MD, are two of the staff members supporting West Virginia University ILD Clinic, where the ILD Clinician Toolkit is being utilized.
“ILD is so prevalent here, so we thought it would be an excellent opportunity to do the quality improvement project here because we really do need the resources to improve the care of our [patients with ILD],” Dr. Abdullah said. “For the entire state of West Virginia, we’re the only ILD center.”
In West Virginia, many factors are at play making ILD prevalent, with a recent study showing that the state has the second highest rate of interstitial pulmonary fibrosis, Dr. Abdullah said. This is all due to the economy of the state, the rurality of the population, and the occupational hazards with common jobs like coal mining and farming.
“This topic about bridging the gap and early diagnosis really resonated with us because we see all these patients who end up seeing us after they’ve been on oxygen for years, when they can’t do anything else,” Dr. Ahmed said. “There was a big gap here, and we saw that every day in our clinical practice.”
Since implementing the ILD Clinician Toolkit into their program, the two have started providing these resources to primary care physicians in an effort to help expedite their workups when they see patients with common ILD symptoms. This was done through grand rounds and educational conferences for those practicing in family medicine, internal medicine, and pediatric medicine. And more education is planned for the future.
They have also created working relationships with these departments and have encouraged them to send patients to the ILD Clinic, so patients don’t have to be referred to multiple different physicians.
The next step for the project is to implement telemedicine capabilities, which will allow the team to roll out the patient questionnaire from the toolkit. The questionnaire helps physicians gather a detailed history about their patients, including their past and current medications, surgeries, occupational and environmental exposures, and known comorbidities.
“We definitely want to reach out via telemedicine to patients because, at this point in time, some of our patients travel 3, 4 hours one way just to come see us. So, if we can make it more accessible, we will,” Dr. Abdullah said.
Their plan is to provide iPads that are equipped with the questionnaire and other toolkit resources to the providers. Through this method, the team will be able to see how often the questionnaire is used.
“We are very thankful for this grant because I do think we are saving lives,” Dr. Abdullah said. “Any little thing that we can do to improve the outcomes of these patients who have a rare but difficult-to-treat disease—it’s crucial. This gives us the ability to reach out and help patients who are out of our physical bounds.”
Diagnosing ILD among underrepresented minority populations in Chicago
Dr. Kavitha Selvan is conducting her quality improvement research project at the University of Chicago, alongside her team.
“The community we serve in South Chicago houses a significant number of underrepresented [minority populations],” she said.
“We know that Black patients with ILD experience higher rates of hospitalization, compared with White patients,” she said. “And they are hospitalized, require lung transplants, and die at a younger age too.”
In clinical practice, Dr. Selvan has noticed a trend of patients being referred for evaluation of possible ILD later and later. In some cases, several years go by before the appropriate work for ILD is initiated, and that valuable time lost leads to irreversible loss of lung function.
Dr. Selvan’s plan is to partner with primary care providers who are seeing these patients first in order to expedite the work-up and referral of ILD when appropriate and, ultimately, reduce the amount of time that passes between symptom onset and definitive diagnosis.
“To me, this grant and the resources it provided represented an important opportunity to improve outcomes in the high-risk patients we care for through early disease recognition and treatment,” she said.
Dr. Selvan’s project began with educating members of the Primary Care Group at UChicago on risk factors and exam findings that may suggest ILD in patients coming to clinic with nonspecific respiratory complaints. Then they had to equip providers with the ILD Clinician Toolkit and reach patients by handing out the patient questionnaire in primary care clinic.
The next step for this project is going to be dissecting the answers to a postintervention survey that was sent out to understand the practices and comfort of primary care providers in evaluating suspected ILD and the utility of the additional resources created by Dr. Selvan’s team.
“My hope is that we can utilize this partnership with the Primary Care Group to provide the education that’s needed both on the patient side and the provider side, like knowing not to ignore respiratory symptoms, knowing which patients warrant ILD-specific testing, and knowing what the appropriate tests are. In doing so, we can get patients into ILD clinic earlier, confirm their diagnosis, and get them initiated on the appropriate therapies sooner,” she said.
Dr. Selvan credits the quality improvement grant as being fundamental in her success as a fellow and early faculty at UChicago Medicine and believes that this project has created a culture of awareness that wouldn’t have been possible without funding.
“I truly believe that early detection and risk factor modification is the most critical aspect of interstitial lung disease care, and the mechanism for how we’re going to actually improve patient outcomes in our community,” Dr. Selvan said. “Building the infrastructure to accomplish that requires time, resources, and support from institutions and philanthropic foundations that believe in that mission too."
Opportunities like this are made possible by generous contributions from our donors. Make a gift to CHEST and select “Clinical Research” to help aid future research into interstitial lung disease and much more.
Interstitial lung diseases (ILDs), with their many ubiquitous symptoms, are often hard to diagnose in patients. That’s why Amirahwaty Abdullah, MBBS, and Kavitha Selvan, MD, see value in educating clinicians on how to identify and diagnose ILD.
Both Dr. Abdullah and Dr. Selvan received quality improvement grants from CHEST in October 2023 to do just that. Their projects put the ILD Clinician Toolkit into practice, created as a part of CHEST’s Bridging Specialties™: Timely Diagnosis for ILD initiative aimed at shortening the time to diagnosis.
Recently, CHEST caught up with the two grant recipients to see how their projects were progressing.
Combating the prevalence of ILDs in West Virginia
Dr. Abdullah and Co-Principal Investigator, Haroon Ahmed, MD, are two of the staff members supporting West Virginia University ILD Clinic, where the ILD Clinician Toolkit is being utilized.
“ILD is so prevalent here, so we thought it would be an excellent opportunity to do the quality improvement project here because we really do need the resources to improve the care of our [patients with ILD],” Dr. Abdullah said. “For the entire state of West Virginia, we’re the only ILD center.”
In West Virginia, many factors are at play making ILD prevalent, with a recent study showing that the state has the second highest rate of interstitial pulmonary fibrosis, Dr. Abdullah said. This is all due to the economy of the state, the rurality of the population, and the occupational hazards with common jobs like coal mining and farming.
“This topic about bridging the gap and early diagnosis really resonated with us because we see all these patients who end up seeing us after they’ve been on oxygen for years, when they can’t do anything else,” Dr. Ahmed said. “There was a big gap here, and we saw that every day in our clinical practice.”
Since implementing the ILD Clinician Toolkit into their program, the two have started providing these resources to primary care physicians in an effort to help expedite their workups when they see patients with common ILD symptoms. This was done through grand rounds and educational conferences for those practicing in family medicine, internal medicine, and pediatric medicine. And more education is planned for the future.
They have also created working relationships with these departments and have encouraged them to send patients to the ILD Clinic, so patients don’t have to be referred to multiple different physicians.
The next step for the project is to implement telemedicine capabilities, which will allow the team to roll out the patient questionnaire from the toolkit. The questionnaire helps physicians gather a detailed history about their patients, including their past and current medications, surgeries, occupational and environmental exposures, and known comorbidities.
“We definitely want to reach out via telemedicine to patients because, at this point in time, some of our patients travel 3, 4 hours one way just to come see us. So, if we can make it more accessible, we will,” Dr. Abdullah said.
Their plan is to provide iPads that are equipped with the questionnaire and other toolkit resources to the providers. Through this method, the team will be able to see how often the questionnaire is used.
“We are very thankful for this grant because I do think we are saving lives,” Dr. Abdullah said. “Any little thing that we can do to improve the outcomes of these patients who have a rare but difficult-to-treat disease—it’s crucial. This gives us the ability to reach out and help patients who are out of our physical bounds.”
Diagnosing ILD among underrepresented minority populations in Chicago
Dr. Kavitha Selvan is conducting her quality improvement research project at the University of Chicago, alongside her team.
“The community we serve in South Chicago houses a significant number of underrepresented [minority populations],” she said.
“We know that Black patients with ILD experience higher rates of hospitalization, compared with White patients,” she said. “And they are hospitalized, require lung transplants, and die at a younger age too.”
In clinical practice, Dr. Selvan has noticed a trend of patients being referred for evaluation of possible ILD later and later. In some cases, several years go by before the appropriate work for ILD is initiated, and that valuable time lost leads to irreversible loss of lung function.
Dr. Selvan’s plan is to partner with primary care providers who are seeing these patients first in order to expedite the work-up and referral of ILD when appropriate and, ultimately, reduce the amount of time that passes between symptom onset and definitive diagnosis.
“To me, this grant and the resources it provided represented an important opportunity to improve outcomes in the high-risk patients we care for through early disease recognition and treatment,” she said.
Dr. Selvan’s project began with educating members of the Primary Care Group at UChicago on risk factors and exam findings that may suggest ILD in patients coming to clinic with nonspecific respiratory complaints. Then they had to equip providers with the ILD Clinician Toolkit and reach patients by handing out the patient questionnaire in primary care clinic.
The next step for this project is going to be dissecting the answers to a postintervention survey that was sent out to understand the practices and comfort of primary care providers in evaluating suspected ILD and the utility of the additional resources created by Dr. Selvan’s team.
“My hope is that we can utilize this partnership with the Primary Care Group to provide the education that’s needed both on the patient side and the provider side, like knowing not to ignore respiratory symptoms, knowing which patients warrant ILD-specific testing, and knowing what the appropriate tests are. In doing so, we can get patients into ILD clinic earlier, confirm their diagnosis, and get them initiated on the appropriate therapies sooner,” she said.
Dr. Selvan credits the quality improvement grant as being fundamental in her success as a fellow and early faculty at UChicago Medicine and believes that this project has created a culture of awareness that wouldn’t have been possible without funding.
“I truly believe that early detection and risk factor modification is the most critical aspect of interstitial lung disease care, and the mechanism for how we’re going to actually improve patient outcomes in our community,” Dr. Selvan said. “Building the infrastructure to accomplish that requires time, resources, and support from institutions and philanthropic foundations that believe in that mission too."
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