User login
Climate change demands ‘green’ endoscopy
Climate change is a global threat, and it presents a dual problem to health care: The system must address health threats that may be caused or exacerbated by climate change, while at the same time minimizing its environmental impact, according to the authors of a paper in Techniques and Innovations in Gastrointestinal Endoscopy.
Because of how often it is performed, endoscopy may have one of the highest environmental impacts of any health care procedure. Waste produced by endoscopy is the third largest source in a typical hospital, equivalent yearly to burning 39 million pounds of coal or 13,500 tons of plastic. That makes endoscopy a key target in reducing the environmental footprint of health care, according to the authors, who were led by Rosemary Haddock, MBChB, MRCP, of Ninewells Hospital in Dundee, Scotland.
Climate change has direct impacts on health, ranging from the effects of wildfire smoke and pollution on respiratory and cardiac health to food insecurity, heat stroke, and alterations to the geographic ranges of vector-borne diseases. It also raises the risk of future pandemics like COVID-19. “Climate change is a major threat to health and threatens to undermine the last 50 years of public health gains,” the authors wrote.
Although the effects of climate change on gastrointestinal diseases has not been studied as extensively as other organ systems, there are known impacts. These include more gastrointestinal infections at higher temperatures, the risk of enteric pathogens and viral hepatitis as a result of flooding and higher water temperatures, and malnutrition caused by the disruption of food crops and distribution. “It seems a little unlikely that the organs which we are interested in as gastroenterologists and hepatologists are largely exempt from the direct effects of hotter temperatures, when every other human organ system appears to be affected almost without exception,” the authors wrote.
Those issues put an onus on health care to address climate change, not only in health care delivery but also to find ways to reduce emissions as an industry. Hospitals and other large facilities can act as “anchor institutions” that set an example within the community and influence others since they procure goods and services and own assets and land. To date, few institutions have adopted this stance.
A key question is how health care institutions can reduce resource use while maintaining quality of care. One approach is to identify areas of medical overuse, where wasteful practices have no patient benefit. The authors believe that a reduction in endoscopic procedures could have one of the largest impacts on carbon emissions. They emphasized that reduced numbers of procedures would likely have greater effect than making procedures “greener.”
Some endoscopic procedures offer little value to the patient. The approach of screening to combat disease, introduced in 1968, should be challenged in some patient groups because it can lead to unnecessary procedures.
The American Gastroenterological Association has identified some procedures as commonly overused, including screening colonoscopy in average-risk individuals, surveillance colonoscopy for low-risk polyps, and surveillance esophagogastroduodenoscopy in Barrett’s esophagus. The authors note that performing fewer endoscopies will require shifts in behavior, referral patterns, education, and culture, all of which will take time.
In the meantime, endoscopists can take some steps to reduce the footprint of existing procedures: source supplies through sustainable means, which is important because supply chain emissions account for more than half of health care emissions; seek out sources of renewable energy; use their institution’s status as an “anchor institution” to pressure suppliers into using sustainable practices; evaluate less invasive procedures, such as Cytosponge or fecal immunochemical test; employ reusable or recyclable equipment; minimize the use of nitrous oxide, which is a key greenhouse gas; segregate infectious waste; and develop multiple recycling streams.
The authors have no relevant financial disclosures.
Endoscopy has a large environmental impact and generates the third-highest amount of waste in health care facilities. Its annual CO2 emissions in the United States are equivalent to 39 million pounds of coal. Mining of elements used in endoscopy equipment such as molybdenum and titanium is destructive to the environment.
The authors state that this puts an onus on health care to address climate change, not only in health care delivery but also to find ways to reduce emissions as an industry.
A key question posed by the authors is how health care institutions can reduce use of resources while maintaining quality of care. They emphasize the importance of both local/individual changes and the support of national bodies and institutions to achieve these goals. There is an urgent need to incentivize development of greener endoscopy units, to increase focus on studies tackling medical excess, and for behavioral change to reduce unnecessary procedures.
Kaveh Sharzehi, MD, MS, is the medical director of endoscopy and associate professor of medicine, division of gastroenterology & hepatology, at Oregon Health & Science University. He has no conflicts.
Endoscopy has a large environmental impact and generates the third-highest amount of waste in health care facilities. Its annual CO2 emissions in the United States are equivalent to 39 million pounds of coal. Mining of elements used in endoscopy equipment such as molybdenum and titanium is destructive to the environment.
The authors state that this puts an onus on health care to address climate change, not only in health care delivery but also to find ways to reduce emissions as an industry.
A key question posed by the authors is how health care institutions can reduce use of resources while maintaining quality of care. They emphasize the importance of both local/individual changes and the support of national bodies and institutions to achieve these goals. There is an urgent need to incentivize development of greener endoscopy units, to increase focus on studies tackling medical excess, and for behavioral change to reduce unnecessary procedures.
Kaveh Sharzehi, MD, MS, is the medical director of endoscopy and associate professor of medicine, division of gastroenterology & hepatology, at Oregon Health & Science University. He has no conflicts.
Endoscopy has a large environmental impact and generates the third-highest amount of waste in health care facilities. Its annual CO2 emissions in the United States are equivalent to 39 million pounds of coal. Mining of elements used in endoscopy equipment such as molybdenum and titanium is destructive to the environment.
The authors state that this puts an onus on health care to address climate change, not only in health care delivery but also to find ways to reduce emissions as an industry.
A key question posed by the authors is how health care institutions can reduce use of resources while maintaining quality of care. They emphasize the importance of both local/individual changes and the support of national bodies and institutions to achieve these goals. There is an urgent need to incentivize development of greener endoscopy units, to increase focus on studies tackling medical excess, and for behavioral change to reduce unnecessary procedures.
Kaveh Sharzehi, MD, MS, is the medical director of endoscopy and associate professor of medicine, division of gastroenterology & hepatology, at Oregon Health & Science University. He has no conflicts.
Climate change is a global threat, and it presents a dual problem to health care: The system must address health threats that may be caused or exacerbated by climate change, while at the same time minimizing its environmental impact, according to the authors of a paper in Techniques and Innovations in Gastrointestinal Endoscopy.
Because of how often it is performed, endoscopy may have one of the highest environmental impacts of any health care procedure. Waste produced by endoscopy is the third largest source in a typical hospital, equivalent yearly to burning 39 million pounds of coal or 13,500 tons of plastic. That makes endoscopy a key target in reducing the environmental footprint of health care, according to the authors, who were led by Rosemary Haddock, MBChB, MRCP, of Ninewells Hospital in Dundee, Scotland.
Climate change has direct impacts on health, ranging from the effects of wildfire smoke and pollution on respiratory and cardiac health to food insecurity, heat stroke, and alterations to the geographic ranges of vector-borne diseases. It also raises the risk of future pandemics like COVID-19. “Climate change is a major threat to health and threatens to undermine the last 50 years of public health gains,” the authors wrote.
Although the effects of climate change on gastrointestinal diseases has not been studied as extensively as other organ systems, there are known impacts. These include more gastrointestinal infections at higher temperatures, the risk of enteric pathogens and viral hepatitis as a result of flooding and higher water temperatures, and malnutrition caused by the disruption of food crops and distribution. “It seems a little unlikely that the organs which we are interested in as gastroenterologists and hepatologists are largely exempt from the direct effects of hotter temperatures, when every other human organ system appears to be affected almost without exception,” the authors wrote.
Those issues put an onus on health care to address climate change, not only in health care delivery but also to find ways to reduce emissions as an industry. Hospitals and other large facilities can act as “anchor institutions” that set an example within the community and influence others since they procure goods and services and own assets and land. To date, few institutions have adopted this stance.
A key question is how health care institutions can reduce resource use while maintaining quality of care. One approach is to identify areas of medical overuse, where wasteful practices have no patient benefit. The authors believe that a reduction in endoscopic procedures could have one of the largest impacts on carbon emissions. They emphasized that reduced numbers of procedures would likely have greater effect than making procedures “greener.”
Some endoscopic procedures offer little value to the patient. The approach of screening to combat disease, introduced in 1968, should be challenged in some patient groups because it can lead to unnecessary procedures.
The American Gastroenterological Association has identified some procedures as commonly overused, including screening colonoscopy in average-risk individuals, surveillance colonoscopy for low-risk polyps, and surveillance esophagogastroduodenoscopy in Barrett’s esophagus. The authors note that performing fewer endoscopies will require shifts in behavior, referral patterns, education, and culture, all of which will take time.
In the meantime, endoscopists can take some steps to reduce the footprint of existing procedures: source supplies through sustainable means, which is important because supply chain emissions account for more than half of health care emissions; seek out sources of renewable energy; use their institution’s status as an “anchor institution” to pressure suppliers into using sustainable practices; evaluate less invasive procedures, such as Cytosponge or fecal immunochemical test; employ reusable or recyclable equipment; minimize the use of nitrous oxide, which is a key greenhouse gas; segregate infectious waste; and develop multiple recycling streams.
The authors have no relevant financial disclosures.
Climate change is a global threat, and it presents a dual problem to health care: The system must address health threats that may be caused or exacerbated by climate change, while at the same time minimizing its environmental impact, according to the authors of a paper in Techniques and Innovations in Gastrointestinal Endoscopy.
Because of how often it is performed, endoscopy may have one of the highest environmental impacts of any health care procedure. Waste produced by endoscopy is the third largest source in a typical hospital, equivalent yearly to burning 39 million pounds of coal or 13,500 tons of plastic. That makes endoscopy a key target in reducing the environmental footprint of health care, according to the authors, who were led by Rosemary Haddock, MBChB, MRCP, of Ninewells Hospital in Dundee, Scotland.
Climate change has direct impacts on health, ranging from the effects of wildfire smoke and pollution on respiratory and cardiac health to food insecurity, heat stroke, and alterations to the geographic ranges of vector-borne diseases. It also raises the risk of future pandemics like COVID-19. “Climate change is a major threat to health and threatens to undermine the last 50 years of public health gains,” the authors wrote.
Although the effects of climate change on gastrointestinal diseases has not been studied as extensively as other organ systems, there are known impacts. These include more gastrointestinal infections at higher temperatures, the risk of enteric pathogens and viral hepatitis as a result of flooding and higher water temperatures, and malnutrition caused by the disruption of food crops and distribution. “It seems a little unlikely that the organs which we are interested in as gastroenterologists and hepatologists are largely exempt from the direct effects of hotter temperatures, when every other human organ system appears to be affected almost without exception,” the authors wrote.
Those issues put an onus on health care to address climate change, not only in health care delivery but also to find ways to reduce emissions as an industry. Hospitals and other large facilities can act as “anchor institutions” that set an example within the community and influence others since they procure goods and services and own assets and land. To date, few institutions have adopted this stance.
A key question is how health care institutions can reduce resource use while maintaining quality of care. One approach is to identify areas of medical overuse, where wasteful practices have no patient benefit. The authors believe that a reduction in endoscopic procedures could have one of the largest impacts on carbon emissions. They emphasized that reduced numbers of procedures would likely have greater effect than making procedures “greener.”
Some endoscopic procedures offer little value to the patient. The approach of screening to combat disease, introduced in 1968, should be challenged in some patient groups because it can lead to unnecessary procedures.
The American Gastroenterological Association has identified some procedures as commonly overused, including screening colonoscopy in average-risk individuals, surveillance colonoscopy for low-risk polyps, and surveillance esophagogastroduodenoscopy in Barrett’s esophagus. The authors note that performing fewer endoscopies will require shifts in behavior, referral patterns, education, and culture, all of which will take time.
In the meantime, endoscopists can take some steps to reduce the footprint of existing procedures: source supplies through sustainable means, which is important because supply chain emissions account for more than half of health care emissions; seek out sources of renewable energy; use their institution’s status as an “anchor institution” to pressure suppliers into using sustainable practices; evaluate less invasive procedures, such as Cytosponge or fecal immunochemical test; employ reusable or recyclable equipment; minimize the use of nitrous oxide, which is a key greenhouse gas; segregate infectious waste; and develop multiple recycling streams.
The authors have no relevant financial disclosures.
FROM TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY
Case: Patient with statin-associated muscle symptoms
A 66-year-old woman is discharged from the hospital after an MI. Her discharge medications include atorvastatin 40 mg, lisinopril 20 mg, acetylsalicylic acid 81 mg, and clopidogrel 75 mg. At this patient’s follow-up appointment, she mentions that she has muscle pain and stiffness in both legs and her back. Her labs include thyroid-stimulating hormone of 2.0 and vitamin D of 40. She stops the atorvastatin for 2 weeks with resolution of her symptoms.
Which treatment recommendation would you make for this patient?
A. Restart atorvastatin
B. Start rosuvastatin twice a week
C. Start ezetimibe
D. Start a PCSK9 inhibitor
We often see high-risk cardiovascular disease patients who are concerned about muscle side effects brought on by statins. I think we all can agree that this patient needs aggressive medical therapy for prevention of secondary cardiovascular events. I would restart her atorvastatin.
Neilsen and Nordestgaard found that early statin discontinuation rates increased from 6% in 1995 to 18% in 2010.1
Early statin discontinuation correlated with negative statin-related news stories, their paper states. This suggests either an increased awareness of side effects or a possible nocebo effect.
Statin rechallenge results
Joy and colleagues reported the results on eight patients who had developed myalgias within 3 weeks of starting a statin. These patients, who received placebo or statin, completed an N-of-1 trial with three double-blind, crossover comparisons separated by 3-week washout periods.
Patients were evaluated pain on a visual analog scale (VAS). For each N-of-1 trial there was no statistically significant difference in pain or myalgia score between those who took statin and placebo. Five of the eight patients chose to continue on statins at the end of the trial.
Herrett and colleagues performed a more extensive series of N-of-1 trials involving 200 patients who had stopped or were considering stopping statins because of muscle symptoms.3 Participants either received 2 months of atorvastatin 20 mg or placebo for 2-month blocks six times. They rated their muscle symptoms on a VAS at the end of each block. There was no difference in muscle symptom scores between the statin and placebo periods.
Wood and colleagues took it a step further, when they studied an N-of-1 trial that included statin, placebo, and no treatment.4 Each participant received four bottles of atorvastatin 20 mg, four bottles of placebo, and four empty bottles. Each month they used treatment from the bottles based on random sequence and reported daily symptom scores. The mean symptom intensity was 8.0 during no-tablet months, 15.4 during placebo months (P < .001, compared with no-tablet months), and 16.3 during statin months (P < .001, compared with no-tablet months; P = .39, compared with placebo).
Taylor and colleagues studied 120 patients who had prior statin-associated muscle complaints.5 Each patient received either simvastatin 20 mg or placebo for 4 weeks, and then were switched for an additional 4 weeks. A total of 43 patients (36%) had pain on simvastatin but not placebo, 21 (17%) had no pain with either treatment, 21 (17%) reported pain with both treatments, and 35 (29%) had pain with placebo but not simvastatin. These studies support the concept of nocebo effect in patients who have muscle symptoms on statins.
So what should be done? Brennan and Roy did a retrospective study of 118 patients referred to a lipid clinic as being statin intolerant to two or more statins.6 Most of the patients were able to tolerate a statin: 71% tolerated same statin rechallenge, 53% tolerated statin switch, and 57% tolerated a nonstatin therapy.
In the Prosisa study, only 27% of patients who reported statin-associated muscle symptoms had reappearance of muscle symptoms after rechallenge with a statin.7
Research implications
Rechallenge with the same statin seems to be a reasonable first step, followed by switching to a different statin. I also share the concept of nocebo effect with my patients, and tell them I believe they have an excellent chance of tolerating the statin.
Pearl: The majority of patients with muscle symptoms while taking a statin likely have a nocebo effect, and are likely to tolerate rechallenge with the same statin.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Nielsen SF and Nordestgaard BG. Eur Heart J. 2016;37:908-16.
2. Joy TR et al. Ann Intern Med. 2014;160:301-10.
3. Herrett E et al. BMJ. 2021 Feb 24;372:n135.
4. Wood FA et al. N Engl J Med 2020;383:2182-4.
5. Taylor BA et al. Atherosclerosis. 2017;256:100-4.
6. Brennen ET and Roy TR. Can J Card. 2017;33(5):666-73.
7. Bonaiti Fet al. Atherosclerosis. 2020;315:E13-4.
A 66-year-old woman is discharged from the hospital after an MI. Her discharge medications include atorvastatin 40 mg, lisinopril 20 mg, acetylsalicylic acid 81 mg, and clopidogrel 75 mg. At this patient’s follow-up appointment, she mentions that she has muscle pain and stiffness in both legs and her back. Her labs include thyroid-stimulating hormone of 2.0 and vitamin D of 40. She stops the atorvastatin for 2 weeks with resolution of her symptoms.
Which treatment recommendation would you make for this patient?
A. Restart atorvastatin
B. Start rosuvastatin twice a week
C. Start ezetimibe
D. Start a PCSK9 inhibitor
We often see high-risk cardiovascular disease patients who are concerned about muscle side effects brought on by statins. I think we all can agree that this patient needs aggressive medical therapy for prevention of secondary cardiovascular events. I would restart her atorvastatin.
Neilsen and Nordestgaard found that early statin discontinuation rates increased from 6% in 1995 to 18% in 2010.1
Early statin discontinuation correlated with negative statin-related news stories, their paper states. This suggests either an increased awareness of side effects or a possible nocebo effect.
Statin rechallenge results
Joy and colleagues reported the results on eight patients who had developed myalgias within 3 weeks of starting a statin. These patients, who received placebo or statin, completed an N-of-1 trial with three double-blind, crossover comparisons separated by 3-week washout periods.
Patients were evaluated pain on a visual analog scale (VAS). For each N-of-1 trial there was no statistically significant difference in pain or myalgia score between those who took statin and placebo. Five of the eight patients chose to continue on statins at the end of the trial.
Herrett and colleagues performed a more extensive series of N-of-1 trials involving 200 patients who had stopped or were considering stopping statins because of muscle symptoms.3 Participants either received 2 months of atorvastatin 20 mg or placebo for 2-month blocks six times. They rated their muscle symptoms on a VAS at the end of each block. There was no difference in muscle symptom scores between the statin and placebo periods.
Wood and colleagues took it a step further, when they studied an N-of-1 trial that included statin, placebo, and no treatment.4 Each participant received four bottles of atorvastatin 20 mg, four bottles of placebo, and four empty bottles. Each month they used treatment from the bottles based on random sequence and reported daily symptom scores. The mean symptom intensity was 8.0 during no-tablet months, 15.4 during placebo months (P < .001, compared with no-tablet months), and 16.3 during statin months (P < .001, compared with no-tablet months; P = .39, compared with placebo).
Taylor and colleagues studied 120 patients who had prior statin-associated muscle complaints.5 Each patient received either simvastatin 20 mg or placebo for 4 weeks, and then were switched for an additional 4 weeks. A total of 43 patients (36%) had pain on simvastatin but not placebo, 21 (17%) had no pain with either treatment, 21 (17%) reported pain with both treatments, and 35 (29%) had pain with placebo but not simvastatin. These studies support the concept of nocebo effect in patients who have muscle symptoms on statins.
So what should be done? Brennan and Roy did a retrospective study of 118 patients referred to a lipid clinic as being statin intolerant to two or more statins.6 Most of the patients were able to tolerate a statin: 71% tolerated same statin rechallenge, 53% tolerated statin switch, and 57% tolerated a nonstatin therapy.
In the Prosisa study, only 27% of patients who reported statin-associated muscle symptoms had reappearance of muscle symptoms after rechallenge with a statin.7
Research implications
Rechallenge with the same statin seems to be a reasonable first step, followed by switching to a different statin. I also share the concept of nocebo effect with my patients, and tell them I believe they have an excellent chance of tolerating the statin.
Pearl: The majority of patients with muscle symptoms while taking a statin likely have a nocebo effect, and are likely to tolerate rechallenge with the same statin.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Nielsen SF and Nordestgaard BG. Eur Heart J. 2016;37:908-16.
2. Joy TR et al. Ann Intern Med. 2014;160:301-10.
3. Herrett E et al. BMJ. 2021 Feb 24;372:n135.
4. Wood FA et al. N Engl J Med 2020;383:2182-4.
5. Taylor BA et al. Atherosclerosis. 2017;256:100-4.
6. Brennen ET and Roy TR. Can J Card. 2017;33(5):666-73.
7. Bonaiti Fet al. Atherosclerosis. 2020;315:E13-4.
A 66-year-old woman is discharged from the hospital after an MI. Her discharge medications include atorvastatin 40 mg, lisinopril 20 mg, acetylsalicylic acid 81 mg, and clopidogrel 75 mg. At this patient’s follow-up appointment, she mentions that she has muscle pain and stiffness in both legs and her back. Her labs include thyroid-stimulating hormone of 2.0 and vitamin D of 40. She stops the atorvastatin for 2 weeks with resolution of her symptoms.
Which treatment recommendation would you make for this patient?
A. Restart atorvastatin
B. Start rosuvastatin twice a week
C. Start ezetimibe
D. Start a PCSK9 inhibitor
We often see high-risk cardiovascular disease patients who are concerned about muscle side effects brought on by statins. I think we all can agree that this patient needs aggressive medical therapy for prevention of secondary cardiovascular events. I would restart her atorvastatin.
Neilsen and Nordestgaard found that early statin discontinuation rates increased from 6% in 1995 to 18% in 2010.1
Early statin discontinuation correlated with negative statin-related news stories, their paper states. This suggests either an increased awareness of side effects or a possible nocebo effect.
Statin rechallenge results
Joy and colleagues reported the results on eight patients who had developed myalgias within 3 weeks of starting a statin. These patients, who received placebo or statin, completed an N-of-1 trial with three double-blind, crossover comparisons separated by 3-week washout periods.
Patients were evaluated pain on a visual analog scale (VAS). For each N-of-1 trial there was no statistically significant difference in pain or myalgia score between those who took statin and placebo. Five of the eight patients chose to continue on statins at the end of the trial.
Herrett and colleagues performed a more extensive series of N-of-1 trials involving 200 patients who had stopped or were considering stopping statins because of muscle symptoms.3 Participants either received 2 months of atorvastatin 20 mg or placebo for 2-month blocks six times. They rated their muscle symptoms on a VAS at the end of each block. There was no difference in muscle symptom scores between the statin and placebo periods.
Wood and colleagues took it a step further, when they studied an N-of-1 trial that included statin, placebo, and no treatment.4 Each participant received four bottles of atorvastatin 20 mg, four bottles of placebo, and four empty bottles. Each month they used treatment from the bottles based on random sequence and reported daily symptom scores. The mean symptom intensity was 8.0 during no-tablet months, 15.4 during placebo months (P < .001, compared with no-tablet months), and 16.3 during statin months (P < .001, compared with no-tablet months; P = .39, compared with placebo).
Taylor and colleagues studied 120 patients who had prior statin-associated muscle complaints.5 Each patient received either simvastatin 20 mg or placebo for 4 weeks, and then were switched for an additional 4 weeks. A total of 43 patients (36%) had pain on simvastatin but not placebo, 21 (17%) had no pain with either treatment, 21 (17%) reported pain with both treatments, and 35 (29%) had pain with placebo but not simvastatin. These studies support the concept of nocebo effect in patients who have muscle symptoms on statins.
So what should be done? Brennan and Roy did a retrospective study of 118 patients referred to a lipid clinic as being statin intolerant to two or more statins.6 Most of the patients were able to tolerate a statin: 71% tolerated same statin rechallenge, 53% tolerated statin switch, and 57% tolerated a nonstatin therapy.
In the Prosisa study, only 27% of patients who reported statin-associated muscle symptoms had reappearance of muscle symptoms after rechallenge with a statin.7
Research implications
Rechallenge with the same statin seems to be a reasonable first step, followed by switching to a different statin. I also share the concept of nocebo effect with my patients, and tell them I believe they have an excellent chance of tolerating the statin.
Pearl: The majority of patients with muscle symptoms while taking a statin likely have a nocebo effect, and are likely to tolerate rechallenge with the same statin.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Nielsen SF and Nordestgaard BG. Eur Heart J. 2016;37:908-16.
2. Joy TR et al. Ann Intern Med. 2014;160:301-10.
3. Herrett E et al. BMJ. 2021 Feb 24;372:n135.
4. Wood FA et al. N Engl J Med 2020;383:2182-4.
5. Taylor BA et al. Atherosclerosis. 2017;256:100-4.
6. Brennen ET and Roy TR. Can J Card. 2017;33(5):666-73.
7. Bonaiti Fet al. Atherosclerosis. 2020;315:E13-4.
‘Quadpill’ bests monotherapy for initial BP lowering: QUARTET
A “quadpill” containing quarter doses of four blood pressure (BP)–lowering medications was more effective than monotherapy for initial treatment of hypertension, with similar tolerability, in the 1-year, phase 3 QUARTET randomized, active-control trial.
Clara Chow, MD, PhD, academic director of the Westmead Applied Research Centre, University of Sydney, presented the findings in a late-breaking trial session at the annual congress of the European Society of Cardiology. The study was simultaneously published in The Lancet.
The primary outcome, mean unattended office BP at 12 weeks, dropped from 142/86 mm Hg to 120/71 mm Hg in patients who received the daily quadpill – a capsule containing irbesartan, amlodipine, indapamide, and bisoprolol – and fell from 140/83 mm Hg to 127/79 mm Hg in patients who received a daily full dose of irbesartan.
This 6.9 mm Hg greater drop in systolic BP at 12 months is clinically meaningful, Dr. Chow told this news organization. “If maintained, it would be expected to confer about a 15%-20% reduction” in heart disease, stroke, and heart failure.
In the SPRINT study, she noted, the final systolic BP was 120 mm Hg in the intervention group and 134 mm Hg in the control group, and the difference was associated with a 27% reduction in the composite cardiovascular (CV) outcome.
The results of QUARTET suggest that, “even in those with stage 1 hypertension, we can safely reduce BP to a significant degree by this simple approach, compared to usual care,” Salim Yusuf, MD, DPhil, a long-time advocate of a polypill approach, said in an email.
Importantly, Dr. Chow pointed out, at 12 months, 81% of patients treated with the quadpill versus 62% of patients treated with monotherapy had BP control (<140/90 mm Hg). Patients who received monotherapy did not “catch up,” even though a higher percentage received stepped-up therapy.
The quadpill dosing strategy aligns with the latest 2018 ESC/European Society of Hypertension guidelines, which recommend starting antihypertensive treatment with more than one drug, session cochair Thomas Kahan, MD, PhD, Karolinska Institute, Danderyd Hospital, department of clinical sciences, Stockholm, commented.
“How many drugs should be in the initial step?” he asked. “Is four better than three or two, or should we have even more drugs at low doses?”
The trial was not designed to answer these questions, Dr. Chow replied. “We were really comparing [the quadpill] against what the majority of people around the planet are still doing, which is starting on one drug and slowly but surely stepping it up,” she said.
The quadpill was actually a capsule, she clarified, that contained four generic BP medications available in half doses in Australia. The half doses were cut in half and the medications were encapsulated. The control drug was prepared in an identical-looking capsule.
It is important to note that “the time to BP control was shorter in patients who received the quadpill versus monotherapy,” session cochair Felix Mahfoud, MD, internal medicine and cardiology, Saarland University Hospital, Hamburg, Germany, pointed out, because “in clinical practice we aim to get patients to BP control as quickly as possible.”
“What is new here is the use of four drugs, each given at quarter doses,” Dr. Yusuf, director of the Population Health Research Institute, McMaster University, Hamilton, Ont., said. Although a few questions remain, “this study emphasizes the importance and potential benefits and simplicity of using combination BP-lowering drugs at low doses.”
For guidelines to be changed, he observed, the findings would have to be replicated in independent studies, and the quadpill would likely have to be shown to be superior to the dual pill.
“It took about 20 years [to change guidelines] after the first evidence that combinations of two pills were preferable to single-drug combinations,” he noted.
“I hope that in most people with elevated BP, at least a two-drug combination plus a statin plus aspirin will be prescribed,” Dr. Yusuf said. “This can reduce the risk of CVD events by 50% or more – a big impact both for the individual and for populations. The quad pill may have a role in this approach.”
Four-in-one pill
Worldwide, hypertension control is poor, Dr. Chow said, because of the need for multiple medications, treatment inertia, and concerns about adverse events.
The researchers hypothesized that initial antihypertensive treatment with a four-in-one pill with quarter doses of each medication would minimize side effects, maximize BP lowering, and overcome these treatment barriers and concerns. A pilot study of this strategy published by the group in 2017 showed promise.
QUARTET randomized 591 adults with hypertension, seen at clinics in four states in Australia from June 2017 through August 2020.
Patients were either receiving no antihypertensive medication and had an unattended standard office BP of 140/90 to 179/109 mm Hg or daytime ambulatory BP greater than 135/95 mm Hg, or they were on BP-lowering monotherapy and had a BP of 130/85 to 179/109 mm Hg or daytime ambulatory BP greater than 125/80 mm Hg. Patients who were taking antihypertensive therapy entered a washout period before the trial.
The researchers randomized 291 participants to receive 150 mg irbesartan daily (usual care or control group).
The other 300 participants received a daily quadpill containing 37.5 mg irbesartan, 1.25 mg amlodipine, 0.625 mg indapamide, and 2.5 mg bisoprolol. The first three drugs are the most commonly prescribed angiotensin II receptor blocker, calcium channel blocker, and thiazide or thiazidelike diuretic in Australia, and the last drug, a beta-blocker, has a long duration of action, the study protocol explains.
Patients in both groups had similar baseline characteristics. They were a mean age of 58 years, 40% were women, and 82% were White. They also had a mean body mass index of 31 kg/m2. About 8% were current smokers, and about 54% were not taking a BP-lowering drug.
Participants had clinic visits at baseline, 6 weeks, and 12 weeks, and if they continued the study, at 26 weeks and 52 weeks.
If a patient’s blood pressure was higher than 140/90 mm Hg, clinicians could add another medication, starting with amlodipine 5 mg.
At 12 weeks, 15% of patients in the intervention group and 40% in the control group had stepped up treatment.
Despite greater up-titration in the usual care group, BP control remained higher in the quadpill group, Dr. Chow pointed out. That is, patients in the quadpill group were more likely than patients in the usual care group to have a BP less than 140/90 mm Hg (76% vs. 58% respectively; P < .0001).
Patients in the quadpill group also had lower daytime and nighttime ambulatory systolic BP.
At 12 months, among the 417 patients who continued treatment, patients in the quadpill group had a 7.7 mm Hg greater drop in systolic BP, compared with patients in the control group, (P < .001).
There were no significant differences in adverse events, which were most commonly dizziness (31% and 25%) or muscle cramps, gastrointestinal complaints, headache, or musculoskeletal complaints.
At 12 weeks, there were seven serious adverse events in the intervention group versus three in the control group. There were 12 treatment withdrawals in the intervention group versus seven in the control group (P = .27).
Remaining questions, upcoming phase 3 U.S. study
“While the [QUARTET] results are impressive, we are left with a number of questions,” Dr. Yusuf said.
Would the results be the same with a three-drug combo or even a two-drug combo at half doses? In the HOPE 3 trial, a two-drug combo at half doses provided similar results to the current study, over a much longer mean follow-up of 5.6 years, he noted.
Also, is the quadpill associated with higher rates of diabetes or higher creatinine levels in the long term? “Given that we do not have any data on long-term clinical outcomes from a four-drug combination,” Dr. Yusuf said, “caution should be utilized.”
Would the reduced risk of CVD be greater with a combination of low doses of two BP-lowering drugs plus a statin plus aspirin? That may be superior, he said, “based on recent information published on the polypill indicating a 50% relative risk reduction in CVD events.”
The related phase 2 QUARTET US trial should shed further light on a quadpill strategy. Patients with hypertension are being randomized to a daily quadpill containing 2 mg candesartan, 1.25 mg amlodipine besylate, 0.625 mg indapamide, and 2.5 mg bisoprolol, or to usual care, 8 mg candesartan daily.
Investigators plan to enroll 87 participants in the Chicago area, with estimated study completion by March 31, 2023.
The study was supported by an Australian National Health and Medical Research Council grant. The George Institute for Global Health has submitted patent applications for low–fixed-dose combination products to treat CV or cardiometabolic disease. Dr. Chow and coauthor Kris Rogers, PhD, senior biostatistician at The George Institute for Global Health, Newtown, Australia, are listed as inventors, but they do not have direct financial interests in these patent applications.
A version of this article first appeared on Medscape.com.
A “quadpill” containing quarter doses of four blood pressure (BP)–lowering medications was more effective than monotherapy for initial treatment of hypertension, with similar tolerability, in the 1-year, phase 3 QUARTET randomized, active-control trial.
Clara Chow, MD, PhD, academic director of the Westmead Applied Research Centre, University of Sydney, presented the findings in a late-breaking trial session at the annual congress of the European Society of Cardiology. The study was simultaneously published in The Lancet.
The primary outcome, mean unattended office BP at 12 weeks, dropped from 142/86 mm Hg to 120/71 mm Hg in patients who received the daily quadpill – a capsule containing irbesartan, amlodipine, indapamide, and bisoprolol – and fell from 140/83 mm Hg to 127/79 mm Hg in patients who received a daily full dose of irbesartan.
This 6.9 mm Hg greater drop in systolic BP at 12 months is clinically meaningful, Dr. Chow told this news organization. “If maintained, it would be expected to confer about a 15%-20% reduction” in heart disease, stroke, and heart failure.
In the SPRINT study, she noted, the final systolic BP was 120 mm Hg in the intervention group and 134 mm Hg in the control group, and the difference was associated with a 27% reduction in the composite cardiovascular (CV) outcome.
The results of QUARTET suggest that, “even in those with stage 1 hypertension, we can safely reduce BP to a significant degree by this simple approach, compared to usual care,” Salim Yusuf, MD, DPhil, a long-time advocate of a polypill approach, said in an email.
Importantly, Dr. Chow pointed out, at 12 months, 81% of patients treated with the quadpill versus 62% of patients treated with monotherapy had BP control (<140/90 mm Hg). Patients who received monotherapy did not “catch up,” even though a higher percentage received stepped-up therapy.
The quadpill dosing strategy aligns with the latest 2018 ESC/European Society of Hypertension guidelines, which recommend starting antihypertensive treatment with more than one drug, session cochair Thomas Kahan, MD, PhD, Karolinska Institute, Danderyd Hospital, department of clinical sciences, Stockholm, commented.
“How many drugs should be in the initial step?” he asked. “Is four better than three or two, or should we have even more drugs at low doses?”
The trial was not designed to answer these questions, Dr. Chow replied. “We were really comparing [the quadpill] against what the majority of people around the planet are still doing, which is starting on one drug and slowly but surely stepping it up,” she said.
The quadpill was actually a capsule, she clarified, that contained four generic BP medications available in half doses in Australia. The half doses were cut in half and the medications were encapsulated. The control drug was prepared in an identical-looking capsule.
It is important to note that “the time to BP control was shorter in patients who received the quadpill versus monotherapy,” session cochair Felix Mahfoud, MD, internal medicine and cardiology, Saarland University Hospital, Hamburg, Germany, pointed out, because “in clinical practice we aim to get patients to BP control as quickly as possible.”
“What is new here is the use of four drugs, each given at quarter doses,” Dr. Yusuf, director of the Population Health Research Institute, McMaster University, Hamilton, Ont., said. Although a few questions remain, “this study emphasizes the importance and potential benefits and simplicity of using combination BP-lowering drugs at low doses.”
For guidelines to be changed, he observed, the findings would have to be replicated in independent studies, and the quadpill would likely have to be shown to be superior to the dual pill.
“It took about 20 years [to change guidelines] after the first evidence that combinations of two pills were preferable to single-drug combinations,” he noted.
“I hope that in most people with elevated BP, at least a two-drug combination plus a statin plus aspirin will be prescribed,” Dr. Yusuf said. “This can reduce the risk of CVD events by 50% or more – a big impact both for the individual and for populations. The quad pill may have a role in this approach.”
Four-in-one pill
Worldwide, hypertension control is poor, Dr. Chow said, because of the need for multiple medications, treatment inertia, and concerns about adverse events.
The researchers hypothesized that initial antihypertensive treatment with a four-in-one pill with quarter doses of each medication would minimize side effects, maximize BP lowering, and overcome these treatment barriers and concerns. A pilot study of this strategy published by the group in 2017 showed promise.
QUARTET randomized 591 adults with hypertension, seen at clinics in four states in Australia from June 2017 through August 2020.
Patients were either receiving no antihypertensive medication and had an unattended standard office BP of 140/90 to 179/109 mm Hg or daytime ambulatory BP greater than 135/95 mm Hg, or they were on BP-lowering monotherapy and had a BP of 130/85 to 179/109 mm Hg or daytime ambulatory BP greater than 125/80 mm Hg. Patients who were taking antihypertensive therapy entered a washout period before the trial.
The researchers randomized 291 participants to receive 150 mg irbesartan daily (usual care or control group).
The other 300 participants received a daily quadpill containing 37.5 mg irbesartan, 1.25 mg amlodipine, 0.625 mg indapamide, and 2.5 mg bisoprolol. The first three drugs are the most commonly prescribed angiotensin II receptor blocker, calcium channel blocker, and thiazide or thiazidelike diuretic in Australia, and the last drug, a beta-blocker, has a long duration of action, the study protocol explains.
Patients in both groups had similar baseline characteristics. They were a mean age of 58 years, 40% were women, and 82% were White. They also had a mean body mass index of 31 kg/m2. About 8% were current smokers, and about 54% were not taking a BP-lowering drug.
Participants had clinic visits at baseline, 6 weeks, and 12 weeks, and if they continued the study, at 26 weeks and 52 weeks.
If a patient’s blood pressure was higher than 140/90 mm Hg, clinicians could add another medication, starting with amlodipine 5 mg.
At 12 weeks, 15% of patients in the intervention group and 40% in the control group had stepped up treatment.
Despite greater up-titration in the usual care group, BP control remained higher in the quadpill group, Dr. Chow pointed out. That is, patients in the quadpill group were more likely than patients in the usual care group to have a BP less than 140/90 mm Hg (76% vs. 58% respectively; P < .0001).
Patients in the quadpill group also had lower daytime and nighttime ambulatory systolic BP.
At 12 months, among the 417 patients who continued treatment, patients in the quadpill group had a 7.7 mm Hg greater drop in systolic BP, compared with patients in the control group, (P < .001).
There were no significant differences in adverse events, which were most commonly dizziness (31% and 25%) or muscle cramps, gastrointestinal complaints, headache, or musculoskeletal complaints.
At 12 weeks, there were seven serious adverse events in the intervention group versus three in the control group. There were 12 treatment withdrawals in the intervention group versus seven in the control group (P = .27).
Remaining questions, upcoming phase 3 U.S. study
“While the [QUARTET] results are impressive, we are left with a number of questions,” Dr. Yusuf said.
Would the results be the same with a three-drug combo or even a two-drug combo at half doses? In the HOPE 3 trial, a two-drug combo at half doses provided similar results to the current study, over a much longer mean follow-up of 5.6 years, he noted.
Also, is the quadpill associated with higher rates of diabetes or higher creatinine levels in the long term? “Given that we do not have any data on long-term clinical outcomes from a four-drug combination,” Dr. Yusuf said, “caution should be utilized.”
Would the reduced risk of CVD be greater with a combination of low doses of two BP-lowering drugs plus a statin plus aspirin? That may be superior, he said, “based on recent information published on the polypill indicating a 50% relative risk reduction in CVD events.”
The related phase 2 QUARTET US trial should shed further light on a quadpill strategy. Patients with hypertension are being randomized to a daily quadpill containing 2 mg candesartan, 1.25 mg amlodipine besylate, 0.625 mg indapamide, and 2.5 mg bisoprolol, or to usual care, 8 mg candesartan daily.
Investigators plan to enroll 87 participants in the Chicago area, with estimated study completion by March 31, 2023.
The study was supported by an Australian National Health and Medical Research Council grant. The George Institute for Global Health has submitted patent applications for low–fixed-dose combination products to treat CV or cardiometabolic disease. Dr. Chow and coauthor Kris Rogers, PhD, senior biostatistician at The George Institute for Global Health, Newtown, Australia, are listed as inventors, but they do not have direct financial interests in these patent applications.
A version of this article first appeared on Medscape.com.
A “quadpill” containing quarter doses of four blood pressure (BP)–lowering medications was more effective than monotherapy for initial treatment of hypertension, with similar tolerability, in the 1-year, phase 3 QUARTET randomized, active-control trial.
Clara Chow, MD, PhD, academic director of the Westmead Applied Research Centre, University of Sydney, presented the findings in a late-breaking trial session at the annual congress of the European Society of Cardiology. The study was simultaneously published in The Lancet.
The primary outcome, mean unattended office BP at 12 weeks, dropped from 142/86 mm Hg to 120/71 mm Hg in patients who received the daily quadpill – a capsule containing irbesartan, amlodipine, indapamide, and bisoprolol – and fell from 140/83 mm Hg to 127/79 mm Hg in patients who received a daily full dose of irbesartan.
This 6.9 mm Hg greater drop in systolic BP at 12 months is clinically meaningful, Dr. Chow told this news organization. “If maintained, it would be expected to confer about a 15%-20% reduction” in heart disease, stroke, and heart failure.
In the SPRINT study, she noted, the final systolic BP was 120 mm Hg in the intervention group and 134 mm Hg in the control group, and the difference was associated with a 27% reduction in the composite cardiovascular (CV) outcome.
The results of QUARTET suggest that, “even in those with stage 1 hypertension, we can safely reduce BP to a significant degree by this simple approach, compared to usual care,” Salim Yusuf, MD, DPhil, a long-time advocate of a polypill approach, said in an email.
Importantly, Dr. Chow pointed out, at 12 months, 81% of patients treated with the quadpill versus 62% of patients treated with monotherapy had BP control (<140/90 mm Hg). Patients who received monotherapy did not “catch up,” even though a higher percentage received stepped-up therapy.
The quadpill dosing strategy aligns with the latest 2018 ESC/European Society of Hypertension guidelines, which recommend starting antihypertensive treatment with more than one drug, session cochair Thomas Kahan, MD, PhD, Karolinska Institute, Danderyd Hospital, department of clinical sciences, Stockholm, commented.
“How many drugs should be in the initial step?” he asked. “Is four better than three or two, or should we have even more drugs at low doses?”
The trial was not designed to answer these questions, Dr. Chow replied. “We were really comparing [the quadpill] against what the majority of people around the planet are still doing, which is starting on one drug and slowly but surely stepping it up,” she said.
The quadpill was actually a capsule, she clarified, that contained four generic BP medications available in half doses in Australia. The half doses were cut in half and the medications were encapsulated. The control drug was prepared in an identical-looking capsule.
It is important to note that “the time to BP control was shorter in patients who received the quadpill versus monotherapy,” session cochair Felix Mahfoud, MD, internal medicine and cardiology, Saarland University Hospital, Hamburg, Germany, pointed out, because “in clinical practice we aim to get patients to BP control as quickly as possible.”
“What is new here is the use of four drugs, each given at quarter doses,” Dr. Yusuf, director of the Population Health Research Institute, McMaster University, Hamilton, Ont., said. Although a few questions remain, “this study emphasizes the importance and potential benefits and simplicity of using combination BP-lowering drugs at low doses.”
For guidelines to be changed, he observed, the findings would have to be replicated in independent studies, and the quadpill would likely have to be shown to be superior to the dual pill.
“It took about 20 years [to change guidelines] after the first evidence that combinations of two pills were preferable to single-drug combinations,” he noted.
“I hope that in most people with elevated BP, at least a two-drug combination plus a statin plus aspirin will be prescribed,” Dr. Yusuf said. “This can reduce the risk of CVD events by 50% or more – a big impact both for the individual and for populations. The quad pill may have a role in this approach.”
Four-in-one pill
Worldwide, hypertension control is poor, Dr. Chow said, because of the need for multiple medications, treatment inertia, and concerns about adverse events.
The researchers hypothesized that initial antihypertensive treatment with a four-in-one pill with quarter doses of each medication would minimize side effects, maximize BP lowering, and overcome these treatment barriers and concerns. A pilot study of this strategy published by the group in 2017 showed promise.
QUARTET randomized 591 adults with hypertension, seen at clinics in four states in Australia from June 2017 through August 2020.
Patients were either receiving no antihypertensive medication and had an unattended standard office BP of 140/90 to 179/109 mm Hg or daytime ambulatory BP greater than 135/95 mm Hg, or they were on BP-lowering monotherapy and had a BP of 130/85 to 179/109 mm Hg or daytime ambulatory BP greater than 125/80 mm Hg. Patients who were taking antihypertensive therapy entered a washout period before the trial.
The researchers randomized 291 participants to receive 150 mg irbesartan daily (usual care or control group).
The other 300 participants received a daily quadpill containing 37.5 mg irbesartan, 1.25 mg amlodipine, 0.625 mg indapamide, and 2.5 mg bisoprolol. The first three drugs are the most commonly prescribed angiotensin II receptor blocker, calcium channel blocker, and thiazide or thiazidelike diuretic in Australia, and the last drug, a beta-blocker, has a long duration of action, the study protocol explains.
Patients in both groups had similar baseline characteristics. They were a mean age of 58 years, 40% were women, and 82% were White. They also had a mean body mass index of 31 kg/m2. About 8% were current smokers, and about 54% were not taking a BP-lowering drug.
Participants had clinic visits at baseline, 6 weeks, and 12 weeks, and if they continued the study, at 26 weeks and 52 weeks.
If a patient’s blood pressure was higher than 140/90 mm Hg, clinicians could add another medication, starting with amlodipine 5 mg.
At 12 weeks, 15% of patients in the intervention group and 40% in the control group had stepped up treatment.
Despite greater up-titration in the usual care group, BP control remained higher in the quadpill group, Dr. Chow pointed out. That is, patients in the quadpill group were more likely than patients in the usual care group to have a BP less than 140/90 mm Hg (76% vs. 58% respectively; P < .0001).
Patients in the quadpill group also had lower daytime and nighttime ambulatory systolic BP.
At 12 months, among the 417 patients who continued treatment, patients in the quadpill group had a 7.7 mm Hg greater drop in systolic BP, compared with patients in the control group, (P < .001).
There were no significant differences in adverse events, which were most commonly dizziness (31% and 25%) or muscle cramps, gastrointestinal complaints, headache, or musculoskeletal complaints.
At 12 weeks, there were seven serious adverse events in the intervention group versus three in the control group. There were 12 treatment withdrawals in the intervention group versus seven in the control group (P = .27).
Remaining questions, upcoming phase 3 U.S. study
“While the [QUARTET] results are impressive, we are left with a number of questions,” Dr. Yusuf said.
Would the results be the same with a three-drug combo or even a two-drug combo at half doses? In the HOPE 3 trial, a two-drug combo at half doses provided similar results to the current study, over a much longer mean follow-up of 5.6 years, he noted.
Also, is the quadpill associated with higher rates of diabetes or higher creatinine levels in the long term? “Given that we do not have any data on long-term clinical outcomes from a four-drug combination,” Dr. Yusuf said, “caution should be utilized.”
Would the reduced risk of CVD be greater with a combination of low doses of two BP-lowering drugs plus a statin plus aspirin? That may be superior, he said, “based on recent information published on the polypill indicating a 50% relative risk reduction in CVD events.”
The related phase 2 QUARTET US trial should shed further light on a quadpill strategy. Patients with hypertension are being randomized to a daily quadpill containing 2 mg candesartan, 1.25 mg amlodipine besylate, 0.625 mg indapamide, and 2.5 mg bisoprolol, or to usual care, 8 mg candesartan daily.
Investigators plan to enroll 87 participants in the Chicago area, with estimated study completion by March 31, 2023.
The study was supported by an Australian National Health and Medical Research Council grant. The George Institute for Global Health has submitted patent applications for low–fixed-dose combination products to treat CV or cardiometabolic disease. Dr. Chow and coauthor Kris Rogers, PhD, senior biostatistician at The George Institute for Global Health, Newtown, Australia, are listed as inventors, but they do not have direct financial interests in these patent applications.
A version of this article first appeared on Medscape.com.
FROM ESC CONGRESS 2021
Remember the past, be wary of the future
A Perspective on the intended Philip Morris International acquisition of Vectura
On July 9, Philip Morris International Inc. (PMI) issued a statement of intent to purchase Vectura Group plc (Vectura), a provider of inhaled drug delivery solutions. According to the statement, the acquisition contributes to the PMI goal to move “beyond nicotine” by leveraging Vectura’s expertise in inhalation and aerosolization into adjacent areas.
Given PMI’s strong ties to tobacco, the acquisition raises concerns across the medical field. D. Robert McCaffree, MD, Master FCCP, shares his thoughts on the prospective acquisition in the following guest feature.
August 2021: D. Robert McCaffree, MD, Master FCCP
In 2018, Dr. Neeraj Desai and I published an editorial in the journal CHEST®. The title was, in part, “Is Big Tobacco Still Trying to Deceive the Public? ... ”1 Before I give an opinion about the answer, I should give some background on events eliciting the editorial.
In 1999, the U.S. Department of Justice (DOJ) sued major tobacco companies (Philip Morris, USA; Altria; RJ Reynolds; and Lorillard) for being in violation of the Racketeer Influenced Corrupt Organization Act (RICO) in that they colluded for decades to mislead the public about the risks of smoking and risks of secondhand smoke, downplayed the addictiveness of nicotine, manipulated nicotine levels, marketed cigarettes as “low tar” or “light” when they knew these were no less hazardous than full-flavored cigarettes, purposefully targeted youth, and failed to produce a safer cigarette.
In 2006, Judge Gladys Kessler of the D.C. District Court issued a1 700-page opinion finding the defendants had violated RICO. In her words,
• “[This case] is about an industry, and in particular these defendants, that survives, and profits, from selling a highly addictive product which causes diseases that lead to ... [an] immeasurable amount of human suffering ... they have consistently, repeatedly and with enormous skill and sophistication, denied these facts to the public, the Government, and to the public health community.”
“Defendants have marketed and sold their lethal products with zeal, with deception, with a single-minded focus on their financial success, and without regard for the human tragedy ... exacted.”
• “Over the course of more than 50 years, defendants lied, misrepresented, and deceived the American public, including ... the young people they avidly sought as ‘replacement’ smokers.”
• “The evidence in this case clearly establishes that defendants have not ceased engaging in unlawful activity ... ”
Since, under RICO, the government could not recover monetary damages but only require corrective actions going forward, the court ordered them to publish “corrective statements” (five different ones in total) in major publications and on television during prime time over the course of several months, as well as at the point of sale. (They are still appealing the point-of-sale display.)
Of course, the defendants appealed, but those appeals were largely thwarted until the (almost) final order in 2017, which then led to our editorial in 2018.
While this is a rather long introduction, I thought it necessary to depict the long-standing nature and behavioral patterns of deception, distortion, and destructive behavior of this industry – all designed to maintain their incredible profits - before trying to answer the question posed in our editorial.
Since all of the above, is there evidence the industry’s behaviors have changed? On the negative side, there is a recent study published on the Tobacco Free Kids website documenting the past and continued marketing to women and girls, with all the adverse consequences to women’s health.2 The industry continues to produce and market cigarettes to everyone, including youths and focused markets such as Blacks and LGBTQ populations. However, they are quite aware that the future of combustible tobacco, the major source of their incredible profits, is threatened.
Currently, most of the profits from Philip Morris International (PMI), as well as the other major players, come from combustible products. But, the CEO of PMI has stated that he thinks combustible tobacco products will be gone in 10 to 15 years and PMI will be selling only smoke-free products by 2025. So, to preserve similar profits as their combustible products diminish, they have made major investments in vaping products, such as Juul, and development of other noncombustible tobacco products. But these are still addictive, and any reduction in health consequences is still being evaluated. A prime example of trying to change their image is Philip Morris’ Beyond Nicotine campaign. However, currently all the companies continue to produce combustible products in large amounts, both locally and internationally.
One way of assessing the vision of any company is to see where it is putting its money. Currently, all major tobacco companies are investing in marijuana companies. For example, Philip Morris has invested $2.4 billion into Cosmos, a Canadian marijuana company.
They also recently purchased Vectura, Fertin, and Kraft Foods. I know, it’s hard to see where Kraft Foods fits in here, but Vectura, an inhalational device manufacturer, and Fertin, which makes nicotine gum, as well as vehicles such as powders, pouches that dissolve in the mouth, and lozenges, certainly do fit in.
My take on these recent acquisitions is that tobacco companies realize combustibles are dying. However, they continue to develop and market nicotine in noncombustible forms. They are likely looking to move into marijuana, at least as an investment. It’s not a huge leap to consider the possibility that the purchase of Vectura will help develop delivery systems for nicotine, marijuana, and possibly medications. It’s unclear whether PMI intends to get further into inhaled pharmaceuticals.
Bottom line is that, as pulmonary physicians, we need to be aware of all developments in inhaled substances and delivery methods. On the upside, everything the industry is currently doing is apparently more transparent than they have been in the past. They are not yet, however, ceasing production and marketing of cigarettes.
It’s also important that we remind ourselves of their past actions because, personally, that past still bothers me, and I’m not quite ready to trust them. When it comes to “Big Tobacco,” it is appropriate that we always keep in mind the immortal words, often repeated in various forms, of Edgar Allen Poe, master teller of horror stories, “Believe nothing you hear and only half that you see.”3
References
1. McCaffree DR and Desai NR. Is big tobacco still trying to deceive the public? This is no time to rest on our laurels. Chest. 2018 May;153(5):1085-6. doi: 10.1016/j.chest.2018.01.012.
2. A lifetime of damage: How Big Tobacco’s predatory marketing practices harms the health of women and girls. Tobacco-Free Kids. May 2021.
3. Quote Investigator. 2017 Jun 23. “The system of Dr. Tarr and Prof. Fether,” from Graham’s Magazine, November 1845.
A Perspective on the intended Philip Morris International acquisition of Vectura
A Perspective on the intended Philip Morris International acquisition of Vectura
On July 9, Philip Morris International Inc. (PMI) issued a statement of intent to purchase Vectura Group plc (Vectura), a provider of inhaled drug delivery solutions. According to the statement, the acquisition contributes to the PMI goal to move “beyond nicotine” by leveraging Vectura’s expertise in inhalation and aerosolization into adjacent areas.
Given PMI’s strong ties to tobacco, the acquisition raises concerns across the medical field. D. Robert McCaffree, MD, Master FCCP, shares his thoughts on the prospective acquisition in the following guest feature.
August 2021: D. Robert McCaffree, MD, Master FCCP
In 2018, Dr. Neeraj Desai and I published an editorial in the journal CHEST®. The title was, in part, “Is Big Tobacco Still Trying to Deceive the Public? ... ”1 Before I give an opinion about the answer, I should give some background on events eliciting the editorial.
In 1999, the U.S. Department of Justice (DOJ) sued major tobacco companies (Philip Morris, USA; Altria; RJ Reynolds; and Lorillard) for being in violation of the Racketeer Influenced Corrupt Organization Act (RICO) in that they colluded for decades to mislead the public about the risks of smoking and risks of secondhand smoke, downplayed the addictiveness of nicotine, manipulated nicotine levels, marketed cigarettes as “low tar” or “light” when they knew these were no less hazardous than full-flavored cigarettes, purposefully targeted youth, and failed to produce a safer cigarette.
In 2006, Judge Gladys Kessler of the D.C. District Court issued a1 700-page opinion finding the defendants had violated RICO. In her words,
• “[This case] is about an industry, and in particular these defendants, that survives, and profits, from selling a highly addictive product which causes diseases that lead to ... [an] immeasurable amount of human suffering ... they have consistently, repeatedly and with enormous skill and sophistication, denied these facts to the public, the Government, and to the public health community.”
“Defendants have marketed and sold their lethal products with zeal, with deception, with a single-minded focus on their financial success, and without regard for the human tragedy ... exacted.”
• “Over the course of more than 50 years, defendants lied, misrepresented, and deceived the American public, including ... the young people they avidly sought as ‘replacement’ smokers.”
• “The evidence in this case clearly establishes that defendants have not ceased engaging in unlawful activity ... ”
Since, under RICO, the government could not recover monetary damages but only require corrective actions going forward, the court ordered them to publish “corrective statements” (five different ones in total) in major publications and on television during prime time over the course of several months, as well as at the point of sale. (They are still appealing the point-of-sale display.)
Of course, the defendants appealed, but those appeals were largely thwarted until the (almost) final order in 2017, which then led to our editorial in 2018.
While this is a rather long introduction, I thought it necessary to depict the long-standing nature and behavioral patterns of deception, distortion, and destructive behavior of this industry – all designed to maintain their incredible profits - before trying to answer the question posed in our editorial.
Since all of the above, is there evidence the industry’s behaviors have changed? On the negative side, there is a recent study published on the Tobacco Free Kids website documenting the past and continued marketing to women and girls, with all the adverse consequences to women’s health.2 The industry continues to produce and market cigarettes to everyone, including youths and focused markets such as Blacks and LGBTQ populations. However, they are quite aware that the future of combustible tobacco, the major source of their incredible profits, is threatened.
Currently, most of the profits from Philip Morris International (PMI), as well as the other major players, come from combustible products. But, the CEO of PMI has stated that he thinks combustible tobacco products will be gone in 10 to 15 years and PMI will be selling only smoke-free products by 2025. So, to preserve similar profits as their combustible products diminish, they have made major investments in vaping products, such as Juul, and development of other noncombustible tobacco products. But these are still addictive, and any reduction in health consequences is still being evaluated. A prime example of trying to change their image is Philip Morris’ Beyond Nicotine campaign. However, currently all the companies continue to produce combustible products in large amounts, both locally and internationally.
One way of assessing the vision of any company is to see where it is putting its money. Currently, all major tobacco companies are investing in marijuana companies. For example, Philip Morris has invested $2.4 billion into Cosmos, a Canadian marijuana company.
They also recently purchased Vectura, Fertin, and Kraft Foods. I know, it’s hard to see where Kraft Foods fits in here, but Vectura, an inhalational device manufacturer, and Fertin, which makes nicotine gum, as well as vehicles such as powders, pouches that dissolve in the mouth, and lozenges, certainly do fit in.
My take on these recent acquisitions is that tobacco companies realize combustibles are dying. However, they continue to develop and market nicotine in noncombustible forms. They are likely looking to move into marijuana, at least as an investment. It’s not a huge leap to consider the possibility that the purchase of Vectura will help develop delivery systems for nicotine, marijuana, and possibly medications. It’s unclear whether PMI intends to get further into inhaled pharmaceuticals.
Bottom line is that, as pulmonary physicians, we need to be aware of all developments in inhaled substances and delivery methods. On the upside, everything the industry is currently doing is apparently more transparent than they have been in the past. They are not yet, however, ceasing production and marketing of cigarettes.
It’s also important that we remind ourselves of their past actions because, personally, that past still bothers me, and I’m not quite ready to trust them. When it comes to “Big Tobacco,” it is appropriate that we always keep in mind the immortal words, often repeated in various forms, of Edgar Allen Poe, master teller of horror stories, “Believe nothing you hear and only half that you see.”3
References
1. McCaffree DR and Desai NR. Is big tobacco still trying to deceive the public? This is no time to rest on our laurels. Chest. 2018 May;153(5):1085-6. doi: 10.1016/j.chest.2018.01.012.
2. A lifetime of damage: How Big Tobacco’s predatory marketing practices harms the health of women and girls. Tobacco-Free Kids. May 2021.
3. Quote Investigator. 2017 Jun 23. “The system of Dr. Tarr and Prof. Fether,” from Graham’s Magazine, November 1845.
On July 9, Philip Morris International Inc. (PMI) issued a statement of intent to purchase Vectura Group plc (Vectura), a provider of inhaled drug delivery solutions. According to the statement, the acquisition contributes to the PMI goal to move “beyond nicotine” by leveraging Vectura’s expertise in inhalation and aerosolization into adjacent areas.
Given PMI’s strong ties to tobacco, the acquisition raises concerns across the medical field. D. Robert McCaffree, MD, Master FCCP, shares his thoughts on the prospective acquisition in the following guest feature.
August 2021: D. Robert McCaffree, MD, Master FCCP
In 2018, Dr. Neeraj Desai and I published an editorial in the journal CHEST®. The title was, in part, “Is Big Tobacco Still Trying to Deceive the Public? ... ”1 Before I give an opinion about the answer, I should give some background on events eliciting the editorial.
In 1999, the U.S. Department of Justice (DOJ) sued major tobacco companies (Philip Morris, USA; Altria; RJ Reynolds; and Lorillard) for being in violation of the Racketeer Influenced Corrupt Organization Act (RICO) in that they colluded for decades to mislead the public about the risks of smoking and risks of secondhand smoke, downplayed the addictiveness of nicotine, manipulated nicotine levels, marketed cigarettes as “low tar” or “light” when they knew these were no less hazardous than full-flavored cigarettes, purposefully targeted youth, and failed to produce a safer cigarette.
In 2006, Judge Gladys Kessler of the D.C. District Court issued a1 700-page opinion finding the defendants had violated RICO. In her words,
• “[This case] is about an industry, and in particular these defendants, that survives, and profits, from selling a highly addictive product which causes diseases that lead to ... [an] immeasurable amount of human suffering ... they have consistently, repeatedly and with enormous skill and sophistication, denied these facts to the public, the Government, and to the public health community.”
“Defendants have marketed and sold their lethal products with zeal, with deception, with a single-minded focus on their financial success, and without regard for the human tragedy ... exacted.”
• “Over the course of more than 50 years, defendants lied, misrepresented, and deceived the American public, including ... the young people they avidly sought as ‘replacement’ smokers.”
• “The evidence in this case clearly establishes that defendants have not ceased engaging in unlawful activity ... ”
Since, under RICO, the government could not recover monetary damages but only require corrective actions going forward, the court ordered them to publish “corrective statements” (five different ones in total) in major publications and on television during prime time over the course of several months, as well as at the point of sale. (They are still appealing the point-of-sale display.)
Of course, the defendants appealed, but those appeals were largely thwarted until the (almost) final order in 2017, which then led to our editorial in 2018.
While this is a rather long introduction, I thought it necessary to depict the long-standing nature and behavioral patterns of deception, distortion, and destructive behavior of this industry – all designed to maintain their incredible profits - before trying to answer the question posed in our editorial.
Since all of the above, is there evidence the industry’s behaviors have changed? On the negative side, there is a recent study published on the Tobacco Free Kids website documenting the past and continued marketing to women and girls, with all the adverse consequences to women’s health.2 The industry continues to produce and market cigarettes to everyone, including youths and focused markets such as Blacks and LGBTQ populations. However, they are quite aware that the future of combustible tobacco, the major source of their incredible profits, is threatened.
Currently, most of the profits from Philip Morris International (PMI), as well as the other major players, come from combustible products. But, the CEO of PMI has stated that he thinks combustible tobacco products will be gone in 10 to 15 years and PMI will be selling only smoke-free products by 2025. So, to preserve similar profits as their combustible products diminish, they have made major investments in vaping products, such as Juul, and development of other noncombustible tobacco products. But these are still addictive, and any reduction in health consequences is still being evaluated. A prime example of trying to change their image is Philip Morris’ Beyond Nicotine campaign. However, currently all the companies continue to produce combustible products in large amounts, both locally and internationally.
One way of assessing the vision of any company is to see where it is putting its money. Currently, all major tobacco companies are investing in marijuana companies. For example, Philip Morris has invested $2.4 billion into Cosmos, a Canadian marijuana company.
They also recently purchased Vectura, Fertin, and Kraft Foods. I know, it’s hard to see where Kraft Foods fits in here, but Vectura, an inhalational device manufacturer, and Fertin, which makes nicotine gum, as well as vehicles such as powders, pouches that dissolve in the mouth, and lozenges, certainly do fit in.
My take on these recent acquisitions is that tobacco companies realize combustibles are dying. However, they continue to develop and market nicotine in noncombustible forms. They are likely looking to move into marijuana, at least as an investment. It’s not a huge leap to consider the possibility that the purchase of Vectura will help develop delivery systems for nicotine, marijuana, and possibly medications. It’s unclear whether PMI intends to get further into inhaled pharmaceuticals.
Bottom line is that, as pulmonary physicians, we need to be aware of all developments in inhaled substances and delivery methods. On the upside, everything the industry is currently doing is apparently more transparent than they have been in the past. They are not yet, however, ceasing production and marketing of cigarettes.
It’s also important that we remind ourselves of their past actions because, personally, that past still bothers me, and I’m not quite ready to trust them. When it comes to “Big Tobacco,” it is appropriate that we always keep in mind the immortal words, often repeated in various forms, of Edgar Allen Poe, master teller of horror stories, “Believe nothing you hear and only half that you see.”3
References
1. McCaffree DR and Desai NR. Is big tobacco still trying to deceive the public? This is no time to rest on our laurels. Chest. 2018 May;153(5):1085-6. doi: 10.1016/j.chest.2018.01.012.
2. A lifetime of damage: How Big Tobacco’s predatory marketing practices harms the health of women and girls. Tobacco-Free Kids. May 2021.
3. Quote Investigator. 2017 Jun 23. “The system of Dr. Tarr and Prof. Fether,” from Graham’s Magazine, November 1845.
In memoriam
Paul D. Stein, MD, Master FCCP
Past President (1992-1993) of the American College of Chest Physicians (CHEST), Dr. Paul D. Stein, Master FCCP, died on July 15, 2021, in Boynton Beach, Florida. His long career in cardiovascular research included monumental studies in pulmonary embolism, pulmonary hypertension, and valvular heart disease.
Dr. Stein was regarded as a world expert on pulmonary embolism. His contributions to medicine include hundreds of published articles, five books, and countless lectures that have given the world its current understanding of heart and pulmonary diseases. Throughout his almost 50 years as a member of CHEST, as Past President, and as a Master Fellow, Dr. Stein served the College graciously in these and many other leadership roles. We extend heartfelt condolences to the Stein family.
Editor’s Note: In 2016, Dr. Stein provided CHEST Physician with a wonderful update on his current activities. You can find it in the November 2016 issue on page 54.
Paul D. Stein, MD, Master FCCP
Past President (1992-1993) of the American College of Chest Physicians (CHEST), Dr. Paul D. Stein, Master FCCP, died on July 15, 2021, in Boynton Beach, Florida. His long career in cardiovascular research included monumental studies in pulmonary embolism, pulmonary hypertension, and valvular heart disease.
Dr. Stein was regarded as a world expert on pulmonary embolism. His contributions to medicine include hundreds of published articles, five books, and countless lectures that have given the world its current understanding of heart and pulmonary diseases. Throughout his almost 50 years as a member of CHEST, as Past President, and as a Master Fellow, Dr. Stein served the College graciously in these and many other leadership roles. We extend heartfelt condolences to the Stein family.
Editor’s Note: In 2016, Dr. Stein provided CHEST Physician with a wonderful update on his current activities. You can find it in the November 2016 issue on page 54.
Paul D. Stein, MD, Master FCCP
Past President (1992-1993) of the American College of Chest Physicians (CHEST), Dr. Paul D. Stein, Master FCCP, died on July 15, 2021, in Boynton Beach, Florida. His long career in cardiovascular research included monumental studies in pulmonary embolism, pulmonary hypertension, and valvular heart disease.
Dr. Stein was regarded as a world expert on pulmonary embolism. His contributions to medicine include hundreds of published articles, five books, and countless lectures that have given the world its current understanding of heart and pulmonary diseases. Throughout his almost 50 years as a member of CHEST, as Past President, and as a Master Fellow, Dr. Stein served the College graciously in these and many other leadership roles. We extend heartfelt condolences to the Stein family.
Editor’s Note: In 2016, Dr. Stein provided CHEST Physician with a wonderful update on his current activities. You can find it in the November 2016 issue on page 54.
2021 AMA Meeting of the AMA House of Delegates – Updates
The American Medical Association (AMA) conducted its June 2021 AMA Special Meeting of the AMA House of Delegates from June 11-16 virtually. Delegates from more than 170 societies (state societies, specialties, subspecialties, and uniformed services), comprised of nearly 700 physicians, residents, and medical students, gathered for the June 2021 AMA Special Meeting of the AMA House of Delegates (HOD) to consider a wide array of proposals.
CHEST is an active member, and through the HOD and Specialty and Service Society Caucus, CHEST has partnered with AMA and its sister societies to work with each other on important regulatory issues. Chest/Allergy Section Council (participants at this meeting were from the AAAAI, AAOA, AASM, ACAAI, ATS, CHEST, and SCCM) met before the proceedings of the House to discuss pending business. The meeting was hosted by the current CHEST/Allergy council chair Dr. Wesley Vander Ark (AMA Delegate AAOA) and Jami Lucas, CEO AAOA.
Brief updates on the Resolutions
Continuity of care of patients discharged from hospital settings (Adapted as a new policy)
The policy focuses on key issues around the continuity of care of patients. It includes protections of continuity of care for medical services and medications that are prescribed during patient hospitalizations, including when there are formulary or treatment coverage changes that have the potential to disrupt therapy following discharge.
Licensure and telehealth
The policy urges AMA to continue to support state efforts to expand physician licensure recognition across state lines in accordance with the standards and safeguards Coverage and Payment for Telemedicine. (New HOD Policy)
AMA to conduct or commission a study on the effect that telemedicine services have had on health insurance premiums, focusing on the differences between states that had telehealth payment parity provisions in effect prior to the pandemic vs those that did not, and report back at the 2021 Interim Meeting of the AMA House of Delegates. (Directive to Take Action). CHEST has taken an active role in supporting this resolution through advocating for telemedicine services and reimbursement, as well as leading the CHEST Clinician Matching Network that pairs volunteer doctors with hospitals based on their need throughout the country.
Vaccines (Adopted as a new policy)
The policy urges AMA to advocate for the prohibition of the use of patient/customer information collected by retail pharmacies for COVID-19 vaccination scheduling and/or the vaccine administration process for the purpose of commercial marketing or future patient recruiting purposes, especially any targeting based on medical history condition. AMA opposes the sale of medical history data and contact information accumulated through the scheduling or provision of government-funded vaccinations to third parties for use in marketing or advertising.
Additionally, as it relates to vaccines, CHEST has joined a joint society statement supporting a vaccine mandate for all health care workers.
Optimizing match outcomes (Directive to Take Action)
The policy urges AMA to encourage the Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, National Resident Matching Program, and other key stakeholders to jointly create a no-fee, easily accessible clearinghouse of reliable and valid advice and tools for residency program applicants seeking cost-effective methods for applying to and successfully matching into residency.
Ensuring adequate health care resources to address the long COVID crisis and call for increased funding and research for post-viral syndromes
The policy directs AMA to support the development of an ICD-10 code or family of codes to recognize Post-Acute Sequelae of SARS-CoV-2 infection (“PASC” or “Long COVID”) and other novel post-viral syndromes as distinct diagnoses. (New HOD Policy). Further, the policy directs AMA to advocate for legislation to provide funding for research, prevention, control, and treatment of post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19 and AMA provide physicians and medical students with accurate and current information on post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19; and further that AMA collaborate with other medical and educational entities to promote education among patients about post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19, to minimize the harm and disability current and future patients face. (Directive to Take Action)
Medical misinformation in the age of social media (Directive to Take Action)
AMA encourage social media organizations to further strengthen their content moderation policies related to medical misinformation, including, but not limited to, enhanced content monitoring, augmentation of recommendation engines focused on false information, and stronger integration of verified health information. AMA should encourage social media organizations to recognize the spread of medical misinformation over dissemination networks and collaborate with relevant stakeholders, and work with public health agencies to establish relationships with journalists and news agencies to enhance the public reach in disseminating accurate medical information.
Promoting equity in global vaccine distribution
AMA call for the cooperation of all governments and international agencies to share data, research, and resources for the production and distribution of medicines, vaccines, and personal protective equipment (Directive to Take Action); and be it further, AMA promote and support efforts to supply COVID vaccines to 21health care agencies in other parts of the world to be administered to individuals who can’t afford them. (Directive to Take Action). AMA urge the US government to provide all possible assistance, including surplus vaccines and vaccines that have not had emergency use authorization, to the citizens of India and other countries in a similar situation in this humanitarian crisis (New HOD Policy).
CHEST has taken an active role in promoting equity in health care and vaccine distribution in partnership with the American Lung Association and the American Thoracic Society, including establishing a research grant program focused on this topic.
Addressing inflammatory and untruthful online ratings (Directive to Take Action)
AMA take action that would urge online review organizations to create internal mechanisms ensuring due process to physicians before the publication of negative reviews.
This is just a small sampling of the activities and more information, including reports from the various Councils, are available on the AMA website.
CHEST members interested in the AMA policy-making process may observe any AMA-HOD meeting or participate in the AMA’s democratic processes. Attendees will also be able to increase their knowledge and skills at no cost. They will also be able to connect with more than 1,500 peers and other meeting attendees from across the country. CHEST members with the time (there are two 5-day meetings each year) and interest are invited to apply to be an official CHEST delegate to the AMA. Contact Suzanne Sletto at [email protected] for details.
Delegates and alternate delegates to the House of Delegates (HOD) play a critical role in the democratic policy-making process that is the foundation of the AMA. Their role is multi-dimensional and includes:
- Advocacy for patients within the HOD to improve the health of the public and the health care system;
- Representation of the perspectives of their sponsoring organization to the HOD;
- Representation of their physician and medical student constituents in the decision-making process of the HOD;
- Representation of the AMA and its House of Delegates to member and nonmember physicians, medical associations, and others; and
- Solicitation of input from and provision of feedback to constituents.
Also, HOD delegates and alternate delegates are expected to foster a positive and useful two-way relationship between grassroots physicians and the CHEST leadership.
Dr. Desai is with the Chicago Chest Center and AMITA Health Suburban Lung Associates; and the Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago.
The American Medical Association (AMA) conducted its June 2021 AMA Special Meeting of the AMA House of Delegates from June 11-16 virtually. Delegates from more than 170 societies (state societies, specialties, subspecialties, and uniformed services), comprised of nearly 700 physicians, residents, and medical students, gathered for the June 2021 AMA Special Meeting of the AMA House of Delegates (HOD) to consider a wide array of proposals.
CHEST is an active member, and through the HOD and Specialty and Service Society Caucus, CHEST has partnered with AMA and its sister societies to work with each other on important regulatory issues. Chest/Allergy Section Council (participants at this meeting were from the AAAAI, AAOA, AASM, ACAAI, ATS, CHEST, and SCCM) met before the proceedings of the House to discuss pending business. The meeting was hosted by the current CHEST/Allergy council chair Dr. Wesley Vander Ark (AMA Delegate AAOA) and Jami Lucas, CEO AAOA.
Brief updates on the Resolutions
Continuity of care of patients discharged from hospital settings (Adapted as a new policy)
The policy focuses on key issues around the continuity of care of patients. It includes protections of continuity of care for medical services and medications that are prescribed during patient hospitalizations, including when there are formulary or treatment coverage changes that have the potential to disrupt therapy following discharge.
Licensure and telehealth
The policy urges AMA to continue to support state efforts to expand physician licensure recognition across state lines in accordance with the standards and safeguards Coverage and Payment for Telemedicine. (New HOD Policy)
AMA to conduct or commission a study on the effect that telemedicine services have had on health insurance premiums, focusing on the differences between states that had telehealth payment parity provisions in effect prior to the pandemic vs those that did not, and report back at the 2021 Interim Meeting of the AMA House of Delegates. (Directive to Take Action). CHEST has taken an active role in supporting this resolution through advocating for telemedicine services and reimbursement, as well as leading the CHEST Clinician Matching Network that pairs volunteer doctors with hospitals based on their need throughout the country.
Vaccines (Adopted as a new policy)
The policy urges AMA to advocate for the prohibition of the use of patient/customer information collected by retail pharmacies for COVID-19 vaccination scheduling and/or the vaccine administration process for the purpose of commercial marketing or future patient recruiting purposes, especially any targeting based on medical history condition. AMA opposes the sale of medical history data and contact information accumulated through the scheduling or provision of government-funded vaccinations to third parties for use in marketing or advertising.
Additionally, as it relates to vaccines, CHEST has joined a joint society statement supporting a vaccine mandate for all health care workers.
Optimizing match outcomes (Directive to Take Action)
The policy urges AMA to encourage the Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, National Resident Matching Program, and other key stakeholders to jointly create a no-fee, easily accessible clearinghouse of reliable and valid advice and tools for residency program applicants seeking cost-effective methods for applying to and successfully matching into residency.
Ensuring adequate health care resources to address the long COVID crisis and call for increased funding and research for post-viral syndromes
The policy directs AMA to support the development of an ICD-10 code or family of codes to recognize Post-Acute Sequelae of SARS-CoV-2 infection (“PASC” or “Long COVID”) and other novel post-viral syndromes as distinct diagnoses. (New HOD Policy). Further, the policy directs AMA to advocate for legislation to provide funding for research, prevention, control, and treatment of post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19 and AMA provide physicians and medical students with accurate and current information on post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19; and further that AMA collaborate with other medical and educational entities to promote education among patients about post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19, to minimize the harm and disability current and future patients face. (Directive to Take Action)
Medical misinformation in the age of social media (Directive to Take Action)
AMA encourage social media organizations to further strengthen their content moderation policies related to medical misinformation, including, but not limited to, enhanced content monitoring, augmentation of recommendation engines focused on false information, and stronger integration of verified health information. AMA should encourage social media organizations to recognize the spread of medical misinformation over dissemination networks and collaborate with relevant stakeholders, and work with public health agencies to establish relationships with journalists and news agencies to enhance the public reach in disseminating accurate medical information.
Promoting equity in global vaccine distribution
AMA call for the cooperation of all governments and international agencies to share data, research, and resources for the production and distribution of medicines, vaccines, and personal protective equipment (Directive to Take Action); and be it further, AMA promote and support efforts to supply COVID vaccines to 21health care agencies in other parts of the world to be administered to individuals who can’t afford them. (Directive to Take Action). AMA urge the US government to provide all possible assistance, including surplus vaccines and vaccines that have not had emergency use authorization, to the citizens of India and other countries in a similar situation in this humanitarian crisis (New HOD Policy).
CHEST has taken an active role in promoting equity in health care and vaccine distribution in partnership with the American Lung Association and the American Thoracic Society, including establishing a research grant program focused on this topic.
Addressing inflammatory and untruthful online ratings (Directive to Take Action)
AMA take action that would urge online review organizations to create internal mechanisms ensuring due process to physicians before the publication of negative reviews.
This is just a small sampling of the activities and more information, including reports from the various Councils, are available on the AMA website.
CHEST members interested in the AMA policy-making process may observe any AMA-HOD meeting or participate in the AMA’s democratic processes. Attendees will also be able to increase their knowledge and skills at no cost. They will also be able to connect with more than 1,500 peers and other meeting attendees from across the country. CHEST members with the time (there are two 5-day meetings each year) and interest are invited to apply to be an official CHEST delegate to the AMA. Contact Suzanne Sletto at [email protected] for details.
Delegates and alternate delegates to the House of Delegates (HOD) play a critical role in the democratic policy-making process that is the foundation of the AMA. Their role is multi-dimensional and includes:
- Advocacy for patients within the HOD to improve the health of the public and the health care system;
- Representation of the perspectives of their sponsoring organization to the HOD;
- Representation of their physician and medical student constituents in the decision-making process of the HOD;
- Representation of the AMA and its House of Delegates to member and nonmember physicians, medical associations, and others; and
- Solicitation of input from and provision of feedback to constituents.
Also, HOD delegates and alternate delegates are expected to foster a positive and useful two-way relationship between grassroots physicians and the CHEST leadership.
Dr. Desai is with the Chicago Chest Center and AMITA Health Suburban Lung Associates; and the Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago.
The American Medical Association (AMA) conducted its June 2021 AMA Special Meeting of the AMA House of Delegates from June 11-16 virtually. Delegates from more than 170 societies (state societies, specialties, subspecialties, and uniformed services), comprised of nearly 700 physicians, residents, and medical students, gathered for the June 2021 AMA Special Meeting of the AMA House of Delegates (HOD) to consider a wide array of proposals.
CHEST is an active member, and through the HOD and Specialty and Service Society Caucus, CHEST has partnered with AMA and its sister societies to work with each other on important regulatory issues. Chest/Allergy Section Council (participants at this meeting were from the AAAAI, AAOA, AASM, ACAAI, ATS, CHEST, and SCCM) met before the proceedings of the House to discuss pending business. The meeting was hosted by the current CHEST/Allergy council chair Dr. Wesley Vander Ark (AMA Delegate AAOA) and Jami Lucas, CEO AAOA.
Brief updates on the Resolutions
Continuity of care of patients discharged from hospital settings (Adapted as a new policy)
The policy focuses on key issues around the continuity of care of patients. It includes protections of continuity of care for medical services and medications that are prescribed during patient hospitalizations, including when there are formulary or treatment coverage changes that have the potential to disrupt therapy following discharge.
Licensure and telehealth
The policy urges AMA to continue to support state efforts to expand physician licensure recognition across state lines in accordance with the standards and safeguards Coverage and Payment for Telemedicine. (New HOD Policy)
AMA to conduct or commission a study on the effect that telemedicine services have had on health insurance premiums, focusing on the differences between states that had telehealth payment parity provisions in effect prior to the pandemic vs those that did not, and report back at the 2021 Interim Meeting of the AMA House of Delegates. (Directive to Take Action). CHEST has taken an active role in supporting this resolution through advocating for telemedicine services and reimbursement, as well as leading the CHEST Clinician Matching Network that pairs volunteer doctors with hospitals based on their need throughout the country.
Vaccines (Adopted as a new policy)
The policy urges AMA to advocate for the prohibition of the use of patient/customer information collected by retail pharmacies for COVID-19 vaccination scheduling and/or the vaccine administration process for the purpose of commercial marketing or future patient recruiting purposes, especially any targeting based on medical history condition. AMA opposes the sale of medical history data and contact information accumulated through the scheduling or provision of government-funded vaccinations to third parties for use in marketing or advertising.
Additionally, as it relates to vaccines, CHEST has joined a joint society statement supporting a vaccine mandate for all health care workers.
Optimizing match outcomes (Directive to Take Action)
The policy urges AMA to encourage the Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, National Resident Matching Program, and other key stakeholders to jointly create a no-fee, easily accessible clearinghouse of reliable and valid advice and tools for residency program applicants seeking cost-effective methods for applying to and successfully matching into residency.
Ensuring adequate health care resources to address the long COVID crisis and call for increased funding and research for post-viral syndromes
The policy directs AMA to support the development of an ICD-10 code or family of codes to recognize Post-Acute Sequelae of SARS-CoV-2 infection (“PASC” or “Long COVID”) and other novel post-viral syndromes as distinct diagnoses. (New HOD Policy). Further, the policy directs AMA to advocate for legislation to provide funding for research, prevention, control, and treatment of post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19 and AMA provide physicians and medical students with accurate and current information on post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19; and further that AMA collaborate with other medical and educational entities to promote education among patients about post-viral syndromes and long-term sequelae associated with viral infections, such as COVID-19, to minimize the harm and disability current and future patients face. (Directive to Take Action)
Medical misinformation in the age of social media (Directive to Take Action)
AMA encourage social media organizations to further strengthen their content moderation policies related to medical misinformation, including, but not limited to, enhanced content monitoring, augmentation of recommendation engines focused on false information, and stronger integration of verified health information. AMA should encourage social media organizations to recognize the spread of medical misinformation over dissemination networks and collaborate with relevant stakeholders, and work with public health agencies to establish relationships with journalists and news agencies to enhance the public reach in disseminating accurate medical information.
Promoting equity in global vaccine distribution
AMA call for the cooperation of all governments and international agencies to share data, research, and resources for the production and distribution of medicines, vaccines, and personal protective equipment (Directive to Take Action); and be it further, AMA promote and support efforts to supply COVID vaccines to 21health care agencies in other parts of the world to be administered to individuals who can’t afford them. (Directive to Take Action). AMA urge the US government to provide all possible assistance, including surplus vaccines and vaccines that have not had emergency use authorization, to the citizens of India and other countries in a similar situation in this humanitarian crisis (New HOD Policy).
CHEST has taken an active role in promoting equity in health care and vaccine distribution in partnership with the American Lung Association and the American Thoracic Society, including establishing a research grant program focused on this topic.
Addressing inflammatory and untruthful online ratings (Directive to Take Action)
AMA take action that would urge online review organizations to create internal mechanisms ensuring due process to physicians before the publication of negative reviews.
This is just a small sampling of the activities and more information, including reports from the various Councils, are available on the AMA website.
CHEST members interested in the AMA policy-making process may observe any AMA-HOD meeting or participate in the AMA’s democratic processes. Attendees will also be able to increase their knowledge and skills at no cost. They will also be able to connect with more than 1,500 peers and other meeting attendees from across the country. CHEST members with the time (there are two 5-day meetings each year) and interest are invited to apply to be an official CHEST delegate to the AMA. Contact Suzanne Sletto at [email protected] for details.
Delegates and alternate delegates to the House of Delegates (HOD) play a critical role in the democratic policy-making process that is the foundation of the AMA. Their role is multi-dimensional and includes:
- Advocacy for patients within the HOD to improve the health of the public and the health care system;
- Representation of the perspectives of their sponsoring organization to the HOD;
- Representation of their physician and medical student constituents in the decision-making process of the HOD;
- Representation of the AMA and its House of Delegates to member and nonmember physicians, medical associations, and others; and
- Solicitation of input from and provision of feedback to constituents.
Also, HOD delegates and alternate delegates are expected to foster a positive and useful two-way relationship between grassroots physicians and the CHEST leadership.
Dr. Desai is with the Chicago Chest Center and AMITA Health Suburban Lung Associates; and the Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago.
Destruction in the air; Empathy in the ICU; Respiratory therapist shortage; COPD and sleep disordered breathing; And more....
Occupational and environmental health
Destruction in the air
Building collapse, such as that of the Surfside condominiums in Miami, Florida, results not only in tragic loss of life but also leads to devastating effects on lung health. Following the World Trade Center collapse, a massive particle dust cloud of up to 11,000 tons of PM2.5 was dispersed, 90% of which was particles greater than 10 mcm (Rom et al. Proc Am Thorac Soc. 2010 May;7[2]:142-5).
Fine particulate matter has been associated with multiple lung conditions. Those who arrive on site in the first 24 hours may have immediate changes in FEV1 and FVC. Acute eosinophilic pneumonia has also been described in the initial aftermath (Rom et al. Am J Respir Crit Care Med. 2002;166(6):785).
Chronic lung diseases such as chronic obstructive pulmonary disease and asthma, may worsen with repeated exposure. One Swedish study demonstrated an increased incidence of chronic lower respiratory disease in cement and demolition workers compared with the general labor force (Purdue et al. Thorax. 2007 Jan;62[1]:51-6). Clean-up sites may contain a variety of materials associated with occupational lung diseases, like chrysolite asbestos, silica, and heavy metals.
Prevention remains key. In the United States, the Occupational Safety and Health Administration requires all construction and demolition sites to have a dust control plan. Primary prevention includes the use of N-95 masks and watering sites. N-95 masks protect against particulate matter PM2.5 and smaller (Zhou et al. J Thorac Dis. 2018 Mar;10[3]:2059-69. Watering sites, while useful, can be challenging depending on the size and temperature of the area. Workers in high-risk occupations should have prior screening with pulmonary function testing. After an exposure, it is recommended pulmonary function testing be repeated, with close interval monitoring.
Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
Tyler Church, DO
Jason Unger, MD
Fellow-in-training Members
Bathmapriya Balakrishnan, MD
Steering Committee Member
Palliative care and end of life
Empathy in the ICU
The importance of empathetic patient care has never seemed so significant with patients isolated from the standard support systems in a pandemic that has pushed health care to its limits. While empathy can clearly impact patient outcomes (Rakel DP et al. Fam Med. 2009;41[7]:494-501), the practicality of delivering empathic care is less well defined. Into this void step Dr. Jessica Bunin and colleagues (Bunin J et al. J Crit Care. 2021;29;65:156-63), who present a scoping review of the limited literature in an effort to address gaps in the practice of empathy. Perhaps unsurprising but most critically, the authors found that far from being a dichotomous construct, empathy is a “complex phenomenon” that exists on a continuum. It is inconsistently defined in the existing literature, with the inclusion of cognitive, affective, and somatic processes variable. Equally important, they identified that practicing empathy carries risk in addition to its beneficial applications for both patients and intensivists.
Far from being easily identifiable, measured, and taught, this concept of empathy as a nuanced and contextually charged skill that requires practice and reflection aligns it with other skills and tools used in the care of our critically ill patients. This group has suggested that a clear definition of empathy, transparent discussion of the risks and benefits of using empathy, attention to developing environments that minimize barriers and facilitate the practice of empathy in clinical care, and the growth of educational practice to promote attention to self-care in the use of empathy will overall benefit both patient and physician well-being. At the very least, we need to allow ourselves grace to fail and learn as we strive to provide empathic care for our patients and ourselves.
Laura Johnson, MD, FCCP
NetWork Ex-Officio
Respiratory care network
National campaign to address respiratory therapist shortage
As our population grows, hospitals and physician practices face a rapidly growing need for more specialized, high-quality respiratory care; but the numbers of respiratory therapists are not keeping pace. (U.S. Bureau of Labor Statistics. Occupational Outlook Handbook. Respiratory Therapists).
To inspire a new generation of respiratory therapists and promote this lifesaving profession, the American Association for Respiratory Care (AARC), the Commission on Accreditation for Respiratory Care (CoARC), and The National Board for Respiratory Care (NBRC) are pursuing a multiyear, national campaign called The World Needs More RTs. This campaign has three primary goals:
1. Enhance the value of the respiratory care profession.
2. Recruit and retain more respiratory therapists.
3. Shape future leadership in respiratory care.
There are factors behind the current and impending future inadequate numbers of respiratory therapists:
- Decrease in undergraduate enrollment.
- Increase in retirements.
- Escalation of burnout in health care.
This campaign aims to address these factors, enhance interest in the profession, and prevent further decline in RT numbers.
Respiratory therapists make an invaluable impact on patient care, and simply put, the world needs more RTs. More RTs are needed to provide lifesaving care in the critical care units, emergency departments, and clinics (Shaw RC, Benavente JL. AARC Human Resources Survey of Acute Care Hospital Employers. NBRC 2020). More RTs are needed to educate the next RT generation (Shaw RC, Benavente JL. AARC Human Resources Survey of Education Programs. NBRC 2020). To see how you can champion the campaign, visit MoreRTs.com.
Lori Tinkler, MBA
CEO, NBRC
Steering Committee Member
De De Gardner, DrPH, RRT, FCCP
Vice-Chair
Sleep disorders
COPD and sleep-disordered breathing: Updates and steps forward
The presence of sleep breathing disorders in individuals with COPD, in the form of COPD and OSA overlap syndrome (OVS) or chronic hypercarbic respiratory failure (CHRF), portend poor outcomes when untreated. Treatment of OVS and CHRF are among few interventions that positively impact mortality, readmission rates, and quality of life in patients with COPD.
Higher mortality and readmission rates are seen in those admitted with COPD exacerbations who have OVS compared with COPD alone. Initiation and adherence to PAP therapy decreases mortality and COPD-related hospitalizations (Ioachimescu OC et al. J Clin Sleep Med. 2020;16[2]:267-77; Singh G et al. Sleep Breath. 2019;23[1]:193).
In CHRF, initiation of high intensity noninvasive ventilation (NIV) at least 2 weeks after resolution of acute respiratory failure reduces mortality and prolongs time to readmission (Murphy PB et al. JAMA. 2017;317[21]:2177-86; Kohnlein T et al. Lancet Respir Med. 2014;2:698-705). Initiating home NIV in individuals with acute hypercarbic respiratory failure does not improve readmission rates or time to readmission (Struik FM et al. Thorax. 2014;69:826-34). The new ATS guidelines, therefore, recommend NIV initiation for stable CHRF in COPD, screening for OVS prior to NIV initiation, and targeting PaCO2 normalization (Macrea M et al. Am J Respir Crit Care Med. 2020;202[4]:e74-e87).
Identification and treatment of OVS and CHRF pose unique challenges for clinicians, particularly when navigating current testing and reimbursement guidelines. A multisociety Technical Expert Panel, including members of CHEST, has recently published its recommendations for changes to CMS national coverage determinations for NIV to take the next steps forward (Gay PC et al. Chest. 2021;S0012-3692[21]01481-1).
Megan Lowery, MD
Sreelatha Naik, MD
Steering Committee Members
Thoracic oncology
CHEST releases its newest edition of the tobacco treatment toolkit
Tobacco remains the greatest single cause of morbidity and mortality. Left unaddressed, tobacco is projected to kill 1 billion people worldwide this century. Despite this, only 5% of all tobacco-dependent patients in the United States receive both a medication and even minimal counseling for their addiction.
Tobacco dependence is a severe chronic life-threatening disease. It is with this focus that CHEST released its latest iteration of the Tobacco Dependence Treatment Toolkit. This edition focuses on treating tobacco addiction as a chronic disease, titrating all seven FDA-approved medications toward tobacco abstinence, and medical practice/hospital reimbursement.
The CHEST toolkit is divided into eight sections: Motivational Interviewing, Testing/Diagnostics, Treatment Basics (pharmacologic and nonpharmacologic), Treatment Pearls, Clinical Vignettes and Studies, Special Populations, Treatment for e-Cigarettes and Other Tobacco Products, and Insurance Billing and Telehealth.
Special attention is given to tobacco addiction diagnostics and using these findings to treat the chronic disease of tobacco addiction just like any other chronic disease by aggressively and successfully titrating FDA-approved medications in various permutations and combinations, as needed. The therapeutic goal is assisting the patient to feel normal, minimizing withdrawal throughout the process, so that tobacco abstinence can ultimately be obtained and maintained.
Clinicians and medical centers can receive insurance reimbursement for these diagnostics and associated interventions. This includes both in-office procedures and via telehealth. The CHEST toolkit discusses both in-depth.
A new unique associated feature is our Clinician Interactive Toolkit. This multimedia interactive platform reviews clinician interactions with a tobacco-dependent patient via avatars and can be found here: Clinician Interactive Toolkit.
https://foundation.chestnet.org/lung-health-a-z/smoking-and-tobacco-use/?Item=For-Clinicians
The American College of Chest Physicians’ Tobacco Treatment Toolkit can be downloaded here.
The American College of Chest Physicians’ Tobacco Treatment Toolkit project also included the development of a new video game for tobacco users. Smoke Out: Tobacco Pirates is available for download for free to all at the Apple App Store for iPhones and iPads, and at Google Play (play.google.com/store/apps/details?id=com.gforcelearning.smokeout&hl=en_US&gl=US). The game is fun, the theme is immersive, and the educational content is specifically focused on tobacco users, although clinicians will enjoy it too.
Matthew Bars, MS
Steering Committee Member
Occupational and environmental health
Destruction in the air
Building collapse, such as that of the Surfside condominiums in Miami, Florida, results not only in tragic loss of life but also leads to devastating effects on lung health. Following the World Trade Center collapse, a massive particle dust cloud of up to 11,000 tons of PM2.5 was dispersed, 90% of which was particles greater than 10 mcm (Rom et al. Proc Am Thorac Soc. 2010 May;7[2]:142-5).
Fine particulate matter has been associated with multiple lung conditions. Those who arrive on site in the first 24 hours may have immediate changes in FEV1 and FVC. Acute eosinophilic pneumonia has also been described in the initial aftermath (Rom et al. Am J Respir Crit Care Med. 2002;166(6):785).
Chronic lung diseases such as chronic obstructive pulmonary disease and asthma, may worsen with repeated exposure. One Swedish study demonstrated an increased incidence of chronic lower respiratory disease in cement and demolition workers compared with the general labor force (Purdue et al. Thorax. 2007 Jan;62[1]:51-6). Clean-up sites may contain a variety of materials associated with occupational lung diseases, like chrysolite asbestos, silica, and heavy metals.
Prevention remains key. In the United States, the Occupational Safety and Health Administration requires all construction and demolition sites to have a dust control plan. Primary prevention includes the use of N-95 masks and watering sites. N-95 masks protect against particulate matter PM2.5 and smaller (Zhou et al. J Thorac Dis. 2018 Mar;10[3]:2059-69. Watering sites, while useful, can be challenging depending on the size and temperature of the area. Workers in high-risk occupations should have prior screening with pulmonary function testing. After an exposure, it is recommended pulmonary function testing be repeated, with close interval monitoring.
Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
Tyler Church, DO
Jason Unger, MD
Fellow-in-training Members
Bathmapriya Balakrishnan, MD
Steering Committee Member
Palliative care and end of life
Empathy in the ICU
The importance of empathetic patient care has never seemed so significant with patients isolated from the standard support systems in a pandemic that has pushed health care to its limits. While empathy can clearly impact patient outcomes (Rakel DP et al. Fam Med. 2009;41[7]:494-501), the practicality of delivering empathic care is less well defined. Into this void step Dr. Jessica Bunin and colleagues (Bunin J et al. J Crit Care. 2021;29;65:156-63), who present a scoping review of the limited literature in an effort to address gaps in the practice of empathy. Perhaps unsurprising but most critically, the authors found that far from being a dichotomous construct, empathy is a “complex phenomenon” that exists on a continuum. It is inconsistently defined in the existing literature, with the inclusion of cognitive, affective, and somatic processes variable. Equally important, they identified that practicing empathy carries risk in addition to its beneficial applications for both patients and intensivists.
Far from being easily identifiable, measured, and taught, this concept of empathy as a nuanced and contextually charged skill that requires practice and reflection aligns it with other skills and tools used in the care of our critically ill patients. This group has suggested that a clear definition of empathy, transparent discussion of the risks and benefits of using empathy, attention to developing environments that minimize barriers and facilitate the practice of empathy in clinical care, and the growth of educational practice to promote attention to self-care in the use of empathy will overall benefit both patient and physician well-being. At the very least, we need to allow ourselves grace to fail and learn as we strive to provide empathic care for our patients and ourselves.
Laura Johnson, MD, FCCP
NetWork Ex-Officio
Respiratory care network
National campaign to address respiratory therapist shortage
As our population grows, hospitals and physician practices face a rapidly growing need for more specialized, high-quality respiratory care; but the numbers of respiratory therapists are not keeping pace. (U.S. Bureau of Labor Statistics. Occupational Outlook Handbook. Respiratory Therapists).
To inspire a new generation of respiratory therapists and promote this lifesaving profession, the American Association for Respiratory Care (AARC), the Commission on Accreditation for Respiratory Care (CoARC), and The National Board for Respiratory Care (NBRC) are pursuing a multiyear, national campaign called The World Needs More RTs. This campaign has three primary goals:
1. Enhance the value of the respiratory care profession.
2. Recruit and retain more respiratory therapists.
3. Shape future leadership in respiratory care.
There are factors behind the current and impending future inadequate numbers of respiratory therapists:
- Decrease in undergraduate enrollment.
- Increase in retirements.
- Escalation of burnout in health care.
This campaign aims to address these factors, enhance interest in the profession, and prevent further decline in RT numbers.
Respiratory therapists make an invaluable impact on patient care, and simply put, the world needs more RTs. More RTs are needed to provide lifesaving care in the critical care units, emergency departments, and clinics (Shaw RC, Benavente JL. AARC Human Resources Survey of Acute Care Hospital Employers. NBRC 2020). More RTs are needed to educate the next RT generation (Shaw RC, Benavente JL. AARC Human Resources Survey of Education Programs. NBRC 2020). To see how you can champion the campaign, visit MoreRTs.com.
Lori Tinkler, MBA
CEO, NBRC
Steering Committee Member
De De Gardner, DrPH, RRT, FCCP
Vice-Chair
Sleep disorders
COPD and sleep-disordered breathing: Updates and steps forward
The presence of sleep breathing disorders in individuals with COPD, in the form of COPD and OSA overlap syndrome (OVS) or chronic hypercarbic respiratory failure (CHRF), portend poor outcomes when untreated. Treatment of OVS and CHRF are among few interventions that positively impact mortality, readmission rates, and quality of life in patients with COPD.
Higher mortality and readmission rates are seen in those admitted with COPD exacerbations who have OVS compared with COPD alone. Initiation and adherence to PAP therapy decreases mortality and COPD-related hospitalizations (Ioachimescu OC et al. J Clin Sleep Med. 2020;16[2]:267-77; Singh G et al. Sleep Breath. 2019;23[1]:193).
In CHRF, initiation of high intensity noninvasive ventilation (NIV) at least 2 weeks after resolution of acute respiratory failure reduces mortality and prolongs time to readmission (Murphy PB et al. JAMA. 2017;317[21]:2177-86; Kohnlein T et al. Lancet Respir Med. 2014;2:698-705). Initiating home NIV in individuals with acute hypercarbic respiratory failure does not improve readmission rates or time to readmission (Struik FM et al. Thorax. 2014;69:826-34). The new ATS guidelines, therefore, recommend NIV initiation for stable CHRF in COPD, screening for OVS prior to NIV initiation, and targeting PaCO2 normalization (Macrea M et al. Am J Respir Crit Care Med. 2020;202[4]:e74-e87).
Identification and treatment of OVS and CHRF pose unique challenges for clinicians, particularly when navigating current testing and reimbursement guidelines. A multisociety Technical Expert Panel, including members of CHEST, has recently published its recommendations for changes to CMS national coverage determinations for NIV to take the next steps forward (Gay PC et al. Chest. 2021;S0012-3692[21]01481-1).
Megan Lowery, MD
Sreelatha Naik, MD
Steering Committee Members
Thoracic oncology
CHEST releases its newest edition of the tobacco treatment toolkit
Tobacco remains the greatest single cause of morbidity and mortality. Left unaddressed, tobacco is projected to kill 1 billion people worldwide this century. Despite this, only 5% of all tobacco-dependent patients in the United States receive both a medication and even minimal counseling for their addiction.
Tobacco dependence is a severe chronic life-threatening disease. It is with this focus that CHEST released its latest iteration of the Tobacco Dependence Treatment Toolkit. This edition focuses on treating tobacco addiction as a chronic disease, titrating all seven FDA-approved medications toward tobacco abstinence, and medical practice/hospital reimbursement.
The CHEST toolkit is divided into eight sections: Motivational Interviewing, Testing/Diagnostics, Treatment Basics (pharmacologic and nonpharmacologic), Treatment Pearls, Clinical Vignettes and Studies, Special Populations, Treatment for e-Cigarettes and Other Tobacco Products, and Insurance Billing and Telehealth.
Special attention is given to tobacco addiction diagnostics and using these findings to treat the chronic disease of tobacco addiction just like any other chronic disease by aggressively and successfully titrating FDA-approved medications in various permutations and combinations, as needed. The therapeutic goal is assisting the patient to feel normal, minimizing withdrawal throughout the process, so that tobacco abstinence can ultimately be obtained and maintained.
Clinicians and medical centers can receive insurance reimbursement for these diagnostics and associated interventions. This includes both in-office procedures and via telehealth. The CHEST toolkit discusses both in-depth.
A new unique associated feature is our Clinician Interactive Toolkit. This multimedia interactive platform reviews clinician interactions with a tobacco-dependent patient via avatars and can be found here: Clinician Interactive Toolkit.
https://foundation.chestnet.org/lung-health-a-z/smoking-and-tobacco-use/?Item=For-Clinicians
The American College of Chest Physicians’ Tobacco Treatment Toolkit can be downloaded here.
The American College of Chest Physicians’ Tobacco Treatment Toolkit project also included the development of a new video game for tobacco users. Smoke Out: Tobacco Pirates is available for download for free to all at the Apple App Store for iPhones and iPads, and at Google Play (play.google.com/store/apps/details?id=com.gforcelearning.smokeout&hl=en_US&gl=US). The game is fun, the theme is immersive, and the educational content is specifically focused on tobacco users, although clinicians will enjoy it too.
Matthew Bars, MS
Steering Committee Member
Occupational and environmental health
Destruction in the air
Building collapse, such as that of the Surfside condominiums in Miami, Florida, results not only in tragic loss of life but also leads to devastating effects on lung health. Following the World Trade Center collapse, a massive particle dust cloud of up to 11,000 tons of PM2.5 was dispersed, 90% of which was particles greater than 10 mcm (Rom et al. Proc Am Thorac Soc. 2010 May;7[2]:142-5).
Fine particulate matter has been associated with multiple lung conditions. Those who arrive on site in the first 24 hours may have immediate changes in FEV1 and FVC. Acute eosinophilic pneumonia has also been described in the initial aftermath (Rom et al. Am J Respir Crit Care Med. 2002;166(6):785).
Chronic lung diseases such as chronic obstructive pulmonary disease and asthma, may worsen with repeated exposure. One Swedish study demonstrated an increased incidence of chronic lower respiratory disease in cement and demolition workers compared with the general labor force (Purdue et al. Thorax. 2007 Jan;62[1]:51-6). Clean-up sites may contain a variety of materials associated with occupational lung diseases, like chrysolite asbestos, silica, and heavy metals.
Prevention remains key. In the United States, the Occupational Safety and Health Administration requires all construction and demolition sites to have a dust control plan. Primary prevention includes the use of N-95 masks and watering sites. N-95 masks protect against particulate matter PM2.5 and smaller (Zhou et al. J Thorac Dis. 2018 Mar;10[3]:2059-69. Watering sites, while useful, can be challenging depending on the size and temperature of the area. Workers in high-risk occupations should have prior screening with pulmonary function testing. After an exposure, it is recommended pulmonary function testing be repeated, with close interval monitoring.
Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
Tyler Church, DO
Jason Unger, MD
Fellow-in-training Members
Bathmapriya Balakrishnan, MD
Steering Committee Member
Palliative care and end of life
Empathy in the ICU
The importance of empathetic patient care has never seemed so significant with patients isolated from the standard support systems in a pandemic that has pushed health care to its limits. While empathy can clearly impact patient outcomes (Rakel DP et al. Fam Med. 2009;41[7]:494-501), the practicality of delivering empathic care is less well defined. Into this void step Dr. Jessica Bunin and colleagues (Bunin J et al. J Crit Care. 2021;29;65:156-63), who present a scoping review of the limited literature in an effort to address gaps in the practice of empathy. Perhaps unsurprising but most critically, the authors found that far from being a dichotomous construct, empathy is a “complex phenomenon” that exists on a continuum. It is inconsistently defined in the existing literature, with the inclusion of cognitive, affective, and somatic processes variable. Equally important, they identified that practicing empathy carries risk in addition to its beneficial applications for both patients and intensivists.
Far from being easily identifiable, measured, and taught, this concept of empathy as a nuanced and contextually charged skill that requires practice and reflection aligns it with other skills and tools used in the care of our critically ill patients. This group has suggested that a clear definition of empathy, transparent discussion of the risks and benefits of using empathy, attention to developing environments that minimize barriers and facilitate the practice of empathy in clinical care, and the growth of educational practice to promote attention to self-care in the use of empathy will overall benefit both patient and physician well-being. At the very least, we need to allow ourselves grace to fail and learn as we strive to provide empathic care for our patients and ourselves.
Laura Johnson, MD, FCCP
NetWork Ex-Officio
Respiratory care network
National campaign to address respiratory therapist shortage
As our population grows, hospitals and physician practices face a rapidly growing need for more specialized, high-quality respiratory care; but the numbers of respiratory therapists are not keeping pace. (U.S. Bureau of Labor Statistics. Occupational Outlook Handbook. Respiratory Therapists).
To inspire a new generation of respiratory therapists and promote this lifesaving profession, the American Association for Respiratory Care (AARC), the Commission on Accreditation for Respiratory Care (CoARC), and The National Board for Respiratory Care (NBRC) are pursuing a multiyear, national campaign called The World Needs More RTs. This campaign has three primary goals:
1. Enhance the value of the respiratory care profession.
2. Recruit and retain more respiratory therapists.
3. Shape future leadership in respiratory care.
There are factors behind the current and impending future inadequate numbers of respiratory therapists:
- Decrease in undergraduate enrollment.
- Increase in retirements.
- Escalation of burnout in health care.
This campaign aims to address these factors, enhance interest in the profession, and prevent further decline in RT numbers.
Respiratory therapists make an invaluable impact on patient care, and simply put, the world needs more RTs. More RTs are needed to provide lifesaving care in the critical care units, emergency departments, and clinics (Shaw RC, Benavente JL. AARC Human Resources Survey of Acute Care Hospital Employers. NBRC 2020). More RTs are needed to educate the next RT generation (Shaw RC, Benavente JL. AARC Human Resources Survey of Education Programs. NBRC 2020). To see how you can champion the campaign, visit MoreRTs.com.
Lori Tinkler, MBA
CEO, NBRC
Steering Committee Member
De De Gardner, DrPH, RRT, FCCP
Vice-Chair
Sleep disorders
COPD and sleep-disordered breathing: Updates and steps forward
The presence of sleep breathing disorders in individuals with COPD, in the form of COPD and OSA overlap syndrome (OVS) or chronic hypercarbic respiratory failure (CHRF), portend poor outcomes when untreated. Treatment of OVS and CHRF are among few interventions that positively impact mortality, readmission rates, and quality of life in patients with COPD.
Higher mortality and readmission rates are seen in those admitted with COPD exacerbations who have OVS compared with COPD alone. Initiation and adherence to PAP therapy decreases mortality and COPD-related hospitalizations (Ioachimescu OC et al. J Clin Sleep Med. 2020;16[2]:267-77; Singh G et al. Sleep Breath. 2019;23[1]:193).
In CHRF, initiation of high intensity noninvasive ventilation (NIV) at least 2 weeks after resolution of acute respiratory failure reduces mortality and prolongs time to readmission (Murphy PB et al. JAMA. 2017;317[21]:2177-86; Kohnlein T et al. Lancet Respir Med. 2014;2:698-705). Initiating home NIV in individuals with acute hypercarbic respiratory failure does not improve readmission rates or time to readmission (Struik FM et al. Thorax. 2014;69:826-34). The new ATS guidelines, therefore, recommend NIV initiation for stable CHRF in COPD, screening for OVS prior to NIV initiation, and targeting PaCO2 normalization (Macrea M et al. Am J Respir Crit Care Med. 2020;202[4]:e74-e87).
Identification and treatment of OVS and CHRF pose unique challenges for clinicians, particularly when navigating current testing and reimbursement guidelines. A multisociety Technical Expert Panel, including members of CHEST, has recently published its recommendations for changes to CMS national coverage determinations for NIV to take the next steps forward (Gay PC et al. Chest. 2021;S0012-3692[21]01481-1).
Megan Lowery, MD
Sreelatha Naik, MD
Steering Committee Members
Thoracic oncology
CHEST releases its newest edition of the tobacco treatment toolkit
Tobacco remains the greatest single cause of morbidity and mortality. Left unaddressed, tobacco is projected to kill 1 billion people worldwide this century. Despite this, only 5% of all tobacco-dependent patients in the United States receive both a medication and even minimal counseling for their addiction.
Tobacco dependence is a severe chronic life-threatening disease. It is with this focus that CHEST released its latest iteration of the Tobacco Dependence Treatment Toolkit. This edition focuses on treating tobacco addiction as a chronic disease, titrating all seven FDA-approved medications toward tobacco abstinence, and medical practice/hospital reimbursement.
The CHEST toolkit is divided into eight sections: Motivational Interviewing, Testing/Diagnostics, Treatment Basics (pharmacologic and nonpharmacologic), Treatment Pearls, Clinical Vignettes and Studies, Special Populations, Treatment for e-Cigarettes and Other Tobacco Products, and Insurance Billing and Telehealth.
Special attention is given to tobacco addiction diagnostics and using these findings to treat the chronic disease of tobacco addiction just like any other chronic disease by aggressively and successfully titrating FDA-approved medications in various permutations and combinations, as needed. The therapeutic goal is assisting the patient to feel normal, minimizing withdrawal throughout the process, so that tobacco abstinence can ultimately be obtained and maintained.
Clinicians and medical centers can receive insurance reimbursement for these diagnostics and associated interventions. This includes both in-office procedures and via telehealth. The CHEST toolkit discusses both in-depth.
A new unique associated feature is our Clinician Interactive Toolkit. This multimedia interactive platform reviews clinician interactions with a tobacco-dependent patient via avatars and can be found here: Clinician Interactive Toolkit.
https://foundation.chestnet.org/lung-health-a-z/smoking-and-tobacco-use/?Item=For-Clinicians
The American College of Chest Physicians’ Tobacco Treatment Toolkit can be downloaded here.
The American College of Chest Physicians’ Tobacco Treatment Toolkit project also included the development of a new video game for tobacco users. Smoke Out: Tobacco Pirates is available for download for free to all at the Apple App Store for iPhones and iPads, and at Google Play (play.google.com/store/apps/details?id=com.gforcelearning.smokeout&hl=en_US&gl=US). The game is fun, the theme is immersive, and the educational content is specifically focused on tobacco users, although clinicians will enjoy it too.
Matthew Bars, MS
Steering Committee Member
This month in the journal CHEST®
Editor’s picks
Point: E-cigarettes for harm reduction in tobacco use disorder: Pro. By Dr. C. Bates.
Counterpoint: E-cigarettes for harm reduction in tobacco use disorder: Con. By Dr. H. Kathuria, et al.
Eosinophilic and non-eosinophilic asthma: an expert consensus framework to characterize phenotypes in a global real-life severe asthma cohort. By Dr. L. G. Heaney, et al.Symptoms of mental health disorders in critical care clinicians facing the COVID-19 second wave: A cross-sectional study. By Dr. E. Azoulay, et al.Tobacco smoking and risk for pulmonary fibrosis: A prospective cohort study in UK Biobank.By Dr. V. Bellow, et al.Sleep in the hospitalized child: A contemporary review. By Dr. J. Berger, et al.Avoid the Trap: Non-expanding Lung. By Dr. D. Gillett, et al.Resuscitation a la Carte: Ethical concerns about the practice and theory of partial codes. By Dr. B. Gremmels, et al.
Editor’s picks
Editor’s picks
Point: E-cigarettes for harm reduction in tobacco use disorder: Pro. By Dr. C. Bates.
Counterpoint: E-cigarettes for harm reduction in tobacco use disorder: Con. By Dr. H. Kathuria, et al.
Eosinophilic and non-eosinophilic asthma: an expert consensus framework to characterize phenotypes in a global real-life severe asthma cohort. By Dr. L. G. Heaney, et al.Symptoms of mental health disorders in critical care clinicians facing the COVID-19 second wave: A cross-sectional study. By Dr. E. Azoulay, et al.Tobacco smoking and risk for pulmonary fibrosis: A prospective cohort study in UK Biobank.By Dr. V. Bellow, et al.Sleep in the hospitalized child: A contemporary review. By Dr. J. Berger, et al.Avoid the Trap: Non-expanding Lung. By Dr. D. Gillett, et al.Resuscitation a la Carte: Ethical concerns about the practice and theory of partial codes. By Dr. B. Gremmels, et al.
Point: E-cigarettes for harm reduction in tobacco use disorder: Pro. By Dr. C. Bates.
Counterpoint: E-cigarettes for harm reduction in tobacco use disorder: Con. By Dr. H. Kathuria, et al.
Eosinophilic and non-eosinophilic asthma: an expert consensus framework to characterize phenotypes in a global real-life severe asthma cohort. By Dr. L. G. Heaney, et al.Symptoms of mental health disorders in critical care clinicians facing the COVID-19 second wave: A cross-sectional study. By Dr. E. Azoulay, et al.Tobacco smoking and risk for pulmonary fibrosis: A prospective cohort study in UK Biobank.By Dr. V. Bellow, et al.Sleep in the hospitalized child: A contemporary review. By Dr. J. Berger, et al.Avoid the Trap: Non-expanding Lung. By Dr. D. Gillett, et al.Resuscitation a la Carte: Ethical concerns about the practice and theory of partial codes. By Dr. B. Gremmels, et al.
Staying up to date with consumer sleep technology
With Siri and Alexa sitting at our kitchen tables and listening to our conversations, we have all but forgotten about the before times – when we had to use the Yellow Pages to look up a number or address and when we had no idea how many steps we took in a given day. Wearable technology has become ubiquitous and has us watching not only our step count but also our sleep. Did I get enough deep sleep? What does my sleep score of 82 mean? Should I be worried?
As clinicians, we must also navigate how this information impacts our clinical decision-making and consider how our patients are interpreting these data on a daily basis. There is an inherent assumption that we, as sleep clinicians, will understand the nuances of each consumer-facing sleep technology (CST) whether it is a wearable, a nearable (a device that sits near the body but not on the body), or an app. Very little validation data exist, as most of these technologies are marketed as wellness devices and are not intended to render a diagnosis. It therefore falls to us to determine how to utilize this information in an already busy clinic.
One strategy is to use these technologies as patient engagement tools – a way to increase public awareness of the importance of sleep. While this certainly should be beneficial, oftentimes, the data are confusing and can lead to misunderstandings about what normal sleep should look like. Approaching these data as partners to our patients allows us to set expectations around normal sleep cycles and sleep duration. It also allows us to discuss appropriate sleep timing and sleep hygiene.
Many wearable devices have incorporated oximetry into their metrics, and some claim to have accuracy that is better than hospital-grade oximeters. Many of these companies are no longer in business. Others specify higher accuracy in dark-skinned individuals (“CIRCUL Ring Pulse Oximeter in Dark-Pigmented Individuals: Clinical Study Validates Efficacy and Reliability,” Medical Device News Magazine, Feb. 26, 2021).
Despite these claims, they are registered as wellness devices with the FDA and are not diagnostic devices. Logically, if one of these devices demonstrates worrisome data, then it can prompt further clinical queries and, potentially, objective testing for obstructive sleep apnea (OSA). The reverse, however, cannot be claimed. A normal reading by CST does not obviate the need for objective testing if the clinical symptoms warrant it.
There are CSTs that have been created around very specific needs - such as jet lag- and provide guidance for how to quickly acclimate to the destination time zone by providing nudges for light exposure and timed melatonin or dark glasses (https://www.timeshifter.com/).
Others analyze the sleep space for extrinsic sounds (https://www.sleepcycle.com/), while a plethora of apps provides advice for how to optimize your sleep environment and wind-down routine. There is even a sleep robot designed to facilitate sleep onset (https://somnox.com/). This bean-shaped device is designed to “breathe” as you hold it, and the user is meant to emulate those same breathing patterns. It is a take on the 4-7-8 breathing pattern long endorsed by yogis.
Although validation data are lacking for the vast majority of CST, a recent study (www.ncbi.nlm.nih.gov/pmc/articles/PMC8120339/pdf/zsaa291.pdf).demonstrated that CST had high performance when compared with actigraphy in assessing sleep and wakefulness and, as such, may improve the evaluation of sleep and wake opportunities prior to MSLT or improve identification of circadian sleep-wake disorders. Many practices do not currently utilize actigraphy due to its expense and very limited potential for reimbursement. Using a patient’s sleep-tracking device may allow access to these data without financial outlay. While these data demonstrate the ability of CST to potentially differentiate sleep from wakefulness, it is notable that this study also found that the determination of individual sleep stages is less robust. In general, CST cannot identify an underlying sleep disorder, however, may raise awareness that a disorder might be present.
This leads to more reflection on the role of CST in a typical sleep clinic. Many years ago, discussion around this technology was primarily patient-initiated and often times met with skepticism on the part of the clinician. As technology has improved and has become more accessible, there appears to be more acceptance among our colleagues – not, perhaps, in terms of absolute actionable data, but rather as an opportunity to discuss sleep with our patients and to support their own efforts at improving their sleep. Trends in the data in response to CBT-I or medications can be observed. Abnormalities identified via CST often serve as the initial prompt for a clinical visit and, as such, should not be eschewed. Rather, reframing the use of this information while also addressing other sleep issues is likely to be the more appropriate path forward.
Assessing this information can be time-consuming, and best practice suggests establishing expectations around this process (J Clin Sleep Med 2018 May 15. doi: 10.5664/jcsm.7128).
Agreements can be made with patients that the data are reviewed in the context of a clinical visit rather than longitudinally as data are uploaded and then sent via messaging unless such an understanding has already been agreed upon. RPM billing codes may ultimately allow for reimbursement and recognition of this workload. At the present time, RPM billing is limited to FDA-cleared, prescription devices, and CST does not yet qualify.
There also needs to be recognition of potential harm from CST. Inevitably, some patients will develop orthosomnia, a term coined by Dr. Kelly Baron, where patients become so fixated on achieving perfect sleep scores that it contributes to insomnia. In this case, identification of orthosomnia is made via the clinical visit and patients are advised to stop tracking their sleep for a set period of time. This allows the anxiety around achieving “perfect sleep” to dissipate.
Google and the AASM recently announced a partnership. Essentially, the Google Nest Hub will serve to detect sleep concerns (such as timing of sleep, snoring, insufficient sleep, etc.) and will direct the user to educational resources such as www.sleepeducation.org. The idea behind this is that people are often unaware of an underlying sleep disorder such as OSA and don’t know what to search for. The Nest Hub uses information it collects and directs users to appropriate resources, thus obviating the need to know what to Google.
Clearly, big tech has invested heavily in our field. Between the copious wearables, nearables, and apps that are sleep-focused, these industry giants obviously believe that sleep is worthy of such a significant allocation of resources. This has improved the overall awareness of the importance of sleep and of identifying and treating sleep disorders. While these technologies are no replacement for a clinical evaluation, they can serve as patient engagement tools, as well as potentially large-scale OSA screening tools and may help us improve the percentage of patients with undiagnosed OSA, estimated to be 80% (Frost and Sullivan, “Hidden Health Crisis Costing America Billions,” American Academy of Sleep Medicine, 2016).
CST may allow us to better identify circadian sleep-wake disorders and evaluate sleep satiation prior to MLST that no longer requires investment in expensive actigraphy devices. They also allow us to partner with our patients by meeting them where they are and recognizing the efforts they have already made to improve their sleep before we even meet them.
Dr. Khosla is Medical Director, North Dakota Center for Sleep, Fargo, North Dakota.
With Siri and Alexa sitting at our kitchen tables and listening to our conversations, we have all but forgotten about the before times – when we had to use the Yellow Pages to look up a number or address and when we had no idea how many steps we took in a given day. Wearable technology has become ubiquitous and has us watching not only our step count but also our sleep. Did I get enough deep sleep? What does my sleep score of 82 mean? Should I be worried?
As clinicians, we must also navigate how this information impacts our clinical decision-making and consider how our patients are interpreting these data on a daily basis. There is an inherent assumption that we, as sleep clinicians, will understand the nuances of each consumer-facing sleep technology (CST) whether it is a wearable, a nearable (a device that sits near the body but not on the body), or an app. Very little validation data exist, as most of these technologies are marketed as wellness devices and are not intended to render a diagnosis. It therefore falls to us to determine how to utilize this information in an already busy clinic.
One strategy is to use these technologies as patient engagement tools – a way to increase public awareness of the importance of sleep. While this certainly should be beneficial, oftentimes, the data are confusing and can lead to misunderstandings about what normal sleep should look like. Approaching these data as partners to our patients allows us to set expectations around normal sleep cycles and sleep duration. It also allows us to discuss appropriate sleep timing and sleep hygiene.
Many wearable devices have incorporated oximetry into their metrics, and some claim to have accuracy that is better than hospital-grade oximeters. Many of these companies are no longer in business. Others specify higher accuracy in dark-skinned individuals (“CIRCUL Ring Pulse Oximeter in Dark-Pigmented Individuals: Clinical Study Validates Efficacy and Reliability,” Medical Device News Magazine, Feb. 26, 2021).
Despite these claims, they are registered as wellness devices with the FDA and are not diagnostic devices. Logically, if one of these devices demonstrates worrisome data, then it can prompt further clinical queries and, potentially, objective testing for obstructive sleep apnea (OSA). The reverse, however, cannot be claimed. A normal reading by CST does not obviate the need for objective testing if the clinical symptoms warrant it.
There are CSTs that have been created around very specific needs - such as jet lag- and provide guidance for how to quickly acclimate to the destination time zone by providing nudges for light exposure and timed melatonin or dark glasses (https://www.timeshifter.com/).
Others analyze the sleep space for extrinsic sounds (https://www.sleepcycle.com/), while a plethora of apps provides advice for how to optimize your sleep environment and wind-down routine. There is even a sleep robot designed to facilitate sleep onset (https://somnox.com/). This bean-shaped device is designed to “breathe” as you hold it, and the user is meant to emulate those same breathing patterns. It is a take on the 4-7-8 breathing pattern long endorsed by yogis.
Although validation data are lacking for the vast majority of CST, a recent study (www.ncbi.nlm.nih.gov/pmc/articles/PMC8120339/pdf/zsaa291.pdf).demonstrated that CST had high performance when compared with actigraphy in assessing sleep and wakefulness and, as such, may improve the evaluation of sleep and wake opportunities prior to MSLT or improve identification of circadian sleep-wake disorders. Many practices do not currently utilize actigraphy due to its expense and very limited potential for reimbursement. Using a patient’s sleep-tracking device may allow access to these data without financial outlay. While these data demonstrate the ability of CST to potentially differentiate sleep from wakefulness, it is notable that this study also found that the determination of individual sleep stages is less robust. In general, CST cannot identify an underlying sleep disorder, however, may raise awareness that a disorder might be present.
This leads to more reflection on the role of CST in a typical sleep clinic. Many years ago, discussion around this technology was primarily patient-initiated and often times met with skepticism on the part of the clinician. As technology has improved and has become more accessible, there appears to be more acceptance among our colleagues – not, perhaps, in terms of absolute actionable data, but rather as an opportunity to discuss sleep with our patients and to support their own efforts at improving their sleep. Trends in the data in response to CBT-I or medications can be observed. Abnormalities identified via CST often serve as the initial prompt for a clinical visit and, as such, should not be eschewed. Rather, reframing the use of this information while also addressing other sleep issues is likely to be the more appropriate path forward.
Assessing this information can be time-consuming, and best practice suggests establishing expectations around this process (J Clin Sleep Med 2018 May 15. doi: 10.5664/jcsm.7128).
Agreements can be made with patients that the data are reviewed in the context of a clinical visit rather than longitudinally as data are uploaded and then sent via messaging unless such an understanding has already been agreed upon. RPM billing codes may ultimately allow for reimbursement and recognition of this workload. At the present time, RPM billing is limited to FDA-cleared, prescription devices, and CST does not yet qualify.
There also needs to be recognition of potential harm from CST. Inevitably, some patients will develop orthosomnia, a term coined by Dr. Kelly Baron, where patients become so fixated on achieving perfect sleep scores that it contributes to insomnia. In this case, identification of orthosomnia is made via the clinical visit and patients are advised to stop tracking their sleep for a set period of time. This allows the anxiety around achieving “perfect sleep” to dissipate.
Google and the AASM recently announced a partnership. Essentially, the Google Nest Hub will serve to detect sleep concerns (such as timing of sleep, snoring, insufficient sleep, etc.) and will direct the user to educational resources such as www.sleepeducation.org. The idea behind this is that people are often unaware of an underlying sleep disorder such as OSA and don’t know what to search for. The Nest Hub uses information it collects and directs users to appropriate resources, thus obviating the need to know what to Google.
Clearly, big tech has invested heavily in our field. Between the copious wearables, nearables, and apps that are sleep-focused, these industry giants obviously believe that sleep is worthy of such a significant allocation of resources. This has improved the overall awareness of the importance of sleep and of identifying and treating sleep disorders. While these technologies are no replacement for a clinical evaluation, they can serve as patient engagement tools, as well as potentially large-scale OSA screening tools and may help us improve the percentage of patients with undiagnosed OSA, estimated to be 80% (Frost and Sullivan, “Hidden Health Crisis Costing America Billions,” American Academy of Sleep Medicine, 2016).
CST may allow us to better identify circadian sleep-wake disorders and evaluate sleep satiation prior to MLST that no longer requires investment in expensive actigraphy devices. They also allow us to partner with our patients by meeting them where they are and recognizing the efforts they have already made to improve their sleep before we even meet them.
Dr. Khosla is Medical Director, North Dakota Center for Sleep, Fargo, North Dakota.
With Siri and Alexa sitting at our kitchen tables and listening to our conversations, we have all but forgotten about the before times – when we had to use the Yellow Pages to look up a number or address and when we had no idea how many steps we took in a given day. Wearable technology has become ubiquitous and has us watching not only our step count but also our sleep. Did I get enough deep sleep? What does my sleep score of 82 mean? Should I be worried?
As clinicians, we must also navigate how this information impacts our clinical decision-making and consider how our patients are interpreting these data on a daily basis. There is an inherent assumption that we, as sleep clinicians, will understand the nuances of each consumer-facing sleep technology (CST) whether it is a wearable, a nearable (a device that sits near the body but not on the body), or an app. Very little validation data exist, as most of these technologies are marketed as wellness devices and are not intended to render a diagnosis. It therefore falls to us to determine how to utilize this information in an already busy clinic.
One strategy is to use these technologies as patient engagement tools – a way to increase public awareness of the importance of sleep. While this certainly should be beneficial, oftentimes, the data are confusing and can lead to misunderstandings about what normal sleep should look like. Approaching these data as partners to our patients allows us to set expectations around normal sleep cycles and sleep duration. It also allows us to discuss appropriate sleep timing and sleep hygiene.
Many wearable devices have incorporated oximetry into their metrics, and some claim to have accuracy that is better than hospital-grade oximeters. Many of these companies are no longer in business. Others specify higher accuracy in dark-skinned individuals (“CIRCUL Ring Pulse Oximeter in Dark-Pigmented Individuals: Clinical Study Validates Efficacy and Reliability,” Medical Device News Magazine, Feb. 26, 2021).
Despite these claims, they are registered as wellness devices with the FDA and are not diagnostic devices. Logically, if one of these devices demonstrates worrisome data, then it can prompt further clinical queries and, potentially, objective testing for obstructive sleep apnea (OSA). The reverse, however, cannot be claimed. A normal reading by CST does not obviate the need for objective testing if the clinical symptoms warrant it.
There are CSTs that have been created around very specific needs - such as jet lag- and provide guidance for how to quickly acclimate to the destination time zone by providing nudges for light exposure and timed melatonin or dark glasses (https://www.timeshifter.com/).
Others analyze the sleep space for extrinsic sounds (https://www.sleepcycle.com/), while a plethora of apps provides advice for how to optimize your sleep environment and wind-down routine. There is even a sleep robot designed to facilitate sleep onset (https://somnox.com/). This bean-shaped device is designed to “breathe” as you hold it, and the user is meant to emulate those same breathing patterns. It is a take on the 4-7-8 breathing pattern long endorsed by yogis.
Although validation data are lacking for the vast majority of CST, a recent study (www.ncbi.nlm.nih.gov/pmc/articles/PMC8120339/pdf/zsaa291.pdf).demonstrated that CST had high performance when compared with actigraphy in assessing sleep and wakefulness and, as such, may improve the evaluation of sleep and wake opportunities prior to MSLT or improve identification of circadian sleep-wake disorders. Many practices do not currently utilize actigraphy due to its expense and very limited potential for reimbursement. Using a patient’s sleep-tracking device may allow access to these data without financial outlay. While these data demonstrate the ability of CST to potentially differentiate sleep from wakefulness, it is notable that this study also found that the determination of individual sleep stages is less robust. In general, CST cannot identify an underlying sleep disorder, however, may raise awareness that a disorder might be present.
This leads to more reflection on the role of CST in a typical sleep clinic. Many years ago, discussion around this technology was primarily patient-initiated and often times met with skepticism on the part of the clinician. As technology has improved and has become more accessible, there appears to be more acceptance among our colleagues – not, perhaps, in terms of absolute actionable data, but rather as an opportunity to discuss sleep with our patients and to support their own efforts at improving their sleep. Trends in the data in response to CBT-I or medications can be observed. Abnormalities identified via CST often serve as the initial prompt for a clinical visit and, as such, should not be eschewed. Rather, reframing the use of this information while also addressing other sleep issues is likely to be the more appropriate path forward.
Assessing this information can be time-consuming, and best practice suggests establishing expectations around this process (J Clin Sleep Med 2018 May 15. doi: 10.5664/jcsm.7128).
Agreements can be made with patients that the data are reviewed in the context of a clinical visit rather than longitudinally as data are uploaded and then sent via messaging unless such an understanding has already been agreed upon. RPM billing codes may ultimately allow for reimbursement and recognition of this workload. At the present time, RPM billing is limited to FDA-cleared, prescription devices, and CST does not yet qualify.
There also needs to be recognition of potential harm from CST. Inevitably, some patients will develop orthosomnia, a term coined by Dr. Kelly Baron, where patients become so fixated on achieving perfect sleep scores that it contributes to insomnia. In this case, identification of orthosomnia is made via the clinical visit and patients are advised to stop tracking their sleep for a set period of time. This allows the anxiety around achieving “perfect sleep” to dissipate.
Google and the AASM recently announced a partnership. Essentially, the Google Nest Hub will serve to detect sleep concerns (such as timing of sleep, snoring, insufficient sleep, etc.) and will direct the user to educational resources such as www.sleepeducation.org. The idea behind this is that people are often unaware of an underlying sleep disorder such as OSA and don’t know what to search for. The Nest Hub uses information it collects and directs users to appropriate resources, thus obviating the need to know what to Google.
Clearly, big tech has invested heavily in our field. Between the copious wearables, nearables, and apps that are sleep-focused, these industry giants obviously believe that sleep is worthy of such a significant allocation of resources. This has improved the overall awareness of the importance of sleep and of identifying and treating sleep disorders. While these technologies are no replacement for a clinical evaluation, they can serve as patient engagement tools, as well as potentially large-scale OSA screening tools and may help us improve the percentage of patients with undiagnosed OSA, estimated to be 80% (Frost and Sullivan, “Hidden Health Crisis Costing America Billions,” American Academy of Sleep Medicine, 2016).
CST may allow us to better identify circadian sleep-wake disorders and evaluate sleep satiation prior to MLST that no longer requires investment in expensive actigraphy devices. They also allow us to partner with our patients by meeting them where they are and recognizing the efforts they have already made to improve their sleep before we even meet them.
Dr. Khosla is Medical Director, North Dakota Center for Sleep, Fargo, North Dakota.
CHEST 2021: The beginning of the rest of your career
Is this your first CHEST Annual Meeting? Co-Chair David Zielinski, MD, FCCP, shares some words of wisdom recounting his first experience at CHEST and what first-time attendees can expect from the annual meeting.
My very first CHEST meeting was 10 years ago at CHEST 2011 in Honolulu, Hawaii. I clearly remember my first session being a postgraduate course on Respiratory Management of Neuromuscular Disease and having the opportunity for hands-on teaching with devices and techniques.
Simulation was unique at medical conferences at that time and has continued to evolve at subsequent CHEST meetings.
Looking back, what really sticks out about this experience is what it started for me in terms of my career and learning. I was in a session with some of the biggest names in the field—people who I always looked up to as a relatively junior faculty. I was encouraged to get more involved at CHEST and with the committees. It put the bug in my ear.
A few years later, I started to get involved in the NetWorks. Eventually, I became a faculty member myself alongside these individuals at subsequent CHEST meetings. Meeting these chest medicine professionals also led to more collaborations with them outside of CHEST.
I never imagined this during my first meeting ten years ago. I have now been back to every meeting but one since that first one.
The CHEST Annual Meeting has always stood out for its focus on quality clinical teaching, being ahead of the curve on interactivity and adjusting to the audience’s learning needs.
For me personally, though, the three things that I have always enjoyed are as follows:
Simulation opportunities
One thing that sets apart CHEST 2021 from other conferences is the simulation sessions being offered online.
These sessions are an opportunity to practice your skills and techniques with some of the best educators anywhere in the world. I have always come out of these sessions impressed. I encourage you to try it at least once.
The fun
From the receptions, the meet-ups, pop-up events, CHEST Challenge, the games… the list goes on: the fun element of CHEST makes it a more immersive atmosphere. When the meeting was solely virtual last year, CHEST still aimed to provide fun and will continue to do the same this year. Challenge your colleagues and new friends to games at the CHEST Player Hub online to see which one of you rises to the top of the leaderboard.
The community
CHEST 2021 (and CHEST the organization) helps you make connections and provides opportunities for leadership involvement. CHEST committees are always looking for leaders at all stages of their careers. Attending satellite meetings, like the NetWork open forums that are occurring online before the meeting starts this year, will allow you to begin networking with those with similar interests to your own and hopefully will spark your interest in getting more involved in the future.
For many of us at CHEST, the NetWorks were a great place to start, and you can join one in the area that interests you most. Through my involvement in CHEST, I have become a part of the community, meeting so many other clinicians and educators in my field. I have made great friendships, which keep me coming back every year.
Moving forward
From the beginning, we have been planning CHEST 2021 so that if we needed to go entirely online, we could do so as seamlessly as possible. With the recent decision to cancel the in-person meeting and go fully online, plans are already underway to make CHEST 2021 just as successful as last year’s meeting.
We can give you our commitment that your CHEST 2021 experience will live up to being a world-class event that separates itself from other current online offerings. I will be in attendance and hope to see you online.
Start planning your days with the CHEST 2021 Schedule at A Glance at chestmeeting.chestnet.org.
Is this your first CHEST Annual Meeting? Co-Chair David Zielinski, MD, FCCP, shares some words of wisdom recounting his first experience at CHEST and what first-time attendees can expect from the annual meeting.
My very first CHEST meeting was 10 years ago at CHEST 2011 in Honolulu, Hawaii. I clearly remember my first session being a postgraduate course on Respiratory Management of Neuromuscular Disease and having the opportunity for hands-on teaching with devices and techniques.
Simulation was unique at medical conferences at that time and has continued to evolve at subsequent CHEST meetings.
Looking back, what really sticks out about this experience is what it started for me in terms of my career and learning. I was in a session with some of the biggest names in the field—people who I always looked up to as a relatively junior faculty. I was encouraged to get more involved at CHEST and with the committees. It put the bug in my ear.
A few years later, I started to get involved in the NetWorks. Eventually, I became a faculty member myself alongside these individuals at subsequent CHEST meetings. Meeting these chest medicine professionals also led to more collaborations with them outside of CHEST.
I never imagined this during my first meeting ten years ago. I have now been back to every meeting but one since that first one.
The CHEST Annual Meeting has always stood out for its focus on quality clinical teaching, being ahead of the curve on interactivity and adjusting to the audience’s learning needs.
For me personally, though, the three things that I have always enjoyed are as follows:
Simulation opportunities
One thing that sets apart CHEST 2021 from other conferences is the simulation sessions being offered online.
These sessions are an opportunity to practice your skills and techniques with some of the best educators anywhere in the world. I have always come out of these sessions impressed. I encourage you to try it at least once.
The fun
From the receptions, the meet-ups, pop-up events, CHEST Challenge, the games… the list goes on: the fun element of CHEST makes it a more immersive atmosphere. When the meeting was solely virtual last year, CHEST still aimed to provide fun and will continue to do the same this year. Challenge your colleagues and new friends to games at the CHEST Player Hub online to see which one of you rises to the top of the leaderboard.
The community
CHEST 2021 (and CHEST the organization) helps you make connections and provides opportunities for leadership involvement. CHEST committees are always looking for leaders at all stages of their careers. Attending satellite meetings, like the NetWork open forums that are occurring online before the meeting starts this year, will allow you to begin networking with those with similar interests to your own and hopefully will spark your interest in getting more involved in the future.
For many of us at CHEST, the NetWorks were a great place to start, and you can join one in the area that interests you most. Through my involvement in CHEST, I have become a part of the community, meeting so many other clinicians and educators in my field. I have made great friendships, which keep me coming back every year.
Moving forward
From the beginning, we have been planning CHEST 2021 so that if we needed to go entirely online, we could do so as seamlessly as possible. With the recent decision to cancel the in-person meeting and go fully online, plans are already underway to make CHEST 2021 just as successful as last year’s meeting.
We can give you our commitment that your CHEST 2021 experience will live up to being a world-class event that separates itself from other current online offerings. I will be in attendance and hope to see you online.
Start planning your days with the CHEST 2021 Schedule at A Glance at chestmeeting.chestnet.org.
Is this your first CHEST Annual Meeting? Co-Chair David Zielinski, MD, FCCP, shares some words of wisdom recounting his first experience at CHEST and what first-time attendees can expect from the annual meeting.
My very first CHEST meeting was 10 years ago at CHEST 2011 in Honolulu, Hawaii. I clearly remember my first session being a postgraduate course on Respiratory Management of Neuromuscular Disease and having the opportunity for hands-on teaching with devices and techniques.
Simulation was unique at medical conferences at that time and has continued to evolve at subsequent CHEST meetings.
Looking back, what really sticks out about this experience is what it started for me in terms of my career and learning. I was in a session with some of the biggest names in the field—people who I always looked up to as a relatively junior faculty. I was encouraged to get more involved at CHEST and with the committees. It put the bug in my ear.
A few years later, I started to get involved in the NetWorks. Eventually, I became a faculty member myself alongside these individuals at subsequent CHEST meetings. Meeting these chest medicine professionals also led to more collaborations with them outside of CHEST.
I never imagined this during my first meeting ten years ago. I have now been back to every meeting but one since that first one.
The CHEST Annual Meeting has always stood out for its focus on quality clinical teaching, being ahead of the curve on interactivity and adjusting to the audience’s learning needs.
For me personally, though, the three things that I have always enjoyed are as follows:
Simulation opportunities
One thing that sets apart CHEST 2021 from other conferences is the simulation sessions being offered online.
These sessions are an opportunity to practice your skills and techniques with some of the best educators anywhere in the world. I have always come out of these sessions impressed. I encourage you to try it at least once.
The fun
From the receptions, the meet-ups, pop-up events, CHEST Challenge, the games… the list goes on: the fun element of CHEST makes it a more immersive atmosphere. When the meeting was solely virtual last year, CHEST still aimed to provide fun and will continue to do the same this year. Challenge your colleagues and new friends to games at the CHEST Player Hub online to see which one of you rises to the top of the leaderboard.
The community
CHEST 2021 (and CHEST the organization) helps you make connections and provides opportunities for leadership involvement. CHEST committees are always looking for leaders at all stages of their careers. Attending satellite meetings, like the NetWork open forums that are occurring online before the meeting starts this year, will allow you to begin networking with those with similar interests to your own and hopefully will spark your interest in getting more involved in the future.
For many of us at CHEST, the NetWorks were a great place to start, and you can join one in the area that interests you most. Through my involvement in CHEST, I have become a part of the community, meeting so many other clinicians and educators in my field. I have made great friendships, which keep me coming back every year.
Moving forward
From the beginning, we have been planning CHEST 2021 so that if we needed to go entirely online, we could do so as seamlessly as possible. With the recent decision to cancel the in-person meeting and go fully online, plans are already underway to make CHEST 2021 just as successful as last year’s meeting.
We can give you our commitment that your CHEST 2021 experience will live up to being a world-class event that separates itself from other current online offerings. I will be in attendance and hope to see you online.
Start planning your days with the CHEST 2021 Schedule at A Glance at chestmeeting.chestnet.org.