Society News

To continue to bring awareness to our members, we once again discuss this new add-on Healthcare Common Procedure Coding System code finalized by the Centers for Medicare & Medicaid Services (CMS) for January 1, 2024. This add-on code is for new (99202-99205) and established (99212-99215) office visits. CMS created this add-on code to address the additional costs and resources associated with providing longitudinal care.

G2211 – Visit complexity inherent to evaluation and management (E/M) 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 condition, or a complex condition (Add-on code; list separately in addition to office/outpatient (O/O) E/M visit, new or established)

The documentation should demonstrate the intent and need for ongoing care. Otherwise, no additional documentation is required. CMS pays $16.04 for each service (wRVU = 0.33). It may be reported each time the patient is seen, and there is currently no limit to how often it may be used. Also, there is no additional copay requirement for patients.

Do’s and don’ts

Do report in the following situations when longitudinal care is provided:

• The provider has or intends to have a long-term, ongoing relationship with the patient (ie, G2211 can be used for a new patient visit)
• Audio/video virtual visits
• May be reported with Prolonged Care Services G2212
• When advanced practice providers or physician colleagues in the same specialty practice see the patient (ie, if you see the patient for an urgent visit, but the patient is usually followed by your partner, you can still use G2211)
• When working with graduate medical education trainees (along with the -GC modifier), and as long as the conditions described in the description of G2211 are met

Do NOT report in the following situations:

• If modifier -25 is appended to the E/M service when another service is provided on the same day (eg, pulmonary function tests, 6-minute walk tests, immunization)
• Audio-only virtual visits, hospital, skilled nursing facility, or long-term acute care hospital
• If the patient is not expected to return for ongoing care
• If the reason for longitudinal care does not include a “single, serious condition or a complex condition” (eg, annual visits for a stable 6 mm lung nodule)

CMS expects that this will be billed with 38% of all E/M services initially and potentially up to 54% over time. We feel this is reimbursement for the work being done to care for our patients with single, serious, or complex conditions. Both Medicare and Medicare Advantage plans are expected to reimburse for this service. Whether other payers will do the same is unclear, but it will become clear with time and further negotiation at the local level. In the meantime, members are encouraged to report this code for all appropriate patient encounters.
 

Questions and answers — G2211

Question: What private insurances cover G2211?

Answer: As of March 1, 2024, four national payers have confirmed coverage of G2211:

• Cigna (Medicare Advantage only),
• Humana (commercial and Medicare Advantage),
• United Healthcare (commercial and Medicare Advantage), and
• Aetna (Medicare Advantage).

Question: What needs to be documented for G2211?

Answer: CMS states, “You must document the reason for billing the office and outpatient (O/O) and evaluation and management (E/M). The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation.”

American Thoracic Society (ATS) and CHEST also recommend including a detailed assessment and plan for the visit, as well as any follow-up. The complexity of the visit should be clear in your documentation to support the medical necessity for reporting the G2211.
 

Question: How can a provider show that a new patient visit (99202-99205) is part of continuing care?

Answer: The treating practitioner should make sure their documentation supports their intent to provide ongoing care to the patient. Establishing such intent goes beyond a statement that the provider plans to provide ongoing care or schedule a follow-up visit. The circumstances of the visit should support the extra work involved in becoming the focal point of the patient’s care or providing ongoing care for a serious or complex condition.

Question: Dr. Red works at a primary care practice, is the focal point for a patient’s care, and has reported G2211. If Dr. Yellow, who is in the same specialty, or Mr. Green, a nurse practitioner, is covering for Dr. Red, and the patient comes in for a visit, can they report G2211 for that visit?

Answer: Yes. The same specialty/same provider rules would apply in this situation. But remember that Dr. Yellow’s or Mr. Green’s documentation for that encounter must support the code.

Question: Can a resident report G2211 under the primary care exemption?

Answer: Yes, according to CMS staff, so long as the service and the documentation meet all the requirements for the exemption and the visit complexity code. For example, the resident can only report low-level E/M codes, and the resident must be “the focal point for that person’s care.”

Question: Are there frequency limits for how often we can report G2211, either for a single patient in a given time period or by a provider or a practice?

Answer: Not at this time, but make sure your providers are following the rules for reporting the code. “There’s got to be documentation that suggests why the practitioner believes they are treating the patient on this long-standing, longitudinal trajectory, and we’ll be able to see how that interaction is happening,” senior CMS staff said. CMS staff further issued a subtle warning to providers by reminding them that CMS has a very strong integrity program. Your practice can avoid problems with thorough training, frequent chart review, and encouraging the team to ask questions until you feel that everyone is comfortable with the code.

Question: Are there any limits on the specialties that can report the code? Is it just for primary care providers?

Answer: No. Remember that a provider who is managing a single serious or complex condition can also report the code. But CMS expects the documentation to support the ongoing nature of the treatment. If a patient sees a provider as a one-off encounter, perhaps to manage an acute problem, that visit wouldn’t qualify. But if the provider clearly documents that they are actively managing the patient’s condition, the encounters could qualify.

Question: Will CMS issue a list of conditions that meet the code’s serious or complex condition requirement?

Answer: CMS has included the examples of HIV and sickle cell anemia in existing guidance, and it plans to issue a few more examples “that help folks understand what is expected.” However, it won’t be a complete list of every condition that might qualify.

Originally published in the May 2023 issue of the American Thoracic Society’s ATS Coding & Billing Quarterly. Republished with permission from the American Thoracic Society.

To continue to bring awareness to our members, we once again discuss this new add-on Healthcare Common Procedure Coding System code finalized by the Centers for Medicare & Medicaid Services (CMS) for January 1, 2024. This add-on code is for new (99202-99205) and established (99212-99215) office visits. CMS created this add-on code to address the additional costs and resources associated with providing longitudinal care.

G2211 – Visit complexity inherent to evaluation and management (E/M) 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 condition, or a complex condition (Add-on code; list separately in addition to office/outpatient (O/O) E/M visit, new or established)

The documentation should demonstrate the intent and need for ongoing care. Otherwise, no additional documentation is required. CMS pays $16.04 for each service (wRVU = 0.33). It may be reported each time the patient is seen, and there is currently no limit to how often it may be used. Also, there is no additional copay requirement for patients.

Do’s and don’ts

Do report in the following situations when longitudinal care is provided:

• The provider has or intends to have a long-term, ongoing relationship with the patient (ie, G2211 can be used for a new patient visit)
• Audio/video virtual visits
• May be reported with Prolonged Care Services G2212
• When advanced practice providers or physician colleagues in the same specialty practice see the patient (ie, if you see the patient for an urgent visit, but the patient is usually followed by your partner, you can still use G2211)
• When working with graduate medical education trainees (along with the -GC modifier), and as long as the conditions described in the description of G2211 are met

Do NOT report in the following situations:

• If modifier -25 is appended to the E/M service when another service is provided on the same day (eg, pulmonary function tests, 6-minute walk tests, immunization)
• Audio-only virtual visits, hospital, skilled nursing facility, or long-term acute care hospital
• If the patient is not expected to return for ongoing care
• If the reason for longitudinal care does not include a “single, serious condition or a complex condition” (eg, annual visits for a stable 6 mm lung nodule)

CMS expects that this will be billed with 38% of all E/M services initially and potentially up to 54% over time. We feel this is reimbursement for the work being done to care for our patients with single, serious, or complex conditions. Both Medicare and Medicare Advantage plans are expected to reimburse for this service. Whether other payers will do the same is unclear, but it will become clear with time and further negotiation at the local level. In the meantime, members are encouraged to report this code for all appropriate patient encounters.
 

Questions and answers — G2211

Question: What private insurances cover G2211?

Answer: As of March 1, 2024, four national payers have confirmed coverage of G2211:

• Cigna (Medicare Advantage only),
• Humana (commercial and Medicare Advantage),
• United Healthcare (commercial and Medicare Advantage), and
• Aetna (Medicare Advantage).

Question: What needs to be documented for G2211?

Answer: CMS states, “You must document the reason for billing the office and outpatient (O/O) and evaluation and management (E/M). The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation.”

American Thoracic Society (ATS) and CHEST also recommend including a detailed assessment and plan for the visit, as well as any follow-up. The complexity of the visit should be clear in your documentation to support the medical necessity for reporting the G2211.
 

Question: How can a provider show that a new patient visit (99202-99205) is part of continuing care?

Answer: The treating practitioner should make sure their documentation supports their intent to provide ongoing care to the patient. Establishing such intent goes beyond a statement that the provider plans to provide ongoing care or schedule a follow-up visit. The circumstances of the visit should support the extra work involved in becoming the focal point of the patient’s care or providing ongoing care for a serious or complex condition.

Question: Dr. Red works at a primary care practice, is the focal point for a patient’s care, and has reported G2211. If Dr. Yellow, who is in the same specialty, or Mr. Green, a nurse practitioner, is covering for Dr. Red, and the patient comes in for a visit, can they report G2211 for that visit?

Answer: Yes. The same specialty/same provider rules would apply in this situation. But remember that Dr. Yellow’s or Mr. Green’s documentation for that encounter must support the code.

Question: Can a resident report G2211 under the primary care exemption?

Answer: Yes, according to CMS staff, so long as the service and the documentation meet all the requirements for the exemption and the visit complexity code. For example, the resident can only report low-level E/M codes, and the resident must be “the focal point for that person’s care.”

Question: Are there frequency limits for how often we can report G2211, either for a single patient in a given time period or by a provider or a practice?

Answer: Not at this time, but make sure your providers are following the rules for reporting the code. “There’s got to be documentation that suggests why the practitioner believes they are treating the patient on this long-standing, longitudinal trajectory, and we’ll be able to see how that interaction is happening,” senior CMS staff said. CMS staff further issued a subtle warning to providers by reminding them that CMS has a very strong integrity program. Your practice can avoid problems with thorough training, frequent chart review, and encouraging the team to ask questions until you feel that everyone is comfortable with the code.

Question: Are there any limits on the specialties that can report the code? Is it just for primary care providers?

Answer: No. Remember that a provider who is managing a single serious or complex condition can also report the code. But CMS expects the documentation to support the ongoing nature of the treatment. If a patient sees a provider as a one-off encounter, perhaps to manage an acute problem, that visit wouldn’t qualify. But if the provider clearly documents that they are actively managing the patient’s condition, the encounters could qualify.

Question: Will CMS issue a list of conditions that meet the code’s serious or complex condition requirement?

Answer: CMS has included the examples of HIV and sickle cell anemia in existing guidance, and it plans to issue a few more examples “that help folks understand what is expected.” However, it won’t be a complete list of every condition that might qualify.

Originally published in the May 2023 issue of the American Thoracic Society’s ATS Coding & Billing Quarterly. Republished with permission from the American Thoracic Society.

To continue to bring awareness to our members, we once again discuss this new add-on Healthcare Common Procedure Coding System code finalized by the Centers for Medicare & Medicaid Services (CMS) for January 1, 2024. This add-on code is for new (99202-99205) and established (99212-99215) office visits. CMS created this add-on code to address the additional costs and resources associated with providing longitudinal care.

G2211 – Visit complexity inherent to evaluation and management (E/M) 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 condition, or a complex condition (Add-on code; list separately in addition to office/outpatient (O/O) E/M visit, new or established)

The documentation should demonstrate the intent and need for ongoing care. Otherwise, no additional documentation is required. CMS pays $16.04 for each service (wRVU = 0.33). It may be reported each time the patient is seen, and there is currently no limit to how often it may be used. Also, there is no additional copay requirement for patients.

Do’s and don’ts

Do report in the following situations when longitudinal care is provided:

• The provider has or intends to have a long-term, ongoing relationship with the patient (ie, G2211 can be used for a new patient visit)
• Audio/video virtual visits
• May be reported with Prolonged Care Services G2212
• When advanced practice providers or physician colleagues in the same specialty practice see the patient (ie, if you see the patient for an urgent visit, but the patient is usually followed by your partner, you can still use G2211)
• When working with graduate medical education trainees (along with the -GC modifier), and as long as the conditions described in the description of G2211 are met

Do NOT report in the following situations:

• If modifier -25 is appended to the E/M service when another service is provided on the same day (eg, pulmonary function tests, 6-minute walk tests, immunization)
• Audio-only virtual visits, hospital, skilled nursing facility, or long-term acute care hospital
• If the patient is not expected to return for ongoing care
• If the reason for longitudinal care does not include a “single, serious condition or a complex condition” (eg, annual visits for a stable 6 mm lung nodule)

CMS expects that this will be billed with 38% of all E/M services initially and potentially up to 54% over time. We feel this is reimbursement for the work being done to care for our patients with single, serious, or complex conditions. Both Medicare and Medicare Advantage plans are expected to reimburse for this service. Whether other payers will do the same is unclear, but it will become clear with time and further negotiation at the local level. In the meantime, members are encouraged to report this code for all appropriate patient encounters.
 

Questions and answers — G2211

Question: What private insurances cover G2211?

Answer: As of March 1, 2024, four national payers have confirmed coverage of G2211:

• Cigna (Medicare Advantage only),
• Humana (commercial and Medicare Advantage),
• United Healthcare (commercial and Medicare Advantage), and
• Aetna (Medicare Advantage).

Question: What needs to be documented for G2211?

Answer: CMS states, “You must document the reason for billing the office and outpatient (O/O) and evaluation and management (E/M). The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation.”

American Thoracic Society (ATS) and CHEST also recommend including a detailed assessment and plan for the visit, as well as any follow-up. The complexity of the visit should be clear in your documentation to support the medical necessity for reporting the G2211.
 

Question: How can a provider show that a new patient visit (99202-99205) is part of continuing care?

Answer: The treating practitioner should make sure their documentation supports their intent to provide ongoing care to the patient. Establishing such intent goes beyond a statement that the provider plans to provide ongoing care or schedule a follow-up visit. The circumstances of the visit should support the extra work involved in becoming the focal point of the patient’s care or providing ongoing care for a serious or complex condition.

Question: Dr. Red works at a primary care practice, is the focal point for a patient’s care, and has reported G2211. If Dr. Yellow, who is in the same specialty, or Mr. Green, a nurse practitioner, is covering for Dr. Red, and the patient comes in for a visit, can they report G2211 for that visit?

Answer: Yes. The same specialty/same provider rules would apply in this situation. But remember that Dr. Yellow’s or Mr. Green’s documentation for that encounter must support the code.

Question: Can a resident report G2211 under the primary care exemption?

Answer: Yes, according to CMS staff, so long as the service and the documentation meet all the requirements for the exemption and the visit complexity code. For example, the resident can only report low-level E/M codes, and the resident must be “the focal point for that person’s care.”

Question: Are there frequency limits for how often we can report G2211, either for a single patient in a given time period or by a provider or a practice?

Answer: Not at this time, but make sure your providers are following the rules for reporting the code. “There’s got to be documentation that suggests why the practitioner believes they are treating the patient on this long-standing, longitudinal trajectory, and we’ll be able to see how that interaction is happening,” senior CMS staff said. CMS staff further issued a subtle warning to providers by reminding them that CMS has a very strong integrity program. Your practice can avoid problems with thorough training, frequent chart review, and encouraging the team to ask questions until you feel that everyone is comfortable with the code.

Question: Are there any limits on the specialties that can report the code? Is it just for primary care providers?

Answer: No. Remember that a provider who is managing a single serious or complex condition can also report the code. But CMS expects the documentation to support the ongoing nature of the treatment. If a patient sees a provider as a one-off encounter, perhaps to manage an acute problem, that visit wouldn’t qualify. But if the provider clearly documents that they are actively managing the patient’s condition, the encounters could qualify.

Question: Will CMS issue a list of conditions that meet the code’s serious or complex condition requirement?

Answer: CMS has included the examples of HIV and sickle cell anemia in existing guidance, and it plans to issue a few more examples “that help folks understand what is expected.” However, it won’t be a complete list of every condition that might qualify.

Originally published in the May 2023 issue of the American Thoracic Society’s ATS Coding & Billing Quarterly. Republished with permission from the American Thoracic Society.

Journal CHEST^®

Does Rheumatoid Arthritis Increase the Risk of COPD? 

By: Chiwook Chung, MD, and colleagues

This study utilizing the Korean National Health Insurance Database suggests that patients with rheumatoid arthritis (RA) face a significantly higher risk of developing COPD compared with the general population. Notably, individuals with seropositive RA exhibit a greater risk of COPD onset than those with seronegative RA. Although smoking history didn’t affect the relationship between RA and COPD, monitoring respiratory symptoms and pulmonary function in patients with RA, especially patients who are seropositive, is crucial. These findings underscore the importance of interdisciplinary collaboration between rheumatologists and pulmonologists to enhance early detection and management strategies for pulmonary complications in patients with RA.

CHEST

CHEST Pulmonary^®

The Lung Cancer Prediction Model “Stress Test” 

By: Brent E. Heideman, MD, and colleagues

Current lung cancer prediction models have limited utility in high-risk patients referred for diagnostic biopsy. In a study of 322 indeterminate pulmonary nodules, the Brock, Mayo Clinic, Herder, and Veterans Affairs models showed modest discrimination between benign and malignant nodules (AUCs 0.67-0.77). The models performed poorly for low-risk patients (negative predictive values 63%-71%) and suboptimally for high-risk patients (positive predictive values 73%-87%), suggesting referring physicians use additional clinical information not captured in these models to identify high-risk patients needing biopsy. New prediction models and biomarkers specifically developed and calibrated for high-risk populations are needed to better inform clinical decision-making. Incorporating interval imaging to assess changes in nodule characteristics could potentially improve model performance. Tailored risk assessment tools are crucial for optimizing management and reducing unnecessary invasive procedures in this challenging patient population.

CHEST

CHEST Critical Care ^®

Characterizing Cardiac Function in ICU Survivors of Sepsis 

By: Kevin Garrity, MBChB, and colleagues

While chronic cardiac dysfunction is one of the proposed mechanisms of long-term impairment post critical illness, its prevalence, mechanisms, and associations with disability following admission for sepsis are not well understood. Garrity and colleagues describe the Characterization of Cardiovascular Function in ICU Survivors of Sepsis (CONDUCT-ICU) protocol, a prospective study including two ICUs in Scotland aimed to better define cardiovascular dysfunction in survivors of sepsis. Designed to enroll 69 patients, demographics, cardiac and inflammatory biomarkers, and echocardiograms will be obtained on ICU discharge with additional laboratory data, cardiac magnetic resonance imaging, and patient-reported outcome measures to be obtained at 6 to 10 weeks. This novel multimodal approach will provide understanding into the role of cardiovascular dysfunction following critical illness as well as offer mechanistic insights. The investigators hope to obtain operational and pilot data for larger future studies.

CHEST

– Commentary by Eugene Yuriditsky, MD, FCCP, Member of the CHEST Physician Editorial Board

Journal CHEST^®

Does Rheumatoid Arthritis Increase the Risk of COPD? 

By: Chiwook Chung, MD, and colleagues

This study utilizing the Korean National Health Insurance Database suggests that patients with rheumatoid arthritis (RA) face a significantly higher risk of developing COPD compared with the general population. Notably, individuals with seropositive RA exhibit a greater risk of COPD onset than those with seronegative RA. Although smoking history didn’t affect the relationship between RA and COPD, monitoring respiratory symptoms and pulmonary function in patients with RA, especially patients who are seropositive, is crucial. These findings underscore the importance of interdisciplinary collaboration between rheumatologists and pulmonologists to enhance early detection and management strategies for pulmonary complications in patients with RA.

CHEST

CHEST Pulmonary^®

The Lung Cancer Prediction Model “Stress Test” 

By: Brent E. Heideman, MD, and colleagues

Current lung cancer prediction models have limited utility in high-risk patients referred for diagnostic biopsy. In a study of 322 indeterminate pulmonary nodules, the Brock, Mayo Clinic, Herder, and Veterans Affairs models showed modest discrimination between benign and malignant nodules (AUCs 0.67-0.77). The models performed poorly for low-risk patients (negative predictive values 63%-71%) and suboptimally for high-risk patients (positive predictive values 73%-87%), suggesting referring physicians use additional clinical information not captured in these models to identify high-risk patients needing biopsy. New prediction models and biomarkers specifically developed and calibrated for high-risk populations are needed to better inform clinical decision-making. Incorporating interval imaging to assess changes in nodule characteristics could potentially improve model performance. Tailored risk assessment tools are crucial for optimizing management and reducing unnecessary invasive procedures in this challenging patient population.

CHEST

CHEST Critical Care ^®

Characterizing Cardiac Function in ICU Survivors of Sepsis 

By: Kevin Garrity, MBChB, and colleagues

While chronic cardiac dysfunction is one of the proposed mechanisms of long-term impairment post critical illness, its prevalence, mechanisms, and associations with disability following admission for sepsis are not well understood. Garrity and colleagues describe the Characterization of Cardiovascular Function in ICU Survivors of Sepsis (CONDUCT-ICU) protocol, a prospective study including two ICUs in Scotland aimed to better define cardiovascular dysfunction in survivors of sepsis. Designed to enroll 69 patients, demographics, cardiac and inflammatory biomarkers, and echocardiograms will be obtained on ICU discharge with additional laboratory data, cardiac magnetic resonance imaging, and patient-reported outcome measures to be obtained at 6 to 10 weeks. This novel multimodal approach will provide understanding into the role of cardiovascular dysfunction following critical illness as well as offer mechanistic insights. The investigators hope to obtain operational and pilot data for larger future studies.

CHEST

– Commentary by Eugene Yuriditsky, MD, FCCP, Member of the CHEST Physician Editorial Board

Journal CHEST^®

Does Rheumatoid Arthritis Increase the Risk of COPD? 

By: Chiwook Chung, MD, and colleagues

This study utilizing the Korean National Health Insurance Database suggests that patients with rheumatoid arthritis (RA) face a significantly higher risk of developing COPD compared with the general population. Notably, individuals with seropositive RA exhibit a greater risk of COPD onset than those with seronegative RA. Although smoking history didn’t affect the relationship between RA and COPD, monitoring respiratory symptoms and pulmonary function in patients with RA, especially patients who are seropositive, is crucial. These findings underscore the importance of interdisciplinary collaboration between rheumatologists and pulmonologists to enhance early detection and management strategies for pulmonary complications in patients with RA.

CHEST

CHEST Pulmonary^®

The Lung Cancer Prediction Model “Stress Test” 

By: Brent E. Heideman, MD, and colleagues

Current lung cancer prediction models have limited utility in high-risk patients referred for diagnostic biopsy. In a study of 322 indeterminate pulmonary nodules, the Brock, Mayo Clinic, Herder, and Veterans Affairs models showed modest discrimination between benign and malignant nodules (AUCs 0.67-0.77). The models performed poorly for low-risk patients (negative predictive values 63%-71%) and suboptimally for high-risk patients (positive predictive values 73%-87%), suggesting referring physicians use additional clinical information not captured in these models to identify high-risk patients needing biopsy. New prediction models and biomarkers specifically developed and calibrated for high-risk populations are needed to better inform clinical decision-making. Incorporating interval imaging to assess changes in nodule characteristics could potentially improve model performance. Tailored risk assessment tools are crucial for optimizing management and reducing unnecessary invasive procedures in this challenging patient population.

CHEST

CHEST Critical Care ^®

Characterizing Cardiac Function in ICU Survivors of Sepsis 

By: Kevin Garrity, MBChB, and colleagues

While chronic cardiac dysfunction is one of the proposed mechanisms of long-term impairment post critical illness, its prevalence, mechanisms, and associations with disability following admission for sepsis are not well understood. Garrity and colleagues describe the Characterization of Cardiovascular Function in ICU Survivors of Sepsis (CONDUCT-ICU) protocol, a prospective study including two ICUs in Scotland aimed to better define cardiovascular dysfunction in survivors of sepsis. Designed to enroll 69 patients, demographics, cardiac and inflammatory biomarkers, and echocardiograms will be obtained on ICU discharge with additional laboratory data, cardiac magnetic resonance imaging, and patient-reported outcome measures to be obtained at 6 to 10 weeks. This novel multimodal approach will provide understanding into the role of cardiovascular dysfunction following critical illness as well as offer mechanistic insights. The investigators hope to obtain operational and pilot data for larger future studies.

CHEST

– Commentary by Eugene Yuriditsky, MD, FCCP, Member of the CHEST Physician Editorial Board

Lisa Mathew, MD, wants to quell any misconceptions that private practice is dull or routine. “That has not been my experience at all,” says Dr. Mathew, a partner with South Denver Gastroenterology in the suburbs of Denver, Colorado.

For Dr. Mathew, working in private practice offers a rich professional experience, not just in the day-to-day experiences of medicine, but in practice management innovation and patient care delivery. “It’s an area within GI where we can be quite nimble in trialing new technologies, optimizing patients’ access to care and working to ensure a positive patient experience,” she said.

Nationwide, a flourishing GI private practice community engages in ongoing dialogue about improvements, navigating a changing healthcare environment, and innovation. “That has been a surprising and wonderful twist in my career,” she added.

South Denver Gastroenterology

Dr. Mathew fosters that dialogue through Gastro Broadcast, a podcast she shares with several other GI physicians. Targeted toward private GI practice, it highlights innovations within the community, providing updates on practice management and other technological advances.

In an interview, she spoke frankly about her favorite recent podcast guest, the challenges she’s faced in her career, and why her fellow GI specialists are her “tribe.”
 

Q: Why did you choose GI?

Dr. Mathew: In medical school at Duke University, I was considering going into ob.gyn., but academically I was a little more drawn toward internal medicine. While I was in my residency at the University of Pennsylvania, I really clicked with the gastroenterologists. I enjoyed their sense of humor. They were dealing with complex medical issues but doing so with a sense of levity and enjoyment in their work. When I entered fellowship at the University of Washington, I felt like I found my tribe. This was a group of people who really love their work, love medicine, love being able to develop their procedural skills, and keep a sense of humor about themselves. I married a cardiologist (and he’s a hilarious cardiologist), but the world of cardiology is a little more buttoned up. I like that GI is a little more relaxed.

Q: What gives you the most joy in your day-to-day practice?

Dr. Mathew: My patients. They are funny and genuine, and they allow you into these moments of vulnerability — it’s an honor to walk through that together. I’m always so grateful for the trust they put in me in those moments. As my practice has matured, it’s been incredible to watch those relationships grow, as well as begin caring for husbands, wives, sons and daughters of my patients. I enjoy being a part of my community.

Q: Can you talk about an interesting recent guest you had on your podcast? Who was it and why did he or she stand out?

Dr. Mathew: Russ Arjal, MD, AGAF, cofounder, chief medical officer and president of Telebelly Health. He’s been working on a platform for exclusively telehealth services that improves access to care; pairing patients with brick-and-mortar gastroenterology to provide any necessary procedural care, such as colonoscopy and upper endoscopy. It was a fantastic interview. I think it’s so refreshing and inspiring to see how people innovate within the field of GI. On the procedural side, you see this all the time. With my advanced endoscopy colleagues, they’re constantly pushing the boundaries of what we can do procedurally. My academic colleagues are constantly thinking through what the next best treatment is or how best can we optimize care. And, in the world of private practice, we’re thinking about practice care delivery — how to improve access and make the experience of being a patient better, with the ultimate goal of improving health outcomes.
 

Q: What fears did you have to push past to get to where you are in your career?

Dr. Mathew: Imposter Syndrome is a very, very common issue, maybe somewhat more for women in GI. I think it’s something that everybody wrestles with to some degree. For me, it was developing confidence not just in my clinical skills, but in learning all the complexities of running a small business. It takes time to develop confidence in your abilities and judgment. I think to some degree, that’s normal. It just takes a while to settle into whatever your chosen career path is. Having a community and strong mentors to support me has made all the difference.

Q: Describe your biggest practice-related challenge and what you are doing to address it.

Dr. Mathew: One of the greatest challenges in my career has been navigating COVID — both with just the tremendous sea change it had on our ability to practice, as well as the financial consequences to someone in private practice. Those were very challenging times to deliver the care that was needed, protect staff, and to maintain a small business. Fortunately, as with many practices across the nation, we’ve emerged through that.

We pivoted, we innovated with telehealth and other services that allowed us to care for our patients. But there were a lot of lessons learned and a lot of difficult moments.
 

Q: What teacher or mentor had the greatest impact on you?

Dr. Mathew: My dad has taught me the value of hard work. Being a physician just comes in tandem with hard work. And my mom, who is a nurse, has always shown the importance of empathy. Without it, everything else is a little empty. Medicine is a combination of skill and hard work, but also an ability to connect with other people. Empathy is essential to that.

Q: Describe how you would spend a free Saturday afternoon.

Dr. Mathew: We have three children who are native Coloradans so skiing is their birthright. Our entire family are diehard skiers. This is our joy. When you talk about the beach versus mountains debate, we are firmly team mountains. On a perfect Saturday afternoon, I’m on the slopes with my little crew, just tearing it up, having a great time.

Lightning Round

Texting or talking?

Texting

Favorite city in U.S. besides the one you live in?

Washington, D.C.

Favorite breakfast?

Avocado toast

Place you most want to travel to?

South America

Favorite junk food?

Candy

Favorite season?

Winter

How many cups of coffee do you drink per day?

2 or 3

If you weren’t a gastroenterologist, what would you be?

Ski coach

Best Halloween costume you ever wore?

Bunch of grapes

Favorite type of music?

Indie folk

Favorite movie genre?

Books, not into movies

Cat person or dog person?

Neither, but I am a certified beekeeper

What song do you have to sing along with when you hear it?

Anything by Queen

Introvert or extrovert?

Extrovert with introverted tendencies

Favorite holiday?

Thanksgiving

Optimist or pessimist?

100% glass half full

Lisa Mathew, MD, wants to quell any misconceptions that private practice is dull or routine. “That has not been my experience at all,” says Dr. Mathew, a partner with South Denver Gastroenterology in the suburbs of Denver, Colorado.

For Dr. Mathew, working in private practice offers a rich professional experience, not just in the day-to-day experiences of medicine, but in practice management innovation and patient care delivery. “It’s an area within GI where we can be quite nimble in trialing new technologies, optimizing patients’ access to care and working to ensure a positive patient experience,” she said.

Nationwide, a flourishing GI private practice community engages in ongoing dialogue about improvements, navigating a changing healthcare environment, and innovation. “That has been a surprising and wonderful twist in my career,” she added.

South Denver Gastroenterology

Dr. Mathew fosters that dialogue through Gastro Broadcast, a podcast she shares with several other GI physicians. Targeted toward private GI practice, it highlights innovations within the community, providing updates on practice management and other technological advances.

In an interview, she spoke frankly about her favorite recent podcast guest, the challenges she’s faced in her career, and why her fellow GI specialists are her “tribe.”
 

Q: Why did you choose GI?

Dr. Mathew: In medical school at Duke University, I was considering going into ob.gyn., but academically I was a little more drawn toward internal medicine. While I was in my residency at the University of Pennsylvania, I really clicked with the gastroenterologists. I enjoyed their sense of humor. They were dealing with complex medical issues but doing so with a sense of levity and enjoyment in their work. When I entered fellowship at the University of Washington, I felt like I found my tribe. This was a group of people who really love their work, love medicine, love being able to develop their procedural skills, and keep a sense of humor about themselves. I married a cardiologist (and he’s a hilarious cardiologist), but the world of cardiology is a little more buttoned up. I like that GI is a little more relaxed.

Q: What gives you the most joy in your day-to-day practice?

Dr. Mathew: My patients. They are funny and genuine, and they allow you into these moments of vulnerability — it’s an honor to walk through that together. I’m always so grateful for the trust they put in me in those moments. As my practice has matured, it’s been incredible to watch those relationships grow, as well as begin caring for husbands, wives, sons and daughters of my patients. I enjoy being a part of my community.

Q: Can you talk about an interesting recent guest you had on your podcast? Who was it and why did he or she stand out?

Dr. Mathew: Russ Arjal, MD, AGAF, cofounder, chief medical officer and president of Telebelly Health. He’s been working on a platform for exclusively telehealth services that improves access to care; pairing patients with brick-and-mortar gastroenterology to provide any necessary procedural care, such as colonoscopy and upper endoscopy. It was a fantastic interview. I think it’s so refreshing and inspiring to see how people innovate within the field of GI. On the procedural side, you see this all the time. With my advanced endoscopy colleagues, they’re constantly pushing the boundaries of what we can do procedurally. My academic colleagues are constantly thinking through what the next best treatment is or how best can we optimize care. And, in the world of private practice, we’re thinking about practice care delivery — how to improve access and make the experience of being a patient better, with the ultimate goal of improving health outcomes.
 

Q: What fears did you have to push past to get to where you are in your career?

Dr. Mathew: Imposter Syndrome is a very, very common issue, maybe somewhat more for women in GI. I think it’s something that everybody wrestles with to some degree. For me, it was developing confidence not just in my clinical skills, but in learning all the complexities of running a small business. It takes time to develop confidence in your abilities and judgment. I think to some degree, that’s normal. It just takes a while to settle into whatever your chosen career path is. Having a community and strong mentors to support me has made all the difference.

Q: Describe your biggest practice-related challenge and what you are doing to address it.

Dr. Mathew: One of the greatest challenges in my career has been navigating COVID — both with just the tremendous sea change it had on our ability to practice, as well as the financial consequences to someone in private practice. Those were very challenging times to deliver the care that was needed, protect staff, and to maintain a small business. Fortunately, as with many practices across the nation, we’ve emerged through that.

We pivoted, we innovated with telehealth and other services that allowed us to care for our patients. But there were a lot of lessons learned and a lot of difficult moments.
 

Q: What teacher or mentor had the greatest impact on you?

Dr. Mathew: My dad has taught me the value of hard work. Being a physician just comes in tandem with hard work. And my mom, who is a nurse, has always shown the importance of empathy. Without it, everything else is a little empty. Medicine is a combination of skill and hard work, but also an ability to connect with other people. Empathy is essential to that.

Q: Describe how you would spend a free Saturday afternoon.

Dr. Mathew: We have three children who are native Coloradans so skiing is their birthright. Our entire family are diehard skiers. This is our joy. When you talk about the beach versus mountains debate, we are firmly team mountains. On a perfect Saturday afternoon, I’m on the slopes with my little crew, just tearing it up, having a great time.

Lightning Round

Texting or talking?

Texting

Favorite city in U.S. besides the one you live in?

Washington, D.C.

Favorite breakfast?

Avocado toast

Place you most want to travel to?

South America

Favorite junk food?

Candy

Favorite season?

Winter

How many cups of coffee do you drink per day?

2 or 3

If you weren’t a gastroenterologist, what would you be?

Ski coach

Best Halloween costume you ever wore?

Bunch of grapes

Favorite type of music?

Indie folk

Favorite movie genre?

Books, not into movies

Cat person or dog person?

Neither, but I am a certified beekeeper

What song do you have to sing along with when you hear it?

Anything by Queen

Introvert or extrovert?

Extrovert with introverted tendencies

Favorite holiday?

Thanksgiving

Optimist or pessimist?

100% glass half full

Lisa Mathew, MD, wants to quell any misconceptions that private practice is dull or routine. “That has not been my experience at all,” says Dr. Mathew, a partner with South Denver Gastroenterology in the suburbs of Denver, Colorado.

For Dr. Mathew, working in private practice offers a rich professional experience, not just in the day-to-day experiences of medicine, but in practice management innovation and patient care delivery. “It’s an area within GI where we can be quite nimble in trialing new technologies, optimizing patients’ access to care and working to ensure a positive patient experience,” she said.

Nationwide, a flourishing GI private practice community engages in ongoing dialogue about improvements, navigating a changing healthcare environment, and innovation. “That has been a surprising and wonderful twist in my career,” she added.

South Denver Gastroenterology

Dr. Mathew fosters that dialogue through Gastro Broadcast, a podcast she shares with several other GI physicians. Targeted toward private GI practice, it highlights innovations within the community, providing updates on practice management and other technological advances.

In an interview, she spoke frankly about her favorite recent podcast guest, the challenges she’s faced in her career, and why her fellow GI specialists are her “tribe.”
 

Q: Why did you choose GI?

Dr. Mathew: In medical school at Duke University, I was considering going into ob.gyn., but academically I was a little more drawn toward internal medicine. While I was in my residency at the University of Pennsylvania, I really clicked with the gastroenterologists. I enjoyed their sense of humor. They were dealing with complex medical issues but doing so with a sense of levity and enjoyment in their work. When I entered fellowship at the University of Washington, I felt like I found my tribe. This was a group of people who really love their work, love medicine, love being able to develop their procedural skills, and keep a sense of humor about themselves. I married a cardiologist (and he’s a hilarious cardiologist), but the world of cardiology is a little more buttoned up. I like that GI is a little more relaxed.

Q: What gives you the most joy in your day-to-day practice?

Dr. Mathew: My patients. They are funny and genuine, and they allow you into these moments of vulnerability — it’s an honor to walk through that together. I’m always so grateful for the trust they put in me in those moments. As my practice has matured, it’s been incredible to watch those relationships grow, as well as begin caring for husbands, wives, sons and daughters of my patients. I enjoy being a part of my community.

Q: Can you talk about an interesting recent guest you had on your podcast? Who was it and why did he or she stand out?

Dr. Mathew: Russ Arjal, MD, AGAF, cofounder, chief medical officer and president of Telebelly Health. He’s been working on a platform for exclusively telehealth services that improves access to care; pairing patients with brick-and-mortar gastroenterology to provide any necessary procedural care, such as colonoscopy and upper endoscopy. It was a fantastic interview. I think it’s so refreshing and inspiring to see how people innovate within the field of GI. On the procedural side, you see this all the time. With my advanced endoscopy colleagues, they’re constantly pushing the boundaries of what we can do procedurally. My academic colleagues are constantly thinking through what the next best treatment is or how best can we optimize care. And, in the world of private practice, we’re thinking about practice care delivery — how to improve access and make the experience of being a patient better, with the ultimate goal of improving health outcomes.
 

Q: What fears did you have to push past to get to where you are in your career?

Dr. Mathew: Imposter Syndrome is a very, very common issue, maybe somewhat more for women in GI. I think it’s something that everybody wrestles with to some degree. For me, it was developing confidence not just in my clinical skills, but in learning all the complexities of running a small business. It takes time to develop confidence in your abilities and judgment. I think to some degree, that’s normal. It just takes a while to settle into whatever your chosen career path is. Having a community and strong mentors to support me has made all the difference.

Q: Describe your biggest practice-related challenge and what you are doing to address it.

Dr. Mathew: One of the greatest challenges in my career has been navigating COVID — both with just the tremendous sea change it had on our ability to practice, as well as the financial consequences to someone in private practice. Those were very challenging times to deliver the care that was needed, protect staff, and to maintain a small business. Fortunately, as with many practices across the nation, we’ve emerged through that.

We pivoted, we innovated with telehealth and other services that allowed us to care for our patients. But there were a lot of lessons learned and a lot of difficult moments.
 

Q: What teacher or mentor had the greatest impact on you?

Dr. Mathew: My dad has taught me the value of hard work. Being a physician just comes in tandem with hard work. And my mom, who is a nurse, has always shown the importance of empathy. Without it, everything else is a little empty. Medicine is a combination of skill and hard work, but also an ability to connect with other people. Empathy is essential to that.

Q: Describe how you would spend a free Saturday afternoon.

Dr. Mathew: We have three children who are native Coloradans so skiing is their birthright. Our entire family are diehard skiers. This is our joy. When you talk about the beach versus mountains debate, we are firmly team mountains. On a perfect Saturday afternoon, I’m on the slopes with my little crew, just tearing it up, having a great time.

Lightning Round

Texting or talking?

Texting

Favorite city in U.S. besides the one you live in?

Washington, D.C.

Favorite breakfast?

Avocado toast

Place you most want to travel to?

South America

Favorite junk food?

Candy

Favorite season?

Winter

How many cups of coffee do you drink per day?

2 or 3

If you weren’t a gastroenterologist, what would you be?

Ski coach

Best Halloween costume you ever wore?

Bunch of grapes

Favorite type of music?

Indie folk

Favorite movie genre?

Books, not into movies

Cat person or dog person?

Neither, but I am a certified beekeeper

What song do you have to sing along with when you hear it?

Anything by Queen

Introvert or extrovert?

Extrovert with introverted tendencies

Favorite holiday?

Thanksgiving

Optimist or pessimist?

100% glass half full

The American Gastroenterological Association (AGA) is proud to announce that it has selected 79 recipients to receive research funding through the annual AGA Research Foundation Awards Program. The program serves as a catalyst for discovery and career growth among the most promising researchers in gastroenterology and hepatology.

“This year’s awardees are an exceptional group of investigators who are committed to furthering patient care through research,” said Michael Camilleri, MD, AGAF, chair, AGA Research Foundation. “The AGA Research Foundation is proud to fund these investigators and their ongoing efforts to advance GI research at a critical time in their careers. We believe the Foundation’s investment will ultimately enable new discoveries in gastroenterology and hepatology that will benefit patients.”

Treatment options for digestive diseases begin with vigorous research. The AGA Research Foundation supports medical investigators as they advance our understanding of gastrointestinal and liver conditions. Here are this year’s award recipients:
 

RESEARCH SCHOLAR AWARDS

AGA Research Scholar Award 

• Karen Jane Dunbar, PhD, Columbia University, New York, New York
• Aaron Hecht, MD, PhD, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
• Sarah Maxwell, MD, University of California, San Francisco
• Chung Sang Tse, MD, University of Pennsylvania, Philadelphia, Pennsylvania
• Jason (Yanjia) Zhang, MD, PhD, Boston Children’s Hospital, Massachusetts

AGA-Bristol Myers Squibb Research Scholar Award in Inflammatory Bowel Disease

• Joseph R. Burclaff, PhD, University of North Carolina at Chapel Hill

SPECIALTY AWARDS

AGA-Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer

• Swathi Eluri, MD, MSCR, Mayo Clinic, Rochester, Minnesota

AGA-R. Robert & Sally Funderburg Research Award in Gastric Cancer

• Jianwen Que, MD, PhD, Columbia University, New York, New York

AGA-Pfizer Fellowship-to-Faculty Transition Award

• Lianna Wood, MD, PhD, Boston Children’s Hospital, Massachusetts

AGA-Ironwood Fellowship-to-Faculty Transition Award

• ZeNan Li Chang, MD, PhD, Washington University School of Medicine, St. Louis, Missouri

PILOT AWARDS

AGA Pilot Research Award

• Linda C. Cummings, MD, MS, University Hospitals Cleveland Medical Center, Cleveland, Ohio
• Pooja Mehta, MD, MSCS, University of Colorado Denver
• Guilherme Piovezani Ramos, MD, Boston Children’s Hospital
• Simon Schwoerer, PhD, University of Chicago, Illinois
• Yankai Wen, PhD, University of Texas Health Science Center at Houston

AGA-Pfizer Pilot Research Award in Non-Alcoholic Steatohepatitis

• Alice Cheng, PhD, Stanford University, California
• Petra Hirsova, PhD, PharmD, Mayo Clinic, Rochester, Minnesota
• Sarah Maxwell, MD, University of California, San Francisco

AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease

• David Boone, PhD, Indiana University, Indianapolis, Indiana
• Sara Chloe Di Rienzi, PhD, Baylor College of Medicine, Houston, Texas
• Jared Andrew Sninsky, MD, MSCR, Baylor College of Medicine, Houston, Texas

UNDERGRADUATE RESEARCH AWARDS

AGA-Aman Armaan Ahmed Family Surf for Success Program

• Eli Burstein, Yeshiva University, New York, New York
• Chloe Carlisle, University of Florida, Gainesville, Florida
• Adna Hassan, University of Minnesota Rochester
• Nicole Rodriguez Hilario, Barry University, Miami, Florida
• Maryam Jimoh, College of Wooster, Wooster, Ohio
• Viktoriya Kalinina, Brandeis University, Waltham, Massachusetts

AGA-Dr. Harvey Young Education & Development Foundation’s Young Guts Scholar Program

• Rafaella Lavalle Lacerda de Almeida, Michigan State University, East Lansing, Michigan
• Lara Cheesman, John’s Hopkins University School of Medicine, Baltimore, Maryland
• Cass Condray, University of Oklahoma, Norman, Oklahoma
• Daniel Juarez, Columbia University, New York, New York
• Jason Lin, University of Michigan, Ann Arbor, Michigan
• Riya Malhotra, Case Western Reserve University, Cleveland, Ohio
• Brian Nguyen, Brown University, Providence, Rhode Island
• Mahmoud (Moudy) Salem, Stony Brook University, Stony Brook, New York

ABSTRACT AWARDS

AGA Fellow Abstract of the Year Award

• Andrea Tou, MD Children’s Hospital of Philadelphia, Pennsylvania

AGA Fellow Abstract Awards

• Manik Aggarwal, MBBS, Mayo Clinic, Rochester, Minnesota
• Kole Buckley, PhD, University of Pennsylvania, Philadelphia, Pennsylvania
• Jane Ha, MD, Massachusetts General Hospital, Boston, Massachusetts
• Brent Hiramoto, MD, Brigham and Women’s Hospital, Boston, Massachusetts
• Md Obaidul Islam, PhD, University of Miami, Coral Gables, Florida
• Kanak Kennedy, MD, MPH, Children’s Hospital of Philadelphia, Pennsylvania
• Hanseul Kim, PhD, MS, Massachusetts General Hospital, Boston, Massachusetts
• Chiraag Kulkarni, MD, Stanford University, Stanford, California
• Su-Hyung Lee, PhD, DVM, Vanderbilt University Medical Center, Nashville, Tennessee
• Caroline Muiler, PhD, Yale School of Medicine, New Haven, Connecticut
• Sarah Najjar, PhD, New York University, New York, New York
• Ronaldo Panganiban, MD, PhD Penn State Hershey Medical Center, Hershey, Pennsylvania
• Perseus Patel, MD, Stanford University, California
• Hassan Sinan, MD, Johns Hopkins University, Baltimore, Maryland
• Patricia Snarski, PhD, Tulane University, New Orleans, Louisiana
• Fernando Vicentini, PhD, MS, McMaster University, Hamilton, Ontario, Canada
• Remington Winter, MD, University of Manitoba – Health Sciences Centre, Winnipeg, Manitoba, Canada
• Tiaosi Xing, PhD, MBBS, MS, Penn State College of Medicine, Hershey, Pennsylvania

AGA Student Abstract of the Year Award

• Jazmyne Jackson, Temple University, Philadelphia, Pennsylvania

AGA Student Abstract Award

• Valentina Alvarez, University of Washington School of Medicine, Seattle, Washington
• Yasaman Bahojb Habibyan, MS, University of Calgary, Alberta, Canada
• Tessa Herman, MD, University of Minnesota, Minneapolis-Saint Paul, Minnesota
• Jason Jin, Yale School of Medicine, New Haven, Connecticut
• Frederikke Larsen, Western University, London, Ontario, Canada
• Kara McNamara, Vanderbilt University, Nashville, Tennessee
• Julia Sessions, MD, University of Virginia, Charlottesville, Virginia
• Scott Silvey, MS, Virginia Commonwealth University, Richmond, Virginia
• Vijaya Sundaram, Marshall University School of Medicine, Huntington, West Virginia
• Kafayat Yusuf, MS, University of Kansas Medical Center, Kansas City, Kansas

AGA–Eric Esrailian Student Abstract Prize

• Brent Gawey, MD, MS, Mayo Clinic, Rochester, Minnesota
• Fei Li, MBBS, MS, University of Michigan, Ann Arbor, Michigan
• Emily Wong, University of Toronto, Ontario, Canada
• Jordan Woodard, MD, Prisma Health – Upstate, Greenville, South Carolina

AGA–Radhika Srinivasan Student Abstract Prize

• Raz Abdulqadir, MS, Penn State College of Medicine, Hershey, Pennsylvania
• Rebecca Ekeanyanwu, MHS, Meharry Medical College, Nashville, Tennessee
• Jared Morris, MD, University of Manitoba, Winnipeg City, Manitoba, Canada
• Rachel Stubler, Medical University of South Carolina, Charleston, South Carolina

AGA Abstract Award for Health Disparities Research

• Saqr Alsakarneh, MD University of Missouri-Kansas City
• Marco Noriega, MD, Beth Israel Deaconess Medical Center, Boston, Massachusetts
• Temitope Olasehinde, MD, University Hospitals/Case Western Reserve University, Cleveland, Ohio
• Gabrielle Waclawik, MD, MPH, University of Wisconsin, Madison, Wisconsin

AGA-Moti L. & Kamla Rustgi International Travel Award

• W. Keith Tan, MBChB, University of Cambridge, Cambridge, England
• Elsa van Liere, MD Amsterdam Universitair Medische Centra, Amsterdam, Netherlands

The American Gastroenterological Association (AGA) is proud to announce that it has selected 79 recipients to receive research funding through the annual AGA Research Foundation Awards Program. The program serves as a catalyst for discovery and career growth among the most promising researchers in gastroenterology and hepatology.

“This year’s awardees are an exceptional group of investigators who are committed to furthering patient care through research,” said Michael Camilleri, MD, AGAF, chair, AGA Research Foundation. “The AGA Research Foundation is proud to fund these investigators and their ongoing efforts to advance GI research at a critical time in their careers. We believe the Foundation’s investment will ultimately enable new discoveries in gastroenterology and hepatology that will benefit patients.”

Treatment options for digestive diseases begin with vigorous research. The AGA Research Foundation supports medical investigators as they advance our understanding of gastrointestinal and liver conditions. Here are this year’s award recipients:
 

RESEARCH SCHOLAR AWARDS

AGA Research Scholar Award 

• Karen Jane Dunbar, PhD, Columbia University, New York, New York
• Aaron Hecht, MD, PhD, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
• Sarah Maxwell, MD, University of California, San Francisco
• Chung Sang Tse, MD, University of Pennsylvania, Philadelphia, Pennsylvania
• Jason (Yanjia) Zhang, MD, PhD, Boston Children’s Hospital, Massachusetts

AGA-Bristol Myers Squibb Research Scholar Award in Inflammatory Bowel Disease

• Joseph R. Burclaff, PhD, University of North Carolina at Chapel Hill

SPECIALTY AWARDS

AGA-Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer

• Swathi Eluri, MD, MSCR, Mayo Clinic, Rochester, Minnesota

AGA-R. Robert & Sally Funderburg Research Award in Gastric Cancer

• Jianwen Que, MD, PhD, Columbia University, New York, New York

AGA-Pfizer Fellowship-to-Faculty Transition Award

• Lianna Wood, MD, PhD, Boston Children’s Hospital, Massachusetts

AGA-Ironwood Fellowship-to-Faculty Transition Award

• ZeNan Li Chang, MD, PhD, Washington University School of Medicine, St. Louis, Missouri

PILOT AWARDS

AGA Pilot Research Award

• Linda C. Cummings, MD, MS, University Hospitals Cleveland Medical Center, Cleveland, Ohio
• Pooja Mehta, MD, MSCS, University of Colorado Denver
• Guilherme Piovezani Ramos, MD, Boston Children’s Hospital
• Simon Schwoerer, PhD, University of Chicago, Illinois
• Yankai Wen, PhD, University of Texas Health Science Center at Houston

AGA-Pfizer Pilot Research Award in Non-Alcoholic Steatohepatitis

• Alice Cheng, PhD, Stanford University, California
• Petra Hirsova, PhD, PharmD, Mayo Clinic, Rochester, Minnesota
• Sarah Maxwell, MD, University of California, San Francisco

AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease

• David Boone, PhD, Indiana University, Indianapolis, Indiana
• Sara Chloe Di Rienzi, PhD, Baylor College of Medicine, Houston, Texas
• Jared Andrew Sninsky, MD, MSCR, Baylor College of Medicine, Houston, Texas

UNDERGRADUATE RESEARCH AWARDS

AGA-Aman Armaan Ahmed Family Surf for Success Program

• Eli Burstein, Yeshiva University, New York, New York
• Chloe Carlisle, University of Florida, Gainesville, Florida
• Adna Hassan, University of Minnesota Rochester
• Nicole Rodriguez Hilario, Barry University, Miami, Florida
• Maryam Jimoh, College of Wooster, Wooster, Ohio
• Viktoriya Kalinina, Brandeis University, Waltham, Massachusetts

AGA-Dr. Harvey Young Education & Development Foundation’s Young Guts Scholar Program

• Rafaella Lavalle Lacerda de Almeida, Michigan State University, East Lansing, Michigan
• Lara Cheesman, John’s Hopkins University School of Medicine, Baltimore, Maryland
• Cass Condray, University of Oklahoma, Norman, Oklahoma
• Daniel Juarez, Columbia University, New York, New York
• Jason Lin, University of Michigan, Ann Arbor, Michigan
• Riya Malhotra, Case Western Reserve University, Cleveland, Ohio
• Brian Nguyen, Brown University, Providence, Rhode Island
• Mahmoud (Moudy) Salem, Stony Brook University, Stony Brook, New York

ABSTRACT AWARDS

AGA Fellow Abstract of the Year Award

• Andrea Tou, MD Children’s Hospital of Philadelphia, Pennsylvania

AGA Fellow Abstract Awards

• Manik Aggarwal, MBBS, Mayo Clinic, Rochester, Minnesota
• Kole Buckley, PhD, University of Pennsylvania, Philadelphia, Pennsylvania
• Jane Ha, MD, Massachusetts General Hospital, Boston, Massachusetts
• Brent Hiramoto, MD, Brigham and Women’s Hospital, Boston, Massachusetts
• Md Obaidul Islam, PhD, University of Miami, Coral Gables, Florida
• Kanak Kennedy, MD, MPH, Children’s Hospital of Philadelphia, Pennsylvania
• Hanseul Kim, PhD, MS, Massachusetts General Hospital, Boston, Massachusetts
• Chiraag Kulkarni, MD, Stanford University, Stanford, California
• Su-Hyung Lee, PhD, DVM, Vanderbilt University Medical Center, Nashville, Tennessee
• Caroline Muiler, PhD, Yale School of Medicine, New Haven, Connecticut
• Sarah Najjar, PhD, New York University, New York, New York
• Ronaldo Panganiban, MD, PhD Penn State Hershey Medical Center, Hershey, Pennsylvania
• Perseus Patel, MD, Stanford University, California
• Hassan Sinan, MD, Johns Hopkins University, Baltimore, Maryland
• Patricia Snarski, PhD, Tulane University, New Orleans, Louisiana
• Fernando Vicentini, PhD, MS, McMaster University, Hamilton, Ontario, Canada
• Remington Winter, MD, University of Manitoba – Health Sciences Centre, Winnipeg, Manitoba, Canada
• Tiaosi Xing, PhD, MBBS, MS, Penn State College of Medicine, Hershey, Pennsylvania

AGA Student Abstract of the Year Award

• Jazmyne Jackson, Temple University, Philadelphia, Pennsylvania

AGA Student Abstract Award

• Valentina Alvarez, University of Washington School of Medicine, Seattle, Washington
• Yasaman Bahojb Habibyan, MS, University of Calgary, Alberta, Canada
• Tessa Herman, MD, University of Minnesota, Minneapolis-Saint Paul, Minnesota
• Jason Jin, Yale School of Medicine, New Haven, Connecticut
• Frederikke Larsen, Western University, London, Ontario, Canada
• Kara McNamara, Vanderbilt University, Nashville, Tennessee
• Julia Sessions, MD, University of Virginia, Charlottesville, Virginia
• Scott Silvey, MS, Virginia Commonwealth University, Richmond, Virginia
• Vijaya Sundaram, Marshall University School of Medicine, Huntington, West Virginia
• Kafayat Yusuf, MS, University of Kansas Medical Center, Kansas City, Kansas

AGA–Eric Esrailian Student Abstract Prize

• Brent Gawey, MD, MS, Mayo Clinic, Rochester, Minnesota
• Fei Li, MBBS, MS, University of Michigan, Ann Arbor, Michigan
• Emily Wong, University of Toronto, Ontario, Canada
• Jordan Woodard, MD, Prisma Health – Upstate, Greenville, South Carolina

AGA–Radhika Srinivasan Student Abstract Prize

• Raz Abdulqadir, MS, Penn State College of Medicine, Hershey, Pennsylvania
• Rebecca Ekeanyanwu, MHS, Meharry Medical College, Nashville, Tennessee
• Jared Morris, MD, University of Manitoba, Winnipeg City, Manitoba, Canada
• Rachel Stubler, Medical University of South Carolina, Charleston, South Carolina

AGA Abstract Award for Health Disparities Research

• Saqr Alsakarneh, MD University of Missouri-Kansas City
• Marco Noriega, MD, Beth Israel Deaconess Medical Center, Boston, Massachusetts
• Temitope Olasehinde, MD, University Hospitals/Case Western Reserve University, Cleveland, Ohio
• Gabrielle Waclawik, MD, MPH, University of Wisconsin, Madison, Wisconsin

AGA-Moti L. & Kamla Rustgi International Travel Award

• W. Keith Tan, MBChB, University of Cambridge, Cambridge, England
• Elsa van Liere, MD Amsterdam Universitair Medische Centra, Amsterdam, Netherlands

The American Gastroenterological Association (AGA) is proud to announce that it has selected 79 recipients to receive research funding through the annual AGA Research Foundation Awards Program. The program serves as a catalyst for discovery and career growth among the most promising researchers in gastroenterology and hepatology.

“This year’s awardees are an exceptional group of investigators who are committed to furthering patient care through research,” said Michael Camilleri, MD, AGAF, chair, AGA Research Foundation. “The AGA Research Foundation is proud to fund these investigators and their ongoing efforts to advance GI research at a critical time in their careers. We believe the Foundation’s investment will ultimately enable new discoveries in gastroenterology and hepatology that will benefit patients.”

Treatment options for digestive diseases begin with vigorous research. The AGA Research Foundation supports medical investigators as they advance our understanding of gastrointestinal and liver conditions. Here are this year’s award recipients:
 

RESEARCH SCHOLAR AWARDS

AGA Research Scholar Award 

• Karen Jane Dunbar, PhD, Columbia University, New York, New York
• Aaron Hecht, MD, PhD, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
• Sarah Maxwell, MD, University of California, San Francisco
• Chung Sang Tse, MD, University of Pennsylvania, Philadelphia, Pennsylvania
• Jason (Yanjia) Zhang, MD, PhD, Boston Children’s Hospital, Massachusetts

AGA-Bristol Myers Squibb Research Scholar Award in Inflammatory Bowel Disease

• Joseph R. Burclaff, PhD, University of North Carolina at Chapel Hill

SPECIALTY AWARDS

AGA-Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer

• Swathi Eluri, MD, MSCR, Mayo Clinic, Rochester, Minnesota

AGA-R. Robert & Sally Funderburg Research Award in Gastric Cancer

• Jianwen Que, MD, PhD, Columbia University, New York, New York

AGA-Pfizer Fellowship-to-Faculty Transition Award

• Lianna Wood, MD, PhD, Boston Children’s Hospital, Massachusetts

AGA-Ironwood Fellowship-to-Faculty Transition Award

• ZeNan Li Chang, MD, PhD, Washington University School of Medicine, St. Louis, Missouri

PILOT AWARDS

AGA Pilot Research Award

• Linda C. Cummings, MD, MS, University Hospitals Cleveland Medical Center, Cleveland, Ohio
• Pooja Mehta, MD, MSCS, University of Colorado Denver
• Guilherme Piovezani Ramos, MD, Boston Children’s Hospital
• Simon Schwoerer, PhD, University of Chicago, Illinois
• Yankai Wen, PhD, University of Texas Health Science Center at Houston

AGA-Pfizer Pilot Research Award in Non-Alcoholic Steatohepatitis

• Alice Cheng, PhD, Stanford University, California
• Petra Hirsova, PhD, PharmD, Mayo Clinic, Rochester, Minnesota
• Sarah Maxwell, MD, University of California, San Francisco

AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease

• David Boone, PhD, Indiana University, Indianapolis, Indiana
• Sara Chloe Di Rienzi, PhD, Baylor College of Medicine, Houston, Texas
• Jared Andrew Sninsky, MD, MSCR, Baylor College of Medicine, Houston, Texas

UNDERGRADUATE RESEARCH AWARDS

AGA-Aman Armaan Ahmed Family Surf for Success Program

• Eli Burstein, Yeshiva University, New York, New York
• Chloe Carlisle, University of Florida, Gainesville, Florida
• Adna Hassan, University of Minnesota Rochester
• Nicole Rodriguez Hilario, Barry University, Miami, Florida
• Maryam Jimoh, College of Wooster, Wooster, Ohio
• Viktoriya Kalinina, Brandeis University, Waltham, Massachusetts

AGA-Dr. Harvey Young Education & Development Foundation’s Young Guts Scholar Program

• Rafaella Lavalle Lacerda de Almeida, Michigan State University, East Lansing, Michigan
• Lara Cheesman, John’s Hopkins University School of Medicine, Baltimore, Maryland
• Cass Condray, University of Oklahoma, Norman, Oklahoma
• Daniel Juarez, Columbia University, New York, New York
• Jason Lin, University of Michigan, Ann Arbor, Michigan
• Riya Malhotra, Case Western Reserve University, Cleveland, Ohio
• Brian Nguyen, Brown University, Providence, Rhode Island
• Mahmoud (Moudy) Salem, Stony Brook University, Stony Brook, New York

ABSTRACT AWARDS

AGA Fellow Abstract of the Year Award

• Andrea Tou, MD Children’s Hospital of Philadelphia, Pennsylvania

AGA Fellow Abstract Awards

• Manik Aggarwal, MBBS, Mayo Clinic, Rochester, Minnesota
• Kole Buckley, PhD, University of Pennsylvania, Philadelphia, Pennsylvania
• Jane Ha, MD, Massachusetts General Hospital, Boston, Massachusetts
• Brent Hiramoto, MD, Brigham and Women’s Hospital, Boston, Massachusetts
• Md Obaidul Islam, PhD, University of Miami, Coral Gables, Florida
• Kanak Kennedy, MD, MPH, Children’s Hospital of Philadelphia, Pennsylvania
• Hanseul Kim, PhD, MS, Massachusetts General Hospital, Boston, Massachusetts
• Chiraag Kulkarni, MD, Stanford University, Stanford, California
• Su-Hyung Lee, PhD, DVM, Vanderbilt University Medical Center, Nashville, Tennessee
• Caroline Muiler, PhD, Yale School of Medicine, New Haven, Connecticut
• Sarah Najjar, PhD, New York University, New York, New York
• Ronaldo Panganiban, MD, PhD Penn State Hershey Medical Center, Hershey, Pennsylvania
• Perseus Patel, MD, Stanford University, California
• Hassan Sinan, MD, Johns Hopkins University, Baltimore, Maryland
• Patricia Snarski, PhD, Tulane University, New Orleans, Louisiana
• Fernando Vicentini, PhD, MS, McMaster University, Hamilton, Ontario, Canada
• Remington Winter, MD, University of Manitoba – Health Sciences Centre, Winnipeg, Manitoba, Canada
• Tiaosi Xing, PhD, MBBS, MS, Penn State College of Medicine, Hershey, Pennsylvania

AGA Student Abstract of the Year Award

• Jazmyne Jackson, Temple University, Philadelphia, Pennsylvania

AGA Student Abstract Award

• Valentina Alvarez, University of Washington School of Medicine, Seattle, Washington
• Yasaman Bahojb Habibyan, MS, University of Calgary, Alberta, Canada
• Tessa Herman, MD, University of Minnesota, Minneapolis-Saint Paul, Minnesota
• Jason Jin, Yale School of Medicine, New Haven, Connecticut
• Frederikke Larsen, Western University, London, Ontario, Canada
• Kara McNamara, Vanderbilt University, Nashville, Tennessee
• Julia Sessions, MD, University of Virginia, Charlottesville, Virginia
• Scott Silvey, MS, Virginia Commonwealth University, Richmond, Virginia
• Vijaya Sundaram, Marshall University School of Medicine, Huntington, West Virginia
• Kafayat Yusuf, MS, University of Kansas Medical Center, Kansas City, Kansas

AGA–Eric Esrailian Student Abstract Prize

• Brent Gawey, MD, MS, Mayo Clinic, Rochester, Minnesota
• Fei Li, MBBS, MS, University of Michigan, Ann Arbor, Michigan
• Emily Wong, University of Toronto, Ontario, Canada
• Jordan Woodard, MD, Prisma Health – Upstate, Greenville, South Carolina

AGA–Radhika Srinivasan Student Abstract Prize

• Raz Abdulqadir, MS, Penn State College of Medicine, Hershey, Pennsylvania
• Rebecca Ekeanyanwu, MHS, Meharry Medical College, Nashville, Tennessee
• Jared Morris, MD, University of Manitoba, Winnipeg City, Manitoba, Canada
• Rachel Stubler, Medical University of South Carolina, Charleston, South Carolina

AGA Abstract Award for Health Disparities Research

• Saqr Alsakarneh, MD University of Missouri-Kansas City
• Marco Noriega, MD, Beth Israel Deaconess Medical Center, Boston, Massachusetts
• Temitope Olasehinde, MD, University Hospitals/Case Western Reserve University, Cleveland, Ohio
• Gabrielle Waclawik, MD, MPH, University of Wisconsin, Madison, Wisconsin

AGA-Moti L. & Kamla Rustgi International Travel Award

• W. Keith Tan, MBChB, University of Cambridge, Cambridge, England
• Elsa van Liere, MD Amsterdam Universitair Medische Centra, Amsterdam, Netherlands

Maria T. Abreu, MD, AGAF, has been inducted as the 119th president of the AGA Institute. She currently serves as the Martin Kalser Endowed Chair of Gastroenterology; professor of medicine, microbiology, and immunology; and director of the Crohn’s and Colitis Center at the University of Miami. Dr. Abreu is the fifth woman to lead AGA as president.

Born in New York and raised in New Jersey, Dr. Abreu grew up surrounded by a strong, tight-knit Cuban community. Her family moved to Miami when she was in the ninth grade. She later entered the 6-year medical program at the University of Miami, which was the beginning of her unparalleled academic and professional excellence in medicine.

University of Miami

Dr. Abreu is a leader in inflammatory bowel disease patient care, and she was honored by the prestigious Sherman Prize in 2019. Her service to AGA is lengthy and begins when she took on the role of fellow representative for the research grant committee. She has since sat on both the government advocacy and diversity committees. She also served as the chair of the Immunology, Microbiology and Inflammatory Bowel Diseases Section of the AGA Council, and later as chair of the full AGA Council. While chair she developed a more streamlined in-person planning committee meeting to better organize DDW.

When asked about goals for her presidency, Dr. Abreu wants to make DDW a better experience for the modern gastroenterologist. This includes finding that perfect balance between digesting the latest education and science with networking and socializing. She plans to collaborate with the presidents of the other societies to make this come to fruition.

Perhaps the area that Dr. Abreu is most passionate about is welcoming and fostering the growth of women in gastroenterology. She wants to support women who want to succeed in academics and in practice, who want ergonomics to match their work needs, and who want to have families.

“Maria is the ultimate ‘triple threat’: master scientist, master clinician, and devoted mentor. She has not only been a major player advancing knowledge in IBD, but also motivating and pushing others to develop successful careers,” said Andres Yarur, MD, AGAF, associate professor of medicine at Cedars-Sinai Medical Center. “Her work, brilliance, passion, and charm inspire all of us and will continue to inspire many generations to come.”

Maria T. Abreu, MD, AGAF, has been inducted as the 119th president of the AGA Institute. She currently serves as the Martin Kalser Endowed Chair of Gastroenterology; professor of medicine, microbiology, and immunology; and director of the Crohn’s and Colitis Center at the University of Miami. Dr. Abreu is the fifth woman to lead AGA as president.

Born in New York and raised in New Jersey, Dr. Abreu grew up surrounded by a strong, tight-knit Cuban community. Her family moved to Miami when she was in the ninth grade. She later entered the 6-year medical program at the University of Miami, which was the beginning of her unparalleled academic and professional excellence in medicine.

University of Miami

Dr. Abreu is a leader in inflammatory bowel disease patient care, and she was honored by the prestigious Sherman Prize in 2019. Her service to AGA is lengthy and begins when she took on the role of fellow representative for the research grant committee. She has since sat on both the government advocacy and diversity committees. She also served as the chair of the Immunology, Microbiology and Inflammatory Bowel Diseases Section of the AGA Council, and later as chair of the full AGA Council. While chair she developed a more streamlined in-person planning committee meeting to better organize DDW.

When asked about goals for her presidency, Dr. Abreu wants to make DDW a better experience for the modern gastroenterologist. This includes finding that perfect balance between digesting the latest education and science with networking and socializing. She plans to collaborate with the presidents of the other societies to make this come to fruition.

Perhaps the area that Dr. Abreu is most passionate about is welcoming and fostering the growth of women in gastroenterology. She wants to support women who want to succeed in academics and in practice, who want ergonomics to match their work needs, and who want to have families.

“Maria is the ultimate ‘triple threat’: master scientist, master clinician, and devoted mentor. She has not only been a major player advancing knowledge in IBD, but also motivating and pushing others to develop successful careers,” said Andres Yarur, MD, AGAF, associate professor of medicine at Cedars-Sinai Medical Center. “Her work, brilliance, passion, and charm inspire all of us and will continue to inspire many generations to come.”

Maria T. Abreu, MD, AGAF, has been inducted as the 119th president of the AGA Institute. She currently serves as the Martin Kalser Endowed Chair of Gastroenterology; professor of medicine, microbiology, and immunology; and director of the Crohn’s and Colitis Center at the University of Miami. Dr. Abreu is the fifth woman to lead AGA as president.

Born in New York and raised in New Jersey, Dr. Abreu grew up surrounded by a strong, tight-knit Cuban community. Her family moved to Miami when she was in the ninth grade. She later entered the 6-year medical program at the University of Miami, which was the beginning of her unparalleled academic and professional excellence in medicine.

University of Miami

Dr. Abreu is a leader in inflammatory bowel disease patient care, and she was honored by the prestigious Sherman Prize in 2019. Her service to AGA is lengthy and begins when she took on the role of fellow representative for the research grant committee. She has since sat on both the government advocacy and diversity committees. She also served as the chair of the Immunology, Microbiology and Inflammatory Bowel Diseases Section of the AGA Council, and later as chair of the full AGA Council. While chair she developed a more streamlined in-person planning committee meeting to better organize DDW.

When asked about goals for her presidency, Dr. Abreu wants to make DDW a better experience for the modern gastroenterologist. This includes finding that perfect balance between digesting the latest education and science with networking and socializing. She plans to collaborate with the presidents of the other societies to make this come to fruition.

Perhaps the area that Dr. Abreu is most passionate about is welcoming and fostering the growth of women in gastroenterology. She wants to support women who want to succeed in academics and in practice, who want ergonomics to match their work needs, and who want to have families.

“Maria is the ultimate ‘triple threat’: master scientist, master clinician, and devoted mentor. She has not only been a major player advancing knowledge in IBD, but also motivating and pushing others to develop successful careers,” said Andres Yarur, MD, AGAF, associate professor of medicine at Cedars-Sinai Medical Center. “Her work, brilliance, passion, and charm inspire all of us and will continue to inspire many generations to come.”

CHICAGO — Have a great tech idea to improve gastroenterology? Start-up companies have the potential to transform the practice of medicine, and to make founders a nice pot of money, but it is a difficult road. At the 2024 AGA Tech Summit, held at the Chicago headquarters of MATTER, a global healthcare startup incubator, investors and gastroenterologists discussed some of the key challenges and opportunities for GI startups.

The road is daunting, and founders must be dedicated to their companies but also maintain life balance. “It is very easy, following your passion, for your life to get out of check. I don’t know what the divorce rate is for entrepreneurs, but I personally was a victim of that. The culture that we built was addictive and it became all encompassing, and at the same time [I neglected] my home life,” Scott Fraser, managing director of the consulting company Fraser Healthcare, said during a “Scars and Stripes” panel at the summit.

Barry M. Hertzberg

For those willing to navigate those waters, there is help. Investors are prepared to provide seed money for companies with good ideas and a strong market. AGA itself has stepped into the investment field with its GI Opportunity Fund, which it launched in 2022 through a partnership with Varia Ventures. The fund’s capital comes from AGA members, with a minimum investment of $25,000. To date, AGA has made investments in six companies, at around $100,000 per company. “It’s not a large amount that we’re investing. We’re a lead investor that signals to other venture capital companies that this is a viable company,” Tom Serena, CEO of AGA, said in an interview.

The fund grew out of AGA’s commitment to boosting early-stage companies in the gastroenterology space. AGA has always supported GI device and tech companies through its Center for GI Innovation and Technology, which sponsored the AGA Tech Summit. The center now provides resources and advice for GI innovators and startups. The AGA Tech Summit has created a gathering place for entrepreneurs and innovators to share their experiences and learn from one another. “But what we were missing was the last mile, which is getting funding to the companies,” said Mr. Serena. The summit itself has been modified to increase the venture capital presence. “That’s the networking we’re trying to [create] here. Venture capitalists are well acquainted with these companies, but we feel that AGA can bring clinical due diligence, and the startups want to be exposed to venture capital,” said Mr. Serena.

During the “Learn from VC Strategists” panel, investors shared advice for entrepreneurs. The emphasis throughout was on marketable ideas that can fundamentally change healthcare practice, though inventions may not have the whiz-bang appeal of some new technologies of years past.

“We’re particularly focused on clinical models that actually work. There were a lot of companies for many years that were doing things that had minimal impact, or very incremental impact. Maybe they were helping identify certain patients, but they weren’t actually engaging those patients. We’re now looking very end-to-end and trying to make sure that it’s not just a good idea, but one that you can actually roll out, engage patients, and see the [return on investment] in that patient data,” said Kelsey Maguire, managing director of the Blue Venture Fund, which is a collaborative effort across Blue Cross Blue Shield companies.

Blue Venture Fund

AGA

Karen L. Richard Photography

Arboretum Ventures

CHICAGO — Have a great tech idea to improve gastroenterology? Start-up companies have the potential to transform the practice of medicine, and to make founders a nice pot of money, but it is a difficult road. At the 2024 AGA Tech Summit, held at the Chicago headquarters of MATTER, a global healthcare startup incubator, investors and gastroenterologists discussed some of the key challenges and opportunities for GI startups.

The road is daunting, and founders must be dedicated to their companies but also maintain life balance. “It is very easy, following your passion, for your life to get out of check. I don’t know what the divorce rate is for entrepreneurs, but I personally was a victim of that. The culture that we built was addictive and it became all encompassing, and at the same time [I neglected] my home life,” Scott Fraser, managing director of the consulting company Fraser Healthcare, said during a “Scars and Stripes” panel at the summit.

Barry M. Hertzberg

For those willing to navigate those waters, there is help. Investors are prepared to provide seed money for companies with good ideas and a strong market. AGA itself has stepped into the investment field with its GI Opportunity Fund, which it launched in 2022 through a partnership with Varia Ventures. The fund’s capital comes from AGA members, with a minimum investment of $25,000. To date, AGA has made investments in six companies, at around $100,000 per company. “It’s not a large amount that we’re investing. We’re a lead investor that signals to other venture capital companies that this is a viable company,” Tom Serena, CEO of AGA, said in an interview.

The fund grew out of AGA’s commitment to boosting early-stage companies in the gastroenterology space. AGA has always supported GI device and tech companies through its Center for GI Innovation and Technology, which sponsored the AGA Tech Summit. The center now provides resources and advice for GI innovators and startups. The AGA Tech Summit has created a gathering place for entrepreneurs and innovators to share their experiences and learn from one another. “But what we were missing was the last mile, which is getting funding to the companies,” said Mr. Serena. The summit itself has been modified to increase the venture capital presence. “That’s the networking we’re trying to [create] here. Venture capitalists are well acquainted with these companies, but we feel that AGA can bring clinical due diligence, and the startups want to be exposed to venture capital,” said Mr. Serena.

During the “Learn from VC Strategists” panel, investors shared advice for entrepreneurs. The emphasis throughout was on marketable ideas that can fundamentally change healthcare practice, though inventions may not have the whiz-bang appeal of some new technologies of years past.

“We’re particularly focused on clinical models that actually work. There were a lot of companies for many years that were doing things that had minimal impact, or very incremental impact. Maybe they were helping identify certain patients, but they weren’t actually engaging those patients. We’re now looking very end-to-end and trying to make sure that it’s not just a good idea, but one that you can actually roll out, engage patients, and see the [return on investment] in that patient data,” said Kelsey Maguire, managing director of the Blue Venture Fund, which is a collaborative effort across Blue Cross Blue Shield companies.

Blue Venture Fund

AGA

Karen L. Richard Photography

Arboretum Ventures

CHICAGO — Have a great tech idea to improve gastroenterology? Start-up companies have the potential to transform the practice of medicine, and to make founders a nice pot of money, but it is a difficult road. At the 2024 AGA Tech Summit, held at the Chicago headquarters of MATTER, a global healthcare startup incubator, investors and gastroenterologists discussed some of the key challenges and opportunities for GI startups.

The road is daunting, and founders must be dedicated to their companies but also maintain life balance. “It is very easy, following your passion, for your life to get out of check. I don’t know what the divorce rate is for entrepreneurs, but I personally was a victim of that. The culture that we built was addictive and it became all encompassing, and at the same time [I neglected] my home life,” Scott Fraser, managing director of the consulting company Fraser Healthcare, said during a “Scars and Stripes” panel at the summit.

Barry M. Hertzberg

For those willing to navigate those waters, there is help. Investors are prepared to provide seed money for companies with good ideas and a strong market. AGA itself has stepped into the investment field with its GI Opportunity Fund, which it launched in 2022 through a partnership with Varia Ventures. The fund’s capital comes from AGA members, with a minimum investment of $25,000. To date, AGA has made investments in six companies, at around $100,000 per company. “It’s not a large amount that we’re investing. We’re a lead investor that signals to other venture capital companies that this is a viable company,” Tom Serena, CEO of AGA, said in an interview.

The fund grew out of AGA’s commitment to boosting early-stage companies in the gastroenterology space. AGA has always supported GI device and tech companies through its Center for GI Innovation and Technology, which sponsored the AGA Tech Summit. The center now provides resources and advice for GI innovators and startups. The AGA Tech Summit has created a gathering place for entrepreneurs and innovators to share their experiences and learn from one another. “But what we were missing was the last mile, which is getting funding to the companies,” said Mr. Serena. The summit itself has been modified to increase the venture capital presence. “That’s the networking we’re trying to [create] here. Venture capitalists are well acquainted with these companies, but we feel that AGA can bring clinical due diligence, and the startups want to be exposed to venture capital,” said Mr. Serena.

During the “Learn from VC Strategists” panel, investors shared advice for entrepreneurs. The emphasis throughout was on marketable ideas that can fundamentally change healthcare practice, though inventions may not have the whiz-bang appeal of some new technologies of years past.

“We’re particularly focused on clinical models that actually work. There were a lot of companies for many years that were doing things that had minimal impact, or very incremental impact. Maybe they were helping identify certain patients, but they weren’t actually engaging those patients. We’re now looking very end-to-end and trying to make sure that it’s not just a good idea, but one that you can actually roll out, engage patients, and see the [return on investment] in that patient data,” said Kelsey Maguire, managing director of the Blue Venture Fund, which is a collaborative effort across Blue Cross Blue Shield companies.

Blue Venture Fund

AGA

Karen L. Richard Photography

Arboretum Ventures

Journal CHEST^® | The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients

By: Charles Chin Han Lew, PhD, et al

Current international critical care guidelines based on expert opinion recommend high protein treatment (average 1.6 g/kg/d) for critically ill patients diagnosed with preexisting malnutrition to improve clinical outcomes. This multicenter, randomized controlled clinical trial investigated the effects of high vs usual protein treatment in 1,301 critically ill patients across 16 countries. Preexisting malnutrition was independently associated with the primary outcome of slower time to discharge alive (TTDA) (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20).

Most importantly, this study demonstrated an association between malnutrition and slower TTDA; however, this association was not modified by high protein treatment. This research challenges current international critical care nutrition guidelines.

CHEST

By: Kevin P. Seitz, MD, et al

The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot study conducted in a medical ICU exploring how different mechanical ventilation modes affect ventilator-free days in critically ill patients. This trial aims to determine which ventilation mode maximizes the days patients spend alive without invasive ventilation. By switching between ventilation modes each month, the study ensures a thorough assessment under uniform clinical conditions. The trial’s protocol and statistical analysis plan were defined before the end of enrollment, which bolsters the rigor, reproducibility, and transparency of the findings. Initial findings indicate the necessity for an expanded, multicenter trial to definitively identify the optimal ventilation mode, as current data do not universally prefer one method over others. This research has significant implications for clinical practice, potentially altering mechanical ventilation guidelines and improving patient outcomes by reducing the time spent on mechanical ventilation.

Journal CHEST^® | The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients

By: Charles Chin Han Lew, PhD, et al

Current international critical care guidelines based on expert opinion recommend high protein treatment (average 1.6 g/kg/d) for critically ill patients diagnosed with preexisting malnutrition to improve clinical outcomes. This multicenter, randomized controlled clinical trial investigated the effects of high vs usual protein treatment in 1,301 critically ill patients across 16 countries. Preexisting malnutrition was independently associated with the primary outcome of slower time to discharge alive (TTDA) (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20).

Most importantly, this study demonstrated an association between malnutrition and slower TTDA; however, this association was not modified by high protein treatment. This research challenges current international critical care nutrition guidelines.

CHEST

By: Kevin P. Seitz, MD, et al

The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot study conducted in a medical ICU exploring how different mechanical ventilation modes affect ventilator-free days in critically ill patients. This trial aims to determine which ventilation mode maximizes the days patients spend alive without invasive ventilation. By switching between ventilation modes each month, the study ensures a thorough assessment under uniform clinical conditions. The trial’s protocol and statistical analysis plan were defined before the end of enrollment, which bolsters the rigor, reproducibility, and transparency of the findings. Initial findings indicate the necessity for an expanded, multicenter trial to definitively identify the optimal ventilation mode, as current data do not universally prefer one method over others. This research has significant implications for clinical practice, potentially altering mechanical ventilation guidelines and improving patient outcomes by reducing the time spent on mechanical ventilation.

Journal CHEST^® | The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients

By: Charles Chin Han Lew, PhD, et al

Current international critical care guidelines based on expert opinion recommend high protein treatment (average 1.6 g/kg/d) for critically ill patients diagnosed with preexisting malnutrition to improve clinical outcomes. This multicenter, randomized controlled clinical trial investigated the effects of high vs usual protein treatment in 1,301 critically ill patients across 16 countries. Preexisting malnutrition was independently associated with the primary outcome of slower time to discharge alive (TTDA) (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20).

Most importantly, this study demonstrated an association between malnutrition and slower TTDA; however, this association was not modified by high protein treatment. This research challenges current international critical care nutrition guidelines.

CHEST

By: Kevin P. Seitz, MD, et al

The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot study conducted in a medical ICU exploring how different mechanical ventilation modes affect ventilator-free days in critically ill patients. This trial aims to determine which ventilation mode maximizes the days patients spend alive without invasive ventilation. By switching between ventilation modes each month, the study ensures a thorough assessment under uniform clinical conditions. The trial’s protocol and statistical analysis plan were defined before the end of enrollment, which bolsters the rigor, reproducibility, and transparency of the findings. Initial findings indicate the necessity for an expanded, multicenter trial to definitively identify the optimal ventilation mode, as current data do not universally prefer one method over others. This research has significant implications for clinical practice, potentially altering mechanical ventilation guidelines and improving patient outcomes by reducing the time spent on mechanical ventilation.

As we enter summer, it’s hard to believe that we’re halfway through my presidency. Registration for CHEST 2024 (October 6 to 9) is now open, and October will be here before we know it. We’re thrilled to host the CHEST Annual Meeting in Boston for the first time ever and hope to see you there to experience all that the meeting has to offer.

I’m happy to share that we received more than 4,000 abstract and case report submissions from clinicians at all stages of their careers, and, for the first year, we had a dedicated category to solicit submissions from physician assistants (PAs), nurse practitioners (NPs), respiratory therapists, and other members of the broader health care team.

CHEST

In both my practice and my time as CHEST President, I’ve been reflecting on the benefits of the multidisciplinary team—especially in the ICU. Because this is a setting that relies heavily on a team aspect, every member of the care team is a great asset.

CHEST is working to ensure that all integral members of our professional health care teams have the resources they need to best serve our patients. We encourage advanced practice providers (APPs) to apply to serve on our committees during the current open call, and we recently launched a dedicated APP Intersection column, called APP Intersection, within this publication to elevate diverse perspectives. I anticipate more is on the horizon.

In my experience, I have seen tremendous success in partnering with and complementing each other, rather than competing for space when caring for a patient. Each and every one of us shares the same goal of providing the best patient care, and we each bring our own strengths.

Our future is ripe with opportunities to better serve the whole care team—MDs, PAs, NPs, and more—and it starts with recognizing the needs of everyone within the organization. To help CHEST better serve our members, I encourage you to take a short survey about your professional hurdles.

And please, do not hesitate to contact me ([email protected]) with suggestions or just to introduce yourself.



All the best,

Jack

As we enter summer, it’s hard to believe that we’re halfway through my presidency. Registration for CHEST 2024 (October 6 to 9) is now open, and October will be here before we know it. We’re thrilled to host the CHEST Annual Meeting in Boston for the first time ever and hope to see you there to experience all that the meeting has to offer.

I’m happy to share that we received more than 4,000 abstract and case report submissions from clinicians at all stages of their careers, and, for the first year, we had a dedicated category to solicit submissions from physician assistants (PAs), nurse practitioners (NPs), respiratory therapists, and other members of the broader health care team.

CHEST

In both my practice and my time as CHEST President, I’ve been reflecting on the benefits of the multidisciplinary team—especially in the ICU. Because this is a setting that relies heavily on a team aspect, every member of the care team is a great asset.

CHEST is working to ensure that all integral members of our professional health care teams have the resources they need to best serve our patients. We encourage advanced practice providers (APPs) to apply to serve on our committees during the current open call, and we recently launched a dedicated APP Intersection column, called APP Intersection, within this publication to elevate diverse perspectives. I anticipate more is on the horizon.

In my experience, I have seen tremendous success in partnering with and complementing each other, rather than competing for space when caring for a patient. Each and every one of us shares the same goal of providing the best patient care, and we each bring our own strengths.

Our future is ripe with opportunities to better serve the whole care team—MDs, PAs, NPs, and more—and it starts with recognizing the needs of everyone within the organization. To help CHEST better serve our members, I encourage you to take a short survey about your professional hurdles.

And please, do not hesitate to contact me ([email protected]) with suggestions or just to introduce yourself.



All the best,

Jack

As we enter summer, it’s hard to believe that we’re halfway through my presidency. Registration for CHEST 2024 (October 6 to 9) is now open, and October will be here before we know it. We’re thrilled to host the CHEST Annual Meeting in Boston for the first time ever and hope to see you there to experience all that the meeting has to offer.

I’m happy to share that we received more than 4,000 abstract and case report submissions from clinicians at all stages of their careers, and, for the first year, we had a dedicated category to solicit submissions from physician assistants (PAs), nurse practitioners (NPs), respiratory therapists, and other members of the broader health care team.

CHEST

In both my practice and my time as CHEST President, I’ve been reflecting on the benefits of the multidisciplinary team—especially in the ICU. Because this is a setting that relies heavily on a team aspect, every member of the care team is a great asset.

CHEST is working to ensure that all integral members of our professional health care teams have the resources they need to best serve our patients. We encourage advanced practice providers (APPs) to apply to serve on our committees during the current open call, and we recently launched a dedicated APP Intersection column, called APP Intersection, within this publication to elevate diverse perspectives. I anticipate more is on the horizon.

In my experience, I have seen tremendous success in partnering with and complementing each other, rather than competing for space when caring for a patient. Each and every one of us shares the same goal of providing the best patient care, and we each bring our own strengths.

Our future is ripe with opportunities to better serve the whole care team—MDs, PAs, NPs, and more—and it starts with recognizing the needs of everyone within the organization. To help CHEST better serve our members, I encourage you to take a short survey about your professional hurdles.

And please, do not hesitate to contact me ([email protected]) with suggestions or just to introduce yourself.



All the best,

Jack

APP INTERSECTION

In the intricate tapestry of health care, the roles of advanced practice registered nurses, also known as nurse practitioners (NPs), have evolved beyond the confines of clinical settings. Once solely seen as caregivers at the bedside, these nursing professionals now stand at the forefront of advocacy, policymaking, and patient empowerment.

The journey into the realm of nursing often begins with a passion for healing and caring for others. However, for many, this path frequently leads to overcoming barriers to patient care, restrictions to practice, and lengthy red tape in the face of care teams that do not fully understand the scope and role of the NP.

CHEST

Delving into health policy intricacies, efforts focus on understanding how legislative decisions directly impact patient care. Involvement in advocacy aims to improve health care access, promote patient-centered policies, and reduce disparities in the workforce and patient care.

Achieving sound primary care for people with multiple comorbid conditions requires the skills and abilities of all members of the health care workforce, including NPs.¹ NPs have assumed an increasing role in recent decades as primary care providers for people with chronic diseases, while national trends show few physicians entering and staying in primary care.^2,3,4,5 NPs are the nation’s fastest-growing primary care workforce, with nearly 90% of them trained to deliver primary care.^6,7 Yet, NPs continue to experience reduced reimbursement for services compared with their physician counterparts.

Barriers to practice reduce the productivity and capacity of these health care professionals. Not permitting NPs to practice to the full extent of their licensure and education decreases the types and amounts of health care services that can be provided for people who need care.⁸As noted in the Future of Nursing 2020-2030 report, this restriction also has significant implications for addressing the disparities in access to health care between rural and urban areas. A recent systemic review revealed that full practice authority is associated with higher numbers of NPs in rural areas and in primary care where there is a shortage of physicians. Full practice authority is associated with increased access to care and utilization of health care services, lower cost of care, and no decrease in quality of care.^9,10 As stated in the National Council of State Boards of Nursing 2022 Environmental Scan, regulators and nurse leaders are responsible for upholding rules and regulations of nursing practice as well as ensuring that standards of care are met and patients are protected.¹¹

Of equal importance is regulator awareness of the degree to which barriers continue to impact NP practice and limit aspects of care that directly influence care quality and access. Nursing leaders can have a significant impact on removing nonregulatory barriers to practice, such as changing outdated hospital bylaws that restrict NP practice. In turn, regulators can support efforts to remove unnecessary barriers to NP practice.

Fueled by experience in reduced practice, NPs become catalysts for change, transcending the role of health care providers. At the core of the NP role lies a commitment to patient advocacy. Beyond diagnosing and treating illnesses, NPs champion patients’ rights, ensuring their voices in health care decision-making. Advocacy efforts range from expanding access to essential services to promoting preventive care and fighting discrimination. By embracing roles as caregivers and agents of change, NPs can help the health care system emerge equitable, accessible, and patient-centric.
 

Ms. Kavanaugh is Assistant Dean of Graduate Nursing, University of Mount Saint Vincent, Pulmonary Critical Care Nurse Practitioner, Stamford Hospital.
 

References

1. McMenamin, A., Turi, E., Schlak, A., & Poghosyan, L. (2023). A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions. Medical care research and review: MCRR, 80(6), 563–581. https://doi.org/10.1177/10775587231186720

2. Fraze T, Briggs A, Whitcomb E, Peck K, & Meara E (2020). Role of nurse practitioners in caring for patients with complex health needs. Medical Care, 58(10), 853–860. 10.1097/mlr.0000000000001364

3. Xue Y, Goodwin J, Adhikari D, Raji M, & Kuo Y (2017). Trends in primary care provision to medicare beneficiaries by physicians, nurse practitioners, or physician assistants: 2008–2014. Journal of Primary Care & Community Health, 8(4), 256–263. 10.1177/2150131917736634

4. Buerhaus P (2018). Nurse practitioners: A solution to America’s primary care crisis. American Enterprise Institute. https://www.aei.org/research-products/report/nurse-practitioners-a-solution-to-americas-primary-care-crisis/

5. Xue Y, Goodwin J, Adhikari D, Raji M, & Kuo Y (2017). Trends in primary care provision to medicare beneficiaries by physicians, nurse practitioners, or physician assistants: 2008–2014. Journal of Primary Care & Community Health, 8(4), 256–263. 10.1177/2150131917736634

6. American Association of Nurse Practitioners. (2022). Nurse practitioners in primary care. https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioners-in-primary-care

7. Auerbach, D. I. (2012). Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Medical Care, 50(7), 606-610. doi: http://dx.doi.org/10.1097/MLR.0b013e318249d6e7

8. National Academy of Medicine . The National Academies Press; 2021. The future of nursing 2020-2030: Charting a path to achieve health equity.

9. Yang BK, Trinkoff AM, Zito JM, Burcu M, Safer DJ, Storr CL, Johantgen ME, & Idzik S (2017). Nurse practitioner independent practice authority and mental health service delivery in U.S. Community Health Centers. Psychiatric Services, 68(10), 1032–1038. 10.1176/appi.ps.201600495

10. Xue Y., Kannan V., Greener E., Smith J.A., Brasch J., Johnson B.A., Spetz J. Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties. Journal of Nursing Regulation. 2018;8(4):5–13. doi: 10.1016/S2155-8256(17)30176-X.

11. National Council of State Boards of Nursing The NCSBN 2022 environmental scan: Resiliency, achievement, and public protection. Journal of Nursing Regulation. 2022;12:S3–S55. doi: 10.1016/S2155-8256(22)00015-1.
 

APP INTERSECTION

In the intricate tapestry of health care, the roles of advanced practice registered nurses, also known as nurse practitioners (NPs), have evolved beyond the confines of clinical settings. Once solely seen as caregivers at the bedside, these nursing professionals now stand at the forefront of advocacy, policymaking, and patient empowerment.

The journey into the realm of nursing often begins with a passion for healing and caring for others. However, for many, this path frequently leads to overcoming barriers to patient care, restrictions to practice, and lengthy red tape in the face of care teams that do not fully understand the scope and role of the NP.

CHEST

Delving into health policy intricacies, efforts focus on understanding how legislative decisions directly impact patient care. Involvement in advocacy aims to improve health care access, promote patient-centered policies, and reduce disparities in the workforce and patient care.

Achieving sound primary care for people with multiple comorbid conditions requires the skills and abilities of all members of the health care workforce, including NPs.¹ NPs have assumed an increasing role in recent decades as primary care providers for people with chronic diseases, while national trends show few physicians entering and staying in primary care.^2,3,4,5 NPs are the nation’s fastest-growing primary care workforce, with nearly 90% of them trained to deliver primary care.^6,7 Yet, NPs continue to experience reduced reimbursement for services compared with their physician counterparts.

Barriers to practice reduce the productivity and capacity of these health care professionals. Not permitting NPs to practice to the full extent of their licensure and education decreases the types and amounts of health care services that can be provided for people who need care.⁸As noted in the Future of Nursing 2020-2030 report, this restriction also has significant implications for addressing the disparities in access to health care between rural and urban areas. A recent systemic review revealed that full practice authority is associated with higher numbers of NPs in rural areas and in primary care where there is a shortage of physicians. Full practice authority is associated with increased access to care and utilization of health care services, lower cost of care, and no decrease in quality of care.^9,10 As stated in the National Council of State Boards of Nursing 2022 Environmental Scan, regulators and nurse leaders are responsible for upholding rules and regulations of nursing practice as well as ensuring that standards of care are met and patients are protected.¹¹

Of equal importance is regulator awareness of the degree to which barriers continue to impact NP practice and limit aspects of care that directly influence care quality and access. Nursing leaders can have a significant impact on removing nonregulatory barriers to practice, such as changing outdated hospital bylaws that restrict NP practice. In turn, regulators can support efforts to remove unnecessary barriers to NP practice.

Fueled by experience in reduced practice, NPs become catalysts for change, transcending the role of health care providers. At the core of the NP role lies a commitment to patient advocacy. Beyond diagnosing and treating illnesses, NPs champion patients’ rights, ensuring their voices in health care decision-making. Advocacy efforts range from expanding access to essential services to promoting preventive care and fighting discrimination. By embracing roles as caregivers and agents of change, NPs can help the health care system emerge equitable, accessible, and patient-centric.
 

Ms. Kavanaugh is Assistant Dean of Graduate Nursing, University of Mount Saint Vincent, Pulmonary Critical Care Nurse Practitioner, Stamford Hospital.
 

References

1. McMenamin, A., Turi, E., Schlak, A., & Poghosyan, L. (2023). A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions. Medical care research and review: MCRR, 80(6), 563–581. https://doi.org/10.1177/10775587231186720

2. Fraze T, Briggs A, Whitcomb E, Peck K, & Meara E (2020). Role of nurse practitioners in caring for patients with complex health needs. Medical Care, 58(10), 853–860. 10.1097/mlr.0000000000001364

3. Xue Y, Goodwin J, Adhikari D, Raji M, & Kuo Y (2017). Trends in primary care provision to medicare beneficiaries by physicians, nurse practitioners, or physician assistants: 2008–2014. Journal of Primary Care & Community Health, 8(4), 256–263. 10.1177/2150131917736634

4. Buerhaus P (2018). Nurse practitioners: A solution to America’s primary care crisis. American Enterprise Institute. https://www.aei.org/research-products/report/nurse-practitioners-a-solution-to-americas-primary-care-crisis/

5. Xue Y, Goodwin J, Adhikari D, Raji M, & Kuo Y (2017). Trends in primary care provision to medicare beneficiaries by physicians, nurse practitioners, or physician assistants: 2008–2014. Journal of Primary Care & Community Health, 8(4), 256–263. 10.1177/2150131917736634

6. American Association of Nurse Practitioners. (2022). Nurse practitioners in primary care. https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioners-in-primary-care

7. Auerbach, D. I. (2012). Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Medical Care, 50(7), 606-610. doi: http://dx.doi.org/10.1097/MLR.0b013e318249d6e7

8. National Academy of Medicine . The National Academies Press; 2021. The future of nursing 2020-2030: Charting a path to achieve health equity.

9. Yang BK, Trinkoff AM, Zito JM, Burcu M, Safer DJ, Storr CL, Johantgen ME, & Idzik S (2017). Nurse practitioner independent practice authority and mental health service delivery in U.S. Community Health Centers. Psychiatric Services, 68(10), 1032–1038. 10.1176/appi.ps.201600495

10. Xue Y., Kannan V., Greener E., Smith J.A., Brasch J., Johnson B.A., Spetz J. Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties. Journal of Nursing Regulation. 2018;8(4):5–13. doi: 10.1016/S2155-8256(17)30176-X.

11. National Council of State Boards of Nursing The NCSBN 2022 environmental scan: Resiliency, achievement, and public protection. Journal of Nursing Regulation. 2022;12:S3–S55. doi: 10.1016/S2155-8256(22)00015-1.
 

APP INTERSECTION

In the intricate tapestry of health care, the roles of advanced practice registered nurses, also known as nurse practitioners (NPs), have evolved beyond the confines of clinical settings. Once solely seen as caregivers at the bedside, these nursing professionals now stand at the forefront of advocacy, policymaking, and patient empowerment.

The journey into the realm of nursing often begins with a passion for healing and caring for others. However, for many, this path frequently leads to overcoming barriers to patient care, restrictions to practice, and lengthy red tape in the face of care teams that do not fully understand the scope and role of the NP.

CHEST

Delving into health policy intricacies, efforts focus on understanding how legislative decisions directly impact patient care. Involvement in advocacy aims to improve health care access, promote patient-centered policies, and reduce disparities in the workforce and patient care.

Achieving sound primary care for people with multiple comorbid conditions requires the skills and abilities of all members of the health care workforce, including NPs.¹ NPs have assumed an increasing role in recent decades as primary care providers for people with chronic diseases, while national trends show few physicians entering and staying in primary care.^2,3,4,5 NPs are the nation’s fastest-growing primary care workforce, with nearly 90% of them trained to deliver primary care.^6,7 Yet, NPs continue to experience reduced reimbursement for services compared with their physician counterparts.

Barriers to practice reduce the productivity and capacity of these health care professionals. Not permitting NPs to practice to the full extent of their licensure and education decreases the types and amounts of health care services that can be provided for people who need care.⁸As noted in the Future of Nursing 2020-2030 report, this restriction also has significant implications for addressing the disparities in access to health care between rural and urban areas. A recent systemic review revealed that full practice authority is associated with higher numbers of NPs in rural areas and in primary care where there is a shortage of physicians. Full practice authority is associated with increased access to care and utilization of health care services, lower cost of care, and no decrease in quality of care.^9,10 As stated in the National Council of State Boards of Nursing 2022 Environmental Scan, regulators and nurse leaders are responsible for upholding rules and regulations of nursing practice as well as ensuring that standards of care are met and patients are protected.¹¹

Of equal importance is regulator awareness of the degree to which barriers continue to impact NP practice and limit aspects of care that directly influence care quality and access. Nursing leaders can have a significant impact on removing nonregulatory barriers to practice, such as changing outdated hospital bylaws that restrict NP practice. In turn, regulators can support efforts to remove unnecessary barriers to NP practice.

Fueled by experience in reduced practice, NPs become catalysts for change, transcending the role of health care providers. At the core of the NP role lies a commitment to patient advocacy. Beyond diagnosing and treating illnesses, NPs champion patients’ rights, ensuring their voices in health care decision-making. Advocacy efforts range from expanding access to essential services to promoting preventive care and fighting discrimination. By embracing roles as caregivers and agents of change, NPs can help the health care system emerge equitable, accessible, and patient-centric.
 

Ms. Kavanaugh is Assistant Dean of Graduate Nursing, University of Mount Saint Vincent, Pulmonary Critical Care Nurse Practitioner, Stamford Hospital.
 

References

1. McMenamin, A., Turi, E., Schlak, A., & Poghosyan, L. (2023). A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions. Medical care research and review: MCRR, 80(6), 563–581. https://doi.org/10.1177/10775587231186720

2. Fraze T, Briggs A, Whitcomb E, Peck K, & Meara E (2020). Role of nurse practitioners in caring for patients with complex health needs. Medical Care, 58(10), 853–860. 10.1097/mlr.0000000000001364

3. Xue Y, Goodwin J, Adhikari D, Raji M, & Kuo Y (2017). Trends in primary care provision to medicare beneficiaries by physicians, nurse practitioners, or physician assistants: 2008–2014. Journal of Primary Care & Community Health, 8(4), 256–263. 10.1177/2150131917736634

4. Buerhaus P (2018). Nurse practitioners: A solution to America’s primary care crisis. American Enterprise Institute. https://www.aei.org/research-products/report/nurse-practitioners-a-solution-to-americas-primary-care-crisis/

5. Xue Y, Goodwin J, Adhikari D, Raji M, & Kuo Y (2017). Trends in primary care provision to medicare beneficiaries by physicians, nurse practitioners, or physician assistants: 2008–2014. Journal of Primary Care & Community Health, 8(4), 256–263. 10.1177/2150131917736634

6. American Association of Nurse Practitioners. (2022). Nurse practitioners in primary care. https://www.aanp.org/advocacy/advocacy-resource/position-statements/nurse-practitioners-in-primary-care

7. Auerbach, D. I. (2012). Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Medical Care, 50(7), 606-610. doi: http://dx.doi.org/10.1097/MLR.0b013e318249d6e7

8. National Academy of Medicine . The National Academies Press; 2021. The future of nursing 2020-2030: Charting a path to achieve health equity.

9. Yang BK, Trinkoff AM, Zito JM, Burcu M, Safer DJ, Storr CL, Johantgen ME, & Idzik S (2017). Nurse practitioner independent practice authority and mental health service delivery in U.S. Community Health Centers. Psychiatric Services, 68(10), 1032–1038. 10.1176/appi.ps.201600495

10. Xue Y., Kannan V., Greener E., Smith J.A., Brasch J., Johnson B.A., Spetz J. Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties. Journal of Nursing Regulation. 2018;8(4):5–13. doi: 10.1016/S2155-8256(17)30176-X.

11. National Council of State Boards of Nursing The NCSBN 2022 environmental scan: Resiliency, achievement, and public protection. Journal of Nursing Regulation. 2022;12:S3–S55. doi: 10.1016/S2155-8256(22)00015-1.
 

Military service is a hazard-ridden profession. It’s easy to recognize the direct dangers from warfighting, such as gunfire and explosions, but the risks from environmental, chemical, and other occupational exposures can be harder to see.

Combustion-based waste management systems, otherwise known as “burn pits,” were used in deployed environments by the US military from the 1990s to the early 2010s. These burn pits were commonly used to eliminate plastics, electronics, munitions, metals, wood, chemicals, and even human waste. At the height of the recent conflicts in Afghanistan, Iraq, and other southwest Asia locations, more than 70% of military installations employed at least one, and nearly 4 million service members were exposed to some degree to their emissions.

CHEST

Reports of burn pits being related to organic disease have garnered widespread media attention. Initially, this came through anecdotal reports of post-deployment respiratory symptoms. Over time, the conditions attributed to burn pits expanded to include newly diagnosed respiratory diseases and malignancies. The composition of burn pit emissions sparked concern after fine particulate matter, volatile organic compounds, dioxins, and polycyclic aromatic hydrocarbons were detected. Each has previously been associated with an increased risk of respiratory disease or malignancy.

Ultimately, Congress passed the 2022 Promise to Address Comprehensive Toxins (PACT) Act, presumptively linking more than 20 diagnoses to burn pits. The PACT Act provides countless veterans access to low-cost or free medical care for their respective conditions.
 

What do we know about burn pits and deployment-related respiratory disease?

Data from the Millennium Cohort Study noted an approximately 40% increase in respiratory symptoms among individuals returning from deployment but no increase in the frequency of diagnosed respiratory diseases.¹ This study and others definitively established a temporal relationship between deployment and respiratory symptoms. Soon after, a retrospective, observational study of service members with post-deployment respiratory symptoms found a high prevalence of constrictive bronchiolitis (CB) identified by lung biopsy.² Patients in this group reported exposure to burn pits and a sulfur mine fire in the Mosul area while deployed. Most had normal imaging and pulmonary function testing before biopsy, confounding the clinical significance of the CB finding. The publication of this report led to increased investigation of respiratory function during and after deployment.

CHEST

In a series of prospective studies that included full pulmonary function testing, impulse oscillometry, cardiopulmonary exercise testing, bronchoscopy, and, occasionally, lung biopsy to evaluate post-deployment dyspnea, only a small minority received a diagnosis of clinically significant lung disease.^3,4 Additionally, when comparing spirometry and impulse oscillometry results from before and after deployment, no decline in lung function was observed in a population of service members reporting regular burn pit exposure.⁵ These studies suggest that at the population level, deployment does not lead to abnormalities in the structure and function of the respiratory system.

The National Academies of Sciences published two separate reviews of burn pit exposure and outcomes in 2011 and 2020.^6,7 They found insufficient evidence to support a causal relationship between burn pit exposure and pulmonary disease. They highlighted studies on the composition of emissions from the area surrounding the largest military burn pit in Iraq. Levels of particulate matter, volatile organic compounds, and polycyclic aromatic hydrocarbons were elevated when compared with those of a typical American city but were similar to the pollution levels seen in the region at the time. Given these findings, they suggested ambient air pollution may have contributed more to clinically significant disease than burn pit emissions.
 

How do we interpret this mixed data?

At the population level, we have yet to find conclusive data directly linking burn pit exposure to the development of any respiratory disease. Does this mean that burn pits are not harmful?

Not necessarily. Research on outcomes related to burn pit exposure is challenging given the heterogeneity in exposure volume. Much of the research is retrospective and subject to recall bias. Relationships may be distorted, and the precision of reported symptoms and exposure levels is altered. Given these challenges, it’s unsurprising that evidence of causality has yet to be proven. In addition, some portion of service members has been diagnosed with respiratory disease that could be related to burn pit exposure.

What is now indisputable is that deployment to southwest Asia leads to an increase in respiratory complaints. Whether veteran respiratory symptoms are due to burn pits, ambient pollution, environmental particulate matter, or dust storms is less clinically relevant. These symptoms require attention, investigation, and management.
 

What does this mean for the future medical care of service members and veterans?

Many veterans with post-deployment respiratory symptoms undergo extensive evaluations without obtaining a definitive diagnosis. A recent consensus statement on deployment-related respiratory symptoms provides a framework for evaluation in such cases.⁸ In keeping with that statement, we recommend veterans be referred to centers with expertise in this field, such as the Department of Veterans Affairs (VA) or military health centers, when deployment-related respiratory symptoms are reported. When the evaluation does not lead to a treatable diagnosis, these centers can provide multidisciplinary care to address the symptoms of dyspnea, cough, fatigue, and exercise intolerance to improve functional status.

Despite uncertainty in the evidence or challenges in diagnosis, both the Department of Defense (DoD) and VA remain fully committed to addressing the health concerns of service members and veterans. Notably, the VA has already screened more than 5 million veterans for toxic military exposures in accordance with the PACT Act and is providing ongoing screening and care for veterans with post-deployment respiratory symptoms. Furthermore, the DoD and VA have dedicated large portions of their research budgets to investigating the impacts of exposures during military service and optimizing the care of those with respiratory symptoms. With these commitments to patient care and research, our veterans’ respiratory health can now be optimized, and future risks can be mitigated.
 

Dr. Haynes is Fellow, Pulmonary and Critical Care Medicine, Walter Reed National Military Medical Center, Assistant Professor of Medicine, Uniformed Services University. Dr. Nations is Pulmonary and Critical Care Medicine, Deputy Chief of Staff for Operations, Washington DC VA Medical Center, Associate Professor of Medicine, Uniformed Services University.

References

1. Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD; Margaret A. K. Ryan for the Millennium Cohort Study Team. Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: a prospective population-based study. Am J Epidemiol. 2009;170(11):1433-1442. Preprint. Posted online October 22, 2009. PMID: 19850627. doi: 10.1093/aje/kwp287

2. King MS, Eisenberg R, Newman JH, et al. Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan. N Engl J Med. 2011;365(3):222-230. Erratum in: N Engl J Med. 2011;365(18):1749. PMID: 21774710; PMCID: PMC3296566. doi: 10.1056/NEJMoa1101388

3. Morris MJ, Dodson DW, Lucero PF, et al. Study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE). Am J Respir Crit Care Med. 2014;190(1):77-84. PMID: 24922562. doi: 10.1164/rccm.201402-0372OC

4. Morris MJ, Walter RJ, McCann ET, et al. Clinical evaluation of deployed military personnel with chronic respiratory symptoms: study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE) III. Chest. 2020;157(6):1559-1567. Preprint. Posted online February 1, 2020. PMID: 32017933. doi: 10.1016/j.chest.2020.01.024

5. Morris MJ, Skabelund AJ, Rawlins FA 3rd, Gallup RA, Aden JK, Holley AB. Study of active duty military personnel for environmental deployment exposures: pre- and post-deployment spirometry (STAMPEDE II). Respir Care. 2019;64(5):536-544. Preprint. Posted online January 8, 2019.PMID: 30622173. doi: 10.4187/respcare.06396

6. Institute of Medicine. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. The National Academies Press; 2011. https://doi.org/10.17226/13209

7. National Academies of Sciences, Engineering, and Medicine. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. The National Academies Press; 2020. https://doi.org/10.17226/25837

8. Falvo MJ, Sotolongo AM, Osterholzer JJ, et al. Consensus statements on deployment-related respiratory disease, inclusive of constrictive bronchiolitis: a modified Delphi study. Chest. 2023;163(3):599-609. Preprint. Posted November 4, 2022. PMID: 36343686; PMCID: PMC10154857. doi: 10.1016/j.chest.2022.10.031

Military service is a hazard-ridden profession. It’s easy to recognize the direct dangers from warfighting, such as gunfire and explosions, but the risks from environmental, chemical, and other occupational exposures can be harder to see.

Combustion-based waste management systems, otherwise known as “burn pits,” were used in deployed environments by the US military from the 1990s to the early 2010s. These burn pits were commonly used to eliminate plastics, electronics, munitions, metals, wood, chemicals, and even human waste. At the height of the recent conflicts in Afghanistan, Iraq, and other southwest Asia locations, more than 70% of military installations employed at least one, and nearly 4 million service members were exposed to some degree to their emissions.

CHEST

Reports of burn pits being related to organic disease have garnered widespread media attention. Initially, this came through anecdotal reports of post-deployment respiratory symptoms. Over time, the conditions attributed to burn pits expanded to include newly diagnosed respiratory diseases and malignancies. The composition of burn pit emissions sparked concern after fine particulate matter, volatile organic compounds, dioxins, and polycyclic aromatic hydrocarbons were detected. Each has previously been associated with an increased risk of respiratory disease or malignancy.

Ultimately, Congress passed the 2022 Promise to Address Comprehensive Toxins (PACT) Act, presumptively linking more than 20 diagnoses to burn pits. The PACT Act provides countless veterans access to low-cost or free medical care for their respective conditions.
 

What do we know about burn pits and deployment-related respiratory disease?

Data from the Millennium Cohort Study noted an approximately 40% increase in respiratory symptoms among individuals returning from deployment but no increase in the frequency of diagnosed respiratory diseases.¹ This study and others definitively established a temporal relationship between deployment and respiratory symptoms. Soon after, a retrospective, observational study of service members with post-deployment respiratory symptoms found a high prevalence of constrictive bronchiolitis (CB) identified by lung biopsy.² Patients in this group reported exposure to burn pits and a sulfur mine fire in the Mosul area while deployed. Most had normal imaging and pulmonary function testing before biopsy, confounding the clinical significance of the CB finding. The publication of this report led to increased investigation of respiratory function during and after deployment.

CHEST

In a series of prospective studies that included full pulmonary function testing, impulse oscillometry, cardiopulmonary exercise testing, bronchoscopy, and, occasionally, lung biopsy to evaluate post-deployment dyspnea, only a small minority received a diagnosis of clinically significant lung disease.^3,4 Additionally, when comparing spirometry and impulse oscillometry results from before and after deployment, no decline in lung function was observed in a population of service members reporting regular burn pit exposure.⁵ These studies suggest that at the population level, deployment does not lead to abnormalities in the structure and function of the respiratory system.

The National Academies of Sciences published two separate reviews of burn pit exposure and outcomes in 2011 and 2020.^6,7 They found insufficient evidence to support a causal relationship between burn pit exposure and pulmonary disease. They highlighted studies on the composition of emissions from the area surrounding the largest military burn pit in Iraq. Levels of particulate matter, volatile organic compounds, and polycyclic aromatic hydrocarbons were elevated when compared with those of a typical American city but were similar to the pollution levels seen in the region at the time. Given these findings, they suggested ambient air pollution may have contributed more to clinically significant disease than burn pit emissions.
 

How do we interpret this mixed data?

At the population level, we have yet to find conclusive data directly linking burn pit exposure to the development of any respiratory disease. Does this mean that burn pits are not harmful?

Not necessarily. Research on outcomes related to burn pit exposure is challenging given the heterogeneity in exposure volume. Much of the research is retrospective and subject to recall bias. Relationships may be distorted, and the precision of reported symptoms and exposure levels is altered. Given these challenges, it’s unsurprising that evidence of causality has yet to be proven. In addition, some portion of service members has been diagnosed with respiratory disease that could be related to burn pit exposure.

What is now indisputable is that deployment to southwest Asia leads to an increase in respiratory complaints. Whether veteran respiratory symptoms are due to burn pits, ambient pollution, environmental particulate matter, or dust storms is less clinically relevant. These symptoms require attention, investigation, and management.
 

What does this mean for the future medical care of service members and veterans?

Many veterans with post-deployment respiratory symptoms undergo extensive evaluations without obtaining a definitive diagnosis. A recent consensus statement on deployment-related respiratory symptoms provides a framework for evaluation in such cases.⁸ In keeping with that statement, we recommend veterans be referred to centers with expertise in this field, such as the Department of Veterans Affairs (VA) or military health centers, when deployment-related respiratory symptoms are reported. When the evaluation does not lead to a treatable diagnosis, these centers can provide multidisciplinary care to address the symptoms of dyspnea, cough, fatigue, and exercise intolerance to improve functional status.

Despite uncertainty in the evidence or challenges in diagnosis, both the Department of Defense (DoD) and VA remain fully committed to addressing the health concerns of service members and veterans. Notably, the VA has already screened more than 5 million veterans for toxic military exposures in accordance with the PACT Act and is providing ongoing screening and care for veterans with post-deployment respiratory symptoms. Furthermore, the DoD and VA have dedicated large portions of their research budgets to investigating the impacts of exposures during military service and optimizing the care of those with respiratory symptoms. With these commitments to patient care and research, our veterans’ respiratory health can now be optimized, and future risks can be mitigated.
 

Dr. Haynes is Fellow, Pulmonary and Critical Care Medicine, Walter Reed National Military Medical Center, Assistant Professor of Medicine, Uniformed Services University. Dr. Nations is Pulmonary and Critical Care Medicine, Deputy Chief of Staff for Operations, Washington DC VA Medical Center, Associate Professor of Medicine, Uniformed Services University.

References

1. Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD; Margaret A. K. Ryan for the Millennium Cohort Study Team. Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: a prospective population-based study. Am J Epidemiol. 2009;170(11):1433-1442. Preprint. Posted online October 22, 2009. PMID: 19850627. doi: 10.1093/aje/kwp287

2. King MS, Eisenberg R, Newman JH, et al. Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan. N Engl J Med. 2011;365(3):222-230. Erratum in: N Engl J Med. 2011;365(18):1749. PMID: 21774710; PMCID: PMC3296566. doi: 10.1056/NEJMoa1101388

3. Morris MJ, Dodson DW, Lucero PF, et al. Study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE). Am J Respir Crit Care Med. 2014;190(1):77-84. PMID: 24922562. doi: 10.1164/rccm.201402-0372OC

4. Morris MJ, Walter RJ, McCann ET, et al. Clinical evaluation of deployed military personnel with chronic respiratory symptoms: study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE) III. Chest. 2020;157(6):1559-1567. Preprint. Posted online February 1, 2020. PMID: 32017933. doi: 10.1016/j.chest.2020.01.024

5. Morris MJ, Skabelund AJ, Rawlins FA 3rd, Gallup RA, Aden JK, Holley AB. Study of active duty military personnel for environmental deployment exposures: pre- and post-deployment spirometry (STAMPEDE II). Respir Care. 2019;64(5):536-544. Preprint. Posted online January 8, 2019.PMID: 30622173. doi: 10.4187/respcare.06396

6. Institute of Medicine. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. The National Academies Press; 2011. https://doi.org/10.17226/13209

7. National Academies of Sciences, Engineering, and Medicine. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. The National Academies Press; 2020. https://doi.org/10.17226/25837

8. Falvo MJ, Sotolongo AM, Osterholzer JJ, et al. Consensus statements on deployment-related respiratory disease, inclusive of constrictive bronchiolitis: a modified Delphi study. Chest. 2023;163(3):599-609. Preprint. Posted November 4, 2022. PMID: 36343686; PMCID: PMC10154857. doi: 10.1016/j.chest.2022.10.031

Military service is a hazard-ridden profession. It’s easy to recognize the direct dangers from warfighting, such as gunfire and explosions, but the risks from environmental, chemical, and other occupational exposures can be harder to see.

Combustion-based waste management systems, otherwise known as “burn pits,” were used in deployed environments by the US military from the 1990s to the early 2010s. These burn pits were commonly used to eliminate plastics, electronics, munitions, metals, wood, chemicals, and even human waste. At the height of the recent conflicts in Afghanistan, Iraq, and other southwest Asia locations, more than 70% of military installations employed at least one, and nearly 4 million service members were exposed to some degree to their emissions.

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Reports of burn pits being related to organic disease have garnered widespread media attention. Initially, this came through anecdotal reports of post-deployment respiratory symptoms. Over time, the conditions attributed to burn pits expanded to include newly diagnosed respiratory diseases and malignancies. The composition of burn pit emissions sparked concern after fine particulate matter, volatile organic compounds, dioxins, and polycyclic aromatic hydrocarbons were detected. Each has previously been associated with an increased risk of respiratory disease or malignancy.

Ultimately, Congress passed the 2022 Promise to Address Comprehensive Toxins (PACT) Act, presumptively linking more than 20 diagnoses to burn pits. The PACT Act provides countless veterans access to low-cost or free medical care for their respective conditions.
 

What do we know about burn pits and deployment-related respiratory disease?

Data from the Millennium Cohort Study noted an approximately 40% increase in respiratory symptoms among individuals returning from deployment but no increase in the frequency of diagnosed respiratory diseases.¹ This study and others definitively established a temporal relationship between deployment and respiratory symptoms. Soon after, a retrospective, observational study of service members with post-deployment respiratory symptoms found a high prevalence of constrictive bronchiolitis (CB) identified by lung biopsy.² Patients in this group reported exposure to burn pits and a sulfur mine fire in the Mosul area while deployed. Most had normal imaging and pulmonary function testing before biopsy, confounding the clinical significance of the CB finding. The publication of this report led to increased investigation of respiratory function during and after deployment.

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In a series of prospective studies that included full pulmonary function testing, impulse oscillometry, cardiopulmonary exercise testing, bronchoscopy, and, occasionally, lung biopsy to evaluate post-deployment dyspnea, only a small minority received a diagnosis of clinically significant lung disease.^3,4 Additionally, when comparing spirometry and impulse oscillometry results from before and after deployment, no decline in lung function was observed in a population of service members reporting regular burn pit exposure.⁵ These studies suggest that at the population level, deployment does not lead to abnormalities in the structure and function of the respiratory system.

The National Academies of Sciences published two separate reviews of burn pit exposure and outcomes in 2011 and 2020.^6,7 They found insufficient evidence to support a causal relationship between burn pit exposure and pulmonary disease. They highlighted studies on the composition of emissions from the area surrounding the largest military burn pit in Iraq. Levels of particulate matter, volatile organic compounds, and polycyclic aromatic hydrocarbons were elevated when compared with those of a typical American city but were similar to the pollution levels seen in the region at the time. Given these findings, they suggested ambient air pollution may have contributed more to clinically significant disease than burn pit emissions.
 

How do we interpret this mixed data?

At the population level, we have yet to find conclusive data directly linking burn pit exposure to the development of any respiratory disease. Does this mean that burn pits are not harmful?

Not necessarily. Research on outcomes related to burn pit exposure is challenging given the heterogeneity in exposure volume. Much of the research is retrospective and subject to recall bias. Relationships may be distorted, and the precision of reported symptoms and exposure levels is altered. Given these challenges, it’s unsurprising that evidence of causality has yet to be proven. In addition, some portion of service members has been diagnosed with respiratory disease that could be related to burn pit exposure.

What is now indisputable is that deployment to southwest Asia leads to an increase in respiratory complaints. Whether veteran respiratory symptoms are due to burn pits, ambient pollution, environmental particulate matter, or dust storms is less clinically relevant. These symptoms require attention, investigation, and management.
 

What does this mean for the future medical care of service members and veterans?

Many veterans with post-deployment respiratory symptoms undergo extensive evaluations without obtaining a definitive diagnosis. A recent consensus statement on deployment-related respiratory symptoms provides a framework for evaluation in such cases.⁸ In keeping with that statement, we recommend veterans be referred to centers with expertise in this field, such as the Department of Veterans Affairs (VA) or military health centers, when deployment-related respiratory symptoms are reported. When the evaluation does not lead to a treatable diagnosis, these centers can provide multidisciplinary care to address the symptoms of dyspnea, cough, fatigue, and exercise intolerance to improve functional status.

Despite uncertainty in the evidence or challenges in diagnosis, both the Department of Defense (DoD) and VA remain fully committed to addressing the health concerns of service members and veterans. Notably, the VA has already screened more than 5 million veterans for toxic military exposures in accordance with the PACT Act and is providing ongoing screening and care for veterans with post-deployment respiratory symptoms. Furthermore, the DoD and VA have dedicated large portions of their research budgets to investigating the impacts of exposures during military service and optimizing the care of those with respiratory symptoms. With these commitments to patient care and research, our veterans’ respiratory health can now be optimized, and future risks can be mitigated.
 

Dr. Haynes is Fellow, Pulmonary and Critical Care Medicine, Walter Reed National Military Medical Center, Assistant Professor of Medicine, Uniformed Services University. Dr. Nations is Pulmonary and Critical Care Medicine, Deputy Chief of Staff for Operations, Washington DC VA Medical Center, Associate Professor of Medicine, Uniformed Services University.

References

1. Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD; Margaret A. K. Ryan for the Millennium Cohort Study Team. Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: a prospective population-based study. Am J Epidemiol. 2009;170(11):1433-1442. Preprint. Posted online October 22, 2009. PMID: 19850627. doi: 10.1093/aje/kwp287

2. King MS, Eisenberg R, Newman JH, et al. Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan. N Engl J Med. 2011;365(3):222-230. Erratum in: N Engl J Med. 2011;365(18):1749. PMID: 21774710; PMCID: PMC3296566. doi: 10.1056/NEJMoa1101388

3. Morris MJ, Dodson DW, Lucero PF, et al. Study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE). Am J Respir Crit Care Med. 2014;190(1):77-84. PMID: 24922562. doi: 10.1164/rccm.201402-0372OC

4. Morris MJ, Walter RJ, McCann ET, et al. Clinical evaluation of deployed military personnel with chronic respiratory symptoms: study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE) III. Chest. 2020;157(6):1559-1567. Preprint. Posted online February 1, 2020. PMID: 32017933. doi: 10.1016/j.chest.2020.01.024

5. Morris MJ, Skabelund AJ, Rawlins FA 3rd, Gallup RA, Aden JK, Holley AB. Study of active duty military personnel for environmental deployment exposures: pre- and post-deployment spirometry (STAMPEDE II). Respir Care. 2019;64(5):536-544. Preprint. Posted online January 8, 2019.PMID: 30622173. doi: 10.4187/respcare.06396

6. Institute of Medicine. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. The National Academies Press; 2011. https://doi.org/10.17226/13209

7. National Academies of Sciences, Engineering, and Medicine. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. The National Academies Press; 2020. https://doi.org/10.17226/25837

8. Falvo MJ, Sotolongo AM, Osterholzer JJ, et al. Consensus statements on deployment-related respiratory disease, inclusive of constrictive bronchiolitis: a modified Delphi study. Chest. 2023;163(3):599-609. Preprint. Posted November 4, 2022. PMID: 36343686; PMCID: PMC10154857. doi: 10.1016/j.chest.2022.10.031