About a year ago, I had the opportunity to don the honorary regalia of the American College of Chest Physicians as its 81st President. On that memorable day on the dais in San Antonio, I used the example of James Surowiecki’s book, “The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies, and Nations” to explain how we would use the collective wisdom of our members, our committee and NetWork members, and our talented association staff to build and shape CHEST over the coming year. For those of you not familiar with this concept, Surowiecki, a business columnist for New Yorker, outlines the concept that large groups of people are actually smarter than an elite few at solving the problems of an organization, fostering innovation, collectively coming to wise decisions, or even predicting the future. In channeling the lessons from the book, it has become obvious that listening to our members and partners, rather than trying to make all decisions from the top down, has been an effective method for coming to wise decisions about the strategy and operation of CHEST. Now that it’s already time to hand the responsibility of the organization as President over to my friend and colleague Dr. Stephanie Levine, I’ve reflected on actually how effectively we have listened and how smart the collective crowd has been in moving the success of CHEST forward.

We heard from members that it was difficult to know how to get involved and what happens at the highest leadership levels of the organization. This prompted the development of podcasts dubbed “The Inside Scoop,” recorded live approximately every 2 months and featured various leaders of the organization with an informal way for members to better understand how to become involved in CHEST activities and to feel the pulse of activity of the association between the time the annual meeting ends and the next one begins.

The crowd informed us that communication at the Board of Regents level could be better. To address this, regular communications were sent out to the Board of Regents to update them on activities and discussion of issues between scheduled board meetings, as well as providing board members the opportunity to have access to the minutes of phone calls of the “5Ps,” calls that included the Immediate Past, President-Elect, President-Designate, and current President of the association, as well as the CHEST Foundation President.

We were told by members through focus groups and surveys, then again told by experts we invited to the June board meetings from education, business, design, and venture capital sectors (and who were naïve to CHEST as an association) that we needed to double down on virtual educational offerings to learners across the health-care delivery team and to revamp its information technology infrastructure. To that end, a digital strategy work group was convened with expertise in information technology, social media, and marketing to inventory all digital assets of the College and make recommendations for not just improvement, but for a complete transformation of digital technology created and promulgated by CHEST. The board then approved a budget of nearly $1 million to upgrade and rebuild the user experience within CHEST’s digital environment, including its learning management system. We also opened a multimedia studio at CHEST headquarters, increased the numbers of serious educational gaming opportunities at the annual meeting, and are developing a line of serious game platforms that will allow for “edutainment” opportunities for our members and other learners around the world using various digital platforms.

Colleagues from around the world reminded us that 20% of CHEST membership was international and that our strategic plan included an international strategy. Thanks to the support of our colleagues around the world, we were able to enjoy a tremendously successful CHEST Congress in Bangkok, Thailand, in April, and a smaller regional meeting in June in Athens, Greece. Efforts of the Governance Committee have reshaped the structure of international representation, making it more relevant and allowing its members to have a stronger voice to the Board of Regents. Plans are underway for the next CHEST Congress in June 2020 in Bologna, Italy, to be held in collaboration with the Italian Chapter of CHEST in that country.

In an era when the majority of association annual meetings across multiple specialties are driving toward parity with similar looks, marketing, formats, and expectations, we listened to the needs and desires of attendees of last year’s meeting and have improved CHEST 2019 in New Orleans even more. With the most simulation courses ever delivered at an annual meeting, more serious game opportunities, CHEST Challenge finals, a new innovation competition called “FISH Bowl,” and even a medical escape room, CHEST volunteer leaders and organization staff have worked hard to provide a world class meeting that has a different look and feel from all the others. Plus, the crowd also told us that having CME and MOC credit available for the entire meeting was another variable that was desired, and has now been achieved.

The wisdom of the proverbial crowd of membership has spoken in terms of the need for philanthropic efforts in our specialty. The CHEST Foundation has responded by awarding tens of thousands of dollars to our members to recognize cutting-edge research, community service efforts, and, in addition, has allowed dozens of providers early on in training or in their career to attend the annual meeting with the help of travel grants.

CHEST guidelines continue to be updated and new ones created based on input from expert panel teams. The CHEST journal submission process, review turnaround times, and quality of manuscripts have improved each year thanks to useful feedback from authors and readers. Publications such as CHEST Physician are modified each year based upon feedback from our readers. Critiques from the board review courses have been the driving force keeping live learning formats and the electronic SEEK board preparation questions current and accurate when the science is constantly changing.

Truly, the collective wisdom of our members, talented clinicians and researchers, and colleagues in industry has provided incredibly valuable input to the CHEST leadership team. You have spoken, and we have been listening. Thanks to each of you who have reached out to me during this year as President. Traveling to four continents this past year to better understand the needs of members who are clinicians, educators, researchers, and caregivers positioned in each geographic region has been enlightening, educational, and transformative for me and my family. Your meaningful feedback, keen insights, and passion for outstanding patient care, impactful educational experiences, and life-changing research have helped push CHEST to a higher level of excellence and to offer unparalleled experiences for our members to ultimately provide the very best care to patients.

About a year ago, I had the opportunity to don the honorary regalia of the American College of Chest Physicians as its 81st President. On that memorable day on the dais in San Antonio, I used the example of James Surowiecki’s book, “The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies, and Nations” to explain how we would use the collective wisdom of our members, our committee and NetWork members, and our talented association staff to build and shape CHEST over the coming year. For those of you not familiar with this concept, Surowiecki, a business columnist for New Yorker, outlines the concept that large groups of people are actually smarter than an elite few at solving the problems of an organization, fostering innovation, collectively coming to wise decisions, or even predicting the future. In channeling the lessons from the book, it has become obvious that listening to our members and partners, rather than trying to make all decisions from the top down, has been an effective method for coming to wise decisions about the strategy and operation of CHEST. Now that it’s already time to hand the responsibility of the organization as President over to my friend and colleague Dr. Stephanie Levine, I’ve reflected on actually how effectively we have listened and how smart the collective crowd has been in moving the success of CHEST forward.

We heard from members that it was difficult to know how to get involved and what happens at the highest leadership levels of the organization. This prompted the development of podcasts dubbed “The Inside Scoop,” recorded live approximately every 2 months and featured various leaders of the organization with an informal way for members to better understand how to become involved in CHEST activities and to feel the pulse of activity of the association between the time the annual meeting ends and the next one begins.

The crowd informed us that communication at the Board of Regents level could be better. To address this, regular communications were sent out to the Board of Regents to update them on activities and discussion of issues between scheduled board meetings, as well as providing board members the opportunity to have access to the minutes of phone calls of the “5Ps,” calls that included the Immediate Past, President-Elect, President-Designate, and current President of the association, as well as the CHEST Foundation President.

We were told by members through focus groups and surveys, then again told by experts we invited to the June board meetings from education, business, design, and venture capital sectors (and who were naïve to CHEST as an association) that we needed to double down on virtual educational offerings to learners across the health-care delivery team and to revamp its information technology infrastructure. To that end, a digital strategy work group was convened with expertise in information technology, social media, and marketing to inventory all digital assets of the College and make recommendations for not just improvement, but for a complete transformation of digital technology created and promulgated by CHEST. The board then approved a budget of nearly $1 million to upgrade and rebuild the user experience within CHEST’s digital environment, including its learning management system. We also opened a multimedia studio at CHEST headquarters, increased the numbers of serious educational gaming opportunities at the annual meeting, and are developing a line of serious game platforms that will allow for “edutainment” opportunities for our members and other learners around the world using various digital platforms.

Colleagues from around the world reminded us that 20% of CHEST membership was international and that our strategic plan included an international strategy. Thanks to the support of our colleagues around the world, we were able to enjoy a tremendously successful CHEST Congress in Bangkok, Thailand, in April, and a smaller regional meeting in June in Athens, Greece. Efforts of the Governance Committee have reshaped the structure of international representation, making it more relevant and allowing its members to have a stronger voice to the Board of Regents. Plans are underway for the next CHEST Congress in June 2020 in Bologna, Italy, to be held in collaboration with the Italian Chapter of CHEST in that country.

In an era when the majority of association annual meetings across multiple specialties are driving toward parity with similar looks, marketing, formats, and expectations, we listened to the needs and desires of attendees of last year’s meeting and have improved CHEST 2019 in New Orleans even more. With the most simulation courses ever delivered at an annual meeting, more serious game opportunities, CHEST Challenge finals, a new innovation competition called “FISH Bowl,” and even a medical escape room, CHEST volunteer leaders and organization staff have worked hard to provide a world class meeting that has a different look and feel from all the others. Plus, the crowd also told us that having CME and MOC credit available for the entire meeting was another variable that was desired, and has now been achieved.

The wisdom of the proverbial crowd of membership has spoken in terms of the need for philanthropic efforts in our specialty. The CHEST Foundation has responded by awarding tens of thousands of dollars to our members to recognize cutting-edge research, community service efforts, and, in addition, has allowed dozens of providers early on in training or in their career to attend the annual meeting with the help of travel grants.

CHEST guidelines continue to be updated and new ones created based on input from expert panel teams. The CHEST journal submission process, review turnaround times, and quality of manuscripts have improved each year thanks to useful feedback from authors and readers. Publications such as CHEST Physician are modified each year based upon feedback from our readers. Critiques from the board review courses have been the driving force keeping live learning formats and the electronic SEEK board preparation questions current and accurate when the science is constantly changing.

Truly, the collective wisdom of our members, talented clinicians and researchers, and colleagues in industry has provided incredibly valuable input to the CHEST leadership team. You have spoken, and we have been listening. Thanks to each of you who have reached out to me during this year as President. Traveling to four continents this past year to better understand the needs of members who are clinicians, educators, researchers, and caregivers positioned in each geographic region has been enlightening, educational, and transformative for me and my family. Your meaningful feedback, keen insights, and passion for outstanding patient care, impactful educational experiences, and life-changing research have helped push CHEST to a higher level of excellence and to offer unparalleled experiences for our members to ultimately provide the very best care to patients.

About a year ago, I had the opportunity to don the honorary regalia of the American College of Chest Physicians as its 81st President. On that memorable day on the dais in San Antonio, I used the example of James Surowiecki’s book, “The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies, and Nations” to explain how we would use the collective wisdom of our members, our committee and NetWork members, and our talented association staff to build and shape CHEST over the coming year. For those of you not familiar with this concept, Surowiecki, a business columnist for New Yorker, outlines the concept that large groups of people are actually smarter than an elite few at solving the problems of an organization, fostering innovation, collectively coming to wise decisions, or even predicting the future. In channeling the lessons from the book, it has become obvious that listening to our members and partners, rather than trying to make all decisions from the top down, has been an effective method for coming to wise decisions about the strategy and operation of CHEST. Now that it’s already time to hand the responsibility of the organization as President over to my friend and colleague Dr. Stephanie Levine, I’ve reflected on actually how effectively we have listened and how smart the collective crowd has been in moving the success of CHEST forward.

We heard from members that it was difficult to know how to get involved and what happens at the highest leadership levels of the organization. This prompted the development of podcasts dubbed “The Inside Scoop,” recorded live approximately every 2 months and featured various leaders of the organization with an informal way for members to better understand how to become involved in CHEST activities and to feel the pulse of activity of the association between the time the annual meeting ends and the next one begins.

The crowd informed us that communication at the Board of Regents level could be better. To address this, regular communications were sent out to the Board of Regents to update them on activities and discussion of issues between scheduled board meetings, as well as providing board members the opportunity to have access to the minutes of phone calls of the “5Ps,” calls that included the Immediate Past, President-Elect, President-Designate, and current President of the association, as well as the CHEST Foundation President.

We were told by members through focus groups and surveys, then again told by experts we invited to the June board meetings from education, business, design, and venture capital sectors (and who were naïve to CHEST as an association) that we needed to double down on virtual educational offerings to learners across the health-care delivery team and to revamp its information technology infrastructure. To that end, a digital strategy work group was convened with expertise in information technology, social media, and marketing to inventory all digital assets of the College and make recommendations for not just improvement, but for a complete transformation of digital technology created and promulgated by CHEST. The board then approved a budget of nearly $1 million to upgrade and rebuild the user experience within CHEST’s digital environment, including its learning management system. We also opened a multimedia studio at CHEST headquarters, increased the numbers of serious educational gaming opportunities at the annual meeting, and are developing a line of serious game platforms that will allow for “edutainment” opportunities for our members and other learners around the world using various digital platforms.

Colleagues from around the world reminded us that 20% of CHEST membership was international and that our strategic plan included an international strategy. Thanks to the support of our colleagues around the world, we were able to enjoy a tremendously successful CHEST Congress in Bangkok, Thailand, in April, and a smaller regional meeting in June in Athens, Greece. Efforts of the Governance Committee have reshaped the structure of international representation, making it more relevant and allowing its members to have a stronger voice to the Board of Regents. Plans are underway for the next CHEST Congress in June 2020 in Bologna, Italy, to be held in collaboration with the Italian Chapter of CHEST in that country.

In an era when the majority of association annual meetings across multiple specialties are driving toward parity with similar looks, marketing, formats, and expectations, we listened to the needs and desires of attendees of last year’s meeting and have improved CHEST 2019 in New Orleans even more. With the most simulation courses ever delivered at an annual meeting, more serious game opportunities, CHEST Challenge finals, a new innovation competition called “FISH Bowl,” and even a medical escape room, CHEST volunteer leaders and organization staff have worked hard to provide a world class meeting that has a different look and feel from all the others. Plus, the crowd also told us that having CME and MOC credit available for the entire meeting was another variable that was desired, and has now been achieved.

The wisdom of the proverbial crowd of membership has spoken in terms of the need for philanthropic efforts in our specialty. The CHEST Foundation has responded by awarding tens of thousands of dollars to our members to recognize cutting-edge research, community service efforts, and, in addition, has allowed dozens of providers early on in training or in their career to attend the annual meeting with the help of travel grants.

CHEST guidelines continue to be updated and new ones created based on input from expert panel teams. The CHEST journal submission process, review turnaround times, and quality of manuscripts have improved each year thanks to useful feedback from authors and readers. Publications such as CHEST Physician are modified each year based upon feedback from our readers. Critiques from the board review courses have been the driving force keeping live learning formats and the electronic SEEK board preparation questions current and accurate when the science is constantly changing.

Truly, the collective wisdom of our members, talented clinicians and researchers, and colleagues in industry has provided incredibly valuable input to the CHEST leadership team. You have spoken, and we have been listening. Thanks to each of you who have reached out to me during this year as President. Traveling to four continents this past year to better understand the needs of members who are clinicians, educators, researchers, and caregivers positioned in each geographic region has been enlightening, educational, and transformative for me and my family. Your meaningful feedback, keen insights, and passion for outstanding patient care, impactful educational experiences, and life-changing research have helped push CHEST to a higher level of excellence and to offer unparalleled experiences for our members to ultimately provide the very best care to patients.

The role of imaging for interstitial lung disease (ILD) is of paramount importance. With the growth of high resolution chest computed tomography (HRCT) imaging techniques, we are able to visualize nuances between individual ILDs more critically. HRCT is an essential component of an initial ILD evaluation and also has become part of the armamentarium of tools used for routine management of these patients. The technology of HRCT scans has evolved over the years, most recently with the advent of quantitative HRCT (qCT). The technology employs texture-based classification, which identifies and quantifies different radiographic findings. The arrival of qCT scanning has been slowly emerging as a new player in the ILD world. What exactly is qCT, and what role can, and will it serve for our ILD patients?

Quantitative CT scanning has been introduced since the 1980s, but only within the last 15 years has its use for ILD taken form. Human interpretation of CTs is fraught with subjectivity, based on the interpreting radiologist’s training, experience, and individual visual perception of images. This can result in significant variability in radiographic interpretations and, ultimately, affects a patient’s diagnosis, disease monitoring, treatment, and prognosis. Semiquantitative visual scoring by radiologists is highly variable, especially in areas with limited availability of chest radiologists. qCT employs an automated histogram signature technique that utilizes density and texture-based analysis of the lung parenchyma. Utilizing machine learning from pathologically confirmed datasets, computer programs were trained with specialized thoracic radiologists to distinguish some commonly found radiographic abnormalities into four major groups: ground glass, reticular, honeycombing, and emphysema. In addition, these categories are quantified and spatially depicted on an analysis (Bartholmai, et al. J Thorac Imaging. 2013;28[5]:298). Various computer programs have been built to streamline the process and expedite the interpretation of an individual’s HRCT scan. The more commonly familiar program, CALIPER (Computer-Aided Lung Informatics for Pathology Evaluation and Ratings), has been used in multiple research studies of qCT in ILD and IPF. Each patient’s CT scan is uploaded to the program, and a breakdown of the patient’s lungs into each category is presented. Not only is each abnormality quantified and precisely defined, it is also color-coded by segments to help with visual interpretation by the physician.

The benefit of qCT lies not only in the automated, objective evaluation of interstitial lung disease, but also in its possible use in prognostication and mortality prediction. Neither use has been fully validated as of yet. However, growing evidence shows a promising role in both realms. Thus far, there have been some studies correlating PFT data with qCT findings. A follow-up study of the Scleroderma Lung Study II examined qCT changes over 24 months and correlated those findings with PFTs and patient-reported outcomes. Patients in this study were either treated with cyclophosphamide (CYC) for 1 year/placebo 1 year vs mycophenolate mofetil (MMF) for 2 years. A large portion of patients receiving CYC or MMF had a significant correlation between improved or stable qCT scores and their FVC and TLC. Neither CYC nor MMF was superior in qCT scores, aligning with the findings of the study, which showed noninferiority of MMF compared with CYC (Goldin, et al. Ann Am Thorac Soc. 2018 Nov;15[11]:1286). Interestingly, the improvement of ground glass is often viewed by physicians as positive, since this finding is typically thought of as active inflammation. However, if qCT determines that the fibrosis score actually increases over time, despite an improvement in ground glass, this may more accurately reflect the development of subtle fibrosis that is not easily appreciated by the human eye (Goldin, et al. Ann Am Thorac Soc. 2018 Nov;15[11]:1286). In this context, it is feasible that parenchymal changes occur prior to deterioration on PFTs. Diffusing capacity for carbon monoxide (DLCO) correlates largely with the extent of lung involvement on qCT, but DLCO is not a specific biomarker in predicting severity of ILD (ie, because pHTN or anemia can confound DLCO). Forced vital capacity (FVC) in certain diseases may also confound CT correlation (ie, muscle weakness or extrathoracic restriction from skin disease in systemic sclerosis). The usefulness of PFT data as a clinical endpoint in research studies may be replaced by qCTs more consistent and precise detection of disease modification.

IPF has been an interesting area of exploration for the role of qCT in disease monitoring and possible prognostication. It is known that the presence of honeycombing on HRCT is associated with increased mortality. Patients with a progressive fibrotic ILD have similar mortality rates to those with IPF (Adegunsoye, et al. Ann Am Thorac Soc. 2019 May;16[5]:580). The ability to correlate radiographic findings with mortality could potentially become an important marker of clinical deterioration, especially in those patients who are unable to perform PFTs. In addition, it can also be beneficial in those with co-existent emphysema, since PFTs may be confounded by this overlap. Nakagawa and colleagues proposed a computer-aided method for qCT analysis of honeycombing in patients with IPF. The algorithm for the qCT analysis also has specific parameters to exclude emphysematous lesions on imaging. The %honeycomb area (HA) was correlated with a composite physiologic index derived from PFTs (calculated from FEV1, FVC and DLCO). This tool can accurately quantify the percentage of honeycombing and aid in monitoring IPF. Using this protocol, Nakagawa was able to demonstrate a significant correlation with 3-year mortality, with a marked difference found when using a cutoff value of 4.8% (Nakagawa, et al. Plos One. 2019 Mar; 14[3]:e0214278). Furthermore, patient survival in IPF has been compared against the CALIPER program and PFTs. Mortality for patients was significantly associated with pulmonary vessel volume (PVV), an innovative tool that quantified the volume of the pulmonary artery and veins, which may become a new parameter used for disease monitoring. Using qCT in addition to PFTs provides more tangible evidence to help monitor patients with IPF, guide treatment decisions, and plan for transplant or palliative care. The growing use of PVV in qCT has yet to be fully elucidated, but it does have a promising role (Jacob, et al. Eur Respir J. 2017;49[1]. doi: 10.1183/13993003.01011-2016).

Despite the positive outlook for qCT, there are major issues that limit its widespread use. During the image acquisition process, there is a lack of consistency and quality control, stemming from multiple different manufacturers of CT scan machines, reconstitution methods, radiation doses, and noise or inspiratory efforts of patients. The Radiologic Society of North America (RSNA) is attempting to fix this issue by creating a standardized protocol for collecting images used for qCT (Castillo-Saldana, et al. J Thorac Imaging. 2019 Aug 7. doi: 10.1097/RTI.0000000000000440). In order to move forward with adaptation of qCT, a standardized approach and handling of images needs to be created.

Quantitative CT is an exciting new prospect for the care of patients with ILD. As these patients, and their management, becomes more complex, expanding the toolbox for physicians is much needed. It will be fascinating to see how the role of qCT takes shape over the coming years.
 

Dr. D’Annunzio is with Westmed Medical Group, Rye, N.Y.; Dr. Nayar is a Pulmonary/Critical Care Fellow at NYU School of Medicine; and Dr. Patel is with Columbia University Medical Center.

The role of imaging for interstitial lung disease (ILD) is of paramount importance. With the growth of high resolution chest computed tomography (HRCT) imaging techniques, we are able to visualize nuances between individual ILDs more critically. HRCT is an essential component of an initial ILD evaluation and also has become part of the armamentarium of tools used for routine management of these patients. The technology of HRCT scans has evolved over the years, most recently with the advent of quantitative HRCT (qCT). The technology employs texture-based classification, which identifies and quantifies different radiographic findings. The arrival of qCT scanning has been slowly emerging as a new player in the ILD world. What exactly is qCT, and what role can, and will it serve for our ILD patients?

Quantitative CT scanning has been introduced since the 1980s, but only within the last 15 years has its use for ILD taken form. Human interpretation of CTs is fraught with subjectivity, based on the interpreting radiologist’s training, experience, and individual visual perception of images. This can result in significant variability in radiographic interpretations and, ultimately, affects a patient’s diagnosis, disease monitoring, treatment, and prognosis. Semiquantitative visual scoring by radiologists is highly variable, especially in areas with limited availability of chest radiologists. qCT employs an automated histogram signature technique that utilizes density and texture-based analysis of the lung parenchyma. Utilizing machine learning from pathologically confirmed datasets, computer programs were trained with specialized thoracic radiologists to distinguish some commonly found radiographic abnormalities into four major groups: ground glass, reticular, honeycombing, and emphysema. In addition, these categories are quantified and spatially depicted on an analysis (Bartholmai, et al. J Thorac Imaging. 2013;28[5]:298). Various computer programs have been built to streamline the process and expedite the interpretation of an individual’s HRCT scan. The more commonly familiar program, CALIPER (Computer-Aided Lung Informatics for Pathology Evaluation and Ratings), has been used in multiple research studies of qCT in ILD and IPF. Each patient’s CT scan is uploaded to the program, and a breakdown of the patient’s lungs into each category is presented. Not only is each abnormality quantified and precisely defined, it is also color-coded by segments to help with visual interpretation by the physician.

The benefit of qCT lies not only in the automated, objective evaluation of interstitial lung disease, but also in its possible use in prognostication and mortality prediction. Neither use has been fully validated as of yet. However, growing evidence shows a promising role in both realms. Thus far, there have been some studies correlating PFT data with qCT findings. A follow-up study of the Scleroderma Lung Study II examined qCT changes over 24 months and correlated those findings with PFTs and patient-reported outcomes. Patients in this study were either treated with cyclophosphamide (CYC) for 1 year/placebo 1 year vs mycophenolate mofetil (MMF) for 2 years. A large portion of patients receiving CYC or MMF had a significant correlation between improved or stable qCT scores and their FVC and TLC. Neither CYC nor MMF was superior in qCT scores, aligning with the findings of the study, which showed noninferiority of MMF compared with CYC (Goldin, et al. Ann Am Thorac Soc. 2018 Nov;15[11]:1286). Interestingly, the improvement of ground glass is often viewed by physicians as positive, since this finding is typically thought of as active inflammation. However, if qCT determines that the fibrosis score actually increases over time, despite an improvement in ground glass, this may more accurately reflect the development of subtle fibrosis that is not easily appreciated by the human eye (Goldin, et al. Ann Am Thorac Soc. 2018 Nov;15[11]:1286). In this context, it is feasible that parenchymal changes occur prior to deterioration on PFTs. Diffusing capacity for carbon monoxide (DLCO) correlates largely with the extent of lung involvement on qCT, but DLCO is not a specific biomarker in predicting severity of ILD (ie, because pHTN or anemia can confound DLCO). Forced vital capacity (FVC) in certain diseases may also confound CT correlation (ie, muscle weakness or extrathoracic restriction from skin disease in systemic sclerosis). The usefulness of PFT data as a clinical endpoint in research studies may be replaced by qCTs more consistent and precise detection of disease modification.

IPF has been an interesting area of exploration for the role of qCT in disease monitoring and possible prognostication. It is known that the presence of honeycombing on HRCT is associated with increased mortality. Patients with a progressive fibrotic ILD have similar mortality rates to those with IPF (Adegunsoye, et al. Ann Am Thorac Soc. 2019 May;16[5]:580). The ability to correlate radiographic findings with mortality could potentially become an important marker of clinical deterioration, especially in those patients who are unable to perform PFTs. In addition, it can also be beneficial in those with co-existent emphysema, since PFTs may be confounded by this overlap. Nakagawa and colleagues proposed a computer-aided method for qCT analysis of honeycombing in patients with IPF. The algorithm for the qCT analysis also has specific parameters to exclude emphysematous lesions on imaging. The %honeycomb area (HA) was correlated with a composite physiologic index derived from PFTs (calculated from FEV1, FVC and DLCO). This tool can accurately quantify the percentage of honeycombing and aid in monitoring IPF. Using this protocol, Nakagawa was able to demonstrate a significant correlation with 3-year mortality, with a marked difference found when using a cutoff value of 4.8% (Nakagawa, et al. Plos One. 2019 Mar; 14[3]:e0214278). Furthermore, patient survival in IPF has been compared against the CALIPER program and PFTs. Mortality for patients was significantly associated with pulmonary vessel volume (PVV), an innovative tool that quantified the volume of the pulmonary artery and veins, which may become a new parameter used for disease monitoring. Using qCT in addition to PFTs provides more tangible evidence to help monitor patients with IPF, guide treatment decisions, and plan for transplant or palliative care. The growing use of PVV in qCT has yet to be fully elucidated, but it does have a promising role (Jacob, et al. Eur Respir J. 2017;49[1]. doi: 10.1183/13993003.01011-2016).

Despite the positive outlook for qCT, there are major issues that limit its widespread use. During the image acquisition process, there is a lack of consistency and quality control, stemming from multiple different manufacturers of CT scan machines, reconstitution methods, radiation doses, and noise or inspiratory efforts of patients. The Radiologic Society of North America (RSNA) is attempting to fix this issue by creating a standardized protocol for collecting images used for qCT (Castillo-Saldana, et al. J Thorac Imaging. 2019 Aug 7. doi: 10.1097/RTI.0000000000000440). In order to move forward with adaptation of qCT, a standardized approach and handling of images needs to be created.

Quantitative CT is an exciting new prospect for the care of patients with ILD. As these patients, and their management, becomes more complex, expanding the toolbox for physicians is much needed. It will be fascinating to see how the role of qCT takes shape over the coming years.
 

Dr. D’Annunzio is with Westmed Medical Group, Rye, N.Y.; Dr. Nayar is a Pulmonary/Critical Care Fellow at NYU School of Medicine; and Dr. Patel is with Columbia University Medical Center.

The role of imaging for interstitial lung disease (ILD) is of paramount importance. With the growth of high resolution chest computed tomography (HRCT) imaging techniques, we are able to visualize nuances between individual ILDs more critically. HRCT is an essential component of an initial ILD evaluation and also has become part of the armamentarium of tools used for routine management of these patients. The technology of HRCT scans has evolved over the years, most recently with the advent of quantitative HRCT (qCT). The technology employs texture-based classification, which identifies and quantifies different radiographic findings. The arrival of qCT scanning has been slowly emerging as a new player in the ILD world. What exactly is qCT, and what role can, and will it serve for our ILD patients?

Quantitative CT scanning has been introduced since the 1980s, but only within the last 15 years has its use for ILD taken form. Human interpretation of CTs is fraught with subjectivity, based on the interpreting radiologist’s training, experience, and individual visual perception of images. This can result in significant variability in radiographic interpretations and, ultimately, affects a patient’s diagnosis, disease monitoring, treatment, and prognosis. Semiquantitative visual scoring by radiologists is highly variable, especially in areas with limited availability of chest radiologists. qCT employs an automated histogram signature technique that utilizes density and texture-based analysis of the lung parenchyma. Utilizing machine learning from pathologically confirmed datasets, computer programs were trained with specialized thoracic radiologists to distinguish some commonly found radiographic abnormalities into four major groups: ground glass, reticular, honeycombing, and emphysema. In addition, these categories are quantified and spatially depicted on an analysis (Bartholmai, et al. J Thorac Imaging. 2013;28[5]:298). Various computer programs have been built to streamline the process and expedite the interpretation of an individual’s HRCT scan. The more commonly familiar program, CALIPER (Computer-Aided Lung Informatics for Pathology Evaluation and Ratings), has been used in multiple research studies of qCT in ILD and IPF. Each patient’s CT scan is uploaded to the program, and a breakdown of the patient’s lungs into each category is presented. Not only is each abnormality quantified and precisely defined, it is also color-coded by segments to help with visual interpretation by the physician.

The benefit of qCT lies not only in the automated, objective evaluation of interstitial lung disease, but also in its possible use in prognostication and mortality prediction. Neither use has been fully validated as of yet. However, growing evidence shows a promising role in both realms. Thus far, there have been some studies correlating PFT data with qCT findings. A follow-up study of the Scleroderma Lung Study II examined qCT changes over 24 months and correlated those findings with PFTs and patient-reported outcomes. Patients in this study were either treated with cyclophosphamide (CYC) for 1 year/placebo 1 year vs mycophenolate mofetil (MMF) for 2 years. A large portion of patients receiving CYC or MMF had a significant correlation between improved or stable qCT scores and their FVC and TLC. Neither CYC nor MMF was superior in qCT scores, aligning with the findings of the study, which showed noninferiority of MMF compared with CYC (Goldin, et al. Ann Am Thorac Soc. 2018 Nov;15[11]:1286). Interestingly, the improvement of ground glass is often viewed by physicians as positive, since this finding is typically thought of as active inflammation. However, if qCT determines that the fibrosis score actually increases over time, despite an improvement in ground glass, this may more accurately reflect the development of subtle fibrosis that is not easily appreciated by the human eye (Goldin, et al. Ann Am Thorac Soc. 2018 Nov;15[11]:1286). In this context, it is feasible that parenchymal changes occur prior to deterioration on PFTs. Diffusing capacity for carbon monoxide (DLCO) correlates largely with the extent of lung involvement on qCT, but DLCO is not a specific biomarker in predicting severity of ILD (ie, because pHTN or anemia can confound DLCO). Forced vital capacity (FVC) in certain diseases may also confound CT correlation (ie, muscle weakness or extrathoracic restriction from skin disease in systemic sclerosis). The usefulness of PFT data as a clinical endpoint in research studies may be replaced by qCTs more consistent and precise detection of disease modification.

IPF has been an interesting area of exploration for the role of qCT in disease monitoring and possible prognostication. It is known that the presence of honeycombing on HRCT is associated with increased mortality. Patients with a progressive fibrotic ILD have similar mortality rates to those with IPF (Adegunsoye, et al. Ann Am Thorac Soc. 2019 May;16[5]:580). The ability to correlate radiographic findings with mortality could potentially become an important marker of clinical deterioration, especially in those patients who are unable to perform PFTs. In addition, it can also be beneficial in those with co-existent emphysema, since PFTs may be confounded by this overlap. Nakagawa and colleagues proposed a computer-aided method for qCT analysis of honeycombing in patients with IPF. The algorithm for the qCT analysis also has specific parameters to exclude emphysematous lesions on imaging. The %honeycomb area (HA) was correlated with a composite physiologic index derived from PFTs (calculated from FEV1, FVC and DLCO). This tool can accurately quantify the percentage of honeycombing and aid in monitoring IPF. Using this protocol, Nakagawa was able to demonstrate a significant correlation with 3-year mortality, with a marked difference found when using a cutoff value of 4.8% (Nakagawa, et al. Plos One. 2019 Mar; 14[3]:e0214278). Furthermore, patient survival in IPF has been compared against the CALIPER program and PFTs. Mortality for patients was significantly associated with pulmonary vessel volume (PVV), an innovative tool that quantified the volume of the pulmonary artery and veins, which may become a new parameter used for disease monitoring. Using qCT in addition to PFTs provides more tangible evidence to help monitor patients with IPF, guide treatment decisions, and plan for transplant or palliative care. The growing use of PVV in qCT has yet to be fully elucidated, but it does have a promising role (Jacob, et al. Eur Respir J. 2017;49[1]. doi: 10.1183/13993003.01011-2016).

Despite the positive outlook for qCT, there are major issues that limit its widespread use. During the image acquisition process, there is a lack of consistency and quality control, stemming from multiple different manufacturers of CT scan machines, reconstitution methods, radiation doses, and noise or inspiratory efforts of patients. The Radiologic Society of North America (RSNA) is attempting to fix this issue by creating a standardized protocol for collecting images used for qCT (Castillo-Saldana, et al. J Thorac Imaging. 2019 Aug 7. doi: 10.1097/RTI.0000000000000440). In order to move forward with adaptation of qCT, a standardized approach and handling of images needs to be created.

Quantitative CT is an exciting new prospect for the care of patients with ILD. As these patients, and their management, becomes more complex, expanding the toolbox for physicians is much needed. It will be fascinating to see how the role of qCT takes shape over the coming years.
 

Dr. D’Annunzio is with Westmed Medical Group, Rye, N.Y.; Dr. Nayar is a Pulmonary/Critical Care Fellow at NYU School of Medicine; and Dr. Patel is with Columbia University Medical Center.

Application of basic physiology principles at bedside has changed the approach to the treatment of patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia. Current standard of care for patients with ARDS includes a low tidal volume ventilation strategy (6 mL/kg of ideal body weight), keeping plateau pressures below 30 cm H₂O (Brower RG, et al. N Engl J Med. 2000;342[18]:1301), driving pressures below 15 cm H₂O and adequate positive end-expiratory pressures (PEEP) to keep the alveoli open without overdistension (Villar J, et al. Crit Care Med. 2006;34[5]:1311). However, at this time, despite the awareness of the importance of this intervention, there is no consensus regarding the best method to determine ideal PEEP at the individual patient level.

A thorough understanding of the basic physiologic concepts regarding respiratory pressures is of paramount importance to be able to formulate an opinion. The transpulmonary pressure (or lung distending pressure) is the gradient caused by the difference between alveolar (PA) and pleural pressure (PPL). In order to prevent lung collapse at end-expiration, PA must remain higher than PPL such that the gradient remains outward, preventing end-expiratory collapse and atelectotrauma. To accomplish that, it is necessary to know the end-expiratory PA and PPL. Esophageal balloon pressures (PES) represent central thoracic pressures, but, despite positional and regional variations, they are a good surrogate for average “effective” PPL (Baedorf KE, et al. Med Klin Intensivmed Notfmed. 2018;113[Suppl 1]:13).

Understanding that the value of the PES represents a practical PPL makes it easier to appreciate the potential usefulness of an esophageal balloon to titrate PEEP. The objective of PEEP titration is to prevent de-recruitment, maintain alveolar aeration, and improve the functional size of aerated alveoli. If the applied PEEP is lower than the PPL, the dependent lung regions will collapse. On the other hand, if PEEP is higher than the PPL, the lung would be overdistended, causing barotrauma and hemodynamic compromise.

The question is: Should we use esophageal balloons?Yes, we should.

A single center randomized control trial (EPVent) compared PEEP titration to achieve a positive PL vs standard of care lung protective ventilation (Talmor D, et al. N Engl J Med. 2008;359:2095). The PEEP titration group used significantly higher levels of PEEP, with improved oxygenation and lung compliance. However, there was no significant difference in ventilator-free days or mortality between the groups.

Obese patients are also likely to benefit from PEEP titration guided by an esophageal balloon, as they often have higher levels of intrinsic PEEP. Therefore, the application of higher levels of PEEP to compensate for the higher levels of intrinsic PEEP may help reduce work of breathing and prevent tidal recruitment-de-recruitment and atelectasis. Additionally, low to negative transpulmonary pressures measured using the actual values of PES in obese patients and obese animal models predicted lung collapse and tidal opening and closing (Fumagalli J, et al. Crit Care Med. 2017;45[8]:1374). It is useful to remember that the compliance of the respiratory system (Crs) is the total of the sum of the compliance of the chest wall (Ccw) and the lung compliance (CL). In obese patients, Ccw has a much more significant contribution to the total Crs, and the clinician should be really interested in the CL. At the bedside, esophageal manometry can be very useful to distinguish the contribution of CL and Ccw to the total Crs.

No, we shouldn’t.

Another randomized controlled trial (EPVent-2), by the same group, compared PEEP titration guided by esophageal pressure with empirical PEEP titration, in patients with moderate to severe ARDS (Beitler JR, et al. JAMA. 2019;321[9]:846). The primary outcomes of interest, death, and mechanical ventilator-free days through day 28 were not different between the groups.

Additionally, placement of an esophageal balloon is challenging and operator-dependent. The balloon portion of the esophageal catheter should be positioned in the lower third of the esophagus, behind the heart. Catheter placement is typically performed by inserting it into the stomach to a depth of about 60 cm, and gently pressing on the abdomen and observing a sudden increase in pressure on the ventilator screen. It is then withdrawn to about 40 cm, while looking for cardiac oscillations and pressure change (Talmor D, et al. N Engl J Med. 2008;359:2095). One can see how easily it would be to insert the esophageal balloon incorrectly. A misplaced balloon won’t provide accurate PES and can potentially cause harm.

Final answer: It depends on each individual patient.

Arguments for and against using an esophageal balloon to titrate PEEP in patients with ARDS and refractory hypoxemia are ongoing. Even the two most cited and applied trials on the matter (EPVent and EPVent-2) reported contradictory results. However, when analyzed in depth, both showed better oxygenation with the use of esophageal balloon. EPVent had improvement in oxygenation as its primary endpoint, and it was significant in the esophageal balloon group. EPVent-2 had oxygenation goals, in the form of need for rescue therapies for refractory hypoxemia, as secondary endpoints. Nonetheless, the patients in the esophageal balloon group in EPVent-2 required prone positioning less frequently, had lower use of pulmonary vasodilators, and a lower rate of ECMO consultations. Even though those trials did not show a mortality benefit, both showed an oxygenation benefit.

The ideal single tool that would indicate the “perfect “PEEP for each patient remains to be described. Until then, PEEP titration guided by a combination of ARDSnet PEEP tables, while maintaining a plateau pressure below 30 cm H₂O and considering a driving pressure below 15 cm H₂O should be a clinician’s goal. In patients in the extremes of height and body weight, and/or with conditions that would increase intra-abdominal pressure, such as ascites, a well-placed esophageal balloon while patient is supine might be beneficial.

The truth of the matter is, PEEP should be titrated by a trained intensivist in conjunction with the multidisciplinary ICU team, at patients’ bedside taking into consideration each individual’s unique physiologic and pathophysiologic characteristics at that moment.

Dr. Gallo de Moraes is Assistant Professor of Medicine, and Dr Oeckler is Assistant Professor of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota.

Application of basic physiology principles at bedside has changed the approach to the treatment of patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia. Current standard of care for patients with ARDS includes a low tidal volume ventilation strategy (6 mL/kg of ideal body weight), keeping plateau pressures below 30 cm H₂O (Brower RG, et al. N Engl J Med. 2000;342[18]:1301), driving pressures below 15 cm H₂O and adequate positive end-expiratory pressures (PEEP) to keep the alveoli open without overdistension (Villar J, et al. Crit Care Med. 2006;34[5]:1311). However, at this time, despite the awareness of the importance of this intervention, there is no consensus regarding the best method to determine ideal PEEP at the individual patient level.

A thorough understanding of the basic physiologic concepts regarding respiratory pressures is of paramount importance to be able to formulate an opinion. The transpulmonary pressure (or lung distending pressure) is the gradient caused by the difference between alveolar (PA) and pleural pressure (PPL). In order to prevent lung collapse at end-expiration, PA must remain higher than PPL such that the gradient remains outward, preventing end-expiratory collapse and atelectotrauma. To accomplish that, it is necessary to know the end-expiratory PA and PPL. Esophageal balloon pressures (PES) represent central thoracic pressures, but, despite positional and regional variations, they are a good surrogate for average “effective” PPL (Baedorf KE, et al. Med Klin Intensivmed Notfmed. 2018;113[Suppl 1]:13).

Understanding that the value of the PES represents a practical PPL makes it easier to appreciate the potential usefulness of an esophageal balloon to titrate PEEP. The objective of PEEP titration is to prevent de-recruitment, maintain alveolar aeration, and improve the functional size of aerated alveoli. If the applied PEEP is lower than the PPL, the dependent lung regions will collapse. On the other hand, if PEEP is higher than the PPL, the lung would be overdistended, causing barotrauma and hemodynamic compromise.

The question is: Should we use esophageal balloons?Yes, we should.

A single center randomized control trial (EPVent) compared PEEP titration to achieve a positive PL vs standard of care lung protective ventilation (Talmor D, et al. N Engl J Med. 2008;359:2095). The PEEP titration group used significantly higher levels of PEEP, with improved oxygenation and lung compliance. However, there was no significant difference in ventilator-free days or mortality between the groups.

Obese patients are also likely to benefit from PEEP titration guided by an esophageal balloon, as they often have higher levels of intrinsic PEEP. Therefore, the application of higher levels of PEEP to compensate for the higher levels of intrinsic PEEP may help reduce work of breathing and prevent tidal recruitment-de-recruitment and atelectasis. Additionally, low to negative transpulmonary pressures measured using the actual values of PES in obese patients and obese animal models predicted lung collapse and tidal opening and closing (Fumagalli J, et al. Crit Care Med. 2017;45[8]:1374). It is useful to remember that the compliance of the respiratory system (Crs) is the total of the sum of the compliance of the chest wall (Ccw) and the lung compliance (CL). In obese patients, Ccw has a much more significant contribution to the total Crs, and the clinician should be really interested in the CL. At the bedside, esophageal manometry can be very useful to distinguish the contribution of CL and Ccw to the total Crs.

No, we shouldn’t.

Another randomized controlled trial (EPVent-2), by the same group, compared PEEP titration guided by esophageal pressure with empirical PEEP titration, in patients with moderate to severe ARDS (Beitler JR, et al. JAMA. 2019;321[9]:846). The primary outcomes of interest, death, and mechanical ventilator-free days through day 28 were not different between the groups.

Additionally, placement of an esophageal balloon is challenging and operator-dependent. The balloon portion of the esophageal catheter should be positioned in the lower third of the esophagus, behind the heart. Catheter placement is typically performed by inserting it into the stomach to a depth of about 60 cm, and gently pressing on the abdomen and observing a sudden increase in pressure on the ventilator screen. It is then withdrawn to about 40 cm, while looking for cardiac oscillations and pressure change (Talmor D, et al. N Engl J Med. 2008;359:2095). One can see how easily it would be to insert the esophageal balloon incorrectly. A misplaced balloon won’t provide accurate PES and can potentially cause harm.

Final answer: It depends on each individual patient.

Arguments for and against using an esophageal balloon to titrate PEEP in patients with ARDS and refractory hypoxemia are ongoing. Even the two most cited and applied trials on the matter (EPVent and EPVent-2) reported contradictory results. However, when analyzed in depth, both showed better oxygenation with the use of esophageal balloon. EPVent had improvement in oxygenation as its primary endpoint, and it was significant in the esophageal balloon group. EPVent-2 had oxygenation goals, in the form of need for rescue therapies for refractory hypoxemia, as secondary endpoints. Nonetheless, the patients in the esophageal balloon group in EPVent-2 required prone positioning less frequently, had lower use of pulmonary vasodilators, and a lower rate of ECMO consultations. Even though those trials did not show a mortality benefit, both showed an oxygenation benefit.

The ideal single tool that would indicate the “perfect “PEEP for each patient remains to be described. Until then, PEEP titration guided by a combination of ARDSnet PEEP tables, while maintaining a plateau pressure below 30 cm H₂O and considering a driving pressure below 15 cm H₂O should be a clinician’s goal. In patients in the extremes of height and body weight, and/or with conditions that would increase intra-abdominal pressure, such as ascites, a well-placed esophageal balloon while patient is supine might be beneficial.

The truth of the matter is, PEEP should be titrated by a trained intensivist in conjunction with the multidisciplinary ICU team, at patients’ bedside taking into consideration each individual’s unique physiologic and pathophysiologic characteristics at that moment.

Dr. Gallo de Moraes is Assistant Professor of Medicine, and Dr Oeckler is Assistant Professor of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota.

Application of basic physiology principles at bedside has changed the approach to the treatment of patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia. Current standard of care for patients with ARDS includes a low tidal volume ventilation strategy (6 mL/kg of ideal body weight), keeping plateau pressures below 30 cm H₂O (Brower RG, et al. N Engl J Med. 2000;342[18]:1301), driving pressures below 15 cm H₂O and adequate positive end-expiratory pressures (PEEP) to keep the alveoli open without overdistension (Villar J, et al. Crit Care Med. 2006;34[5]:1311). However, at this time, despite the awareness of the importance of this intervention, there is no consensus regarding the best method to determine ideal PEEP at the individual patient level.

A thorough understanding of the basic physiologic concepts regarding respiratory pressures is of paramount importance to be able to formulate an opinion. The transpulmonary pressure (or lung distending pressure) is the gradient caused by the difference between alveolar (PA) and pleural pressure (PPL). In order to prevent lung collapse at end-expiration, PA must remain higher than PPL such that the gradient remains outward, preventing end-expiratory collapse and atelectotrauma. To accomplish that, it is necessary to know the end-expiratory PA and PPL. Esophageal balloon pressures (PES) represent central thoracic pressures, but, despite positional and regional variations, they are a good surrogate for average “effective” PPL (Baedorf KE, et al. Med Klin Intensivmed Notfmed. 2018;113[Suppl 1]:13).

Understanding that the value of the PES represents a practical PPL makes it easier to appreciate the potential usefulness of an esophageal balloon to titrate PEEP. The objective of PEEP titration is to prevent de-recruitment, maintain alveolar aeration, and improve the functional size of aerated alveoli. If the applied PEEP is lower than the PPL, the dependent lung regions will collapse. On the other hand, if PEEP is higher than the PPL, the lung would be overdistended, causing barotrauma and hemodynamic compromise.

The question is: Should we use esophageal balloons?Yes, we should.

A single center randomized control trial (EPVent) compared PEEP titration to achieve a positive PL vs standard of care lung protective ventilation (Talmor D, et al. N Engl J Med. 2008;359:2095). The PEEP titration group used significantly higher levels of PEEP, with improved oxygenation and lung compliance. However, there was no significant difference in ventilator-free days or mortality between the groups.

Obese patients are also likely to benefit from PEEP titration guided by an esophageal balloon, as they often have higher levels of intrinsic PEEP. Therefore, the application of higher levels of PEEP to compensate for the higher levels of intrinsic PEEP may help reduce work of breathing and prevent tidal recruitment-de-recruitment and atelectasis. Additionally, low to negative transpulmonary pressures measured using the actual values of PES in obese patients and obese animal models predicted lung collapse and tidal opening and closing (Fumagalli J, et al. Crit Care Med. 2017;45[8]:1374). It is useful to remember that the compliance of the respiratory system (Crs) is the total of the sum of the compliance of the chest wall (Ccw) and the lung compliance (CL). In obese patients, Ccw has a much more significant contribution to the total Crs, and the clinician should be really interested in the CL. At the bedside, esophageal manometry can be very useful to distinguish the contribution of CL and Ccw to the total Crs.

No, we shouldn’t.

Another randomized controlled trial (EPVent-2), by the same group, compared PEEP titration guided by esophageal pressure with empirical PEEP titration, in patients with moderate to severe ARDS (Beitler JR, et al. JAMA. 2019;321[9]:846). The primary outcomes of interest, death, and mechanical ventilator-free days through day 28 were not different between the groups.

Additionally, placement of an esophageal balloon is challenging and operator-dependent. The balloon portion of the esophageal catheter should be positioned in the lower third of the esophagus, behind the heart. Catheter placement is typically performed by inserting it into the stomach to a depth of about 60 cm, and gently pressing on the abdomen and observing a sudden increase in pressure on the ventilator screen. It is then withdrawn to about 40 cm, while looking for cardiac oscillations and pressure change (Talmor D, et al. N Engl J Med. 2008;359:2095). One can see how easily it would be to insert the esophageal balloon incorrectly. A misplaced balloon won’t provide accurate PES and can potentially cause harm.

Final answer: It depends on each individual patient.

Arguments for and against using an esophageal balloon to titrate PEEP in patients with ARDS and refractory hypoxemia are ongoing. Even the two most cited and applied trials on the matter (EPVent and EPVent-2) reported contradictory results. However, when analyzed in depth, both showed better oxygenation with the use of esophageal balloon. EPVent had improvement in oxygenation as its primary endpoint, and it was significant in the esophageal balloon group. EPVent-2 had oxygenation goals, in the form of need for rescue therapies for refractory hypoxemia, as secondary endpoints. Nonetheless, the patients in the esophageal balloon group in EPVent-2 required prone positioning less frequently, had lower use of pulmonary vasodilators, and a lower rate of ECMO consultations. Even though those trials did not show a mortality benefit, both showed an oxygenation benefit.

The ideal single tool that would indicate the “perfect “PEEP for each patient remains to be described. Until then, PEEP titration guided by a combination of ARDSnet PEEP tables, while maintaining a plateau pressure below 30 cm H₂O and considering a driving pressure below 15 cm H₂O should be a clinician’s goal. In patients in the extremes of height and body weight, and/or with conditions that would increase intra-abdominal pressure, such as ascites, a well-placed esophageal balloon while patient is supine might be beneficial.

The truth of the matter is, PEEP should be titrated by a trained intensivist in conjunction with the multidisciplinary ICU team, at patients’ bedside taking into consideration each individual’s unique physiologic and pathophysiologic characteristics at that moment.

Dr. Gallo de Moraes is Assistant Professor of Medicine, and Dr Oeckler is Assistant Professor of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota.

Interventional Chest/Diagnostic Procedures

Emergence of robotic-assisted bronchoscopy for the diagnosis of peripheral lung lesions

The diagnostic chest medicine community saw exciting advances in technology for diagnosis of peripheral lung lesions (PLL) with the recent FDA approval of two robotic-assisted bronchoscopy systems (RBS): the Monarch Platform from Auris Health (2018) and the Ion system from Intuitive Surgical (2019). Small pilot studies of 15 (Monarch) and 29 (Ion) subjects, respectively, demonstrated safety and feasibility of biopsy and diagnosis of PLL using RBS (Rojas-Solano, et al. J Bronchol Intervent Pulmonol. 2018;25:168; Fielding et al. Respiration. 2019;98[2]:142). While these studies were not powered to evaluate diagnostic yield, they suggested the potential for improved yields over current technologies.

Current bronchoscopic modalities for diagnosis of PLL include electromagnetic navigation bronchoscopy, radial endobronchial ultrasound, and fluoroscopic guidance, all of which have favorable safety profiles but have been plagued by a wide range in diagnostic yields (38% to 88%) (Eberhardt R, et al. Am J Respir Crit Med. 2007;176[1]:36; Ost DE, et al. Am J Respir Crit Care Med. 2016;193[1]:68). Despite the discordant history of efficacy of PLL sampling modalities, they have gained widespread adoption due to the increasing need to access the periphery. That said, many operators have been left wanting, making new technologies attractive options despite a lack of data. The emergence of RBS may present an opportunity to change the way we approach bronchoscopic procedures, making what was a manual procedure into one the is machine-assisted and, perhaps, improving our accuracy of repetition. The robotic age of lung medicine is an exciting proposition, however, it is paramount that we pursue a robust evidence-based strategy with multicentered clinical trials and move beyond the limitations of registry data in order to carefully embrace these new technologies.

Christina MacRosty, DO

Incoming Fellow-in-Training Member

Jason Akulian, MD, MPH, FCCP

Steering Committee Member
 

Pediatric Chest Medicine

PARDS: A new definition

Pediatric Acute Respiratory Distress Syndrome (PARDS) is a multifactorial clinical syndrome associated with high morbidity and mortality in children. It is caused by disruption of the alveolar epithelial–endothelial permeability barrier leading to accumulation of protein-rich fluid in the alveoli and surfactant degradation. These changes result in a restrictive lung disease characterized by hypoxemia, radiographic opacities, decreased FRC, and lung compliance and increased physiologic dead space. Resolution usually occurs after several weeks, with potential development of fibrosis. The most common cause of ARDS in children is viral respiratory infection, although associated with many underlying conditions, including pneumonia, sepsis, trauma, burns, pancreatitis, inhalation, transfusion, and cardiopulmonary bypass.

In 2015, an international panel of experts convened the Pediatric Acute Lung Injury Consensus Conference (PALICC) to establish new definitions and guidelines for PARDS. The 2015 PALICC definition broadens to include any new parenchymal infiltrate(s) and allows use of pulse oximetry to avoid underestimating ARDS prevalence in children. It also allows utilization of the oxygenation index (OI) and oxygenation saturation index (OSI) rather than the PaO2/Fio2 (P/F) ratio to assess hypoxemia (PARDS: consensus. Pediatr Crit Care Med. 2015;16[5]:428; Orloff et al. Pediatr Allergy Immunol Pulmonol. 2019;32[2]:35).

In a follow-up international, prospective, cross-sectional, observational study across 27 countries, the PALICC definition identified more children as having PARDS than the Berlin definition. The PALICC PARDS severity groupings improved mortality risk stratification. The PALICC PARDS framework appears to be a better tool for future epidemiologic and therapeutic research among children with PARDS (Khemani et al. Lancet Respir Med. 2019;7[2]:115).

Harish Rao, MD

Steering Committee Member
 

SEVEN people have died! Need action now

Pediatricians nationwide have raised the alarm as the numbers of middle- and high-school students who are vaping continues to skyrocket. The National Youth Tobacco survey (2018) showed a 78 % increase in e-cigarette use in high school students with a 48 % increase in middle school students between 2017-2018. Now considered a public health crisis with hundreds of cases of severe respiratory illnesses and seven deaths linked to vaping, physicians, legislators, educators, and respiratory health organizations are joining forces to curb its use in adolescents.

The American College of Chest Physicians has long supported regulation of e-cigarettes, joining the Forum of International Respiratory Societies in a position statement recommending bans on flavored e-cigarettes and the restricting use in areas where children are present.

The Administration announced this week its intention to “ clear the market “ of all flavored e-cigarettes. Sweet and fruit flavorings are known to entice adolescents to try e-cigarettes while the variety and ability to choose their own combinations of flavors continues to bring teens back again and again. We know that the brain continues to develop into our mid-twenties, causing teens to be more vulnerable to the addictive properties of nicotine.

Increasing numbers of exposures in adolescents and the severity of vaping-related illnesses have prompted states to take a proactive approach to keep e-cigarettes out of the hands of children. Michigan was the first state to ban the sale of flavored e-cigarettes online and in brick and mortar stores with compliance to take effect within the next 30 days. Other states are expected to follow suit.

Legislation is an important step in our efforts to curb vaping and protect our children.

Mary Cataletto MD, FAAP, FCCP

NetWork Chair
 

Pulmonary Physiology, Function and Rehabilitation

Pulmonary rehab and COPD

The introduction of pulmonary rehabilitation (PR) into the care of a patient with COPD can be a life-changing intervention. It has not only been shown to significantly improve symptoms, daily function, and quality of life – but also reduce the risk of acute exacerbation (Spruit et al. Am J Respir Crit Care Med. 2013;188[8]:e13). However, the referral rate for PR is extremely low, and many patients with COPD, despite having high symptom burdens, may be unaware of its existence. Unfortunately, this problem is worsened by PR program availability and proximity, with recent estimates suggesting that there are only 831 PR centers in the US for 24 million patients with COPD (Bhatt. Ann Am Thorac Soc. 2019;16[1]:55). As a result, there is an immediate need to explore alternative strategies that enable patients to realize the benefits of PR outside of a facility-based program (Rochester, et al. Am J Respir Crit Care Med. 2015;192[11]:1373).

Recently, there have been many proposals for adapting PR programs to accommodate the maximum number of participants; these have included home-, telehealth- or internet-based programs, and low-impact exercise (eg, yoga or tai-chi) regimens. While these interventions may benefit our patients with COPD, current data do not support that they are a replacement for or replicate the robust outcomes of a formal PR program. It is important that in the process of expanding the availability of “pulmonary rehab,” we do not dilute the process as to limit its returns. Significant attention is being paid to developing novel program designs that utilize technology and nonfacility-based programs – and in the end, there will be a balance struck between beneficial outcomes, program personalization, and proper patient selection for a given regimen.

Eric Gartman, MD, FCCP

Steering Committee Member
 

Thoracic Oncology

A new era in lung cancer diagnostics: Robotic-assisted bronchoscopy

Lung cancer screening leads to increased detection of early stage lung cancer (LC). The majority of nodules detected are peripherally located.

Image-guided bronchoscopic modalities, including radial probe endobronchial ultrasound (r-EBUS) and electromagnetic navigation bronchoscopy (ENB), allow diagnosis of peripheral nodules with a low rate of complications. Although a meta-analysis of image-guided bronchoscopic procedures reported a diagnostic yield of 70% (Wang Memoli JS, et al. Chest. 2012;142[2]:385), the diagnostic yield remains inferior to CT-guided biopsy. Robotic-assisted bronchoscopy (RAB) with four-way steering, 180 degrees of deflection in any direction and better access to peripheral airways may improve the diagnostic yield. Two FDA-approved platforms are commercially available. The Monarch System, (Auris Health) has a 3.2-mm outer diameter and a 1.2-mm working channel. Results from an ongoing prospective, multicenter study in 24 patients revealed successful localization of targeted lesion in 92%, with no significant adverse events (Chen, et al. Am J Respir Crit Care Med. 2019;199:A7304/NCT03727425; Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03727425).

The Ion Endoluminal System (Intuitive Surgical) has a 3.5-mm outer diameter and a 2.0-mm working channel. Preliminary data revealed 96.6% of target lesions were successfully reached, and no adverse events (Fielding et al. Chest. 2017;152[4]:A858). A prospective, multicenter randomized trial is currently ongoing (Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03893539).

The aim of bronchoscopic procedures is to safely and effectively diagnose early stage LC. RAB shows a great deal of potential in the future of LC diagnostics.

Priya Patel MD

Fellow-in-Training Member

Adnan Majid, MD

NetWork Member

Interventional Chest/Diagnostic Procedures

Emergence of robotic-assisted bronchoscopy for the diagnosis of peripheral lung lesions

The diagnostic chest medicine community saw exciting advances in technology for diagnosis of peripheral lung lesions (PLL) with the recent FDA approval of two robotic-assisted bronchoscopy systems (RBS): the Monarch Platform from Auris Health (2018) and the Ion system from Intuitive Surgical (2019). Small pilot studies of 15 (Monarch) and 29 (Ion) subjects, respectively, demonstrated safety and feasibility of biopsy and diagnosis of PLL using RBS (Rojas-Solano, et al. J Bronchol Intervent Pulmonol. 2018;25:168; Fielding et al. Respiration. 2019;98[2]:142). While these studies were not powered to evaluate diagnostic yield, they suggested the potential for improved yields over current technologies.

Current bronchoscopic modalities for diagnosis of PLL include electromagnetic navigation bronchoscopy, radial endobronchial ultrasound, and fluoroscopic guidance, all of which have favorable safety profiles but have been plagued by a wide range in diagnostic yields (38% to 88%) (Eberhardt R, et al. Am J Respir Crit Med. 2007;176[1]:36; Ost DE, et al. Am J Respir Crit Care Med. 2016;193[1]:68). Despite the discordant history of efficacy of PLL sampling modalities, they have gained widespread adoption due to the increasing need to access the periphery. That said, many operators have been left wanting, making new technologies attractive options despite a lack of data. The emergence of RBS may present an opportunity to change the way we approach bronchoscopic procedures, making what was a manual procedure into one the is machine-assisted and, perhaps, improving our accuracy of repetition. The robotic age of lung medicine is an exciting proposition, however, it is paramount that we pursue a robust evidence-based strategy with multicentered clinical trials and move beyond the limitations of registry data in order to carefully embrace these new technologies.

Christina MacRosty, DO

Incoming Fellow-in-Training Member

Jason Akulian, MD, MPH, FCCP

Steering Committee Member
 

Pediatric Chest Medicine

PARDS: A new definition

Pediatric Acute Respiratory Distress Syndrome (PARDS) is a multifactorial clinical syndrome associated with high morbidity and mortality in children. It is caused by disruption of the alveolar epithelial–endothelial permeability barrier leading to accumulation of protein-rich fluid in the alveoli and surfactant degradation. These changes result in a restrictive lung disease characterized by hypoxemia, radiographic opacities, decreased FRC, and lung compliance and increased physiologic dead space. Resolution usually occurs after several weeks, with potential development of fibrosis. The most common cause of ARDS in children is viral respiratory infection, although associated with many underlying conditions, including pneumonia, sepsis, trauma, burns, pancreatitis, inhalation, transfusion, and cardiopulmonary bypass.

In 2015, an international panel of experts convened the Pediatric Acute Lung Injury Consensus Conference (PALICC) to establish new definitions and guidelines for PARDS. The 2015 PALICC definition broadens to include any new parenchymal infiltrate(s) and allows use of pulse oximetry to avoid underestimating ARDS prevalence in children. It also allows utilization of the oxygenation index (OI) and oxygenation saturation index (OSI) rather than the PaO2/Fio2 (P/F) ratio to assess hypoxemia (PARDS: consensus. Pediatr Crit Care Med. 2015;16[5]:428; Orloff et al. Pediatr Allergy Immunol Pulmonol. 2019;32[2]:35).

In a follow-up international, prospective, cross-sectional, observational study across 27 countries, the PALICC definition identified more children as having PARDS than the Berlin definition. The PALICC PARDS severity groupings improved mortality risk stratification. The PALICC PARDS framework appears to be a better tool for future epidemiologic and therapeutic research among children with PARDS (Khemani et al. Lancet Respir Med. 2019;7[2]:115).

Harish Rao, MD

Steering Committee Member
 

SEVEN people have died! Need action now

Pediatricians nationwide have raised the alarm as the numbers of middle- and high-school students who are vaping continues to skyrocket. The National Youth Tobacco survey (2018) showed a 78 % increase in e-cigarette use in high school students with a 48 % increase in middle school students between 2017-2018. Now considered a public health crisis with hundreds of cases of severe respiratory illnesses and seven deaths linked to vaping, physicians, legislators, educators, and respiratory health organizations are joining forces to curb its use in adolescents.

The American College of Chest Physicians has long supported regulation of e-cigarettes, joining the Forum of International Respiratory Societies in a position statement recommending bans on flavored e-cigarettes and the restricting use in areas where children are present.

The Administration announced this week its intention to “ clear the market “ of all flavored e-cigarettes. Sweet and fruit flavorings are known to entice adolescents to try e-cigarettes while the variety and ability to choose their own combinations of flavors continues to bring teens back again and again. We know that the brain continues to develop into our mid-twenties, causing teens to be more vulnerable to the addictive properties of nicotine.

Increasing numbers of exposures in adolescents and the severity of vaping-related illnesses have prompted states to take a proactive approach to keep e-cigarettes out of the hands of children. Michigan was the first state to ban the sale of flavored e-cigarettes online and in brick and mortar stores with compliance to take effect within the next 30 days. Other states are expected to follow suit.

Legislation is an important step in our efforts to curb vaping and protect our children.

Mary Cataletto MD, FAAP, FCCP

NetWork Chair
 

Pulmonary Physiology, Function and Rehabilitation

Pulmonary rehab and COPD

The introduction of pulmonary rehabilitation (PR) into the care of a patient with COPD can be a life-changing intervention. It has not only been shown to significantly improve symptoms, daily function, and quality of life – but also reduce the risk of acute exacerbation (Spruit et al. Am J Respir Crit Care Med. 2013;188[8]:e13). However, the referral rate for PR is extremely low, and many patients with COPD, despite having high symptom burdens, may be unaware of its existence. Unfortunately, this problem is worsened by PR program availability and proximity, with recent estimates suggesting that there are only 831 PR centers in the US for 24 million patients with COPD (Bhatt. Ann Am Thorac Soc. 2019;16[1]:55). As a result, there is an immediate need to explore alternative strategies that enable patients to realize the benefits of PR outside of a facility-based program (Rochester, et al. Am J Respir Crit Care Med. 2015;192[11]:1373).

Recently, there have been many proposals for adapting PR programs to accommodate the maximum number of participants; these have included home-, telehealth- or internet-based programs, and low-impact exercise (eg, yoga or tai-chi) regimens. While these interventions may benefit our patients with COPD, current data do not support that they are a replacement for or replicate the robust outcomes of a formal PR program. It is important that in the process of expanding the availability of “pulmonary rehab,” we do not dilute the process as to limit its returns. Significant attention is being paid to developing novel program designs that utilize technology and nonfacility-based programs – and in the end, there will be a balance struck between beneficial outcomes, program personalization, and proper patient selection for a given regimen.

Eric Gartman, MD, FCCP

Steering Committee Member
 

Thoracic Oncology

A new era in lung cancer diagnostics: Robotic-assisted bronchoscopy

Lung cancer screening leads to increased detection of early stage lung cancer (LC). The majority of nodules detected are peripherally located.

Image-guided bronchoscopic modalities, including radial probe endobronchial ultrasound (r-EBUS) and electromagnetic navigation bronchoscopy (ENB), allow diagnosis of peripheral nodules with a low rate of complications. Although a meta-analysis of image-guided bronchoscopic procedures reported a diagnostic yield of 70% (Wang Memoli JS, et al. Chest. 2012;142[2]:385), the diagnostic yield remains inferior to CT-guided biopsy. Robotic-assisted bronchoscopy (RAB) with four-way steering, 180 degrees of deflection in any direction and better access to peripheral airways may improve the diagnostic yield. Two FDA-approved platforms are commercially available. The Monarch System, (Auris Health) has a 3.2-mm outer diameter and a 1.2-mm working channel. Results from an ongoing prospective, multicenter study in 24 patients revealed successful localization of targeted lesion in 92%, with no significant adverse events (Chen, et al. Am J Respir Crit Care Med. 2019;199:A7304/NCT03727425; Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03727425).

The Ion Endoluminal System (Intuitive Surgical) has a 3.5-mm outer diameter and a 2.0-mm working channel. Preliminary data revealed 96.6% of target lesions were successfully reached, and no adverse events (Fielding et al. Chest. 2017;152[4]:A858). A prospective, multicenter randomized trial is currently ongoing (Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03893539).

The aim of bronchoscopic procedures is to safely and effectively diagnose early stage LC. RAB shows a great deal of potential in the future of LC diagnostics.

Priya Patel MD

Fellow-in-Training Member

Adnan Majid, MD

NetWork Member

Interventional Chest/Diagnostic Procedures

Emergence of robotic-assisted bronchoscopy for the diagnosis of peripheral lung lesions

The diagnostic chest medicine community saw exciting advances in technology for diagnosis of peripheral lung lesions (PLL) with the recent FDA approval of two robotic-assisted bronchoscopy systems (RBS): the Monarch Platform from Auris Health (2018) and the Ion system from Intuitive Surgical (2019). Small pilot studies of 15 (Monarch) and 29 (Ion) subjects, respectively, demonstrated safety and feasibility of biopsy and diagnosis of PLL using RBS (Rojas-Solano, et al. J Bronchol Intervent Pulmonol. 2018;25:168; Fielding et al. Respiration. 2019;98[2]:142). While these studies were not powered to evaluate diagnostic yield, they suggested the potential for improved yields over current technologies.

Current bronchoscopic modalities for diagnosis of PLL include electromagnetic navigation bronchoscopy, radial endobronchial ultrasound, and fluoroscopic guidance, all of which have favorable safety profiles but have been plagued by a wide range in diagnostic yields (38% to 88%) (Eberhardt R, et al. Am J Respir Crit Med. 2007;176[1]:36; Ost DE, et al. Am J Respir Crit Care Med. 2016;193[1]:68). Despite the discordant history of efficacy of PLL sampling modalities, they have gained widespread adoption due to the increasing need to access the periphery. That said, many operators have been left wanting, making new technologies attractive options despite a lack of data. The emergence of RBS may present an opportunity to change the way we approach bronchoscopic procedures, making what was a manual procedure into one the is machine-assisted and, perhaps, improving our accuracy of repetition. The robotic age of lung medicine is an exciting proposition, however, it is paramount that we pursue a robust evidence-based strategy with multicentered clinical trials and move beyond the limitations of registry data in order to carefully embrace these new technologies.

Christina MacRosty, DO

Incoming Fellow-in-Training Member

Jason Akulian, MD, MPH, FCCP

Steering Committee Member
 

Pediatric Chest Medicine

PARDS: A new definition

Pediatric Acute Respiratory Distress Syndrome (PARDS) is a multifactorial clinical syndrome associated with high morbidity and mortality in children. It is caused by disruption of the alveolar epithelial–endothelial permeability barrier leading to accumulation of protein-rich fluid in the alveoli and surfactant degradation. These changes result in a restrictive lung disease characterized by hypoxemia, radiographic opacities, decreased FRC, and lung compliance and increased physiologic dead space. Resolution usually occurs after several weeks, with potential development of fibrosis. The most common cause of ARDS in children is viral respiratory infection, although associated with many underlying conditions, including pneumonia, sepsis, trauma, burns, pancreatitis, inhalation, transfusion, and cardiopulmonary bypass.

In 2015, an international panel of experts convened the Pediatric Acute Lung Injury Consensus Conference (PALICC) to establish new definitions and guidelines for PARDS. The 2015 PALICC definition broadens to include any new parenchymal infiltrate(s) and allows use of pulse oximetry to avoid underestimating ARDS prevalence in children. It also allows utilization of the oxygenation index (OI) and oxygenation saturation index (OSI) rather than the PaO2/Fio2 (P/F) ratio to assess hypoxemia (PARDS: consensus. Pediatr Crit Care Med. 2015;16[5]:428; Orloff et al. Pediatr Allergy Immunol Pulmonol. 2019;32[2]:35).

In a follow-up international, prospective, cross-sectional, observational study across 27 countries, the PALICC definition identified more children as having PARDS than the Berlin definition. The PALICC PARDS severity groupings improved mortality risk stratification. The PALICC PARDS framework appears to be a better tool for future epidemiologic and therapeutic research among children with PARDS (Khemani et al. Lancet Respir Med. 2019;7[2]:115).

Harish Rao, MD

Steering Committee Member
 

SEVEN people have died! Need action now

Pediatricians nationwide have raised the alarm as the numbers of middle- and high-school students who are vaping continues to skyrocket. The National Youth Tobacco survey (2018) showed a 78 % increase in e-cigarette use in high school students with a 48 % increase in middle school students between 2017-2018. Now considered a public health crisis with hundreds of cases of severe respiratory illnesses and seven deaths linked to vaping, physicians, legislators, educators, and respiratory health organizations are joining forces to curb its use in adolescents.

The American College of Chest Physicians has long supported regulation of e-cigarettes, joining the Forum of International Respiratory Societies in a position statement recommending bans on flavored e-cigarettes and the restricting use in areas where children are present.

The Administration announced this week its intention to “ clear the market “ of all flavored e-cigarettes. Sweet and fruit flavorings are known to entice adolescents to try e-cigarettes while the variety and ability to choose their own combinations of flavors continues to bring teens back again and again. We know that the brain continues to develop into our mid-twenties, causing teens to be more vulnerable to the addictive properties of nicotine.

Increasing numbers of exposures in adolescents and the severity of vaping-related illnesses have prompted states to take a proactive approach to keep e-cigarettes out of the hands of children. Michigan was the first state to ban the sale of flavored e-cigarettes online and in brick and mortar stores with compliance to take effect within the next 30 days. Other states are expected to follow suit.

Legislation is an important step in our efforts to curb vaping and protect our children.

Mary Cataletto MD, FAAP, FCCP

NetWork Chair
 

Pulmonary Physiology, Function and Rehabilitation

Pulmonary rehab and COPD

The introduction of pulmonary rehabilitation (PR) into the care of a patient with COPD can be a life-changing intervention. It has not only been shown to significantly improve symptoms, daily function, and quality of life – but also reduce the risk of acute exacerbation (Spruit et al. Am J Respir Crit Care Med. 2013;188[8]:e13). However, the referral rate for PR is extremely low, and many patients with COPD, despite having high symptom burdens, may be unaware of its existence. Unfortunately, this problem is worsened by PR program availability and proximity, with recent estimates suggesting that there are only 831 PR centers in the US for 24 million patients with COPD (Bhatt. Ann Am Thorac Soc. 2019;16[1]:55). As a result, there is an immediate need to explore alternative strategies that enable patients to realize the benefits of PR outside of a facility-based program (Rochester, et al. Am J Respir Crit Care Med. 2015;192[11]:1373).

Recently, there have been many proposals for adapting PR programs to accommodate the maximum number of participants; these have included home-, telehealth- or internet-based programs, and low-impact exercise (eg, yoga or tai-chi) regimens. While these interventions may benefit our patients with COPD, current data do not support that they are a replacement for or replicate the robust outcomes of a formal PR program. It is important that in the process of expanding the availability of “pulmonary rehab,” we do not dilute the process as to limit its returns. Significant attention is being paid to developing novel program designs that utilize technology and nonfacility-based programs – and in the end, there will be a balance struck between beneficial outcomes, program personalization, and proper patient selection for a given regimen.

Eric Gartman, MD, FCCP

Steering Committee Member
 

Thoracic Oncology

A new era in lung cancer diagnostics: Robotic-assisted bronchoscopy

Lung cancer screening leads to increased detection of early stage lung cancer (LC). The majority of nodules detected are peripherally located.

Image-guided bronchoscopic modalities, including radial probe endobronchial ultrasound (r-EBUS) and electromagnetic navigation bronchoscopy (ENB), allow diagnosis of peripheral nodules with a low rate of complications. Although a meta-analysis of image-guided bronchoscopic procedures reported a diagnostic yield of 70% (Wang Memoli JS, et al. Chest. 2012;142[2]:385), the diagnostic yield remains inferior to CT-guided biopsy. Robotic-assisted bronchoscopy (RAB) with four-way steering, 180 degrees of deflection in any direction and better access to peripheral airways may improve the diagnostic yield. Two FDA-approved platforms are commercially available. The Monarch System, (Auris Health) has a 3.2-mm outer diameter and a 1.2-mm working channel. Results from an ongoing prospective, multicenter study in 24 patients revealed successful localization of targeted lesion in 92%, with no significant adverse events (Chen, et al. Am J Respir Crit Care Med. 2019;199:A7304/NCT03727425; Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03727425).

The Ion Endoluminal System (Intuitive Surgical) has a 3.5-mm outer diameter and a 2.0-mm working channel. Preliminary data revealed 96.6% of target lesions were successfully reached, and no adverse events (Fielding et al. Chest. 2017;152[4]:A858). A prospective, multicenter randomized trial is currently ongoing (Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03893539).

The aim of bronchoscopic procedures is to safely and effectively diagnose early stage LC. RAB shows a great deal of potential in the future of LC diagnostics.

Priya Patel MD

Fellow-in-Training Member

Adnan Majid, MD

NetWork Member

ORIGINAL RESEARCH

The Saint Georges Respiratory Questionnaire definition of chronic bronchitis may be a better predictor of COPD exacerbations compared to the classic definition. By Dr. V. Kim, et al.



Confocal laser endomicroscopy (CLE) as a guidance tool for pleural biopsies in malignant pleural mesothelioma. By Dr. L. Wijmans, et al.



Association of Angiotensin Modulators With the Course of Idiopathic Pulmonary Fibrosis. By Dr. M. Kreuter, et al.



Age-Stratified National Trends in Pulmonary Embolism Admissions. By Dr. E. D. Pauley, et al.


COMMENTARY

Solving the Opioid Crisis: Respiratory Depression by Opioids as Critical Endpoint.By Dr. G. Montandon and Dr. A. S. Slutsky.

ORIGINAL RESEARCH

The Saint Georges Respiratory Questionnaire definition of chronic bronchitis may be a better predictor of COPD exacerbations compared to the classic definition. By Dr. V. Kim, et al.



Confocal laser endomicroscopy (CLE) as a guidance tool for pleural biopsies in malignant pleural mesothelioma. By Dr. L. Wijmans, et al.



Association of Angiotensin Modulators With the Course of Idiopathic Pulmonary Fibrosis. By Dr. M. Kreuter, et al.



Age-Stratified National Trends in Pulmonary Embolism Admissions. By Dr. E. D. Pauley, et al.


COMMENTARY

Solving the Opioid Crisis: Respiratory Depression by Opioids as Critical Endpoint.By Dr. G. Montandon and Dr. A. S. Slutsky.

ORIGINAL RESEARCH

The Saint Georges Respiratory Questionnaire definition of chronic bronchitis may be a better predictor of COPD exacerbations compared to the classic definition. By Dr. V. Kim, et al.



Confocal laser endomicroscopy (CLE) as a guidance tool for pleural biopsies in malignant pleural mesothelioma. By Dr. L. Wijmans, et al.



Association of Angiotensin Modulators With the Course of Idiopathic Pulmonary Fibrosis. By Dr. M. Kreuter, et al.



Age-Stratified National Trends in Pulmonary Embolism Admissions. By Dr. E. D. Pauley, et al.


COMMENTARY

Solving the Opioid Crisis: Respiratory Depression by Opioids as Critical Endpoint.By Dr. G. Montandon and Dr. A. S. Slutsky.

E-cigarettes arrived in the U.S. market between 2005 and 2007. Vaping via e-cigarettes involves inhaling substances such as nicotine, flavorings, chemicals, and, sometimes, marijuana and/or other substances deep into the lungs. While the use of these devices is prevalent, the long-term effects are not known. We, as clinicians, need to specifically ask our patients about their use of substances via e-cigarettes because of alarming cases of severe, life-threatening respiratory illnesses recently being reported throughout the United States in young, otherwise healthy, individuals.

As of September 11, 2019, over 380 cases have been reported to the Centers for Disease Control and Prevention (CDC), where young, healthy people from 33 states and one US territory were hospitalized with severe respiratory disease. There have been at least six confirmed deaths and approximately one-third of those who survived required aggressive support with intubation and mechanical ventilation. The number of reported cases is rapidly rising (from 215 possible cases on August 27, 2019). The common theme in these cases is that every patient reported using an e-cigarette product within 90 days of the onset of symptoms, and most within the prior 2 weeks. By definition, other etiologies of respiratory failure, such as infections, collagen vascular, immunologic diseases, and malignancies were excluded.

Between 90% and 98% of patients presented to the hospital with respiratory symptoms, such as shortness of breath, cough, hemoptysis, and/or chest pain. The most common reported e-cigarette product exposure among these case patients is tetrahydrocannabinol, THC (in approximately 80% to 85%); however, some used only nicotine-based products (15% to 20%). In addition, approximately 45% to 50% reported using THC and nicotine-based products. One concerning fact that requires special attention is that some affected patients initially presented with nonrespiratory complaints, such as GI symptoms of nausea, vomiting, and/or diarrhea; constitutional symptoms such as fever (up to 104oF), fatigue, and/or weight loss; and neurologic symptoms such as headaches and even seizures. Many of these symptoms preceded the respiratory symptoms by up to 2 weeks. Therefore, a few of these patients initially presented without significant respiratory symptoms and with normal chest radiographs – but progressed over days to weeks to acute hypoxemic respiratory failure.

Dr. Adams is Professor of Medicine, Pulmonary/Critical Care Division, Distinguished Teaching Professor, UT Health San Antonio; Staff Physician, South Texas Veterans Health Care System, San Antonio, Texas

References

Centers for Disease Control and Prevention. Severe pulmonary disease associated with using e-cigarette products. Health Alert Network. August 30, 2019. CDCHAN-00421. .

https://emergency.cdc.gov/han/han00421.asp

Centers for Disease Control and Prevention. Outbreak of lung illness associated with using e-cigarette products. Investigation Notice. September 6, 2019. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html.

Henry TS et al. Imaging of vaping-associated lung disease. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMc1911995. [Epub ahead of print].

Layden JE et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin – preliminary report. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print].

Maddock SD et al. Pulmonary lipid-laden macrophages and vaping. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMc1912038. [Epub ahead of print].

E-cigarettes arrived in the U.S. market between 2005 and 2007. Vaping via e-cigarettes involves inhaling substances such as nicotine, flavorings, chemicals, and, sometimes, marijuana and/or other substances deep into the lungs. While the use of these devices is prevalent, the long-term effects are not known. We, as clinicians, need to specifically ask our patients about their use of substances via e-cigarettes because of alarming cases of severe, life-threatening respiratory illnesses recently being reported throughout the United States in young, otherwise healthy, individuals.

As of September 11, 2019, over 380 cases have been reported to the Centers for Disease Control and Prevention (CDC), where young, healthy people from 33 states and one US territory were hospitalized with severe respiratory disease. There have been at least six confirmed deaths and approximately one-third of those who survived required aggressive support with intubation and mechanical ventilation. The number of reported cases is rapidly rising (from 215 possible cases on August 27, 2019). The common theme in these cases is that every patient reported using an e-cigarette product within 90 days of the onset of symptoms, and most within the prior 2 weeks. By definition, other etiologies of respiratory failure, such as infections, collagen vascular, immunologic diseases, and malignancies were excluded.

Between 90% and 98% of patients presented to the hospital with respiratory symptoms, such as shortness of breath, cough, hemoptysis, and/or chest pain. The most common reported e-cigarette product exposure among these case patients is tetrahydrocannabinol, THC (in approximately 80% to 85%); however, some used only nicotine-based products (15% to 20%). In addition, approximately 45% to 50% reported using THC and nicotine-based products. One concerning fact that requires special attention is that some affected patients initially presented with nonrespiratory complaints, such as GI symptoms of nausea, vomiting, and/or diarrhea; constitutional symptoms such as fever (up to 104oF), fatigue, and/or weight loss; and neurologic symptoms such as headaches and even seizures. Many of these symptoms preceded the respiratory symptoms by up to 2 weeks. Therefore, a few of these patients initially presented without significant respiratory symptoms and with normal chest radiographs – but progressed over days to weeks to acute hypoxemic respiratory failure.

Dr. Adams is Professor of Medicine, Pulmonary/Critical Care Division, Distinguished Teaching Professor, UT Health San Antonio; Staff Physician, South Texas Veterans Health Care System, San Antonio, Texas

References

Centers for Disease Control and Prevention. Severe pulmonary disease associated with using e-cigarette products. Health Alert Network. August 30, 2019. CDCHAN-00421. .

https://emergency.cdc.gov/han/han00421.asp

Centers for Disease Control and Prevention. Outbreak of lung illness associated with using e-cigarette products. Investigation Notice. September 6, 2019. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html.

Henry TS et al. Imaging of vaping-associated lung disease. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMc1911995. [Epub ahead of print].

Layden JE et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin – preliminary report. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print].

Maddock SD et al. Pulmonary lipid-laden macrophages and vaping. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMc1912038. [Epub ahead of print].

E-cigarettes arrived in the U.S. market between 2005 and 2007. Vaping via e-cigarettes involves inhaling substances such as nicotine, flavorings, chemicals, and, sometimes, marijuana and/or other substances deep into the lungs. While the use of these devices is prevalent, the long-term effects are not known. We, as clinicians, need to specifically ask our patients about their use of substances via e-cigarettes because of alarming cases of severe, life-threatening respiratory illnesses recently being reported throughout the United States in young, otherwise healthy, individuals.

As of September 11, 2019, over 380 cases have been reported to the Centers for Disease Control and Prevention (CDC), where young, healthy people from 33 states and one US territory were hospitalized with severe respiratory disease. There have been at least six confirmed deaths and approximately one-third of those who survived required aggressive support with intubation and mechanical ventilation. The number of reported cases is rapidly rising (from 215 possible cases on August 27, 2019). The common theme in these cases is that every patient reported using an e-cigarette product within 90 days of the onset of symptoms, and most within the prior 2 weeks. By definition, other etiologies of respiratory failure, such as infections, collagen vascular, immunologic diseases, and malignancies were excluded.

Between 90% and 98% of patients presented to the hospital with respiratory symptoms, such as shortness of breath, cough, hemoptysis, and/or chest pain. The most common reported e-cigarette product exposure among these case patients is tetrahydrocannabinol, THC (in approximately 80% to 85%); however, some used only nicotine-based products (15% to 20%). In addition, approximately 45% to 50% reported using THC and nicotine-based products. One concerning fact that requires special attention is that some affected patients initially presented with nonrespiratory complaints, such as GI symptoms of nausea, vomiting, and/or diarrhea; constitutional symptoms such as fever (up to 104oF), fatigue, and/or weight loss; and neurologic symptoms such as headaches and even seizures. Many of these symptoms preceded the respiratory symptoms by up to 2 weeks. Therefore, a few of these patients initially presented without significant respiratory symptoms and with normal chest radiographs – but progressed over days to weeks to acute hypoxemic respiratory failure.

Dr. Adams is Professor of Medicine, Pulmonary/Critical Care Division, Distinguished Teaching Professor, UT Health San Antonio; Staff Physician, South Texas Veterans Health Care System, San Antonio, Texas

References

Centers for Disease Control and Prevention. Severe pulmonary disease associated with using e-cigarette products. Health Alert Network. August 30, 2019. CDCHAN-00421. .

https://emergency.cdc.gov/han/han00421.asp

Centers for Disease Control and Prevention. Outbreak of lung illness associated with using e-cigarette products. Investigation Notice. September 6, 2019. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html.

Henry TS et al. Imaging of vaping-associated lung disease. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMc1911995. [Epub ahead of print].

Layden JE et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin – preliminary report. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print].

Maddock SD et al. Pulmonary lipid-laden macrophages and vaping. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMc1912038. [Epub ahead of print].

There may be some positive changes coming to evaluation and management (E/M) services effective January 1, 2021. In the proposed calendar year 2020 Physician Fee Schedule (CY 2020 PFS), the Centers for Medicare & Medicaid Services (CMS) suggested a number of coding, payment, and documentation changes for office/outpatient E/M visits, Current Procedural Terminology (CPT^®) codes 99201-99215. A summary of these changes include:

• Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021. This would include deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215;

• Elimination of the use of history and/or physical exam to select among code levels;

• Choice of time or medical decision making to decide the level of office/outpatient E/M visit (using the revised CPT interpretive guidelines for medical decision making);

• Payment for prolonged office/outpatient E/M visits using the revised CPT code for such services, including separate payment for new CPT code 99XXX and deletion of Healthcare Common Procedure Coding System (HCPCS) code GPRO1 (extended office/outpatient E/M visit) that was previously finalized for 2021;

• Revise the descriptor for HCPCS code GPC1X and delete HCPCS code GCG0X; and

• Increase in value for HCPCS code GPC1X and allowing it to be reported with all office/outpatient E/M visit levels.

These changes were recommended by CMS to improve payment accuracy, reduce the administrative burden, and better reflect the current practice of medicine. These changes are predicted to result in a simplification of physician documentation and a redistribution of payments favoring providers who deliver primary care or care to more complex patients.


In CY 2019 PFS, CMS proposed to pay a single (blended) rate for office/outpatient visits 2-4, but due to comments from stakeholders, including specialty societies, CMS proposed to accept alternate recommendations by AMA/CPT. These recommendations include using medical decision making or time to determine the level of a visit, rather than the schema that was based on history and physical exam and outlined in the 1995/1997 guidelines. This resulted in elimination of CPT code 99201 and changes to the descriptors of 99202-99215. These codes were resurveyed by the Relative Value Update Committee (RUC) resulting in new values and times. (See Table 1).


One can see that there has been an incremental increase in time and value for most codes. When selecting a code based upon time, there is a range that is defined for each code,and additional information about the codes, including the descriptors and ranges, can be found on the AMA website https://www.ama-assn.org/cpt-evaluation-and-management.

For CPT codes 99205 and 99215 (level 5 codes), an add-on code has also been proposed that would account for additional time spent above the new levels defined in the codes. The descriptor for CPT 99XXX (the final numbers have not yet been assigned) reads Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services). 99XXX is similar to CPT add-on code 99292 in that it may be used multiple times for a single encounter. This is illustrated in Table 2.


However, 99XXX is only used with level 5 codes. It will replace HCPCS code GPRO1, which had been finalized in the CY 2019 PFS. The proposed code will have a value of 0.61 RVU.


Finally, there is a proposal to revise the descriptor for HCPCS code GPC1X and eliminate HCPCS code GCG0X. The new descriptor for GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) is being updated to simplify the coding and, with the elimination of GCG0X, to remove the perception that the code is primary care or specialty specific. The value of GPC1X is also being increased to 0.33 RVU.

It must be made clear that these changes are proposals only, and CMS is still reviewing stakeholder and public comments. Any actual changes will not be codified until publication of the CY2020 PFS later this year. Additional information regarding the proposed rule can be found by accessing https://federalregister.gov/d/2019-16041.

There may be some positive changes coming to evaluation and management (E/M) services effective January 1, 2021. In the proposed calendar year 2020 Physician Fee Schedule (CY 2020 PFS), the Centers for Medicare & Medicaid Services (CMS) suggested a number of coding, payment, and documentation changes for office/outpatient E/M visits, Current Procedural Terminology (CPT^®) codes 99201-99215. A summary of these changes include:

• Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021. This would include deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215;

• Elimination of the use of history and/or physical exam to select among code levels;

• Choice of time or medical decision making to decide the level of office/outpatient E/M visit (using the revised CPT interpretive guidelines for medical decision making);

• Payment for prolonged office/outpatient E/M visits using the revised CPT code for such services, including separate payment for new CPT code 99XXX and deletion of Healthcare Common Procedure Coding System (HCPCS) code GPRO1 (extended office/outpatient E/M visit) that was previously finalized for 2021;

• Revise the descriptor for HCPCS code GPC1X and delete HCPCS code GCG0X; and

• Increase in value for HCPCS code GPC1X and allowing it to be reported with all office/outpatient E/M visit levels.

These changes were recommended by CMS to improve payment accuracy, reduce the administrative burden, and better reflect the current practice of medicine. These changes are predicted to result in a simplification of physician documentation and a redistribution of payments favoring providers who deliver primary care or care to more complex patients.


In CY 2019 PFS, CMS proposed to pay a single (blended) rate for office/outpatient visits 2-4, but due to comments from stakeholders, including specialty societies, CMS proposed to accept alternate recommendations by AMA/CPT. These recommendations include using medical decision making or time to determine the level of a visit, rather than the schema that was based on history and physical exam and outlined in the 1995/1997 guidelines. This resulted in elimination of CPT code 99201 and changes to the descriptors of 99202-99215. These codes were resurveyed by the Relative Value Update Committee (RUC) resulting in new values and times. (See Table 1).


One can see that there has been an incremental increase in time and value for most codes. When selecting a code based upon time, there is a range that is defined for each code,and additional information about the codes, including the descriptors and ranges, can be found on the AMA website https://www.ama-assn.org/cpt-evaluation-and-management.

For CPT codes 99205 and 99215 (level 5 codes), an add-on code has also been proposed that would account for additional time spent above the new levels defined in the codes. The descriptor for CPT 99XXX (the final numbers have not yet been assigned) reads Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services). 99XXX is similar to CPT add-on code 99292 in that it may be used multiple times for a single encounter. This is illustrated in Table 2.


However, 99XXX is only used with level 5 codes. It will replace HCPCS code GPRO1, which had been finalized in the CY 2019 PFS. The proposed code will have a value of 0.61 RVU.


Finally, there is a proposal to revise the descriptor for HCPCS code GPC1X and eliminate HCPCS code GCG0X. The new descriptor for GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) is being updated to simplify the coding and, with the elimination of GCG0X, to remove the perception that the code is primary care or specialty specific. The value of GPC1X is also being increased to 0.33 RVU.

It must be made clear that these changes are proposals only, and CMS is still reviewing stakeholder and public comments. Any actual changes will not be codified until publication of the CY2020 PFS later this year. Additional information regarding the proposed rule can be found by accessing https://federalregister.gov/d/2019-16041.

There may be some positive changes coming to evaluation and management (E/M) services effective January 1, 2021. In the proposed calendar year 2020 Physician Fee Schedule (CY 2020 PFS), the Centers for Medicare & Medicaid Services (CMS) suggested a number of coding, payment, and documentation changes for office/outpatient E/M visits, Current Procedural Terminology (CPT^®) codes 99201-99215. A summary of these changes include:

• Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021. This would include deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215;

• Elimination of the use of history and/or physical exam to select among code levels;

• Choice of time or medical decision making to decide the level of office/outpatient E/M visit (using the revised CPT interpretive guidelines for medical decision making);

• Payment for prolonged office/outpatient E/M visits using the revised CPT code for such services, including separate payment for new CPT code 99XXX and deletion of Healthcare Common Procedure Coding System (HCPCS) code GPRO1 (extended office/outpatient E/M visit) that was previously finalized for 2021;

• Revise the descriptor for HCPCS code GPC1X and delete HCPCS code GCG0X; and

• Increase in value for HCPCS code GPC1X and allowing it to be reported with all office/outpatient E/M visit levels.

These changes were recommended by CMS to improve payment accuracy, reduce the administrative burden, and better reflect the current practice of medicine. These changes are predicted to result in a simplification of physician documentation and a redistribution of payments favoring providers who deliver primary care or care to more complex patients.


In CY 2019 PFS, CMS proposed to pay a single (blended) rate for office/outpatient visits 2-4, but due to comments from stakeholders, including specialty societies, CMS proposed to accept alternate recommendations by AMA/CPT. These recommendations include using medical decision making or time to determine the level of a visit, rather than the schema that was based on history and physical exam and outlined in the 1995/1997 guidelines. This resulted in elimination of CPT code 99201 and changes to the descriptors of 99202-99215. These codes were resurveyed by the Relative Value Update Committee (RUC) resulting in new values and times. (See Table 1).


One can see that there has been an incremental increase in time and value for most codes. When selecting a code based upon time, there is a range that is defined for each code,and additional information about the codes, including the descriptors and ranges, can be found on the AMA website https://www.ama-assn.org/cpt-evaluation-and-management.

For CPT codes 99205 and 99215 (level 5 codes), an add-on code has also been proposed that would account for additional time spent above the new levels defined in the codes. The descriptor for CPT 99XXX (the final numbers have not yet been assigned) reads Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services). 99XXX is similar to CPT add-on code 99292 in that it may be used multiple times for a single encounter. This is illustrated in Table 2.


However, 99XXX is only used with level 5 codes. It will replace HCPCS code GPRO1, which had been finalized in the CY 2019 PFS. The proposed code will have a value of 0.61 RVU.


Finally, there is a proposal to revise the descriptor for HCPCS code GPC1X and eliminate HCPCS code GCG0X. The new descriptor for GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) is being updated to simplify the coding and, with the elimination of GCG0X, to remove the perception that the code is primary care or specialty specific. The value of GPC1X is also being increased to 0.33 RVU.

It must be made clear that these changes are proposals only, and CMS is still reviewing stakeholder and public comments. Any actual changes will not be codified until publication of the CY2020 PFS later this year. Additional information regarding the proposed rule can be found by accessing https://federalregister.gov/d/2019-16041.

Keeping up to date and maintaining currency on developments in medicine are a routine part of medical practice, but the means by which this is accomplished are changing rapidly. Training, maintenance of certification, continuing education, mentoring, and career development will all be transformed in the coming years because of new technology and changing needs of physicians. Traditional learning channels such as print media and in-person courses will give way to options that emphasize ease of access, collaboration with fellow learners, and digitally optimized content.

Education and content delivery

The primary distribution channels for keeping medical professionals current in their specialty will continue to shift away from print publications and expand to digital outlets including podcasts, video, and online access to content.¹ Individuals seeking to keep up professionally will increasingly turn to resources that can be found quickly and easily, for example, through voice search. Content that has been optimized to appear quickly and with a clear layout adapted to a wide variety of devices will most likely be consumed at a higher rate than resources from well-established organizations that have not transformed their continuing education content. There is already a growing demand for video and audiocasts accessible via mobile device.²

John D. Buckley, MD, FCCP, professor of medicine and vice chair for education at Indiana University, Indianapolis, sees the transformation of content delivery as a net plus for physicians, with a couple of caveats. He noted, “Whether it is conducting an in-depth literature search, reading/streaming a review lecture, or simply confirming a medical fact, quick access can enhance patient care and advance learning in a manner that meets an individual’s learning style. One potential downside is the risk of unreliable information, so accessing trustworthy sources is essential. Another potential downside is that, while accessing the answer to a very specific question can be done very easily, this might compromise additional learning of related material that used to occur when you had to read an entire book chapter to answer your question. Not only did you answer your question, you learned a lot of other relevant information along the way.”

Online learning is now a vast industry and has been harnessed by millions to further professional learning opportunities. Massive Open Online Courses (MOOCs) are free online courses available for anyone to enroll.³ MOOCs have been established at Harvard, MIT, Microsoft, and other top universities and institutions in subjects like computer science, data science, business, and more. MOOCs are being replicated in conventional universities and are projected to be a model for adult learning in the coming decade.⁴

Another trend is the growing interest in microlearning, defined as short educational activities that deal with relatively small learning units utilized at the point where the learner will actually need the information.⁵

Dr. Buckley sees potential in microlearning for continuing medical education. “It is unlikely that microlearning would be eligible for CME currently unless there were a mechanism for aggregating multiple events into a substantive unit of credit. But the ACCME [Accreditation Council for Continuing Medical Education] has been very adaptive to various forms of learning, so aggregate microlearning for CME credit may be possible in the future.” He added that the benefits of rapid and reliable access of specific information from a trusted source are significant, and the opportunities for microlearning for chest physicians are almost limitless. “Whether searching for the most updated review of a medical topic, or checking to see if your ICU patient’s sedating medication can cause serotonin syndrome, microlearning is already playing a large role in physician education, just less formal that what’s been used historically,” he said.

Institutions for which professional development learning modules are an important revenue stream will increasingly be challenged to compete with open-access courses of varying quality.

A key trend identified in 2018 is accelerating higher-education technology adoption and a growing focus on measured outcomes and learning.⁵ Individuals are interested in personalized learning plans and adaptive learning systems that can provide real-time assessments and immediate feedback. It is expected that learning modules and curricula will be most successful if they are easily accessed, attractively presented, and incorporate immediate feedback on learning progress. Driving technology adoption in higher education in the next 3-5 years will be the proliferation of open educational resources and the rise of new forms of interdisciplinary studies. As the environment for providing and accessing content shifts from pay-to-access to open-access, organizations will need to identify a new value proposition if they wish to grow or maintain related revenue streams.⁶

The implications of these changes in demand are profound for creators of continuing education content for medical professionals. Major investment will be needed in new, possibly costly platforms that deliver high-quality content with accessibility and interactive elements to meet the demands of professionals, the younger generation in particular.⁷ The market will continue to develop new technology to serve continuing education needs and preferences of users, thus fueling competition among stakeholders. With the proliferation of free and low-cost online and virtual programs, continuing education providers may experience a negative impact on an important revenue stream if they don’t identify a competitive advantage that meets the needs of tomorrow’s workforce. However, educational programs and courses that use artificial intelligence, virtual reality, and augmented reality to enhance the learning experience are likely to experience higher levels of use in the coming years.⁸

Workforce diversity and mentoring

A global economy requires organizations to seek a diverse workforce. Diversity can also lead to higher levels of profitability and employee satisfaction. As such, it will be essential for organizations to increase opportunities for individuals from diverse backgrounds to join the workforce. Creating a diverse workforce will mean removing barriers of time and location to skill building through online learning opportunities and facilitation of interdisciplinary career paths.

A critical piece of the emerging model of career development will be mentoring. Many professionals in today’s workforce view mentoring as an opportunity to gain immediate skills and knowledge quickly and effectively. Mentoring has evolved from pairing young professionals with seasoned veterans to creating relationships that match individuals with others who have the skills and knowledge they desire to learn about – regardless of age and experience. Institutions striving to develop a diverse workforce will need many individuals to serve as both mentors and mentees. When searching for solutions to work-related challenges, individuals will increasingly turn to knowledge management and collaboration systems (virtual mentoring) that provide them with the opportunity to match their needs in an efficient and effective manner.

Dr. Buckley values peer-to-peer mentoring as a means of accessing and sharing niche expertise among colleagues, but he acknowledges the difficulties in incorporating it into everyday practice. “The biggest obstacles are probably time and access. More and more learners and mentors are recognizing the tremendous value of effective mentorship, so convincing people is less of an issue than finding time,” he said.

Mentorship will continue to play a central role in the advancement of one’s career, yet women and minorities find it increasingly difficult to match with a mentor within the workplace. These candidates are likely to seek external opportunities. Individuals will evaluate the experience, opportunities for career advancement and the level of diversity and inclusion when seeking and accepting a new job.

Dr. Buckley sees both progress and remaining challenges in reducing barriers to underrepresented groups in medical institutions. “There continues to be a need for ongoing training to help individuals and institutions recognize and eliminate their barriers and biases, both conscious and subconscious, that interfere with achieving diversity and inclusion. Another important limitation is the pipeline of underrepresented groups that are pursuing careers in medicine. We need to do more empowerment, encouragement, and recruitment of underrepresented groups at a very early stage in their education if we ever expect to achieve our goals.”
 

Future challenges

The transformations described above will require a large investment by physicians aiming to maintain professional currency, by creators of continuing education content, and by employers seeking a diversified workforce. All these stakeholders have an interest in the future direction of continuing education and professional training. The development of new platforms for delivery of content that is easily accessible, formatted for a wide variety of devices, and built with real-time feedback functions will require a significant commitment of resources.


References

1. IDC Trackers. “Worldwide semiannual augmented and virtual reality spending guide.” Accessed Sept. 3, 2019.

2. ASAE. “Foresight Works: User’s Guide.” ASAE Foundation, 2018.

3. Online Course Report. “The State of MOOC 2016: A year of massive landscape change for massive open online courses.” Accessed Sept. 3, 2019.

4. Bill & Melinda Gates Foundation. “Postsecondary Success: Data and Information.” Accessed Sept. 4, 2019.

5. QYReports. “The Microlearning Market Report, 2018.” Accessed Sept. 4, 2019.

6. Adams S et al. “NMC Horizon Report: 2018 Higher Education Edition.” Louisville, CO: EDUCAUSE, 2018.

7. An M. “Content trends: Preferences emerge along generational fault lines.” Hubspot: Nov. 6, 2017; updated Dec 14, 2018.

8. Grajek S and Grama J. “Higher education’s 2018 trend watch and top 10 strategic technologies.” EDUCAUSE Review, Jan 29, 2018.

Note: Background research performed by Avenue M Group.

CHEST Inspiration is a collection of programmatic initiatives developed by the American College of Chest Physicians leadership and aimed at stimulating and encouraging innovation within the association. One of the components of CHEST Inspiration is the Environmental Scan, a series of articles focusing on the internal and external environmental factors that bear on success currently and in the future. See “Envisioning the Future: The CHEST Environmental Scan,” CHEST Physician, June 2019, p. 44, for an introduction to the series.

Keeping up to date and maintaining currency on developments in medicine are a routine part of medical practice, but the means by which this is accomplished are changing rapidly. Training, maintenance of certification, continuing education, mentoring, and career development will all be transformed in the coming years because of new technology and changing needs of physicians. Traditional learning channels such as print media and in-person courses will give way to options that emphasize ease of access, collaboration with fellow learners, and digitally optimized content.

Education and content delivery

The primary distribution channels for keeping medical professionals current in their specialty will continue to shift away from print publications and expand to digital outlets including podcasts, video, and online access to content.¹ Individuals seeking to keep up professionally will increasingly turn to resources that can be found quickly and easily, for example, through voice search. Content that has been optimized to appear quickly and with a clear layout adapted to a wide variety of devices will most likely be consumed at a higher rate than resources from well-established organizations that have not transformed their continuing education content. There is already a growing demand for video and audiocasts accessible via mobile device.²

John D. Buckley, MD, FCCP, professor of medicine and vice chair for education at Indiana University, Indianapolis, sees the transformation of content delivery as a net plus for physicians, with a couple of caveats. He noted, “Whether it is conducting an in-depth literature search, reading/streaming a review lecture, or simply confirming a medical fact, quick access can enhance patient care and advance learning in a manner that meets an individual’s learning style. One potential downside is the risk of unreliable information, so accessing trustworthy sources is essential. Another potential downside is that, while accessing the answer to a very specific question can be done very easily, this might compromise additional learning of related material that used to occur when you had to read an entire book chapter to answer your question. Not only did you answer your question, you learned a lot of other relevant information along the way.”

Online learning is now a vast industry and has been harnessed by millions to further professional learning opportunities. Massive Open Online Courses (MOOCs) are free online courses available for anyone to enroll.³ MOOCs have been established at Harvard, MIT, Microsoft, and other top universities and institutions in subjects like computer science, data science, business, and more. MOOCs are being replicated in conventional universities and are projected to be a model for adult learning in the coming decade.⁴

Another trend is the growing interest in microlearning, defined as short educational activities that deal with relatively small learning units utilized at the point where the learner will actually need the information.⁵

Dr. Buckley sees potential in microlearning for continuing medical education. “It is unlikely that microlearning would be eligible for CME currently unless there were a mechanism for aggregating multiple events into a substantive unit of credit. But the ACCME [Accreditation Council for Continuing Medical Education] has been very adaptive to various forms of learning, so aggregate microlearning for CME credit may be possible in the future.” He added that the benefits of rapid and reliable access of specific information from a trusted source are significant, and the opportunities for microlearning for chest physicians are almost limitless. “Whether searching for the most updated review of a medical topic, or checking to see if your ICU patient’s sedating medication can cause serotonin syndrome, microlearning is already playing a large role in physician education, just less formal that what’s been used historically,” he said.

Institutions for which professional development learning modules are an important revenue stream will increasingly be challenged to compete with open-access courses of varying quality.

A key trend identified in 2018 is accelerating higher-education technology adoption and a growing focus on measured outcomes and learning.⁵ Individuals are interested in personalized learning plans and adaptive learning systems that can provide real-time assessments and immediate feedback. It is expected that learning modules and curricula will be most successful if they are easily accessed, attractively presented, and incorporate immediate feedback on learning progress. Driving technology adoption in higher education in the next 3-5 years will be the proliferation of open educational resources and the rise of new forms of interdisciplinary studies. As the environment for providing and accessing content shifts from pay-to-access to open-access, organizations will need to identify a new value proposition if they wish to grow or maintain related revenue streams.⁶

The implications of these changes in demand are profound for creators of continuing education content for medical professionals. Major investment will be needed in new, possibly costly platforms that deliver high-quality content with accessibility and interactive elements to meet the demands of professionals, the younger generation in particular.⁷ The market will continue to develop new technology to serve continuing education needs and preferences of users, thus fueling competition among stakeholders. With the proliferation of free and low-cost online and virtual programs, continuing education providers may experience a negative impact on an important revenue stream if they don’t identify a competitive advantage that meets the needs of tomorrow’s workforce. However, educational programs and courses that use artificial intelligence, virtual reality, and augmented reality to enhance the learning experience are likely to experience higher levels of use in the coming years.⁸

Workforce diversity and mentoring

A global economy requires organizations to seek a diverse workforce. Diversity can also lead to higher levels of profitability and employee satisfaction. As such, it will be essential for organizations to increase opportunities for individuals from diverse backgrounds to join the workforce. Creating a diverse workforce will mean removing barriers of time and location to skill building through online learning opportunities and facilitation of interdisciplinary career paths.

A critical piece of the emerging model of career development will be mentoring. Many professionals in today’s workforce view mentoring as an opportunity to gain immediate skills and knowledge quickly and effectively. Mentoring has evolved from pairing young professionals with seasoned veterans to creating relationships that match individuals with others who have the skills and knowledge they desire to learn about – regardless of age and experience. Institutions striving to develop a diverse workforce will need many individuals to serve as both mentors and mentees. When searching for solutions to work-related challenges, individuals will increasingly turn to knowledge management and collaboration systems (virtual mentoring) that provide them with the opportunity to match their needs in an efficient and effective manner.

Dr. Buckley values peer-to-peer mentoring as a means of accessing and sharing niche expertise among colleagues, but he acknowledges the difficulties in incorporating it into everyday practice. “The biggest obstacles are probably time and access. More and more learners and mentors are recognizing the tremendous value of effective mentorship, so convincing people is less of an issue than finding time,” he said.

Mentorship will continue to play a central role in the advancement of one’s career, yet women and minorities find it increasingly difficult to match with a mentor within the workplace. These candidates are likely to seek external opportunities. Individuals will evaluate the experience, opportunities for career advancement and the level of diversity and inclusion when seeking and accepting a new job.

Dr. Buckley sees both progress and remaining challenges in reducing barriers to underrepresented groups in medical institutions. “There continues to be a need for ongoing training to help individuals and institutions recognize and eliminate their barriers and biases, both conscious and subconscious, that interfere with achieving diversity and inclusion. Another important limitation is the pipeline of underrepresented groups that are pursuing careers in medicine. We need to do more empowerment, encouragement, and recruitment of underrepresented groups at a very early stage in their education if we ever expect to achieve our goals.”
 

Future challenges

The transformations described above will require a large investment by physicians aiming to maintain professional currency, by creators of continuing education content, and by employers seeking a diversified workforce. All these stakeholders have an interest in the future direction of continuing education and professional training. The development of new platforms for delivery of content that is easily accessible, formatted for a wide variety of devices, and built with real-time feedback functions will require a significant commitment of resources.


References

1. IDC Trackers. “Worldwide semiannual augmented and virtual reality spending guide.” Accessed Sept. 3, 2019.

2. ASAE. “Foresight Works: User’s Guide.” ASAE Foundation, 2018.

3. Online Course Report. “The State of MOOC 2016: A year of massive landscape change for massive open online courses.” Accessed Sept. 3, 2019.

4. Bill & Melinda Gates Foundation. “Postsecondary Success: Data and Information.” Accessed Sept. 4, 2019.

5. QYReports. “The Microlearning Market Report, 2018.” Accessed Sept. 4, 2019.

6. Adams S et al. “NMC Horizon Report: 2018 Higher Education Edition.” Louisville, CO: EDUCAUSE, 2018.

7. An M. “Content trends: Preferences emerge along generational fault lines.” Hubspot: Nov. 6, 2017; updated Dec 14, 2018.

8. Grajek S and Grama J. “Higher education’s 2018 trend watch and top 10 strategic technologies.” EDUCAUSE Review, Jan 29, 2018.

Note: Background research performed by Avenue M Group.

CHEST Inspiration is a collection of programmatic initiatives developed by the American College of Chest Physicians leadership and aimed at stimulating and encouraging innovation within the association. One of the components of CHEST Inspiration is the Environmental Scan, a series of articles focusing on the internal and external environmental factors that bear on success currently and in the future. See “Envisioning the Future: The CHEST Environmental Scan,” CHEST Physician, June 2019, p. 44, for an introduction to the series.

Keeping up to date and maintaining currency on developments in medicine are a routine part of medical practice, but the means by which this is accomplished are changing rapidly. Training, maintenance of certification, continuing education, mentoring, and career development will all be transformed in the coming years because of new technology and changing needs of physicians. Traditional learning channels such as print media and in-person courses will give way to options that emphasize ease of access, collaboration with fellow learners, and digitally optimized content.

Education and content delivery

The primary distribution channels for keeping medical professionals current in their specialty will continue to shift away from print publications and expand to digital outlets including podcasts, video, and online access to content.¹ Individuals seeking to keep up professionally will increasingly turn to resources that can be found quickly and easily, for example, through voice search. Content that has been optimized to appear quickly and with a clear layout adapted to a wide variety of devices will most likely be consumed at a higher rate than resources from well-established organizations that have not transformed their continuing education content. There is already a growing demand for video and audiocasts accessible via mobile device.²

John D. Buckley, MD, FCCP, professor of medicine and vice chair for education at Indiana University, Indianapolis, sees the transformation of content delivery as a net plus for physicians, with a couple of caveats. He noted, “Whether it is conducting an in-depth literature search, reading/streaming a review lecture, or simply confirming a medical fact, quick access can enhance patient care and advance learning in a manner that meets an individual’s learning style. One potential downside is the risk of unreliable information, so accessing trustworthy sources is essential. Another potential downside is that, while accessing the answer to a very specific question can be done very easily, this might compromise additional learning of related material that used to occur when you had to read an entire book chapter to answer your question. Not only did you answer your question, you learned a lot of other relevant information along the way.”

Online learning is now a vast industry and has been harnessed by millions to further professional learning opportunities. Massive Open Online Courses (MOOCs) are free online courses available for anyone to enroll.³ MOOCs have been established at Harvard, MIT, Microsoft, and other top universities and institutions in subjects like computer science, data science, business, and more. MOOCs are being replicated in conventional universities and are projected to be a model for adult learning in the coming decade.⁴

Another trend is the growing interest in microlearning, defined as short educational activities that deal with relatively small learning units utilized at the point where the learner will actually need the information.⁵

Dr. Buckley sees potential in microlearning for continuing medical education. “It is unlikely that microlearning would be eligible for CME currently unless there were a mechanism for aggregating multiple events into a substantive unit of credit. But the ACCME [Accreditation Council for Continuing Medical Education] has been very adaptive to various forms of learning, so aggregate microlearning for CME credit may be possible in the future.” He added that the benefits of rapid and reliable access of specific information from a trusted source are significant, and the opportunities for microlearning for chest physicians are almost limitless. “Whether searching for the most updated review of a medical topic, or checking to see if your ICU patient’s sedating medication can cause serotonin syndrome, microlearning is already playing a large role in physician education, just less formal that what’s been used historically,” he said.

Institutions for which professional development learning modules are an important revenue stream will increasingly be challenged to compete with open-access courses of varying quality.

A key trend identified in 2018 is accelerating higher-education technology adoption and a growing focus on measured outcomes and learning.⁵ Individuals are interested in personalized learning plans and adaptive learning systems that can provide real-time assessments and immediate feedback. It is expected that learning modules and curricula will be most successful if they are easily accessed, attractively presented, and incorporate immediate feedback on learning progress. Driving technology adoption in higher education in the next 3-5 years will be the proliferation of open educational resources and the rise of new forms of interdisciplinary studies. As the environment for providing and accessing content shifts from pay-to-access to open-access, organizations will need to identify a new value proposition if they wish to grow or maintain related revenue streams.⁶

The implications of these changes in demand are profound for creators of continuing education content for medical professionals. Major investment will be needed in new, possibly costly platforms that deliver high-quality content with accessibility and interactive elements to meet the demands of professionals, the younger generation in particular.⁷ The market will continue to develop new technology to serve continuing education needs and preferences of users, thus fueling competition among stakeholders. With the proliferation of free and low-cost online and virtual programs, continuing education providers may experience a negative impact on an important revenue stream if they don’t identify a competitive advantage that meets the needs of tomorrow’s workforce. However, educational programs and courses that use artificial intelligence, virtual reality, and augmented reality to enhance the learning experience are likely to experience higher levels of use in the coming years.⁸

Workforce diversity and mentoring

A global economy requires organizations to seek a diverse workforce. Diversity can also lead to higher levels of profitability and employee satisfaction. As such, it will be essential for organizations to increase opportunities for individuals from diverse backgrounds to join the workforce. Creating a diverse workforce will mean removing barriers of time and location to skill building through online learning opportunities and facilitation of interdisciplinary career paths.

A critical piece of the emerging model of career development will be mentoring. Many professionals in today’s workforce view mentoring as an opportunity to gain immediate skills and knowledge quickly and effectively. Mentoring has evolved from pairing young professionals with seasoned veterans to creating relationships that match individuals with others who have the skills and knowledge they desire to learn about – regardless of age and experience. Institutions striving to develop a diverse workforce will need many individuals to serve as both mentors and mentees. When searching for solutions to work-related challenges, individuals will increasingly turn to knowledge management and collaboration systems (virtual mentoring) that provide them with the opportunity to match their needs in an efficient and effective manner.

Dr. Buckley values peer-to-peer mentoring as a means of accessing and sharing niche expertise among colleagues, but he acknowledges the difficulties in incorporating it into everyday practice. “The biggest obstacles are probably time and access. More and more learners and mentors are recognizing the tremendous value of effective mentorship, so convincing people is less of an issue than finding time,” he said.

Mentorship will continue to play a central role in the advancement of one’s career, yet women and minorities find it increasingly difficult to match with a mentor within the workplace. These candidates are likely to seek external opportunities. Individuals will evaluate the experience, opportunities for career advancement and the level of diversity and inclusion when seeking and accepting a new job.

Dr. Buckley sees both progress and remaining challenges in reducing barriers to underrepresented groups in medical institutions. “There continues to be a need for ongoing training to help individuals and institutions recognize and eliminate their barriers and biases, both conscious and subconscious, that interfere with achieving diversity and inclusion. Another important limitation is the pipeline of underrepresented groups that are pursuing careers in medicine. We need to do more empowerment, encouragement, and recruitment of underrepresented groups at a very early stage in their education if we ever expect to achieve our goals.”
 

Future challenges

The transformations described above will require a large investment by physicians aiming to maintain professional currency, by creators of continuing education content, and by employers seeking a diversified workforce. All these stakeholders have an interest in the future direction of continuing education and professional training. The development of new platforms for delivery of content that is easily accessible, formatted for a wide variety of devices, and built with real-time feedback functions will require a significant commitment of resources.


References

1. IDC Trackers. “Worldwide semiannual augmented and virtual reality spending guide.” Accessed Sept. 3, 2019.

2. ASAE. “Foresight Works: User’s Guide.” ASAE Foundation, 2018.

3. Online Course Report. “The State of MOOC 2016: A year of massive landscape change for massive open online courses.” Accessed Sept. 3, 2019.

4. Bill & Melinda Gates Foundation. “Postsecondary Success: Data and Information.” Accessed Sept. 4, 2019.

5. QYReports. “The Microlearning Market Report, 2018.” Accessed Sept. 4, 2019.

6. Adams S et al. “NMC Horizon Report: 2018 Higher Education Edition.” Louisville, CO: EDUCAUSE, 2018.

7. An M. “Content trends: Preferences emerge along generational fault lines.” Hubspot: Nov. 6, 2017; updated Dec 14, 2018.

8. Grajek S and Grama J. “Higher education’s 2018 trend watch and top 10 strategic technologies.” EDUCAUSE Review, Jan 29, 2018.

Note: Background research performed by Avenue M Group.

CHEST Inspiration is a collection of programmatic initiatives developed by the American College of Chest Physicians leadership and aimed at stimulating and encouraging innovation within the association. One of the components of CHEST Inspiration is the Environmental Scan, a series of articles focusing on the internal and external environmental factors that bear on success currently and in the future. See “Envisioning the Future: The CHEST Environmental Scan,” CHEST Physician, June 2019, p. 44, for an introduction to the series.

Patients 50-79 years old with a demonstrably low risk of developing the disease within 15 years probably don’t need to be screened for colorectal cancer. But if their risk of disease is at least 3% over 15 years, patients should be screened, Lise M. Helsingen, MD, and colleagues wrote in BMJ (2019;367:l5515 doi: 10.1136/bmj.l5515).

For these patients, “We suggest screening with one of the four screening options: fecal immunochemical test (FIT) every year, FIT every 2 years, a single sigmoidoscopy, or a single colonoscopy,” wrote Dr. Helsingen of the University of Oslo, and her team.

She chaired a 22-member international panel that developed a collaborative effort from the MAGIC research and innovation program as a part of the BMJ Rapid Recommendations project. The team reviewed 12 research papers comprising almost 1.4 million patients from Denmark, Italy, the Netherlands, Norway, Poland, Spain, Sweden, the United Kingdom, and the United States. Follow-up ranged from 0 to 19.5 years for colorectal cancer incidence and up to 30 years for mortality.

Because of the dearth of relevant data in some studies, however, the projected outcomes had to be simulated, with benefits and harms calculations based on 100% screening adherence. However, the team noted, it’s impossible to achieve complete adherence. Most studies of colorectal screening don’t exceed a 50% adherence level.

“All the modeling data are of low certainty. It is a useful indication, but there is a high chance that new evidence will show a smaller or larger benefit, which in turn may alter these recommendations.”

Compared with no screening, all four screening models reduced the risk of colorectal cancer mortality to a similar level.

• FIT every year, 59%.
• FIT every 2 years, 50%.
• Single sigmoidoscopy, 52%.
• Single colonoscopy, 67%.

Screening had less of an impact on reducing the incidence of colorectal cancer:

• FIT every 2 years, 0.05%.
• FIT every year, 0.15%.
• Single sigmoidoscopy, 27%.
• Single colonoscopy, 34%.

The panel also assessed potential harms. Among almost 1 million patients, the colonoscopy-related mortality rate was 0.03 per 1,000 procedures. The perforation rate was 0.8 per 1,000 colonoscopies after a positive fecal test, and 1.4 per 1,000 screened with sigmoidoscopy. The bleeding rate was 1.9 per 1,000 colonoscopies performed after a positive fecal test, and 3-4 per 1,000 screened with sigmoidoscopy.

Successful implementation of these recommendations hinges on accurate risk assessment, however. The team recommended the QCancer platform as “one of the best performing models for both men and women.”

The calculator includes age, sex, ethnicity, smoking status, alcohol use, family history of gastrointestinal cancer, personal history of other cancers, diabetes, ulcerative colitis, colonic polyps, and body mass index.

“We suggest this model because it is available as an online calculator; includes only risk factors available in routine health care; has been validated in a population separate from the derivation population; has reasonable discriminatory ability; and has a good fit between predicted and observed outcomes. In addition, it is the only online risk calculator we know of that predicts risk over a 15-year time horizon.”

The team stressed that their recommendations can’t be applied to all patients. Because evidence for both screening recommendations was weak – largely because of the dearth of supporting data – patients and physicians should cocreate a personalized screening plan.

“Several factors influence individuals’ decisions whether to be screened, even when they are presented with the same information,” the authors said. These include variation in an individual’s values and preferences, a close balance of benefits versus harms and burdens, and personal preference.

“Some individuals may value a minimally invasive test such as FIT, and the possibility of invasive screening with colonoscopy might put them off screening altogether. Those who most value preventing colorectal cancer or avoiding repeated testing are likely to choose sigmoidoscopy or colonoscopy.”

The authors had no financial conflicts of interest.

SOURCE: BMJ 2019;367:l5515. doi: 10.1136/bmj.l5515.

Patients 50-79 years old with a demonstrably low risk of developing the disease within 15 years probably don’t need to be screened for colorectal cancer. But if their risk of disease is at least 3% over 15 years, patients should be screened, Lise M. Helsingen, MD, and colleagues wrote in BMJ (2019;367:l5515 doi: 10.1136/bmj.l5515).

For these patients, “We suggest screening with one of the four screening options: fecal immunochemical test (FIT) every year, FIT every 2 years, a single sigmoidoscopy, or a single colonoscopy,” wrote Dr. Helsingen of the University of Oslo, and her team.

She chaired a 22-member international panel that developed a collaborative effort from the MAGIC research and innovation program as a part of the BMJ Rapid Recommendations project. The team reviewed 12 research papers comprising almost 1.4 million patients from Denmark, Italy, the Netherlands, Norway, Poland, Spain, Sweden, the United Kingdom, and the United States. Follow-up ranged from 0 to 19.5 years for colorectal cancer incidence and up to 30 years for mortality.

Because of the dearth of relevant data in some studies, however, the projected outcomes had to be simulated, with benefits and harms calculations based on 100% screening adherence. However, the team noted, it’s impossible to achieve complete adherence. Most studies of colorectal screening don’t exceed a 50% adherence level.

“All the modeling data are of low certainty. It is a useful indication, but there is a high chance that new evidence will show a smaller or larger benefit, which in turn may alter these recommendations.”

Compared with no screening, all four screening models reduced the risk of colorectal cancer mortality to a similar level.

• FIT every year, 59%.
• FIT every 2 years, 50%.
• Single sigmoidoscopy, 52%.
• Single colonoscopy, 67%.

Screening had less of an impact on reducing the incidence of colorectal cancer:

• FIT every 2 years, 0.05%.
• FIT every year, 0.15%.
• Single sigmoidoscopy, 27%.
• Single colonoscopy, 34%.

The panel also assessed potential harms. Among almost 1 million patients, the colonoscopy-related mortality rate was 0.03 per 1,000 procedures. The perforation rate was 0.8 per 1,000 colonoscopies after a positive fecal test, and 1.4 per 1,000 screened with sigmoidoscopy. The bleeding rate was 1.9 per 1,000 colonoscopies performed after a positive fecal test, and 3-4 per 1,000 screened with sigmoidoscopy.

Successful implementation of these recommendations hinges on accurate risk assessment, however. The team recommended the QCancer platform as “one of the best performing models for both men and women.”

The calculator includes age, sex, ethnicity, smoking status, alcohol use, family history of gastrointestinal cancer, personal history of other cancers, diabetes, ulcerative colitis, colonic polyps, and body mass index.

“We suggest this model because it is available as an online calculator; includes only risk factors available in routine health care; has been validated in a population separate from the derivation population; has reasonable discriminatory ability; and has a good fit between predicted and observed outcomes. In addition, it is the only online risk calculator we know of that predicts risk over a 15-year time horizon.”

The team stressed that their recommendations can’t be applied to all patients. Because evidence for both screening recommendations was weak – largely because of the dearth of supporting data – patients and physicians should cocreate a personalized screening plan.

“Several factors influence individuals’ decisions whether to be screened, even when they are presented with the same information,” the authors said. These include variation in an individual’s values and preferences, a close balance of benefits versus harms and burdens, and personal preference.

“Some individuals may value a minimally invasive test such as FIT, and the possibility of invasive screening with colonoscopy might put them off screening altogether. Those who most value preventing colorectal cancer or avoiding repeated testing are likely to choose sigmoidoscopy or colonoscopy.”

The authors had no financial conflicts of interest.

SOURCE: BMJ 2019;367:l5515. doi: 10.1136/bmj.l5515.

Patients 50-79 years old with a demonstrably low risk of developing the disease within 15 years probably don’t need to be screened for colorectal cancer. But if their risk of disease is at least 3% over 15 years, patients should be screened, Lise M. Helsingen, MD, and colleagues wrote in BMJ (2019;367:l5515 doi: 10.1136/bmj.l5515).

For these patients, “We suggest screening with one of the four screening options: fecal immunochemical test (FIT) every year, FIT every 2 years, a single sigmoidoscopy, or a single colonoscopy,” wrote Dr. Helsingen of the University of Oslo, and her team.

She chaired a 22-member international panel that developed a collaborative effort from the MAGIC research and innovation program as a part of the BMJ Rapid Recommendations project. The team reviewed 12 research papers comprising almost 1.4 million patients from Denmark, Italy, the Netherlands, Norway, Poland, Spain, Sweden, the United Kingdom, and the United States. Follow-up ranged from 0 to 19.5 years for colorectal cancer incidence and up to 30 years for mortality.

Because of the dearth of relevant data in some studies, however, the projected outcomes had to be simulated, with benefits and harms calculations based on 100% screening adherence. However, the team noted, it’s impossible to achieve complete adherence. Most studies of colorectal screening don’t exceed a 50% adherence level.

“All the modeling data are of low certainty. It is a useful indication, but there is a high chance that new evidence will show a smaller or larger benefit, which in turn may alter these recommendations.”

Compared with no screening, all four screening models reduced the risk of colorectal cancer mortality to a similar level.

• FIT every year, 59%.
• FIT every 2 years, 50%.
• Single sigmoidoscopy, 52%.
• Single colonoscopy, 67%.

Screening had less of an impact on reducing the incidence of colorectal cancer:

• FIT every 2 years, 0.05%.
• FIT every year, 0.15%.
• Single sigmoidoscopy, 27%.
• Single colonoscopy, 34%.

The panel also assessed potential harms. Among almost 1 million patients, the colonoscopy-related mortality rate was 0.03 per 1,000 procedures. The perforation rate was 0.8 per 1,000 colonoscopies after a positive fecal test, and 1.4 per 1,000 screened with sigmoidoscopy. The bleeding rate was 1.9 per 1,000 colonoscopies performed after a positive fecal test, and 3-4 per 1,000 screened with sigmoidoscopy.

Successful implementation of these recommendations hinges on accurate risk assessment, however. The team recommended the QCancer platform as “one of the best performing models for both men and women.”

The calculator includes age, sex, ethnicity, smoking status, alcohol use, family history of gastrointestinal cancer, personal history of other cancers, diabetes, ulcerative colitis, colonic polyps, and body mass index.

“We suggest this model because it is available as an online calculator; includes only risk factors available in routine health care; has been validated in a population separate from the derivation population; has reasonable discriminatory ability; and has a good fit between predicted and observed outcomes. In addition, it is the only online risk calculator we know of that predicts risk over a 15-year time horizon.”

The team stressed that their recommendations can’t be applied to all patients. Because evidence for both screening recommendations was weak – largely because of the dearth of supporting data – patients and physicians should cocreate a personalized screening plan.

“Several factors influence individuals’ decisions whether to be screened, even when they are presented with the same information,” the authors said. These include variation in an individual’s values and preferences, a close balance of benefits versus harms and burdens, and personal preference.

“Some individuals may value a minimally invasive test such as FIT, and the possibility of invasive screening with colonoscopy might put them off screening altogether. Those who most value preventing colorectal cancer or avoiding repeated testing are likely to choose sigmoidoscopy or colonoscopy.”

The authors had no financial conflicts of interest.

SOURCE: BMJ 2019;367:l5515. doi: 10.1136/bmj.l5515.

As the medical field continues to evolve, so do policies and laws designed to accommodate a growing population, and physicians are once again called upon to expand their role in health care. The American Board of Internal Medicine has called for “a commitment to the promotion of public health and preventative medicine, as well as public advocacy on the part of each physician.”¹ In our responsibility to preserve and promote human life, physicians are not only uniquely positioned for advocacy but also inherently assume the role of becoming health care activists.

The American Medical Association has defined physician advocacy as promoting “social, economic, educational, and political changes that ameliorate suffering and contribute to human well being.”² For health care professionals, this translates into ensuring the concerns and best interests of patients are at the core of all decisions.³ For generations, physicians have taken extra steps for patient care in daily practice, including submitting prior authorizations, performing peer review, and taking part in family meetings. Many doctors also participate on hospital committees and boards for quality improvement measures and are leaders in designing strategies to improve patient safety and health care experiences. Although these examples may be viewed as a fundamental part of daily practice, in fact, these roles are consistent with advocacy on a local level. A significant number of physicians participate in medical education, research, and societal duties, which include formulating and reviewing guidelines for medical practice. Participation in conference organizing committees and reviewing medical journals are likewise not uncommon roles among medical practitioners. These efforts to provide education to improve patient care are also forms of advocacy on a national or regional level but often viewed as a standard in professionalism.⁴

It is on the federal and political level in advocacy where physician representation is critical. Health legislation is enacted by Congress and signed into law by the president of the United States.⁵ These laws can drastically affect clinical practice and patient care, especially in the realm of preventive medicine and pharmaceuticals. Gastroenterology is a unique field in which a large portion of practice is dedicated to cancer prevention, by screening age-appropriate individuals and monitoring high-risk patients. The field is rapidly expanding in the pharmaceutical area with new medications for inflammatory bowel disease and groundbreaking treatments for viral hepatitis. The breadth of practice in gastroenterology calls for antiquated laws to be changed to accommodate the development of patient care guidelines. With physicians representing less than 3% of Congress,⁶ the rules that govern our practice are largely left to those unfamiliar with the delivery of health care.

Lack of experience, limited time, and a tradition in medicine that prefers physicians to be apolitical are each contributing factors for reduced participation in federal advocacy.⁷ Professional GI societies, including the American Gastroenterological Association, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, have a presence in public policy to educate lawmakers and promote statutes in gastroenterology. The involvement of these organizations in legislation is critical since public policy directly affects the interests and well-being of patients.

• Reducing the administrative burden of prior authorizations.
• Implementing timely appeals for non–first-line therapies as determined by payers (step therapy).
• Eliminating surprise billing and cost-sharing for screening colonoscopy.
• Preserving patient protections, including for preexisting conditions and preventive services.
• Increasing federal funding and research appropriations for gastrointestinal research.

Communication with and development of relationships with legislators are essential to effective advocacy.^7,8 Health professionals should be well-informed resources for members of Congress and therefore it is pivotal to provide factual information when presenting topics. There are various ways to reach congressional representatives, including personal visits, writing letters, making phone calls, or attending town halls.

Of the aforementioned, in-person meetings are the best way to directly connect with legislators. These allow for time to discuss a legislative issue, including the background and societal impact, proposed initiative, and personal accounts relating to the topic. Attending town halls also will give face-time with legislators, although the format to ask questions often is abbreviated. GI societies use letter writing as a way to increase support for a proposed bill or measure. The efficacy of letter writing increases with higher involvement. Letters are often generated in an online forum that requires the user’s zip code (so the letter can be routed to the appropriate legislator) and name with electronic signature, which are designed for easy use to boost participation.

Understanding that physicians are advocates in daily practice and that federal initiatives have significant impact on patients and clinical practice is the first step to getting involved. Participation at the local level includes connecting with the district offices of congressional leaders through letter writing, making phone calls, or in-person visits. On regional and national levels, involvement with state legislators, GI societies, or personal like-minded groups are ways to initiate federal advocacy. GI societies have federal policy committees, political action committees, and opportunities for early-career gastroenterologists to become involved in advocacy, including the Congressional Advocates Program from the AGA and the Young Physician Leadership Scholars Program from the ACG. Be sure to visit AGA’s Advocacy & Policy page to keep informed about current and future opportunities.

As the population grows and human life expectancy increases, the practice of medicine is a prime target for legislative changes, which ultimately affect patient care and clinical practice. Physicians are respected members of society, have expansive knowledge in disease processes and the delivery of health care to patients, and are naturally patient advocates. For these reasons, it is imperative for doctors to rise to the calling of federal advocacy, to continue to preserve the best interests and dignity of our patients.
 

References

1. ABIM Foundation. Ann Intern Med. 2002;136:243-6.

2. Earnest MA et al. Academic Med. 2010;85(1):63-7.

3. Schwartz L. J Med Ethics. 2002;28:37-40.

4. Howell BA et al. J Gen Intern Med. 2019 Aug 5. https://doi.org/10.1007/s11606-019-05184-3. [epub ahead of print]

5. The House of Representatives.

6. AGA News: https://www.gastro.org/news/new-congress-includes-22-health-care-providers

7. Kupfer SS et al. Gastroenterology. 2019;156(4)8:834-7.

8. Grace ND and LB Dennis. Hepatology. 2007;45(6):1337-9.
 

Dr. Abbasi is a gastroenterologist who works in inflammatory bowel diseases at Cedars-Sinai Medical Center and Santa Monica Gastroenterology, Calif.

As the medical field continues to evolve, so do policies and laws designed to accommodate a growing population, and physicians are once again called upon to expand their role in health care. The American Board of Internal Medicine has called for “a commitment to the promotion of public health and preventative medicine, as well as public advocacy on the part of each physician.”¹ In our responsibility to preserve and promote human life, physicians are not only uniquely positioned for advocacy but also inherently assume the role of becoming health care activists.

The American Medical Association has defined physician advocacy as promoting “social, economic, educational, and political changes that ameliorate suffering and contribute to human well being.”² For health care professionals, this translates into ensuring the concerns and best interests of patients are at the core of all decisions.³ For generations, physicians have taken extra steps for patient care in daily practice, including submitting prior authorizations, performing peer review, and taking part in family meetings. Many doctors also participate on hospital committees and boards for quality improvement measures and are leaders in designing strategies to improve patient safety and health care experiences. Although these examples may be viewed as a fundamental part of daily practice, in fact, these roles are consistent with advocacy on a local level. A significant number of physicians participate in medical education, research, and societal duties, which include formulating and reviewing guidelines for medical practice. Participation in conference organizing committees and reviewing medical journals are likewise not uncommon roles among medical practitioners. These efforts to provide education to improve patient care are also forms of advocacy on a national or regional level but often viewed as a standard in professionalism.⁴

It is on the federal and political level in advocacy where physician representation is critical. Health legislation is enacted by Congress and signed into law by the president of the United States.⁵ These laws can drastically affect clinical practice and patient care, especially in the realm of preventive medicine and pharmaceuticals. Gastroenterology is a unique field in which a large portion of practice is dedicated to cancer prevention, by screening age-appropriate individuals and monitoring high-risk patients. The field is rapidly expanding in the pharmaceutical area with new medications for inflammatory bowel disease and groundbreaking treatments for viral hepatitis. The breadth of practice in gastroenterology calls for antiquated laws to be changed to accommodate the development of patient care guidelines. With physicians representing less than 3% of Congress,⁶ the rules that govern our practice are largely left to those unfamiliar with the delivery of health care.

Lack of experience, limited time, and a tradition in medicine that prefers physicians to be apolitical are each contributing factors for reduced participation in federal advocacy.⁷ Professional GI societies, including the American Gastroenterological Association, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, have a presence in public policy to educate lawmakers and promote statutes in gastroenterology. The involvement of these organizations in legislation is critical since public policy directly affects the interests and well-being of patients.

• Reducing the administrative burden of prior authorizations.
• Implementing timely appeals for non–first-line therapies as determined by payers (step therapy).
• Eliminating surprise billing and cost-sharing for screening colonoscopy.
• Preserving patient protections, including for preexisting conditions and preventive services.
• Increasing federal funding and research appropriations for gastrointestinal research.

Communication with and development of relationships with legislators are essential to effective advocacy.^7,8 Health professionals should be well-informed resources for members of Congress and therefore it is pivotal to provide factual information when presenting topics. There are various ways to reach congressional representatives, including personal visits, writing letters, making phone calls, or attending town halls.

Of the aforementioned, in-person meetings are the best way to directly connect with legislators. These allow for time to discuss a legislative issue, including the background and societal impact, proposed initiative, and personal accounts relating to the topic. Attending town halls also will give face-time with legislators, although the format to ask questions often is abbreviated. GI societies use letter writing as a way to increase support for a proposed bill or measure. The efficacy of letter writing increases with higher involvement. Letters are often generated in an online forum that requires the user’s zip code (so the letter can be routed to the appropriate legislator) and name with electronic signature, which are designed for easy use to boost participation.

Understanding that physicians are advocates in daily practice and that federal initiatives have significant impact on patients and clinical practice is the first step to getting involved. Participation at the local level includes connecting with the district offices of congressional leaders through letter writing, making phone calls, or in-person visits. On regional and national levels, involvement with state legislators, GI societies, or personal like-minded groups are ways to initiate federal advocacy. GI societies have federal policy committees, political action committees, and opportunities for early-career gastroenterologists to become involved in advocacy, including the Congressional Advocates Program from the AGA and the Young Physician Leadership Scholars Program from the ACG. Be sure to visit AGA’s Advocacy & Policy page to keep informed about current and future opportunities.

As the population grows and human life expectancy increases, the practice of medicine is a prime target for legislative changes, which ultimately affect patient care and clinical practice. Physicians are respected members of society, have expansive knowledge in disease processes and the delivery of health care to patients, and are naturally patient advocates. For these reasons, it is imperative for doctors to rise to the calling of federal advocacy, to continue to preserve the best interests and dignity of our patients.
 

References

1. ABIM Foundation. Ann Intern Med. 2002;136:243-6.

2. Earnest MA et al. Academic Med. 2010;85(1):63-7.

3. Schwartz L. J Med Ethics. 2002;28:37-40.

4. Howell BA et al. J Gen Intern Med. 2019 Aug 5. https://doi.org/10.1007/s11606-019-05184-3. [epub ahead of print]

5. The House of Representatives.

6. AGA News: https://www.gastro.org/news/new-congress-includes-22-health-care-providers

7. Kupfer SS et al. Gastroenterology. 2019;156(4)8:834-7.

8. Grace ND and LB Dennis. Hepatology. 2007;45(6):1337-9.
 

Dr. Abbasi is a gastroenterologist who works in inflammatory bowel diseases at Cedars-Sinai Medical Center and Santa Monica Gastroenterology, Calif.

As the medical field continues to evolve, so do policies and laws designed to accommodate a growing population, and physicians are once again called upon to expand their role in health care. The American Board of Internal Medicine has called for “a commitment to the promotion of public health and preventative medicine, as well as public advocacy on the part of each physician.”¹ In our responsibility to preserve and promote human life, physicians are not only uniquely positioned for advocacy but also inherently assume the role of becoming health care activists.

The American Medical Association has defined physician advocacy as promoting “social, economic, educational, and political changes that ameliorate suffering and contribute to human well being.”² For health care professionals, this translates into ensuring the concerns and best interests of patients are at the core of all decisions.³ For generations, physicians have taken extra steps for patient care in daily practice, including submitting prior authorizations, performing peer review, and taking part in family meetings. Many doctors also participate on hospital committees and boards for quality improvement measures and are leaders in designing strategies to improve patient safety and health care experiences. Although these examples may be viewed as a fundamental part of daily practice, in fact, these roles are consistent with advocacy on a local level. A significant number of physicians participate in medical education, research, and societal duties, which include formulating and reviewing guidelines for medical practice. Participation in conference organizing committees and reviewing medical journals are likewise not uncommon roles among medical practitioners. These efforts to provide education to improve patient care are also forms of advocacy on a national or regional level but often viewed as a standard in professionalism.⁴

It is on the federal and political level in advocacy where physician representation is critical. Health legislation is enacted by Congress and signed into law by the president of the United States.⁵ These laws can drastically affect clinical practice and patient care, especially in the realm of preventive medicine and pharmaceuticals. Gastroenterology is a unique field in which a large portion of practice is dedicated to cancer prevention, by screening age-appropriate individuals and monitoring high-risk patients. The field is rapidly expanding in the pharmaceutical area with new medications for inflammatory bowel disease and groundbreaking treatments for viral hepatitis. The breadth of practice in gastroenterology calls for antiquated laws to be changed to accommodate the development of patient care guidelines. With physicians representing less than 3% of Congress,⁶ the rules that govern our practice are largely left to those unfamiliar with the delivery of health care.

Lack of experience, limited time, and a tradition in medicine that prefers physicians to be apolitical are each contributing factors for reduced participation in federal advocacy.⁷ Professional GI societies, including the American Gastroenterological Association, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, have a presence in public policy to educate lawmakers and promote statutes in gastroenterology. The involvement of these organizations in legislation is critical since public policy directly affects the interests and well-being of patients.

• Reducing the administrative burden of prior authorizations.
• Implementing timely appeals for non–first-line therapies as determined by payers (step therapy).
• Eliminating surprise billing and cost-sharing for screening colonoscopy.
• Preserving patient protections, including for preexisting conditions and preventive services.
• Increasing federal funding and research appropriations for gastrointestinal research.

Communication with and development of relationships with legislators are essential to effective advocacy.^7,8 Health professionals should be well-informed resources for members of Congress and therefore it is pivotal to provide factual information when presenting topics. There are various ways to reach congressional representatives, including personal visits, writing letters, making phone calls, or attending town halls.

Of the aforementioned, in-person meetings are the best way to directly connect with legislators. These allow for time to discuss a legislative issue, including the background and societal impact, proposed initiative, and personal accounts relating to the topic. Attending town halls also will give face-time with legislators, although the format to ask questions often is abbreviated. GI societies use letter writing as a way to increase support for a proposed bill or measure. The efficacy of letter writing increases with higher involvement. Letters are often generated in an online forum that requires the user’s zip code (so the letter can be routed to the appropriate legislator) and name with electronic signature, which are designed for easy use to boost participation.

Understanding that physicians are advocates in daily practice and that federal initiatives have significant impact on patients and clinical practice is the first step to getting involved. Participation at the local level includes connecting with the district offices of congressional leaders through letter writing, making phone calls, or in-person visits. On regional and national levels, involvement with state legislators, GI societies, or personal like-minded groups are ways to initiate federal advocacy. GI societies have federal policy committees, political action committees, and opportunities for early-career gastroenterologists to become involved in advocacy, including the Congressional Advocates Program from the AGA and the Young Physician Leadership Scholars Program from the ACG. Be sure to visit AGA’s Advocacy & Policy page to keep informed about current and future opportunities.

As the population grows and human life expectancy increases, the practice of medicine is a prime target for legislative changes, which ultimately affect patient care and clinical practice. Physicians are respected members of society, have expansive knowledge in disease processes and the delivery of health care to patients, and are naturally patient advocates. For these reasons, it is imperative for doctors to rise to the calling of federal advocacy, to continue to preserve the best interests and dignity of our patients.
 

References

1. ABIM Foundation. Ann Intern Med. 2002;136:243-6.

2. Earnest MA et al. Academic Med. 2010;85(1):63-7.

3. Schwartz L. J Med Ethics. 2002;28:37-40.

4. Howell BA et al. J Gen Intern Med. 2019 Aug 5. https://doi.org/10.1007/s11606-019-05184-3. [epub ahead of print]

5. The House of Representatives.

6. AGA News: https://www.gastro.org/news/new-congress-includes-22-health-care-providers

7. Kupfer SS et al. Gastroenterology. 2019;156(4)8:834-7.

8. Grace ND and LB Dennis. Hepatology. 2007;45(6):1337-9.
 

Dr. Abbasi is a gastroenterologist who works in inflammatory bowel diseases at Cedars-Sinai Medical Center and Santa Monica Gastroenterology, Calif.