CHEST Physician

This year’s CHEST Annual Meeting will push the envelope of fun through various educational games and experiences for those attending on-site and online.

CHEST is supercharging the escape room experience with the expansion of two unique on-site escape scenarios to solve, First Contact and Shuttle Crash. In escape rooms, small teams work against the clock to solve a medical puzzle and unlock the final challenges. Those attending online can take a break and join the excitement with First Contact, a mission to Jupiter led by our space lieutenant, William Kelly, MD, FCCP, and faculty and staff game fleet. To build off the futuristic hands-on experiences, CHEST will be debuting intubation procedural simulations using state-of-the-art virtual reality technology.

If you prefer to join the fun using your mobile device, CHEST is releasing daily task-based missions that you can track and complete using your phone. These missions will include a variety of social activities designed around the conference halls, hotels, clinic, and your own home that are sure to get you moving and working as a team.

During the 4 days of the annual meeting, CHEST will also host an exclusive event called “Play With the Pros.” You can test your knowledge and play alongside annual meeting cochairs, Chris Carroll, MD, FCCP, and David Zielinski, MD, FCCP, for the chance to win a grand prize. As an added bonus, CHEST is offering daily prize drawings for players and social media recognition to those who top the leaderboards in the CHEST Player Hub. The Player Hub hosts more than 10 bite-sized mobile games and is available on demand with your CHEST ID.

Additionally, live game breaks hosted by our faculty between education sessions will give you the chance to unwind and play in real time with your peers and colleagues. On-site, CHEST invites you to shoot hoops, drive remote-controlled cars, and shuffle across the gameboard floors. From your couch or desk, you can tune in to test your knowledge in our livestreamed trivia or sign up for the chance to receive a trivia question phone call from our faculty, which is tied to a grand prize.

The opportunities to play and learn during CHEST Games are endless at CHEST 2021!

This year’s CHEST Annual Meeting will push the envelope of fun through various educational games and experiences for those attending on-site and online.

CHEST is supercharging the escape room experience with the expansion of two unique on-site escape scenarios to solve, First Contact and Shuttle Crash. In escape rooms, small teams work against the clock to solve a medical puzzle and unlock the final challenges. Those attending online can take a break and join the excitement with First Contact, a mission to Jupiter led by our space lieutenant, William Kelly, MD, FCCP, and faculty and staff game fleet. To build off the futuristic hands-on experiences, CHEST will be debuting intubation procedural simulations using state-of-the-art virtual reality technology.

If you prefer to join the fun using your mobile device, CHEST is releasing daily task-based missions that you can track and complete using your phone. These missions will include a variety of social activities designed around the conference halls, hotels, clinic, and your own home that are sure to get you moving and working as a team.

During the 4 days of the annual meeting, CHEST will also host an exclusive event called “Play With the Pros.” You can test your knowledge and play alongside annual meeting cochairs, Chris Carroll, MD, FCCP, and David Zielinski, MD, FCCP, for the chance to win a grand prize. As an added bonus, CHEST is offering daily prize drawings for players and social media recognition to those who top the leaderboards in the CHEST Player Hub. The Player Hub hosts more than 10 bite-sized mobile games and is available on demand with your CHEST ID.

Additionally, live game breaks hosted by our faculty between education sessions will give you the chance to unwind and play in real time with your peers and colleagues. On-site, CHEST invites you to shoot hoops, drive remote-controlled cars, and shuffle across the gameboard floors. From your couch or desk, you can tune in to test your knowledge in our livestreamed trivia or sign up for the chance to receive a trivia question phone call from our faculty, which is tied to a grand prize.

The opportunities to play and learn during CHEST Games are endless at CHEST 2021!

This year’s CHEST Annual Meeting will push the envelope of fun through various educational games and experiences for those attending on-site and online.

CHEST is supercharging the escape room experience with the expansion of two unique on-site escape scenarios to solve, First Contact and Shuttle Crash. In escape rooms, small teams work against the clock to solve a medical puzzle and unlock the final challenges. Those attending online can take a break and join the excitement with First Contact, a mission to Jupiter led by our space lieutenant, William Kelly, MD, FCCP, and faculty and staff game fleet. To build off the futuristic hands-on experiences, CHEST will be debuting intubation procedural simulations using state-of-the-art virtual reality technology.

If you prefer to join the fun using your mobile device, CHEST is releasing daily task-based missions that you can track and complete using your phone. These missions will include a variety of social activities designed around the conference halls, hotels, clinic, and your own home that are sure to get you moving and working as a team.

During the 4 days of the annual meeting, CHEST will also host an exclusive event called “Play With the Pros.” You can test your knowledge and play alongside annual meeting cochairs, Chris Carroll, MD, FCCP, and David Zielinski, MD, FCCP, for the chance to win a grand prize. As an added bonus, CHEST is offering daily prize drawings for players and social media recognition to those who top the leaderboards in the CHEST Player Hub. The Player Hub hosts more than 10 bite-sized mobile games and is available on demand with your CHEST ID.

Additionally, live game breaks hosted by our faculty between education sessions will give you the chance to unwind and play in real time with your peers and colleagues. On-site, CHEST invites you to shoot hoops, drive remote-controlled cars, and shuffle across the gameboard floors. From your couch or desk, you can tune in to test your knowledge in our livestreamed trivia or sign up for the chance to receive a trivia question phone call from our faculty, which is tied to a grand prize.

The opportunities to play and learn during CHEST Games are endless at CHEST 2021!

The CHEST Board of Regents met in mid-June for its first in-person meeting in more than a year. It served as a lovely reminder that not only are in-person meetings a more effective way to conduct the business of the College, but that the members of the board have really missed seeing each other without an intervening screen and webcam.

First on the agenda was a recap by the CHEST presidents of their recent strategic retreat. Most relevant to the organization was a recommendation that we revise the manner by which the CHEST strategic plan is set. If the last year has taught us anything, it is that planning for the future is essential, but we must also allow for flexibility when external forces change what the future holds. Accordingly, we will be replacing the former 5-year planning cycle with a more nimble annual review. From a member’s standpoint, this means that you will see more frequent revisions of those plans (Strategic Plan, American College of Chest Physicians).

Over the last year, the CHEST Foundation has sponsored a series of “listening tours,” which has allowed our members and leaders to hear from many of our patients who feel disenfranchised from the medical system because of struggles with communication, finances, and access, among other issues. The willingness of our patients to share their struggles with us has inspired the Foundation to try to make inroads into these, better navigating these barriers. In direct response to what we’ve heard, the team is designing programs to help our caregivers focus on the psychological, social, environmental, and personal factors that impact our patients’ ability to obtain the critical health care that all need and deserve.

Our ability to execute and deliver such programs is contingent on successful fundraising efforts. Ian Nathanson, president of the CHEST Foundation, reviewed fundraising progress with the board. Over these long months, donors, participants, and friends of the Foundation have participated in virtual events designed to foster engagement and comradery through this difficult time. This June, we held a virtual and in-person Belmont Stakes event that has shown that we can adapt to challenging times and that our membership is still incredibly supportive of the Foundation’s mission. Thank you to all of you who participated in or donated to the CHEST Foundation over the last year!

The last 18 months have had a marked impact on our ability to provide the live, interactive learning experiences for which CHEST is known, but efforts in the remote learning space have yielded impressive increases in both the number of remote learning opportunities and the breadth of our members who are using them. As one example, the number of CHEST podcast views quadrupled last year compared with 2019. Although CHEST reopened its headquarters for live learning opportunities this summer, and we are looking to move significantly back toward “business as usual” with CHEST 2021 in Orlando this October, we will also be carefully considering how best to incorporate the lessons learned in the remote offering space as the world reopens in the coming year.

Neil Freedman, chair of CHEST’s Health Advocacy and Policy Committee (HPAC), presented a review of the committee’s work since its inception just over 1 year ago. In addition to putting together a multi-society Technical Expert Panel on the use and coverage of noninvasive ventilation, HPAC worked with 18 other societies in drafting a response to the Agency for Healthcare Research and Quality’s draft on coverage for CPAP therapy for obstructive sleep apnea. For members interested in getting more involved in CHEST’s advocacy efforts, we are seeking self-nominations for members of several working groups (nominations to open soon); in addition, there will be sessions during CHEST 2021 focused on our advocacy efforts and how you can participate, as well as best practices in the advocacy space.

Several months ago, the Exeter Group was asked by the board to analyze how CHEST can expand our organizational efforts in diversity, equity, and inclusion (DEI). Representatives from the Exeter Group joined the meeting to provide board members with preliminary data. Limited interviews with both members and staff have begun to provide a picture of where CHEST has already made some progress in this space, and where our ongoing challenges and opportunities for improvement still exist; it is clear that there is a wide range of opinions on these complicated issues. As our consultants are only 1 month into this 6-month phase of the project, we expect a great deal more information to come, with a plan for ongoing surveys of and focus groups for our members; when you receive one of these requests, please make every effort to complete it as candidly as possible, regardless of your viewpoint. The consulting work will culminate with a final presentation to the board just before the annual meeting in the fall, with specific recommendations on organizational actions that will be used to implement a multiyear DEI plan.

The Governance Committee, represented by Stephanie Levine, made several recommendations to revision of the CHEST Foundations bylaws. Specifically, the new bylaws permit Trustees of the Foundation to be re-elected to positions on the board beyond the current 6-year maximum term after several years away from the position. The position of President-Designate of the Foundation will also be eliminated, allowing for a 2-year term for the President-Elect of the Foundation and a 2-year term for the President of the Foundation.

One of the main challenges for an organization of 19,000 people is to ensure that we can engage as many of our members as possible. The NetWorks structure has historically been the primary mechanism for members to pursue initial leadership opportunities within the College. CHEST Past-President Stephanie Levine previously established a working group to revisit NetWork structure in an effort to ensure ample opportunities for engagement within CHEST. The final agenda item at this board meeting was a discussion about restructuring the CHEST NetWorks to create mechanisms that will help us balance the needs of the College with the energy of the volunteers to maximize productivity and engagement of all parties. The plan would increase the number of leadership positions available within the NetWork structure. While the final nomenclature and distribution of NetWorks amongst the pillars has yet to be finalized, the board was supportive of this modification and expects implementation in the next 12 months, with details to be provided to the membership as they are fleshed out.

After a full day’s agenda, CHEST President Steve Simpson adjourned the board meeting. The Board of Regents will meet remotely in August (the summer call has always been a remote meeting) and again in Orlando in October.

The CHEST Board of Regents met in mid-June for its first in-person meeting in more than a year. It served as a lovely reminder that not only are in-person meetings a more effective way to conduct the business of the College, but that the members of the board have really missed seeing each other without an intervening screen and webcam.

First on the agenda was a recap by the CHEST presidents of their recent strategic retreat. Most relevant to the organization was a recommendation that we revise the manner by which the CHEST strategic plan is set. If the last year has taught us anything, it is that planning for the future is essential, but we must also allow for flexibility when external forces change what the future holds. Accordingly, we will be replacing the former 5-year planning cycle with a more nimble annual review. From a member’s standpoint, this means that you will see more frequent revisions of those plans (Strategic Plan, American College of Chest Physicians).

Over the last year, the CHEST Foundation has sponsored a series of “listening tours,” which has allowed our members and leaders to hear from many of our patients who feel disenfranchised from the medical system because of struggles with communication, finances, and access, among other issues. The willingness of our patients to share their struggles with us has inspired the Foundation to try to make inroads into these, better navigating these barriers. In direct response to what we’ve heard, the team is designing programs to help our caregivers focus on the psychological, social, environmental, and personal factors that impact our patients’ ability to obtain the critical health care that all need and deserve.

Our ability to execute and deliver such programs is contingent on successful fundraising efforts. Ian Nathanson, president of the CHEST Foundation, reviewed fundraising progress with the board. Over these long months, donors, participants, and friends of the Foundation have participated in virtual events designed to foster engagement and comradery through this difficult time. This June, we held a virtual and in-person Belmont Stakes event that has shown that we can adapt to challenging times and that our membership is still incredibly supportive of the Foundation’s mission. Thank you to all of you who participated in or donated to the CHEST Foundation over the last year!

The last 18 months have had a marked impact on our ability to provide the live, interactive learning experiences for which CHEST is known, but efforts in the remote learning space have yielded impressive increases in both the number of remote learning opportunities and the breadth of our members who are using them. As one example, the number of CHEST podcast views quadrupled last year compared with 2019. Although CHEST reopened its headquarters for live learning opportunities this summer, and we are looking to move significantly back toward “business as usual” with CHEST 2021 in Orlando this October, we will also be carefully considering how best to incorporate the lessons learned in the remote offering space as the world reopens in the coming year.

Neil Freedman, chair of CHEST’s Health Advocacy and Policy Committee (HPAC), presented a review of the committee’s work since its inception just over 1 year ago. In addition to putting together a multi-society Technical Expert Panel on the use and coverage of noninvasive ventilation, HPAC worked with 18 other societies in drafting a response to the Agency for Healthcare Research and Quality’s draft on coverage for CPAP therapy for obstructive sleep apnea. For members interested in getting more involved in CHEST’s advocacy efforts, we are seeking self-nominations for members of several working groups (nominations to open soon); in addition, there will be sessions during CHEST 2021 focused on our advocacy efforts and how you can participate, as well as best practices in the advocacy space.

Several months ago, the Exeter Group was asked by the board to analyze how CHEST can expand our organizational efforts in diversity, equity, and inclusion (DEI). Representatives from the Exeter Group joined the meeting to provide board members with preliminary data. Limited interviews with both members and staff have begun to provide a picture of where CHEST has already made some progress in this space, and where our ongoing challenges and opportunities for improvement still exist; it is clear that there is a wide range of opinions on these complicated issues. As our consultants are only 1 month into this 6-month phase of the project, we expect a great deal more information to come, with a plan for ongoing surveys of and focus groups for our members; when you receive one of these requests, please make every effort to complete it as candidly as possible, regardless of your viewpoint. The consulting work will culminate with a final presentation to the board just before the annual meeting in the fall, with specific recommendations on organizational actions that will be used to implement a multiyear DEI plan.

The Governance Committee, represented by Stephanie Levine, made several recommendations to revision of the CHEST Foundations bylaws. Specifically, the new bylaws permit Trustees of the Foundation to be re-elected to positions on the board beyond the current 6-year maximum term after several years away from the position. The position of President-Designate of the Foundation will also be eliminated, allowing for a 2-year term for the President-Elect of the Foundation and a 2-year term for the President of the Foundation.

One of the main challenges for an organization of 19,000 people is to ensure that we can engage as many of our members as possible. The NetWorks structure has historically been the primary mechanism for members to pursue initial leadership opportunities within the College. CHEST Past-President Stephanie Levine previously established a working group to revisit NetWork structure in an effort to ensure ample opportunities for engagement within CHEST. The final agenda item at this board meeting was a discussion about restructuring the CHEST NetWorks to create mechanisms that will help us balance the needs of the College with the energy of the volunteers to maximize productivity and engagement of all parties. The plan would increase the number of leadership positions available within the NetWork structure. While the final nomenclature and distribution of NetWorks amongst the pillars has yet to be finalized, the board was supportive of this modification and expects implementation in the next 12 months, with details to be provided to the membership as they are fleshed out.

After a full day’s agenda, CHEST President Steve Simpson adjourned the board meeting. The Board of Regents will meet remotely in August (the summer call has always been a remote meeting) and again in Orlando in October.

The CHEST Board of Regents met in mid-June for its first in-person meeting in more than a year. It served as a lovely reminder that not only are in-person meetings a more effective way to conduct the business of the College, but that the members of the board have really missed seeing each other without an intervening screen and webcam.

First on the agenda was a recap by the CHEST presidents of their recent strategic retreat. Most relevant to the organization was a recommendation that we revise the manner by which the CHEST strategic plan is set. If the last year has taught us anything, it is that planning for the future is essential, but we must also allow for flexibility when external forces change what the future holds. Accordingly, we will be replacing the former 5-year planning cycle with a more nimble annual review. From a member’s standpoint, this means that you will see more frequent revisions of those plans (Strategic Plan, American College of Chest Physicians).

Over the last year, the CHEST Foundation has sponsored a series of “listening tours,” which has allowed our members and leaders to hear from many of our patients who feel disenfranchised from the medical system because of struggles with communication, finances, and access, among other issues. The willingness of our patients to share their struggles with us has inspired the Foundation to try to make inroads into these, better navigating these barriers. In direct response to what we’ve heard, the team is designing programs to help our caregivers focus on the psychological, social, environmental, and personal factors that impact our patients’ ability to obtain the critical health care that all need and deserve.

Our ability to execute and deliver such programs is contingent on successful fundraising efforts. Ian Nathanson, president of the CHEST Foundation, reviewed fundraising progress with the board. Over these long months, donors, participants, and friends of the Foundation have participated in virtual events designed to foster engagement and comradery through this difficult time. This June, we held a virtual and in-person Belmont Stakes event that has shown that we can adapt to challenging times and that our membership is still incredibly supportive of the Foundation’s mission. Thank you to all of you who participated in or donated to the CHEST Foundation over the last year!

The last 18 months have had a marked impact on our ability to provide the live, interactive learning experiences for which CHEST is known, but efforts in the remote learning space have yielded impressive increases in both the number of remote learning opportunities and the breadth of our members who are using them. As one example, the number of CHEST podcast views quadrupled last year compared with 2019. Although CHEST reopened its headquarters for live learning opportunities this summer, and we are looking to move significantly back toward “business as usual” with CHEST 2021 in Orlando this October, we will also be carefully considering how best to incorporate the lessons learned in the remote offering space as the world reopens in the coming year.

Neil Freedman, chair of CHEST’s Health Advocacy and Policy Committee (HPAC), presented a review of the committee’s work since its inception just over 1 year ago. In addition to putting together a multi-society Technical Expert Panel on the use and coverage of noninvasive ventilation, HPAC worked with 18 other societies in drafting a response to the Agency for Healthcare Research and Quality’s draft on coverage for CPAP therapy for obstructive sleep apnea. For members interested in getting more involved in CHEST’s advocacy efforts, we are seeking self-nominations for members of several working groups (nominations to open soon); in addition, there will be sessions during CHEST 2021 focused on our advocacy efforts and how you can participate, as well as best practices in the advocacy space.

Several months ago, the Exeter Group was asked by the board to analyze how CHEST can expand our organizational efforts in diversity, equity, and inclusion (DEI). Representatives from the Exeter Group joined the meeting to provide board members with preliminary data. Limited interviews with both members and staff have begun to provide a picture of where CHEST has already made some progress in this space, and where our ongoing challenges and opportunities for improvement still exist; it is clear that there is a wide range of opinions on these complicated issues. As our consultants are only 1 month into this 6-month phase of the project, we expect a great deal more information to come, with a plan for ongoing surveys of and focus groups for our members; when you receive one of these requests, please make every effort to complete it as candidly as possible, regardless of your viewpoint. The consulting work will culminate with a final presentation to the board just before the annual meeting in the fall, with specific recommendations on organizational actions that will be used to implement a multiyear DEI plan.

The Governance Committee, represented by Stephanie Levine, made several recommendations to revision of the CHEST Foundations bylaws. Specifically, the new bylaws permit Trustees of the Foundation to be re-elected to positions on the board beyond the current 6-year maximum term after several years away from the position. The position of President-Designate of the Foundation will also be eliminated, allowing for a 2-year term for the President-Elect of the Foundation and a 2-year term for the President of the Foundation.

One of the main challenges for an organization of 19,000 people is to ensure that we can engage as many of our members as possible. The NetWorks structure has historically been the primary mechanism for members to pursue initial leadership opportunities within the College. CHEST Past-President Stephanie Levine previously established a working group to revisit NetWork structure in an effort to ensure ample opportunities for engagement within CHEST. The final agenda item at this board meeting was a discussion about restructuring the CHEST NetWorks to create mechanisms that will help us balance the needs of the College with the energy of the volunteers to maximize productivity and engagement of all parties. The plan would increase the number of leadership positions available within the NetWork structure. While the final nomenclature and distribution of NetWorks amongst the pillars has yet to be finalized, the board was supportive of this modification and expects implementation in the next 12 months, with details to be provided to the membership as they are fleshed out.

After a full day’s agenda, CHEST President Steve Simpson adjourned the board meeting. The Board of Regents will meet remotely in August (the summer call has always been a remote meeting) and again in Orlando in October.

Airways disorders

Eosinophils in COPD

Using peripheral blood eosinophilia (PBE) as a treatable biomarker of airway inflammation in patients with COPD has become an area of controversy in pulmonary medicine.

The proponents find a role for PBE testing in initiation and withdrawal of inhaled corticosteroids (ICS) and as a target for monoclonal antibodies in future studies.¹ Post hoc analyses showed that variable doses of ICS/LABA combination compared with LABA alone in COPD patients were associated with much higher exacerbation reduction in patients with eosinophils counts of ≥2% and magnitude of effect proportionally increased from 29% to 42% with increasing eosinophil count from ≥2% to ≥6% suggesting a dose-response relationship.² A post hoc analysis of the WISDOM trial showed increased risk of exacerbation after ICS discontinuation in COPD patients with high eosinophils (≥300 cells/mcL or ≥4%) while exacerbation risk was not increased in patients with low eosinophils (<150 cells/mcL or <2%).³

The opponents of eosinophil-guided therapy object that the level of evidence is weak as this is based on the post hoc analyses of randomized control trials on patients with increased exacerbation risk at baseline, which in itself is an independent predictor of future exacerbations.⁴ Some observational studies failed to find increased risk of exacerbation with higher eosinophil count while others found that higher eosinophil count was associated with increased survival and better quality of life.^5,6 Anti-eosinophilic biologics have failed to show consistent benefit in exacerbation reduction in COPD patients so far, despite showing a reduction in the PBE.^7-9

The GOLD COPD Guidelines support the use of ICS in patients with eosinophils >300 cells/mcL especially with a history of exacerbation and recommend against ICS in patients with eosinophils <100 cells/mcL.¹⁰

Farrukh Abbas, MD
Steering Committee Fellow-in-Training
Allen J. Blaivas, MD, FCCP
NetWork Chair
 

References

1. Wade RC and Wells JM. Chest. 2020;157(5):1073-5.

2. Pascoe S et al. The Lancet Respir Med. 2015;3(6):435-42.

3. Watz H et al. The Lancet Respir Med. 2016;4(5):390-8.

4. Criner GJ. Chest. 2020;157(5):1075-8.

5. Shin SH et al. Respir Res. 2018;19(1):134.

6. Casanova C et al. Eur Respir J. 2017;50(5):1701162.

7. Pavord ID et al. N Engl J Med. 2017;377(17):1613-29.

8. Criner GJ et al. N Engl J Med. 2019;381(11):1023-34.

9. Mycroft K et al. J Allergy Clin Immunol Pract. 2020 Sep;8(8):2565-74.

10. Global Initiative for Chronic Obstructive Lung Disease 2021 Report.
 

Clinical research

Long-COVID: COVID-19 disease beyond the pandemic

There are increasing reports of persistent multiorgan symptoms following COVID-19 infection.

In December 2020, the National Institute for Health and Care Excellence (NICE) developed guidelines, based primarily on expert opinion, to define and manage ongoing symptomatic COVID-19 (symptoms for 4-12 weeks after infection) and post-COVID syndrome (symptoms present for > 12 weeks without alternative explanation). Subsequently, the National Institutes of Health (NIH), released in February 2021 an initiative to study Post-Acute Sequelae of SARS-CoV2 infection (PASC). Symptoms can include, respiratory (cough, shortness of breath), cardiac (palpitations, chest pain), fatigue and physical limitations, and neurologic (depression, insomnia, cognitive impairment) (Lancet 2020 Dec 12;396[10266]:1861). The majority of patients with post-COVID syndrome have microbiological recovery (PCR negative), and often have radiological recovery. Risk factors include older age, female sex, and comorbidities (Raveendran AV. Diabetes Metab Syndr. 2021 May-June;15[3]:869-75).

Diagnosis and access to care pose significant challenges for post-COVID syndrome, and it is difficult to estimate exactly how many are affected – one report from Italy found that up to 87% of discharged hospitalized patients had persistent symptom(s) at 60 days (Carfi A. JAMA 2020 Aug;324[6]:603-5). Thus far, management recommendations include a multidisciplinary approach to evaluation, symptomatic treatment, organ specific treatment (for example, consideration of corticosteroids for persistent inflammatory interstitial lung disease) (Myall KJ. Ann Am Thorac Soc. 2021 May;8[5]:799-806), physical/occupational therapy, and psychological support. Many institutions have established, or are working to establish post-COVID clinics (Aging Clin Exp Res. 2020 Aug;32[8]:1613-20). Currently, the NIH is offering funding opportunities and there are many clinical trials across the world actively recruiting patients.

Ankita Agarwal, MD
Steering Committee Fellow-in-Training
Bharat Bajantri, MD
Steering Committee Member
Aravind Menon, MD
Steering Committee Fellow-in-Training
 

Critical care

Sedation practices in the ICU: Moving past the COVID-19 pandemic

The COVID-19 pandemic brought unprecedented change to critical care practice patterns, and sedation practices in the intensive care unit are no exception. In a large cohort analysis of over 2,000 adults with COVID-19 (Pun BT, et al. Lancet Respir Med. 2021;9[3]:239-50), 64% of patients received benzodiazepines (median of 7 days), and patients were deeply sedated. More than half of the patients were delirious, with benzodiazepine use associated with increased incidence of delirium. These observations represent a significant departure from well-established pre-COVID best-practices in sedation: light targets, daily sedation interruption, and avoiding continuous benzodiazepine infusions whenever possible (Girard TD, et al. Lancet; 2008;371[9607]:126-34; Fraser GL, et al. Crit Care Med;2013 Sep;41[9 Suppl 1]:S30-8; Riker RR, et al. JAMA;2009;301[5]:489-99).

As COVID-19 case counts begin to improve in many of our communities, we have the opportunity to refocus on best sedation practices and build on a growing body of recent evidence. The MENDS2 trial, completed pre-COVID-19, assigned mechanically ventilated patients with sepsis to either propofol or dexmedetomidine and showed no difference in delirium or coma in this cohort of lightly sedated patients (Hughes CG, et al. N Engl J Med. 2021;384[15]:1424-36). Furthering this point, Olsen et al. found no difference in outcomes when mechanically ventilated patients were randomized to no sedation vs light sedation (Olsen HT, et al. N Engl J Med; 2020;382[12]:1103-11).

While the evidence surrounding sedation strategies in the critically ill continues to grow, one thing is certain: promoting lighter sedation targets and reengaging in sedation-related best practices following the COVID-19 pandemic will continue to play a vital role in improving both short and long-term outcomes for our critically ill patients.

Casey Cable, MD, MSc
Steering Committee Member

Kyle Stinehart, MD
Steering Committee Member
 

Home mechanical ventilation

How to initiate a chronic respiratory failure clinic

Noninvasive ventilation (NIV) is an established treatment for chronic hypercapnic respiratory failure from neuromuscular disorders, COPD, obesity hypoventilation syndrome (OHS), and restrictive thoracic disorders. Previously, hospital admission was considered essential for setup of chronic NIV but with advances in the modes of ventilation and remote monitoring, hospital admission has become less justifiable, especially in countries with centralized medical systems and presence of centers of excellence for home ventilation (Van Den Biggelaar RJM, et al. Chest. 2020;158[6]:2493-2501); Duiverman ML, et al. Thorax. 2020;75:244-52). In the United States, where centralized health care is atypical, management of NIV has been disparate with no clear consensus on practice patterns. Thus, we hope to provide some guidance toward the establishment of such clinics in the U.S.
 

Prior to developing an NIV clinic, establishing a referral source from neuromuscular, rehabilitation/spinal cord injury, bariatric surgery, and COPD programs is important. After this, collaboration with a respiratory therapist through durable medical equipment is essential to building a robust care team. These companies are also important for assisting in remote monitoring, providing overnight pulse oximetry/CO₂ monitoring, mask fitting, and airway clearance. Clinicians are encouraged to develop protocols for initiation and titration of NIV and mouthpiece ventilation. Clinics should provide spirometry, maximal inspiratory pressure, transcutaneous CO₂, and/or blood gas testing. Additionally, in this patient population, wheelchair scales are necessary. Clinical workflow should include a review of NIV downloads, identify asynchronies and troubleshoot it in timely and reliable manner (Blouet S, et al. Int J Chron Obstruct Pulmon Dis. 2018;13:2577-86). Lastly, effort should be made for an adequate assessment of the home situation including layout of home along with family support utilizing social worker and palliative care team. Due to patient mobility, we encourage continued availability of telehealth for these patients.

In summary, strong clinical infrastructure, a robust care team, and an efficient, secure, reliable telemonitoring system are key to provide better care to this vulnerable patient population.

Ashima S. Sahni, MD, MBBS, FCCP
NetWork Member

Amen Sergew, MD
Steering Committee Member

Interstitial and diffuse lung disease

Treatment for pulmonary hypertension secondary to interstitial lung disease

The development of pulmonary hypertension (PH) in patients with interstitial lung disease (ILD) (PH-ILD) is associated with increased supplemental oxygen requirements, reduced functional status, and decreased survival (King CS, et al. Chest. 2020;158[4]:1651).

An inhaled formulation of treprostinil (Tyvaso) is the first treatment option approved by the FDA for patients with PH-ILD, including those with idiopathic pulmonary fibrosis, connective tissue disease-associated ILD, and combined pulmonary fibrosis and emphysema. Approval was based on results from the INCREASE trial (Waxman A, et al. N Engl J Med. 2021;384[4]:325), a phase III multicenter, randomized, double-blinded study comparing the inhaled formulation to placebo in 326 patients over a 16-week period. Participants in the treatment arm were given up to 12 breaths of the formulation per session, four times per day. Subjects treated with this inhaled formulation met the primary study endpoint, an increase in 6-minute walk distance (6MWD) from baseline to week 16, walking 21 m farther than placebo-treated control subjects. Furthermore, patients receiving the new formulation had a decrease in NT-proBNP levels (compared with increases in the placebo arm) and a reduction in clinical worsening (23% of inhalation formulation-treated vs. 33% of placebo-treated subjects). This formulation of treprostinil was well-tolerated with a safety profile consistent with common prostacyclin-related adverse events, including cough, headache, dyspnea, dizziness, nausea, fatigue, and diarrhea. Its approval will dramatically alter the ILD treatment landscape. It now necessitates the use of PH screening in this patient population. However, care will need to be exercised in appropriate patient selection for treatment, using the study inclusion and exclusion criteria as a starting point. Appropriate use of this formulation will hopefully help mitigate the negative outcomes impacting patients with PH-ILD.

Rebecca Anna Gersten, MD
Adrian Shifren, MD
Steering Committee Members

Airways disorders

Eosinophils in COPD

Using peripheral blood eosinophilia (PBE) as a treatable biomarker of airway inflammation in patients with COPD has become an area of controversy in pulmonary medicine.

The proponents find a role for PBE testing in initiation and withdrawal of inhaled corticosteroids (ICS) and as a target for monoclonal antibodies in future studies.¹ Post hoc analyses showed that variable doses of ICS/LABA combination compared with LABA alone in COPD patients were associated with much higher exacerbation reduction in patients with eosinophils counts of ≥2% and magnitude of effect proportionally increased from 29% to 42% with increasing eosinophil count from ≥2% to ≥6% suggesting a dose-response relationship.² A post hoc analysis of the WISDOM trial showed increased risk of exacerbation after ICS discontinuation in COPD patients with high eosinophils (≥300 cells/mcL or ≥4%) while exacerbation risk was not increased in patients with low eosinophils (<150 cells/mcL or <2%).³

The opponents of eosinophil-guided therapy object that the level of evidence is weak as this is based on the post hoc analyses of randomized control trials on patients with increased exacerbation risk at baseline, which in itself is an independent predictor of future exacerbations.⁴ Some observational studies failed to find increased risk of exacerbation with higher eosinophil count while others found that higher eosinophil count was associated with increased survival and better quality of life.^5,6 Anti-eosinophilic biologics have failed to show consistent benefit in exacerbation reduction in COPD patients so far, despite showing a reduction in the PBE.^7-9

The GOLD COPD Guidelines support the use of ICS in patients with eosinophils >300 cells/mcL especially with a history of exacerbation and recommend against ICS in patients with eosinophils <100 cells/mcL.¹⁰

Farrukh Abbas, MD
Steering Committee Fellow-in-Training
Allen J. Blaivas, MD, FCCP
NetWork Chair
 

References

1. Wade RC and Wells JM. Chest. 2020;157(5):1073-5.

2. Pascoe S et al. The Lancet Respir Med. 2015;3(6):435-42.

3. Watz H et al. The Lancet Respir Med. 2016;4(5):390-8.

4. Criner GJ. Chest. 2020;157(5):1075-8.

5. Shin SH et al. Respir Res. 2018;19(1):134.

6. Casanova C et al. Eur Respir J. 2017;50(5):1701162.

7. Pavord ID et al. N Engl J Med. 2017;377(17):1613-29.

8. Criner GJ et al. N Engl J Med. 2019;381(11):1023-34.

9. Mycroft K et al. J Allergy Clin Immunol Pract. 2020 Sep;8(8):2565-74.

10. Global Initiative for Chronic Obstructive Lung Disease 2021 Report.
 

Clinical research

Long-COVID: COVID-19 disease beyond the pandemic

There are increasing reports of persistent multiorgan symptoms following COVID-19 infection.

In December 2020, the National Institute for Health and Care Excellence (NICE) developed guidelines, based primarily on expert opinion, to define and manage ongoing symptomatic COVID-19 (symptoms for 4-12 weeks after infection) and post-COVID syndrome (symptoms present for > 12 weeks without alternative explanation). Subsequently, the National Institutes of Health (NIH), released in February 2021 an initiative to study Post-Acute Sequelae of SARS-CoV2 infection (PASC). Symptoms can include, respiratory (cough, shortness of breath), cardiac (palpitations, chest pain), fatigue and physical limitations, and neurologic (depression, insomnia, cognitive impairment) (Lancet 2020 Dec 12;396[10266]:1861). The majority of patients with post-COVID syndrome have microbiological recovery (PCR negative), and often have radiological recovery. Risk factors include older age, female sex, and comorbidities (Raveendran AV. Diabetes Metab Syndr. 2021 May-June;15[3]:869-75).

Diagnosis and access to care pose significant challenges for post-COVID syndrome, and it is difficult to estimate exactly how many are affected – one report from Italy found that up to 87% of discharged hospitalized patients had persistent symptom(s) at 60 days (Carfi A. JAMA 2020 Aug;324[6]:603-5). Thus far, management recommendations include a multidisciplinary approach to evaluation, symptomatic treatment, organ specific treatment (for example, consideration of corticosteroids for persistent inflammatory interstitial lung disease) (Myall KJ. Ann Am Thorac Soc. 2021 May;8[5]:799-806), physical/occupational therapy, and psychological support. Many institutions have established, or are working to establish post-COVID clinics (Aging Clin Exp Res. 2020 Aug;32[8]:1613-20). Currently, the NIH is offering funding opportunities and there are many clinical trials across the world actively recruiting patients.

Ankita Agarwal, MD
Steering Committee Fellow-in-Training
Bharat Bajantri, MD
Steering Committee Member
Aravind Menon, MD
Steering Committee Fellow-in-Training
 

Critical care

Sedation practices in the ICU: Moving past the COVID-19 pandemic

The COVID-19 pandemic brought unprecedented change to critical care practice patterns, and sedation practices in the intensive care unit are no exception. In a large cohort analysis of over 2,000 adults with COVID-19 (Pun BT, et al. Lancet Respir Med. 2021;9[3]:239-50), 64% of patients received benzodiazepines (median of 7 days), and patients were deeply sedated. More than half of the patients were delirious, with benzodiazepine use associated with increased incidence of delirium. These observations represent a significant departure from well-established pre-COVID best-practices in sedation: light targets, daily sedation interruption, and avoiding continuous benzodiazepine infusions whenever possible (Girard TD, et al. Lancet; 2008;371[9607]:126-34; Fraser GL, et al. Crit Care Med;2013 Sep;41[9 Suppl 1]:S30-8; Riker RR, et al. JAMA;2009;301[5]:489-99).

As COVID-19 case counts begin to improve in many of our communities, we have the opportunity to refocus on best sedation practices and build on a growing body of recent evidence. The MENDS2 trial, completed pre-COVID-19, assigned mechanically ventilated patients with sepsis to either propofol or dexmedetomidine and showed no difference in delirium or coma in this cohort of lightly sedated patients (Hughes CG, et al. N Engl J Med. 2021;384[15]:1424-36). Furthering this point, Olsen et al. found no difference in outcomes when mechanically ventilated patients were randomized to no sedation vs light sedation (Olsen HT, et al. N Engl J Med; 2020;382[12]:1103-11).

While the evidence surrounding sedation strategies in the critically ill continues to grow, one thing is certain: promoting lighter sedation targets and reengaging in sedation-related best practices following the COVID-19 pandemic will continue to play a vital role in improving both short and long-term outcomes for our critically ill patients.

Casey Cable, MD, MSc
Steering Committee Member

Kyle Stinehart, MD
Steering Committee Member
 

Home mechanical ventilation

How to initiate a chronic respiratory failure clinic

Noninvasive ventilation (NIV) is an established treatment for chronic hypercapnic respiratory failure from neuromuscular disorders, COPD, obesity hypoventilation syndrome (OHS), and restrictive thoracic disorders. Previously, hospital admission was considered essential for setup of chronic NIV but with advances in the modes of ventilation and remote monitoring, hospital admission has become less justifiable, especially in countries with centralized medical systems and presence of centers of excellence for home ventilation (Van Den Biggelaar RJM, et al. Chest. 2020;158[6]:2493-2501); Duiverman ML, et al. Thorax. 2020;75:244-52). In the United States, where centralized health care is atypical, management of NIV has been disparate with no clear consensus on practice patterns. Thus, we hope to provide some guidance toward the establishment of such clinics in the U.S.
 

Prior to developing an NIV clinic, establishing a referral source from neuromuscular, rehabilitation/spinal cord injury, bariatric surgery, and COPD programs is important. After this, collaboration with a respiratory therapist through durable medical equipment is essential to building a robust care team. These companies are also important for assisting in remote monitoring, providing overnight pulse oximetry/CO₂ monitoring, mask fitting, and airway clearance. Clinicians are encouraged to develop protocols for initiation and titration of NIV and mouthpiece ventilation. Clinics should provide spirometry, maximal inspiratory pressure, transcutaneous CO₂, and/or blood gas testing. Additionally, in this patient population, wheelchair scales are necessary. Clinical workflow should include a review of NIV downloads, identify asynchronies and troubleshoot it in timely and reliable manner (Blouet S, et al. Int J Chron Obstruct Pulmon Dis. 2018;13:2577-86). Lastly, effort should be made for an adequate assessment of the home situation including layout of home along with family support utilizing social worker and palliative care team. Due to patient mobility, we encourage continued availability of telehealth for these patients.

In summary, strong clinical infrastructure, a robust care team, and an efficient, secure, reliable telemonitoring system are key to provide better care to this vulnerable patient population.

Ashima S. Sahni, MD, MBBS, FCCP
NetWork Member

Amen Sergew, MD
Steering Committee Member

Interstitial and diffuse lung disease

Treatment for pulmonary hypertension secondary to interstitial lung disease

The development of pulmonary hypertension (PH) in patients with interstitial lung disease (ILD) (PH-ILD) is associated with increased supplemental oxygen requirements, reduced functional status, and decreased survival (King CS, et al. Chest. 2020;158[4]:1651).

An inhaled formulation of treprostinil (Tyvaso) is the first treatment option approved by the FDA for patients with PH-ILD, including those with idiopathic pulmonary fibrosis, connective tissue disease-associated ILD, and combined pulmonary fibrosis and emphysema. Approval was based on results from the INCREASE trial (Waxman A, et al. N Engl J Med. 2021;384[4]:325), a phase III multicenter, randomized, double-blinded study comparing the inhaled formulation to placebo in 326 patients over a 16-week period. Participants in the treatment arm were given up to 12 breaths of the formulation per session, four times per day. Subjects treated with this inhaled formulation met the primary study endpoint, an increase in 6-minute walk distance (6MWD) from baseline to week 16, walking 21 m farther than placebo-treated control subjects. Furthermore, patients receiving the new formulation had a decrease in NT-proBNP levels (compared with increases in the placebo arm) and a reduction in clinical worsening (23% of inhalation formulation-treated vs. 33% of placebo-treated subjects). This formulation of treprostinil was well-tolerated with a safety profile consistent with common prostacyclin-related adverse events, including cough, headache, dyspnea, dizziness, nausea, fatigue, and diarrhea. Its approval will dramatically alter the ILD treatment landscape. It now necessitates the use of PH screening in this patient population. However, care will need to be exercised in appropriate patient selection for treatment, using the study inclusion and exclusion criteria as a starting point. Appropriate use of this formulation will hopefully help mitigate the negative outcomes impacting patients with PH-ILD.

Rebecca Anna Gersten, MD
Adrian Shifren, MD
Steering Committee Members

Airways disorders

Eosinophils in COPD

Using peripheral blood eosinophilia (PBE) as a treatable biomarker of airway inflammation in patients with COPD has become an area of controversy in pulmonary medicine.

The proponents find a role for PBE testing in initiation and withdrawal of inhaled corticosteroids (ICS) and as a target for monoclonal antibodies in future studies.¹ Post hoc analyses showed that variable doses of ICS/LABA combination compared with LABA alone in COPD patients were associated with much higher exacerbation reduction in patients with eosinophils counts of ≥2% and magnitude of effect proportionally increased from 29% to 42% with increasing eosinophil count from ≥2% to ≥6% suggesting a dose-response relationship.² A post hoc analysis of the WISDOM trial showed increased risk of exacerbation after ICS discontinuation in COPD patients with high eosinophils (≥300 cells/mcL or ≥4%) while exacerbation risk was not increased in patients with low eosinophils (<150 cells/mcL or <2%).³

The opponents of eosinophil-guided therapy object that the level of evidence is weak as this is based on the post hoc analyses of randomized control trials on patients with increased exacerbation risk at baseline, which in itself is an independent predictor of future exacerbations.⁴ Some observational studies failed to find increased risk of exacerbation with higher eosinophil count while others found that higher eosinophil count was associated with increased survival and better quality of life.^5,6 Anti-eosinophilic biologics have failed to show consistent benefit in exacerbation reduction in COPD patients so far, despite showing a reduction in the PBE.^7-9

The GOLD COPD Guidelines support the use of ICS in patients with eosinophils >300 cells/mcL especially with a history of exacerbation and recommend against ICS in patients with eosinophils <100 cells/mcL.¹⁰

Farrukh Abbas, MD
Steering Committee Fellow-in-Training
Allen J. Blaivas, MD, FCCP
NetWork Chair
 

References

1. Wade RC and Wells JM. Chest. 2020;157(5):1073-5.

2. Pascoe S et al. The Lancet Respir Med. 2015;3(6):435-42.

3. Watz H et al. The Lancet Respir Med. 2016;4(5):390-8.

4. Criner GJ. Chest. 2020;157(5):1075-8.

5. Shin SH et al. Respir Res. 2018;19(1):134.

6. Casanova C et al. Eur Respir J. 2017;50(5):1701162.

7. Pavord ID et al. N Engl J Med. 2017;377(17):1613-29.

8. Criner GJ et al. N Engl J Med. 2019;381(11):1023-34.

9. Mycroft K et al. J Allergy Clin Immunol Pract. 2020 Sep;8(8):2565-74.

10. Global Initiative for Chronic Obstructive Lung Disease 2021 Report.
 

Clinical research

Long-COVID: COVID-19 disease beyond the pandemic

There are increasing reports of persistent multiorgan symptoms following COVID-19 infection.

In December 2020, the National Institute for Health and Care Excellence (NICE) developed guidelines, based primarily on expert opinion, to define and manage ongoing symptomatic COVID-19 (symptoms for 4-12 weeks after infection) and post-COVID syndrome (symptoms present for > 12 weeks without alternative explanation). Subsequently, the National Institutes of Health (NIH), released in February 2021 an initiative to study Post-Acute Sequelae of SARS-CoV2 infection (PASC). Symptoms can include, respiratory (cough, shortness of breath), cardiac (palpitations, chest pain), fatigue and physical limitations, and neurologic (depression, insomnia, cognitive impairment) (Lancet 2020 Dec 12;396[10266]:1861). The majority of patients with post-COVID syndrome have microbiological recovery (PCR negative), and often have radiological recovery. Risk factors include older age, female sex, and comorbidities (Raveendran AV. Diabetes Metab Syndr. 2021 May-June;15[3]:869-75).

Diagnosis and access to care pose significant challenges for post-COVID syndrome, and it is difficult to estimate exactly how many are affected – one report from Italy found that up to 87% of discharged hospitalized patients had persistent symptom(s) at 60 days (Carfi A. JAMA 2020 Aug;324[6]:603-5). Thus far, management recommendations include a multidisciplinary approach to evaluation, symptomatic treatment, organ specific treatment (for example, consideration of corticosteroids for persistent inflammatory interstitial lung disease) (Myall KJ. Ann Am Thorac Soc. 2021 May;8[5]:799-806), physical/occupational therapy, and psychological support. Many institutions have established, or are working to establish post-COVID clinics (Aging Clin Exp Res. 2020 Aug;32[8]:1613-20). Currently, the NIH is offering funding opportunities and there are many clinical trials across the world actively recruiting patients.

Ankita Agarwal, MD
Steering Committee Fellow-in-Training
Bharat Bajantri, MD
Steering Committee Member
Aravind Menon, MD
Steering Committee Fellow-in-Training
 

Critical care

Sedation practices in the ICU: Moving past the COVID-19 pandemic

The COVID-19 pandemic brought unprecedented change to critical care practice patterns, and sedation practices in the intensive care unit are no exception. In a large cohort analysis of over 2,000 adults with COVID-19 (Pun BT, et al. Lancet Respir Med. 2021;9[3]:239-50), 64% of patients received benzodiazepines (median of 7 days), and patients were deeply sedated. More than half of the patients were delirious, with benzodiazepine use associated with increased incidence of delirium. These observations represent a significant departure from well-established pre-COVID best-practices in sedation: light targets, daily sedation interruption, and avoiding continuous benzodiazepine infusions whenever possible (Girard TD, et al. Lancet; 2008;371[9607]:126-34; Fraser GL, et al. Crit Care Med;2013 Sep;41[9 Suppl 1]:S30-8; Riker RR, et al. JAMA;2009;301[5]:489-99).

As COVID-19 case counts begin to improve in many of our communities, we have the opportunity to refocus on best sedation practices and build on a growing body of recent evidence. The MENDS2 trial, completed pre-COVID-19, assigned mechanically ventilated patients with sepsis to either propofol or dexmedetomidine and showed no difference in delirium or coma in this cohort of lightly sedated patients (Hughes CG, et al. N Engl J Med. 2021;384[15]:1424-36). Furthering this point, Olsen et al. found no difference in outcomes when mechanically ventilated patients were randomized to no sedation vs light sedation (Olsen HT, et al. N Engl J Med; 2020;382[12]:1103-11).

While the evidence surrounding sedation strategies in the critically ill continues to grow, one thing is certain: promoting lighter sedation targets and reengaging in sedation-related best practices following the COVID-19 pandemic will continue to play a vital role in improving both short and long-term outcomes for our critically ill patients.

Casey Cable, MD, MSc
Steering Committee Member

Kyle Stinehart, MD
Steering Committee Member
 

Home mechanical ventilation

How to initiate a chronic respiratory failure clinic

Noninvasive ventilation (NIV) is an established treatment for chronic hypercapnic respiratory failure from neuromuscular disorders, COPD, obesity hypoventilation syndrome (OHS), and restrictive thoracic disorders. Previously, hospital admission was considered essential for setup of chronic NIV but with advances in the modes of ventilation and remote monitoring, hospital admission has become less justifiable, especially in countries with centralized medical systems and presence of centers of excellence for home ventilation (Van Den Biggelaar RJM, et al. Chest. 2020;158[6]:2493-2501); Duiverman ML, et al. Thorax. 2020;75:244-52). In the United States, where centralized health care is atypical, management of NIV has been disparate with no clear consensus on practice patterns. Thus, we hope to provide some guidance toward the establishment of such clinics in the U.S.
 

Prior to developing an NIV clinic, establishing a referral source from neuromuscular, rehabilitation/spinal cord injury, bariatric surgery, and COPD programs is important. After this, collaboration with a respiratory therapist through durable medical equipment is essential to building a robust care team. These companies are also important for assisting in remote monitoring, providing overnight pulse oximetry/CO₂ monitoring, mask fitting, and airway clearance. Clinicians are encouraged to develop protocols for initiation and titration of NIV and mouthpiece ventilation. Clinics should provide spirometry, maximal inspiratory pressure, transcutaneous CO₂, and/or blood gas testing. Additionally, in this patient population, wheelchair scales are necessary. Clinical workflow should include a review of NIV downloads, identify asynchronies and troubleshoot it in timely and reliable manner (Blouet S, et al. Int J Chron Obstruct Pulmon Dis. 2018;13:2577-86). Lastly, effort should be made for an adequate assessment of the home situation including layout of home along with family support utilizing social worker and palliative care team. Due to patient mobility, we encourage continued availability of telehealth for these patients.

In summary, strong clinical infrastructure, a robust care team, and an efficient, secure, reliable telemonitoring system are key to provide better care to this vulnerable patient population.

Ashima S. Sahni, MD, MBBS, FCCP
NetWork Member

Amen Sergew, MD
Steering Committee Member

Interstitial and diffuse lung disease

Treatment for pulmonary hypertension secondary to interstitial lung disease

The development of pulmonary hypertension (PH) in patients with interstitial lung disease (ILD) (PH-ILD) is associated with increased supplemental oxygen requirements, reduced functional status, and decreased survival (King CS, et al. Chest. 2020;158[4]:1651).

An inhaled formulation of treprostinil (Tyvaso) is the first treatment option approved by the FDA for patients with PH-ILD, including those with idiopathic pulmonary fibrosis, connective tissue disease-associated ILD, and combined pulmonary fibrosis and emphysema. Approval was based on results from the INCREASE trial (Waxman A, et al. N Engl J Med. 2021;384[4]:325), a phase III multicenter, randomized, double-blinded study comparing the inhaled formulation to placebo in 326 patients over a 16-week period. Participants in the treatment arm were given up to 12 breaths of the formulation per session, four times per day. Subjects treated with this inhaled formulation met the primary study endpoint, an increase in 6-minute walk distance (6MWD) from baseline to week 16, walking 21 m farther than placebo-treated control subjects. Furthermore, patients receiving the new formulation had a decrease in NT-proBNP levels (compared with increases in the placebo arm) and a reduction in clinical worsening (23% of inhalation formulation-treated vs. 33% of placebo-treated subjects). This formulation of treprostinil was well-tolerated with a safety profile consistent with common prostacyclin-related adverse events, including cough, headache, dyspnea, dizziness, nausea, fatigue, and diarrhea. Its approval will dramatically alter the ILD treatment landscape. It now necessitates the use of PH screening in this patient population. However, care will need to be exercised in appropriate patient selection for treatment, using the study inclusion and exclusion criteria as a starting point. Appropriate use of this formulation will hopefully help mitigate the negative outcomes impacting patients with PH-ILD.

Rebecca Anna Gersten, MD
Adrian Shifren, MD
Steering Committee Members

Telemedicine has been proposed as a solution for an array of health care access problems over decades of gradual growth. The vast ramping up of telemedicine during the COVID-19 pandemic greatly expanded the evidence of its feasibility and what appears to be its inevitable incorporation into models of care, according to an update at the Health Policy and Advocacy Conference (HPAC) sponsored by the American College of Chest Physicians.

“The cat is out of the bag,” said Jaspal Singh, MD, FCCP, professor of medicine, Atrium Health, Charlotte, N.C. Due to changes in access and reimbursement to telemedicine driven by the pandemic, he said, “we now have permission to explore new models of care.”

Prior to February 2020, telemedicine was crawling forward at a leisurely pace, according to Dr. Singh. After March 2020, it broke into a run due to enormous demand and met by a rapid response from the U.S. Congress. The first of four legislative bills that directly or indirectly supported telemedicine was passed on March 6.

The Centers for Medicare and Medicaid Services (CMS) responded in kind, making modifications in a number of rules that removed obstacles to telehealth. One modification on April 6, for example, removed the requirement for a preexisting relationship between the clinician and patient, Dr. Singh said. The CMS also subsequently modified reimbursement policies in order to make telemedicine more tenable for physicians.

Given the risk of contagion from face-to-face encounters, telemedicine in the early days of the pandemic was not just attractive but the only practical and safe approach to medical care in many circumstances. Physicians and patients were anxious for health care that did not require in-office visits even though many critical issues for telemedicine, including its relative effectiveness, had not yet been fully evaluated.

Much has been learned regarding the feasibility and acceptability of telemedicine during the pandemic, but Dr. Singh noted that quality of care relative to in-person visits remains weakly supported for most indications. Indeed, he outlined a sizable list of incompletely resolved issues, including optimal payment models, management of privacy concerns, and how to balance advantages to disadvantages.

For patients and physicians, the strengths of telemedicine include greater convenience made possible by the elimination of travel and waiting rooms. For the health care system, it can include less infrastructure and overhead. For many physicians, telemedicine might be perceived as more efficient.

On the other hand, some patients might feel that a clinical encounter is incomplete without a physical examination even when the physician does not feel the physical examination is needed, according to Dr. Singh. He cited a survey suggesting nearly half of patients expressed concern about a lack of connection to health care providers following a virtual visit.

In the same 2020 National Poll on Healthy Aging 2020 survey conducted by the University of Michigan, 67% of respondents reported that the quality of care was not as good as that provided by in-patient visits, and 24% expressed concern about privacy. However, at the time the poll was taken in May 2020, experience with telemedicine among many of the respondents may have been limited. As telemedicine is integrated into routine care, perceptions might change as experience increases.

A distinction between telemedicine in routine care and telemedicine as a strategy to respond to a pandemic is important, Dr. Singh indicated. Dr. Singh was the lead author for a position paper on telemedicine for the diagnosis and treatment of sleep disorders from the American Academy of Sleep Medicine 5 years ago (J Clin Sleep Med. 2015;11:1187-98), but he acknowledged that models of care might differ when responding to abnormal surges in health care demand.

The surge in demand for COVID-19–related care engendered numerous innovative solutions. As examples, Dr. Singh recounted how a virtual hospital was created at his own institution. In a published study, 1,477 patients diagnosed with COVID19 over a 6-week period remained at home and received care in a virtual observation unit (VCU) or a virtual acute care unit (VACU) (Ann Intern Med. 2020;174:192-9). Only a small percentage required eventual hospital admission. In the VACU, patients were able to receive advanced care, including IV fluids and some form of respiratory support .

It is unclear how the COVID-19 pandemic will change telemedicine. Now, with declining cases of the infection, telemedicine is back to a walk after the sprint required during the height of the pandemic, according to Dr. Singh. However, Dr. Singh thinks many physicians and patients will have a different perception of telemedicine after the widespread exposure to this type of care.

In terms of the relative role of in-patient and virtual visits across indications, “we do not know how this will play out, but we will probably end up toggling between the two,” Dr. Singh said.

This is an area that is being followed closely by the CHEST Health Policy and Advocacy Committee, according to Kathleen Sarmiento, MD, FCCP, director, VISN 21 Sleep Clinical Resource Hub for the San Francisco VA Health Care System. A member of that Committee and moderator of the session in which Dr. Singh spoke, Dr. Sarmiento called the effort to bring permanent coverage of telehealth services “the shared responsibility of every medical society engaged in advocacy.”

However, she cautioned that there might be intended and unintended consequences from telehealth that require analysis to develop policies that are in the best interests of effective care. She said, the “ACCP [CHEST], along with its sister societies, does have a role in supporting the evaluation of the impact of these changes on both patients and providers in the fields of pulmonary medicine, critical care, and sleep medicine.”

Dr. Singh reports a financial relationship with AstraZeneca. Dr. Sarmiento reports no relevant financial relationships.

Telemedicine has been proposed as a solution for an array of health care access problems over decades of gradual growth. The vast ramping up of telemedicine during the COVID-19 pandemic greatly expanded the evidence of its feasibility and what appears to be its inevitable incorporation into models of care, according to an update at the Health Policy and Advocacy Conference (HPAC) sponsored by the American College of Chest Physicians.

“The cat is out of the bag,” said Jaspal Singh, MD, FCCP, professor of medicine, Atrium Health, Charlotte, N.C. Due to changes in access and reimbursement to telemedicine driven by the pandemic, he said, “we now have permission to explore new models of care.”

Prior to February 2020, telemedicine was crawling forward at a leisurely pace, according to Dr. Singh. After March 2020, it broke into a run due to enormous demand and met by a rapid response from the U.S. Congress. The first of four legislative bills that directly or indirectly supported telemedicine was passed on March 6.

The Centers for Medicare and Medicaid Services (CMS) responded in kind, making modifications in a number of rules that removed obstacles to telehealth. One modification on April 6, for example, removed the requirement for a preexisting relationship between the clinician and patient, Dr. Singh said. The CMS also subsequently modified reimbursement policies in order to make telemedicine more tenable for physicians.

Given the risk of contagion from face-to-face encounters, telemedicine in the early days of the pandemic was not just attractive but the only practical and safe approach to medical care in many circumstances. Physicians and patients were anxious for health care that did not require in-office visits even though many critical issues for telemedicine, including its relative effectiveness, had not yet been fully evaluated.

Much has been learned regarding the feasibility and acceptability of telemedicine during the pandemic, but Dr. Singh noted that quality of care relative to in-person visits remains weakly supported for most indications. Indeed, he outlined a sizable list of incompletely resolved issues, including optimal payment models, management of privacy concerns, and how to balance advantages to disadvantages.

For patients and physicians, the strengths of telemedicine include greater convenience made possible by the elimination of travel and waiting rooms. For the health care system, it can include less infrastructure and overhead. For many physicians, telemedicine might be perceived as more efficient.

On the other hand, some patients might feel that a clinical encounter is incomplete without a physical examination even when the physician does not feel the physical examination is needed, according to Dr. Singh. He cited a survey suggesting nearly half of patients expressed concern about a lack of connection to health care providers following a virtual visit.

In the same 2020 National Poll on Healthy Aging 2020 survey conducted by the University of Michigan, 67% of respondents reported that the quality of care was not as good as that provided by in-patient visits, and 24% expressed concern about privacy. However, at the time the poll was taken in May 2020, experience with telemedicine among many of the respondents may have been limited. As telemedicine is integrated into routine care, perceptions might change as experience increases.

A distinction between telemedicine in routine care and telemedicine as a strategy to respond to a pandemic is important, Dr. Singh indicated. Dr. Singh was the lead author for a position paper on telemedicine for the diagnosis and treatment of sleep disorders from the American Academy of Sleep Medicine 5 years ago (J Clin Sleep Med. 2015;11:1187-98), but he acknowledged that models of care might differ when responding to abnormal surges in health care demand.

The surge in demand for COVID-19–related care engendered numerous innovative solutions. As examples, Dr. Singh recounted how a virtual hospital was created at his own institution. In a published study, 1,477 patients diagnosed with COVID19 over a 6-week period remained at home and received care in a virtual observation unit (VCU) or a virtual acute care unit (VACU) (Ann Intern Med. 2020;174:192-9). Only a small percentage required eventual hospital admission. In the VACU, patients were able to receive advanced care, including IV fluids and some form of respiratory support .

It is unclear how the COVID-19 pandemic will change telemedicine. Now, with declining cases of the infection, telemedicine is back to a walk after the sprint required during the height of the pandemic, according to Dr. Singh. However, Dr. Singh thinks many physicians and patients will have a different perception of telemedicine after the widespread exposure to this type of care.

In terms of the relative role of in-patient and virtual visits across indications, “we do not know how this will play out, but we will probably end up toggling between the two,” Dr. Singh said.

This is an area that is being followed closely by the CHEST Health Policy and Advocacy Committee, according to Kathleen Sarmiento, MD, FCCP, director, VISN 21 Sleep Clinical Resource Hub for the San Francisco VA Health Care System. A member of that Committee and moderator of the session in which Dr. Singh spoke, Dr. Sarmiento called the effort to bring permanent coverage of telehealth services “the shared responsibility of every medical society engaged in advocacy.”

However, she cautioned that there might be intended and unintended consequences from telehealth that require analysis to develop policies that are in the best interests of effective care. She said, the “ACCP [CHEST], along with its sister societies, does have a role in supporting the evaluation of the impact of these changes on both patients and providers in the fields of pulmonary medicine, critical care, and sleep medicine.”

Dr. Singh reports a financial relationship with AstraZeneca. Dr. Sarmiento reports no relevant financial relationships.

Telemedicine has been proposed as a solution for an array of health care access problems over decades of gradual growth. The vast ramping up of telemedicine during the COVID-19 pandemic greatly expanded the evidence of its feasibility and what appears to be its inevitable incorporation into models of care, according to an update at the Health Policy and Advocacy Conference (HPAC) sponsored by the American College of Chest Physicians.

“The cat is out of the bag,” said Jaspal Singh, MD, FCCP, professor of medicine, Atrium Health, Charlotte, N.C. Due to changes in access and reimbursement to telemedicine driven by the pandemic, he said, “we now have permission to explore new models of care.”

Prior to February 2020, telemedicine was crawling forward at a leisurely pace, according to Dr. Singh. After March 2020, it broke into a run due to enormous demand and met by a rapid response from the U.S. Congress. The first of four legislative bills that directly or indirectly supported telemedicine was passed on March 6.

The Centers for Medicare and Medicaid Services (CMS) responded in kind, making modifications in a number of rules that removed obstacles to telehealth. One modification on April 6, for example, removed the requirement for a preexisting relationship between the clinician and patient, Dr. Singh said. The CMS also subsequently modified reimbursement policies in order to make telemedicine more tenable for physicians.

Given the risk of contagion from face-to-face encounters, telemedicine in the early days of the pandemic was not just attractive but the only practical and safe approach to medical care in many circumstances. Physicians and patients were anxious for health care that did not require in-office visits even though many critical issues for telemedicine, including its relative effectiveness, had not yet been fully evaluated.

Much has been learned regarding the feasibility and acceptability of telemedicine during the pandemic, but Dr. Singh noted that quality of care relative to in-person visits remains weakly supported for most indications. Indeed, he outlined a sizable list of incompletely resolved issues, including optimal payment models, management of privacy concerns, and how to balance advantages to disadvantages.

For patients and physicians, the strengths of telemedicine include greater convenience made possible by the elimination of travel and waiting rooms. For the health care system, it can include less infrastructure and overhead. For many physicians, telemedicine might be perceived as more efficient.

On the other hand, some patients might feel that a clinical encounter is incomplete without a physical examination even when the physician does not feel the physical examination is needed, according to Dr. Singh. He cited a survey suggesting nearly half of patients expressed concern about a lack of connection to health care providers following a virtual visit.

In the same 2020 National Poll on Healthy Aging 2020 survey conducted by the University of Michigan, 67% of respondents reported that the quality of care was not as good as that provided by in-patient visits, and 24% expressed concern about privacy. However, at the time the poll was taken in May 2020, experience with telemedicine among many of the respondents may have been limited. As telemedicine is integrated into routine care, perceptions might change as experience increases.

A distinction between telemedicine in routine care and telemedicine as a strategy to respond to a pandemic is important, Dr. Singh indicated. Dr. Singh was the lead author for a position paper on telemedicine for the diagnosis and treatment of sleep disorders from the American Academy of Sleep Medicine 5 years ago (J Clin Sleep Med. 2015;11:1187-98), but he acknowledged that models of care might differ when responding to abnormal surges in health care demand.

The surge in demand for COVID-19–related care engendered numerous innovative solutions. As examples, Dr. Singh recounted how a virtual hospital was created at his own institution. In a published study, 1,477 patients diagnosed with COVID19 over a 6-week period remained at home and received care in a virtual observation unit (VCU) or a virtual acute care unit (VACU) (Ann Intern Med. 2020;174:192-9). Only a small percentage required eventual hospital admission. In the VACU, patients were able to receive advanced care, including IV fluids and some form of respiratory support .

It is unclear how the COVID-19 pandemic will change telemedicine. Now, with declining cases of the infection, telemedicine is back to a walk after the sprint required during the height of the pandemic, according to Dr. Singh. However, Dr. Singh thinks many physicians and patients will have a different perception of telemedicine after the widespread exposure to this type of care.

In terms of the relative role of in-patient and virtual visits across indications, “we do not know how this will play out, but we will probably end up toggling between the two,” Dr. Singh said.

This is an area that is being followed closely by the CHEST Health Policy and Advocacy Committee, according to Kathleen Sarmiento, MD, FCCP, director, VISN 21 Sleep Clinical Resource Hub for the San Francisco VA Health Care System. A member of that Committee and moderator of the session in which Dr. Singh spoke, Dr. Sarmiento called the effort to bring permanent coverage of telehealth services “the shared responsibility of every medical society engaged in advocacy.”

However, she cautioned that there might be intended and unintended consequences from telehealth that require analysis to develop policies that are in the best interests of effective care. She said, the “ACCP [CHEST], along with its sister societies, does have a role in supporting the evaluation of the impact of these changes on both patients and providers in the fields of pulmonary medicine, critical care, and sleep medicine.”

Dr. Singh reports a financial relationship with AstraZeneca. Dr. Sarmiento reports no relevant financial relationships.

Most U.S. adults (77%) ages 50 and older in the United States rated their overall health as good, very good, or excellent in an online survey conducted by WebMD and Capital Caring Health (CCH), a nonprofit hospice/advanced illness care organization based in Virginia.

Among the respondents, 41% said their health was very good or excellent.

However, the ratings differed largely by race, employment status, and income.

Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.

The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).

Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).

Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).

WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020.  WebMD.com readers were randomly invited to take a 10-minute online survey.
 

Aging at home a priority

The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.

“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.

Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.

The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.

When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
 

Use of telemedicine

Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.

However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%).  They were also more likely to already have used telemedicine.

Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.

Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.

Close to one-quarter of respondents would not allow any type of monitoring.

Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.

People see monitoring of some movements as “Orwellian,” Mr. Cone says.
 

Knowledge of hospice

The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.

When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.

He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.

“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”

Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.

In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”

He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.

However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.

The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
 

Most using hospice are White

More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”

However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.

Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
 

Health costs top concern

The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.

More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).

Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.

A version of this article first appeared on WebMD.com.

Most U.S. adults (77%) ages 50 and older in the United States rated their overall health as good, very good, or excellent in an online survey conducted by WebMD and Capital Caring Health (CCH), a nonprofit hospice/advanced illness care organization based in Virginia.

Among the respondents, 41% said their health was very good or excellent.

However, the ratings differed largely by race, employment status, and income.

Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.

The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).

Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).

Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).

WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020.  WebMD.com readers were randomly invited to take a 10-minute online survey.
 

Aging at home a priority

The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.

“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.

Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.

The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.

When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
 

Use of telemedicine

Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.

However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%).  They were also more likely to already have used telemedicine.

Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.

Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.

Close to one-quarter of respondents would not allow any type of monitoring.

Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.

People see monitoring of some movements as “Orwellian,” Mr. Cone says.
 

Knowledge of hospice

The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.

When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.

He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.

“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”

Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.

In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”

He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.

However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.

The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
 

Most using hospice are White

More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”

However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.

Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
 

Health costs top concern

The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.

More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).

Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.

A version of this article first appeared on WebMD.com.

Most U.S. adults (77%) ages 50 and older in the United States rated their overall health as good, very good, or excellent in an online survey conducted by WebMD and Capital Caring Health (CCH), a nonprofit hospice/advanced illness care organization based in Virginia.

Among the respondents, 41% said their health was very good or excellent.

However, the ratings differed largely by race, employment status, and income.

Employment status was also associated with a significant difference in the way people viewed their health at the top tier and bottom tier.

The middle tier (“good” health) was reported similarly (from 33% to 37%) whether a person was employed, retired, or not employed. However, employed respondents were much more likely to report they had “excellent” or “very good” health (51% vs. 44% for retirees and 21% for the not employed).

Conversely, those who were not employed were far more likely to report “fair” or “poor” health (45%) than those who were employed (13%) or retired (20%).

Similarly, respondents with incomes of less than $50,000 were three times more likely to report their health as “fair” or “poor” than were those with incomes of more than $100,000 (36% vs. 12%).

WebMD/CCH surveyed 3,464 U.S. residents ages 50 and older between Aug. 13 and Nov. 9, 2020.  WebMD.com readers were randomly invited to take a 10-minute online survey.
 

Aging at home a priority

The survey also highlighted a strong preference for aging in place, says Steve Cone, chief of communications and philanthropy at CCH.

“More now than ever before, thanks to the COVID experience, baby boomers and their children really believe that’s the holy grail,” he says.

Mr. Cone notes that the quick spread of COVID-19 through some nursing homes early in the pandemic likely has strengthened people’s resolve to live out their lives in their own homes.

The survey indicated that 85% of people aged 50+ who are living in their own home, a family member’s home, or a loved one’s home responded that it is “very important” or “important” to stay in their home as they age.

When asked what services they would need to continue their living situation, the most common responses were housekeeping, home repair services, and transportation (listed as needs by 35% to 45% of respondents). Regarding changes they would have to make to feel safe in their home as they age, installing grab bars and/or safety rails in the bath/shower was the most popular answer (50%).
 

Use of telemedicine

Respondents were also asked about their acceptance of telemedicine, and 62% said they would be likely or very likely to engage in virtual visits with a doctor it in the future.

However, the likelihood varied by income level. Specifically, respondents with incomes over $100,000 were significantly more likely to say they would use telemedicine in the future than were those with incomes below $50,000 (74% vs. 60%).  They were also more likely to already have used telemedicine.

Although respondents generally embraced telemedicine, they are less confident about some types of monitoring, according to Mr. Cone.

Emergency response (64%) was the leading type of remote monitoring respondents ages 50 and older would allow. Only a minority of respondents would allow the other types of monitoring asked about in the survey.

Close to one-quarter of respondents would not allow any type of monitoring.

Fewer than one-third would allow tracking of medication compliance, refrigerator use, sleep habits, or bathroom use.

People see monitoring of some movements as “Orwellian,” Mr. Cone says.
 

Knowledge of hospice

The survey findings support the need for more widespread use of hospice so people can stay in their homes as they age, Mr. Cone says.

When illness gets severe, “There’s no reason you have to get rushed to the emergency room or wind up in a hospital,” Mr. Cone says.

He notes that hospice and palliative care can come to patients wherever they reside – in their home, an assisted living center, a nursing home, or even a hospital room.

“That doesn’t mean the physician isn’t involved,” he says. “But working as a team, we can keep them in their homes and their lifestyle intact.”

Patients whose doctors attest that they are likely to live a maximum 6 months are eligible for hospice. But most families wait too long to long to start hospice or palliative care for a patient, Mr. Cone says, and may not be aware of what these services typically cover, including meal preparation and pet care.

In the survey, nearly one-third of respondents said they did not know that palliative care is something that “can be given at any stage of a serious illness” or “provides non-medical services (e.g., patient/family communication, help with insurance issues, scheduling appointments, arranging transportation).”

He notes palliative care and hospice are covered by Medicare and Medicaid and also by most private insurance plans or by individual companies providing the service.

However, health care providers may have to overcome a general reluctance to discuss hospice when sharing options for those severely ill.

The survey showed that while 51% of those 50 and older are at least “slightly interested” in learning more about hospice, a nearly equal number say they are “not at all interested” (49%).
 

Most using hospice are White

More than 90% of those surveyed reported that aspects of hospice care, including “comfort and relief from pain at the end of patients’ lives,” providing a dedicated care team, and an alternative to other care settings, are “very important” or “important.”

However, national hospice use rates are extremely low for minorities and the LGBTQ community, according to Mr. Cone. Among Medicare hospice recipients, 82% were white, 8.2% Black, 6.7% Hispanic, and 1.8% Asian or Pacific Islander, according to the National Hospice and Palliative Care Organization.

Those numbers signal a need for outreach to those communities with information on what services are available and how to access them, he says.
 

Health costs top concern

The survey also asked about level of concern regarding matters including family, health, financials, and end-of-life directives and found adults aged 50 and older expressed the greatest amount of concern for health care costs that are not covered by insurance.

More than half (56%) said they were concerned or very concerned about those costs, which was higher than the percentage concerned about losing a spouse (49%).

Respondents were less concerned (“slightly concerned” or “not at all concerned”) about their children living far away, planning end-of life-directives, and falling or having reduced mobility.

A version of this article first appeared on WebMD.com.

A standard medical face mask is more effective at preventing the wearer from inhaling aerosols without causing substantial breathing resistance than various cloth, medical, or respirator masks, new research shows.

“Medical face masks with good filtration efficacies can provide even better protective effects than KN95 respirators,” Christian Sterr, MD, from Philipps University of Marburg (Germany), and colleagues wrote. “FFP2 respirators, on the other hand, could be useful in high-risk situations but require greater breathing effort and therefore physical stress for users.”

Extensive evidence has shown that face masks are an excellent form of source control, preventing infectious people from spreading the SARS-CoV-2 virus into the environment. But evidence has been less clear about how well masks protect the wearer from inhaling particles containing the virus.

The researchers conducted three experiments to test 32 different face masks. The findings were presented at the 31st European Congress of Clinical Microbiology & Infectious Diseases and published online in PLOS One .

First they tested pressure drop, which “relates to how easily air can pass through the material,” said Chris Cappa, PhD, professor of civil and environmental engineering at the University of California, Davis, who was not involved with the study.

“Higher pressure drops mean that there is greater resistance to the air passing through. A higher pressure drop will typically mean breathing through the material will be slightly more challenging, compared to a low pressure drop. There is no relationship between pressure drop and the mask effectiveness,” he said in an interview.

Pressure drop was lowest with type II medical face masks, the typical three-ply surgical masks designed to stop large particles expelled by the wearer from entering the environment, was highest with respirators, including KN95 and FFP2 masks, and varied with the different cloth masks tested.

Next the researchers compared filtration efficacy, which “refers to how well the material removes particles from the air that passes through the mask material,” Dr. Cappa explained. They did this by placing each mask over the opening to an air collector that measured how many particles got through. “A mask that has 100% filtration efficacy will remove all particles from the air that passes through it and 0% means that no particles are removed.”

Cloth masks had the lowest filtration efficacy, at 28%. Certified face masks that met European Standards had a relatively high efficacy, at 70%; for uncertified face masks, filtration efficacy was 63%. As expected, KN95 and FFP2 masks had the highest filtration efficacy, at 94% and 98%, respectively.Finally, the researchers tested as-worn filtration efficacies. They placed each mask on a dummy head with an artificial airway that collected airborne particles. They then pumped a mixture of aerosol particles – ranging in size from 0.3 to 2.0 mcm – and particle-free pressurized air into the air-proof acrylic chamber in which the head was placed.

In this experiment, cloth masks and noncertified face masks were least effective, filtering less than 20% of aerosols. Interestingly, the cloth face mask with the highest filtration on its own (84%) had the lowest filtration efficacy (9%), apparently because of its very high pressure drop (breathing resistance). When more effort is required to breathe through a mask, more air can bypass the filtration system.

A standard medical face mask is more effective at preventing the wearer from inhaling aerosols without causing substantial breathing resistance than various cloth, medical, or respirator masks, new research shows.

“Medical face masks with good filtration efficacies can provide even better protective effects than KN95 respirators,” Christian Sterr, MD, from Philipps University of Marburg (Germany), and colleagues wrote. “FFP2 respirators, on the other hand, could be useful in high-risk situations but require greater breathing effort and therefore physical stress for users.”

Extensive evidence has shown that face masks are an excellent form of source control, preventing infectious people from spreading the SARS-CoV-2 virus into the environment. But evidence has been less clear about how well masks protect the wearer from inhaling particles containing the virus.

The researchers conducted three experiments to test 32 different face masks. The findings were presented at the 31st European Congress of Clinical Microbiology & Infectious Diseases and published online in PLOS One .

First they tested pressure drop, which “relates to how easily air can pass through the material,” said Chris Cappa, PhD, professor of civil and environmental engineering at the University of California, Davis, who was not involved with the study.

“Higher pressure drops mean that there is greater resistance to the air passing through. A higher pressure drop will typically mean breathing through the material will be slightly more challenging, compared to a low pressure drop. There is no relationship between pressure drop and the mask effectiveness,” he said in an interview.

Pressure drop was lowest with type II medical face masks, the typical three-ply surgical masks designed to stop large particles expelled by the wearer from entering the environment, was highest with respirators, including KN95 and FFP2 masks, and varied with the different cloth masks tested.

Next the researchers compared filtration efficacy, which “refers to how well the material removes particles from the air that passes through the mask material,” Dr. Cappa explained. They did this by placing each mask over the opening to an air collector that measured how many particles got through. “A mask that has 100% filtration efficacy will remove all particles from the air that passes through it and 0% means that no particles are removed.”

Cloth masks had the lowest filtration efficacy, at 28%. Certified face masks that met European Standards had a relatively high efficacy, at 70%; for uncertified face masks, filtration efficacy was 63%. As expected, KN95 and FFP2 masks had the highest filtration efficacy, at 94% and 98%, respectively.Finally, the researchers tested as-worn filtration efficacies. They placed each mask on a dummy head with an artificial airway that collected airborne particles. They then pumped a mixture of aerosol particles – ranging in size from 0.3 to 2.0 mcm – and particle-free pressurized air into the air-proof acrylic chamber in which the head was placed.

In this experiment, cloth masks and noncertified face masks were least effective, filtering less than 20% of aerosols. Interestingly, the cloth face mask with the highest filtration on its own (84%) had the lowest filtration efficacy (9%), apparently because of its very high pressure drop (breathing resistance). When more effort is required to breathe through a mask, more air can bypass the filtration system.

A standard medical face mask is more effective at preventing the wearer from inhaling aerosols without causing substantial breathing resistance than various cloth, medical, or respirator masks, new research shows.

“Medical face masks with good filtration efficacies can provide even better protective effects than KN95 respirators,” Christian Sterr, MD, from Philipps University of Marburg (Germany), and colleagues wrote. “FFP2 respirators, on the other hand, could be useful in high-risk situations but require greater breathing effort and therefore physical stress for users.”

Extensive evidence has shown that face masks are an excellent form of source control, preventing infectious people from spreading the SARS-CoV-2 virus into the environment. But evidence has been less clear about how well masks protect the wearer from inhaling particles containing the virus.

The researchers conducted three experiments to test 32 different face masks. The findings were presented at the 31st European Congress of Clinical Microbiology & Infectious Diseases and published online in PLOS One .

First they tested pressure drop, which “relates to how easily air can pass through the material,” said Chris Cappa, PhD, professor of civil and environmental engineering at the University of California, Davis, who was not involved with the study.

“Higher pressure drops mean that there is greater resistance to the air passing through. A higher pressure drop will typically mean breathing through the material will be slightly more challenging, compared to a low pressure drop. There is no relationship between pressure drop and the mask effectiveness,” he said in an interview.

Pressure drop was lowest with type II medical face masks, the typical three-ply surgical masks designed to stop large particles expelled by the wearer from entering the environment, was highest with respirators, including KN95 and FFP2 masks, and varied with the different cloth masks tested.

Next the researchers compared filtration efficacy, which “refers to how well the material removes particles from the air that passes through the mask material,” Dr. Cappa explained. They did this by placing each mask over the opening to an air collector that measured how many particles got through. “A mask that has 100% filtration efficacy will remove all particles from the air that passes through it and 0% means that no particles are removed.”

Cloth masks had the lowest filtration efficacy, at 28%. Certified face masks that met European Standards had a relatively high efficacy, at 70%; for uncertified face masks, filtration efficacy was 63%. As expected, KN95 and FFP2 masks had the highest filtration efficacy, at 94% and 98%, respectively.Finally, the researchers tested as-worn filtration efficacies. They placed each mask on a dummy head with an artificial airway that collected airborne particles. They then pumped a mixture of aerosol particles – ranging in size from 0.3 to 2.0 mcm – and particle-free pressurized air into the air-proof acrylic chamber in which the head was placed.

In this experiment, cloth masks and noncertified face masks were least effective, filtering less than 20% of aerosols. Interestingly, the cloth face mask with the highest filtration on its own (84%) had the lowest filtration efficacy (9%), apparently because of its very high pressure drop (breathing resistance). When more effort is required to breathe through a mask, more air can bypass the filtration system.

Some people recovering from COVID-19 fare worse than current or previous cancer patients when referred to outpatient rehabilitation services, a new study from the CDC demonstrates.

People experiencing ongoing or “long-haul” symptoms after COVID-19 illness were more likely to report pain, challenges with physical activities, and “substantially worse health,” compared with people needing rehabilitation because of cancer, lead author Jessica Rogers-Brown, PhD, and colleagues report.

The study was published online July 9 in Morbidity and Mortality Weekly Report (MMWR).

The CDC investigators compared the self-reported physical and mental health symptoms, physical endurance, and use of health services of 1,295 outpatients recovering from COVID-19 and a control group of another 2,395 outpatients rehabilitating from a previous or current cancer diagnosis who had not experienced COVID-19.

Researchers used electronic health record data from January 2020 to March 2021 in the Select Medical network of outpatient clinics. The study included patients from 36 states and the District of Columbia.

Compared with people referred for cancer rehabilitation, those with COVID-19 symptoms lasting beyond 4 weeks were 2.3 times more likely to report pain, 1.8 times more likely to report worse physical health, and 1.6 times more likely to report difficulty with physical activities, an adjusted odds ratio analysis reveals.

The COVID-19 rehabilitation group also performed significantly worse on a 6-minute walk test, suggesting less physical endurance than people recovering from cancer (P < .001). They also used more rehabilitation services overall than the control group.

The researchers suggest services tailored to the unique physical and mental health rehabilitation needs of the post–COVID-19 patient population could be warranted.

The study does not suggest all people recovering with COVID-19 will fare worse than people recovering from cancer, the authors caution. They note that “these results should not be interpreted to mean that post–COVID-19 patients overall had poorer physical and mental health than patients with cancer.”

“Instead, results indicate that post–COVID-19 patients specifically referred to a large physical rehabilitation network had poorer health measures than those referred for cancer, which indicates that some patients recovering from COVID-19 had substantial rehabilitation needs.”

A version of this article first appeared on Medscape.com.

Some people recovering from COVID-19 fare worse than current or previous cancer patients when referred to outpatient rehabilitation services, a new study from the CDC demonstrates.

People experiencing ongoing or “long-haul” symptoms after COVID-19 illness were more likely to report pain, challenges with physical activities, and “substantially worse health,” compared with people needing rehabilitation because of cancer, lead author Jessica Rogers-Brown, PhD, and colleagues report.

The study was published online July 9 in Morbidity and Mortality Weekly Report (MMWR).

The CDC investigators compared the self-reported physical and mental health symptoms, physical endurance, and use of health services of 1,295 outpatients recovering from COVID-19 and a control group of another 2,395 outpatients rehabilitating from a previous or current cancer diagnosis who had not experienced COVID-19.

Researchers used electronic health record data from January 2020 to March 2021 in the Select Medical network of outpatient clinics. The study included patients from 36 states and the District of Columbia.

Compared with people referred for cancer rehabilitation, those with COVID-19 symptoms lasting beyond 4 weeks were 2.3 times more likely to report pain, 1.8 times more likely to report worse physical health, and 1.6 times more likely to report difficulty with physical activities, an adjusted odds ratio analysis reveals.

The COVID-19 rehabilitation group also performed significantly worse on a 6-minute walk test, suggesting less physical endurance than people recovering from cancer (P < .001). They also used more rehabilitation services overall than the control group.

The researchers suggest services tailored to the unique physical and mental health rehabilitation needs of the post–COVID-19 patient population could be warranted.

The study does not suggest all people recovering with COVID-19 will fare worse than people recovering from cancer, the authors caution. They note that “these results should not be interpreted to mean that post–COVID-19 patients overall had poorer physical and mental health than patients with cancer.”

“Instead, results indicate that post–COVID-19 patients specifically referred to a large physical rehabilitation network had poorer health measures than those referred for cancer, which indicates that some patients recovering from COVID-19 had substantial rehabilitation needs.”

A version of this article first appeared on Medscape.com.

Some people recovering from COVID-19 fare worse than current or previous cancer patients when referred to outpatient rehabilitation services, a new study from the CDC demonstrates.

People experiencing ongoing or “long-haul” symptoms after COVID-19 illness were more likely to report pain, challenges with physical activities, and “substantially worse health,” compared with people needing rehabilitation because of cancer, lead author Jessica Rogers-Brown, PhD, and colleagues report.

The study was published online July 9 in Morbidity and Mortality Weekly Report (MMWR).

The CDC investigators compared the self-reported physical and mental health symptoms, physical endurance, and use of health services of 1,295 outpatients recovering from COVID-19 and a control group of another 2,395 outpatients rehabilitating from a previous or current cancer diagnosis who had not experienced COVID-19.

Researchers used electronic health record data from January 2020 to March 2021 in the Select Medical network of outpatient clinics. The study included patients from 36 states and the District of Columbia.

Compared with people referred for cancer rehabilitation, those with COVID-19 symptoms lasting beyond 4 weeks were 2.3 times more likely to report pain, 1.8 times more likely to report worse physical health, and 1.6 times more likely to report difficulty with physical activities, an adjusted odds ratio analysis reveals.

The COVID-19 rehabilitation group also performed significantly worse on a 6-minute walk test, suggesting less physical endurance than people recovering from cancer (P < .001). They also used more rehabilitation services overall than the control group.

The researchers suggest services tailored to the unique physical and mental health rehabilitation needs of the post–COVID-19 patient population could be warranted.

The study does not suggest all people recovering with COVID-19 will fare worse than people recovering from cancer, the authors caution. They note that “these results should not be interpreted to mean that post–COVID-19 patients overall had poorer physical and mental health than patients with cancer.”

“Instead, results indicate that post–COVID-19 patients specifically referred to a large physical rehabilitation network had poorer health measures than those referred for cancer, which indicates that some patients recovering from COVID-19 had substantial rehabilitation needs.”

A version of this article first appeared on Medscape.com.

The reported prevalence and severity of obstructive sleep apnea in women is lower, compared with men, but the consequences of the disease are “at least the same, if not worse,” with women appearing to have greater susceptibility to adverse OSA-related cardiovascular consequences – particularly as it pertains to endothelial dysfunction, Reena Mehra, MD, MS, said at the virtual annual meeting of the Associated Professional Sleep Societies.

Women more so than men have endothelial dysfunction associated with OSA, “suggesting there is an enhanced sensitivity of the female vascular endothelium to intermittent hypoxia,” said Dr. Mehra, director of sleep disorders research at the Cleveland Clinic and professor of medicine at Case Western Reserve University, also in Cleveland.

Sex-specific differences in the anatomic and physiological characteristics of the upper airway, in fat distribution and in respiratory stability as they relate to OSA have been documented for some time – and today, these and other differences relating to the diagnosis, treatment, and consequences of sleep apnea continue to be studied and elucidated, said Dr. Mehra, Anita Rajagopal, MD, and Chitra Lal, MD, in a session on OSA in women. Each spoke about the breath and implications of these differences, and of increasing recognition of the significance of OSA in women.
 

Likely underdiagnosis

Epidemiologic studies have suggested a three- to fivefold higher prevalence of OSA in men than in women in the general population. But it has also been estimated that 17%-25% of women have sleep apnea, and the prevalence reported in various studies has generally increased with time, said Dr. Rajagopal, department medical director for sleep medicine at Community Physician Network in Indianapolis, and medical director of the Community Health Network Sleep/Wake Disorders Center, also in Indianapolis.

One population-based study in Sweden, reported in 2013, found OSA (defined as an apnea-hypopnea index [AHI] ≥5) in 50% of women aged 20-70, she noted.

It’s quite possible women are being misdiagnosed or underdiagnosed because of their reporting of different symptoms, Dr. Rajagopal said. The Epworth Sleepiness Scale, commonly used to screen for OSA, has not been validated for use in women and has not been strongly associated with daytime sleepiness in women in population-based studies, she said, noting that women who report similar levels of daytime sleepiness to men are less likely to have an ESS score greater than 10.

“We shouldn’t rule out obstructive sleep apnea in women with a low ESS,” Dr. Rajagopal said in an interview after the meeting. Attentiveness to the symptoms more often reported by women – generalized daytime fatigue/lack of energy, insomnia, morning headaches, mood disturbances, and nightmares – is important, as is performance of overnight polysomnography when a home sleep study is negative and there is clinical suspicion of OSA.Respiratory disturbances in women are frequently associated with arousals – which induce less ventilatory instability in women than in men – rather than oxygen desaturations, leading to underestimation of OSA on home sleep testing. Insomnia associated with OSA in women may also increase the likelihood of a false negative result, Dr. Rajagopal said at the meeting.

“It’s really important [in sleep testing] to consider your AHI values in women,” she said. “The AHI value may not provide a true indication of the degree of sleep fragmentation being experienced by patients.” That OSA symptoms manifest in women with lower AHIs has been elucidated in research showing, for instance, that those with an AHI of 2-5 per hour have a similar level of symptoms to men with an AHI of at least 15 per hour, she said.

Women tend to have a clustering of apnea during REM sleep, and it’s possible that “the long-term effects of REM disruption contribute to greater symptomatology at lower AHI values in women compared to men,” Dr. Rajagopal said.

Also at play are when it comes to testing and diagnosis are several other key sex differences, she said. For one, the upper airways in women are less collapsible and more stable during sleep (most evident during non-REM sleep), and respiratory events during sleep are less frequently associated with complete upper airway collapse.

Women also have shorter apneic episodes, but “the longest apneas are associated with a more severe oxygen desaturation,” she said. Moreover, they have more episodes of upper airway resistance during sleep, which in and of itself “has been shown to produce clinical symptoms such as daytime fatigue and clinical depression.”

In her presentation, Dr. Mehra similarly commented on a likely underdiagnosis of OSA in women. In addition to differing symptoms, including palpitations, “women are less likely to have arousals, and have a lesser degree of nocturnal hypoxia compared to men ... perhaps leading to even more of an underdiagnosis.”
 

Unique consequences

Differences in upper airway physiology and other sex-specific differences impacting OSA susceptibility are at least partly attributable to sex hormones, said Dr. Mehra and Dr. Lal, associate professor of medicine at the Medical University of South Carolina, Charleston.

A significant increase in prevalence is seen after menopause, and research has shown that each additional year in menopause is associated with a greater AHI – a “dose-response effect,” Dr. Lal said. An inverse association between hormone replacement therapy and OSA severity has been seen in epidemiological studies including the Sleep Heart Health Study, Dr. Mehra said. But in prospective studies, Dr. Lal noted, hormone replacement therapy has not been shown to decrease AHI.

Experimental and clinical studies suggest that the vascular endothelium is influenced by sex hormones, Dr. Mehra said. Estrogen is known to improve endothelial function by inducing increased nitric oxide bioavailability – important in the setting of hypoxemia, which leads to reduced bioavailability of nitric oxide. “Alterations of sex-specific hormones in OSA may represent a key factor in increasing vulnerability to vascular dysfunction,” Dr. Mehra added.

The Sleep Heart Health Study also documented sex-specific differences, showing a graded increase of troponin with increasing OSA severity category as well as an increase in left ventricular mass thickness, and a 30% increased risk of heart failure or death in women with moderate/severe OSA, compared with women without OSA or with mild OSA, Dr. Mehra said. These findings were not observed in men.

The dominance of REM-related OSA in women raises risk because sleep disturbances during REM sleep are associated with adverse cardiometabolic outcomes including prevalent and incident hypertension, Dr. Mehra noted. “REM-related OSA may also adversely impact glucose metabolism,” she said, “even in the absence of non-REM obstructive sleep apnea.”

Regarding OSA treatment and responsivity, Dr. Mehra said that preliminary, post hoc data from a randomized, controlled trial of the impact of continuous positive airway pressure (CPAP) therapy on cardiovascular biomarkers showed a sex-specific effect. “There were differences in men versus women in terms of responsiveness with regards to biomarkers of inflammation and oxidative stress ... with reductions from CPAP observed in women but not in men,” said Dr. Mehra, a co-investigator of the study.

The data suggests, she said that “these biomarkers may be more responsive to treatment and a reversal of sleep apnea pathophysiology in women.”

Women also appear to respond better than men to upper airway nerve stimulation (UAS), she said, referring to an international registry study showing a 3.6-fold higher odds of responsiveness to the therapy relative to men. Women in the study were 60% less likely to be approved by insurance for UAS, however, making it “a public policy issue, said Dr. Mehra, a coinvestigator.

Dr. Rajagopal, Dr. Mehra, and Dr. Lal all reported that they had no potential conflicts of interest.

The reported prevalence and severity of obstructive sleep apnea in women is lower, compared with men, but the consequences of the disease are “at least the same, if not worse,” with women appearing to have greater susceptibility to adverse OSA-related cardiovascular consequences – particularly as it pertains to endothelial dysfunction, Reena Mehra, MD, MS, said at the virtual annual meeting of the Associated Professional Sleep Societies.

Women more so than men have endothelial dysfunction associated with OSA, “suggesting there is an enhanced sensitivity of the female vascular endothelium to intermittent hypoxia,” said Dr. Mehra, director of sleep disorders research at the Cleveland Clinic and professor of medicine at Case Western Reserve University, also in Cleveland.

Sex-specific differences in the anatomic and physiological characteristics of the upper airway, in fat distribution and in respiratory stability as they relate to OSA have been documented for some time – and today, these and other differences relating to the diagnosis, treatment, and consequences of sleep apnea continue to be studied and elucidated, said Dr. Mehra, Anita Rajagopal, MD, and Chitra Lal, MD, in a session on OSA in women. Each spoke about the breath and implications of these differences, and of increasing recognition of the significance of OSA in women.
 

Likely underdiagnosis

Epidemiologic studies have suggested a three- to fivefold higher prevalence of OSA in men than in women in the general population. But it has also been estimated that 17%-25% of women have sleep apnea, and the prevalence reported in various studies has generally increased with time, said Dr. Rajagopal, department medical director for sleep medicine at Community Physician Network in Indianapolis, and medical director of the Community Health Network Sleep/Wake Disorders Center, also in Indianapolis.

One population-based study in Sweden, reported in 2013, found OSA (defined as an apnea-hypopnea index [AHI] ≥5) in 50% of women aged 20-70, she noted.

It’s quite possible women are being misdiagnosed or underdiagnosed because of their reporting of different symptoms, Dr. Rajagopal said. The Epworth Sleepiness Scale, commonly used to screen for OSA, has not been validated for use in women and has not been strongly associated with daytime sleepiness in women in population-based studies, she said, noting that women who report similar levels of daytime sleepiness to men are less likely to have an ESS score greater than 10.

“We shouldn’t rule out obstructive sleep apnea in women with a low ESS,” Dr. Rajagopal said in an interview after the meeting. Attentiveness to the symptoms more often reported by women – generalized daytime fatigue/lack of energy, insomnia, morning headaches, mood disturbances, and nightmares – is important, as is performance of overnight polysomnography when a home sleep study is negative and there is clinical suspicion of OSA.Respiratory disturbances in women are frequently associated with arousals – which induce less ventilatory instability in women than in men – rather than oxygen desaturations, leading to underestimation of OSA on home sleep testing. Insomnia associated with OSA in women may also increase the likelihood of a false negative result, Dr. Rajagopal said at the meeting.

“It’s really important [in sleep testing] to consider your AHI values in women,” she said. “The AHI value may not provide a true indication of the degree of sleep fragmentation being experienced by patients.” That OSA symptoms manifest in women with lower AHIs has been elucidated in research showing, for instance, that those with an AHI of 2-5 per hour have a similar level of symptoms to men with an AHI of at least 15 per hour, she said.

Women tend to have a clustering of apnea during REM sleep, and it’s possible that “the long-term effects of REM disruption contribute to greater symptomatology at lower AHI values in women compared to men,” Dr. Rajagopal said.

Also at play are when it comes to testing and diagnosis are several other key sex differences, she said. For one, the upper airways in women are less collapsible and more stable during sleep (most evident during non-REM sleep), and respiratory events during sleep are less frequently associated with complete upper airway collapse.

Women also have shorter apneic episodes, but “the longest apneas are associated with a more severe oxygen desaturation,” she said. Moreover, they have more episodes of upper airway resistance during sleep, which in and of itself “has been shown to produce clinical symptoms such as daytime fatigue and clinical depression.”

In her presentation, Dr. Mehra similarly commented on a likely underdiagnosis of OSA in women. In addition to differing symptoms, including palpitations, “women are less likely to have arousals, and have a lesser degree of nocturnal hypoxia compared to men ... perhaps leading to even more of an underdiagnosis.”
 

Unique consequences

Differences in upper airway physiology and other sex-specific differences impacting OSA susceptibility are at least partly attributable to sex hormones, said Dr. Mehra and Dr. Lal, associate professor of medicine at the Medical University of South Carolina, Charleston.

A significant increase in prevalence is seen after menopause, and research has shown that each additional year in menopause is associated with a greater AHI – a “dose-response effect,” Dr. Lal said. An inverse association between hormone replacement therapy and OSA severity has been seen in epidemiological studies including the Sleep Heart Health Study, Dr. Mehra said. But in prospective studies, Dr. Lal noted, hormone replacement therapy has not been shown to decrease AHI.

Experimental and clinical studies suggest that the vascular endothelium is influenced by sex hormones, Dr. Mehra said. Estrogen is known to improve endothelial function by inducing increased nitric oxide bioavailability – important in the setting of hypoxemia, which leads to reduced bioavailability of nitric oxide. “Alterations of sex-specific hormones in OSA may represent a key factor in increasing vulnerability to vascular dysfunction,” Dr. Mehra added.

The Sleep Heart Health Study also documented sex-specific differences, showing a graded increase of troponin with increasing OSA severity category as well as an increase in left ventricular mass thickness, and a 30% increased risk of heart failure or death in women with moderate/severe OSA, compared with women without OSA or with mild OSA, Dr. Mehra said. These findings were not observed in men.

The dominance of REM-related OSA in women raises risk because sleep disturbances during REM sleep are associated with adverse cardiometabolic outcomes including prevalent and incident hypertension, Dr. Mehra noted. “REM-related OSA may also adversely impact glucose metabolism,” she said, “even in the absence of non-REM obstructive sleep apnea.”

Regarding OSA treatment and responsivity, Dr. Mehra said that preliminary, post hoc data from a randomized, controlled trial of the impact of continuous positive airway pressure (CPAP) therapy on cardiovascular biomarkers showed a sex-specific effect. “There were differences in men versus women in terms of responsiveness with regards to biomarkers of inflammation and oxidative stress ... with reductions from CPAP observed in women but not in men,” said Dr. Mehra, a co-investigator of the study.

The data suggests, she said that “these biomarkers may be more responsive to treatment and a reversal of sleep apnea pathophysiology in women.”

Women also appear to respond better than men to upper airway nerve stimulation (UAS), she said, referring to an international registry study showing a 3.6-fold higher odds of responsiveness to the therapy relative to men. Women in the study were 60% less likely to be approved by insurance for UAS, however, making it “a public policy issue, said Dr. Mehra, a coinvestigator.

Dr. Rajagopal, Dr. Mehra, and Dr. Lal all reported that they had no potential conflicts of interest.

The reported prevalence and severity of obstructive sleep apnea in women is lower, compared with men, but the consequences of the disease are “at least the same, if not worse,” with women appearing to have greater susceptibility to adverse OSA-related cardiovascular consequences – particularly as it pertains to endothelial dysfunction, Reena Mehra, MD, MS, said at the virtual annual meeting of the Associated Professional Sleep Societies.

Women more so than men have endothelial dysfunction associated with OSA, “suggesting there is an enhanced sensitivity of the female vascular endothelium to intermittent hypoxia,” said Dr. Mehra, director of sleep disorders research at the Cleveland Clinic and professor of medicine at Case Western Reserve University, also in Cleveland.

Sex-specific differences in the anatomic and physiological characteristics of the upper airway, in fat distribution and in respiratory stability as they relate to OSA have been documented for some time – and today, these and other differences relating to the diagnosis, treatment, and consequences of sleep apnea continue to be studied and elucidated, said Dr. Mehra, Anita Rajagopal, MD, and Chitra Lal, MD, in a session on OSA in women. Each spoke about the breath and implications of these differences, and of increasing recognition of the significance of OSA in women.
 

Likely underdiagnosis

Epidemiologic studies have suggested a three- to fivefold higher prevalence of OSA in men than in women in the general population. But it has also been estimated that 17%-25% of women have sleep apnea, and the prevalence reported in various studies has generally increased with time, said Dr. Rajagopal, department medical director for sleep medicine at Community Physician Network in Indianapolis, and medical director of the Community Health Network Sleep/Wake Disorders Center, also in Indianapolis.

One population-based study in Sweden, reported in 2013, found OSA (defined as an apnea-hypopnea index [AHI] ≥5) in 50% of women aged 20-70, she noted.

It’s quite possible women are being misdiagnosed or underdiagnosed because of their reporting of different symptoms, Dr. Rajagopal said. The Epworth Sleepiness Scale, commonly used to screen for OSA, has not been validated for use in women and has not been strongly associated with daytime sleepiness in women in population-based studies, she said, noting that women who report similar levels of daytime sleepiness to men are less likely to have an ESS score greater than 10.

“We shouldn’t rule out obstructive sleep apnea in women with a low ESS,” Dr. Rajagopal said in an interview after the meeting. Attentiveness to the symptoms more often reported by women – generalized daytime fatigue/lack of energy, insomnia, morning headaches, mood disturbances, and nightmares – is important, as is performance of overnight polysomnography when a home sleep study is negative and there is clinical suspicion of OSA.Respiratory disturbances in women are frequently associated with arousals – which induce less ventilatory instability in women than in men – rather than oxygen desaturations, leading to underestimation of OSA on home sleep testing. Insomnia associated with OSA in women may also increase the likelihood of a false negative result, Dr. Rajagopal said at the meeting.

“It’s really important [in sleep testing] to consider your AHI values in women,” she said. “The AHI value may not provide a true indication of the degree of sleep fragmentation being experienced by patients.” That OSA symptoms manifest in women with lower AHIs has been elucidated in research showing, for instance, that those with an AHI of 2-5 per hour have a similar level of symptoms to men with an AHI of at least 15 per hour, she said.

Women tend to have a clustering of apnea during REM sleep, and it’s possible that “the long-term effects of REM disruption contribute to greater symptomatology at lower AHI values in women compared to men,” Dr. Rajagopal said.

Also at play are when it comes to testing and diagnosis are several other key sex differences, she said. For one, the upper airways in women are less collapsible and more stable during sleep (most evident during non-REM sleep), and respiratory events during sleep are less frequently associated with complete upper airway collapse.

Women also have shorter apneic episodes, but “the longest apneas are associated with a more severe oxygen desaturation,” she said. Moreover, they have more episodes of upper airway resistance during sleep, which in and of itself “has been shown to produce clinical symptoms such as daytime fatigue and clinical depression.”

In her presentation, Dr. Mehra similarly commented on a likely underdiagnosis of OSA in women. In addition to differing symptoms, including palpitations, “women are less likely to have arousals, and have a lesser degree of nocturnal hypoxia compared to men ... perhaps leading to even more of an underdiagnosis.”
 

Unique consequences

Differences in upper airway physiology and other sex-specific differences impacting OSA susceptibility are at least partly attributable to sex hormones, said Dr. Mehra and Dr. Lal, associate professor of medicine at the Medical University of South Carolina, Charleston.

A significant increase in prevalence is seen after menopause, and research has shown that each additional year in menopause is associated with a greater AHI – a “dose-response effect,” Dr. Lal said. An inverse association between hormone replacement therapy and OSA severity has been seen in epidemiological studies including the Sleep Heart Health Study, Dr. Mehra said. But in prospective studies, Dr. Lal noted, hormone replacement therapy has not been shown to decrease AHI.

Experimental and clinical studies suggest that the vascular endothelium is influenced by sex hormones, Dr. Mehra said. Estrogen is known to improve endothelial function by inducing increased nitric oxide bioavailability – important in the setting of hypoxemia, which leads to reduced bioavailability of nitric oxide. “Alterations of sex-specific hormones in OSA may represent a key factor in increasing vulnerability to vascular dysfunction,” Dr. Mehra added.

The Sleep Heart Health Study also documented sex-specific differences, showing a graded increase of troponin with increasing OSA severity category as well as an increase in left ventricular mass thickness, and a 30% increased risk of heart failure or death in women with moderate/severe OSA, compared with women without OSA or with mild OSA, Dr. Mehra said. These findings were not observed in men.

The dominance of REM-related OSA in women raises risk because sleep disturbances during REM sleep are associated with adverse cardiometabolic outcomes including prevalent and incident hypertension, Dr. Mehra noted. “REM-related OSA may also adversely impact glucose metabolism,” she said, “even in the absence of non-REM obstructive sleep apnea.”

Regarding OSA treatment and responsivity, Dr. Mehra said that preliminary, post hoc data from a randomized, controlled trial of the impact of continuous positive airway pressure (CPAP) therapy on cardiovascular biomarkers showed a sex-specific effect. “There were differences in men versus women in terms of responsiveness with regards to biomarkers of inflammation and oxidative stress ... with reductions from CPAP observed in women but not in men,” said Dr. Mehra, a co-investigator of the study.

The data suggests, she said that “these biomarkers may be more responsive to treatment and a reversal of sleep apnea pathophysiology in women.”

Women also appear to respond better than men to upper airway nerve stimulation (UAS), she said, referring to an international registry study showing a 3.6-fold higher odds of responsiveness to the therapy relative to men. Women in the study were 60% less likely to be approved by insurance for UAS, however, making it “a public policy issue, said Dr. Mehra, a coinvestigator.

Dr. Rajagopal, Dr. Mehra, and Dr. Lal all reported that they had no potential conflicts of interest.

People infected with SARS-CoV-2 can experience lingering physiologic effects after they recover, according to early data from an ongoing study that is harnessing the power of Fitbits and other wearable trackers to gauge long-term effects of COVID-19.

“To our knowledge, this is the first study to examine longer duration wearable sensor data. We found a prolonged physiological impact of COVID-19 infection, lasting approximately 2-3 months, on average, but with substantial intra-individual variability,” report Jennifer Radin, PhD, MPH, and colleagues with the Scripps Research Translational Institute, San Diego.

The study was published online July 7 in JAMA Network Open.

The DETECT study is enrolling adults from all over the United States and is collecting their health data from different wearable devices to better understand changes associated with viral illness, including COVID-19.

The current analysis focuses on a subset of 875 device wearers who reported symptoms of an acute respiratory illness and underwent testing for SARS-CoV-2. A total of 234 individuals tested positive for SARS-CoV-2; 641 were presumed to have other viral infections (COVID-19-negative symptomatic individuals).

The investigators found that among people with COVID-19, it took longer to return to baseline status with respect to resting heart rate (RHR), sleep, and activity compared with those who had symptoms of viral illness but who did not have COVID-19.

“This difference was most marked for RHR, with COVID-19-positive individuals initially experiencing a transient bradycardia followed by a prolonged relative tachycardia that did not return to baseline, on average, until 79 days after symptom onset,” Dr. Radin and colleagues reported.

Step count and sleep quantity returned to baseline values sooner than RHR, at 32 days and 24 days, respectively.

Among people with COVID-19, during recovery, trajectories differed with respect to return of RHR to normal in comparison with persons who did not have COVID-19.

The RHR of 32 COVID-19–positive participants (13.7%) remained 5 beats/min greater than their baseline RHR for more than 133 days, on average. During the acute phase of COVID-19, these individuals were more apt to report cough, body ache, and shortness of breath compared with other groups.
 

Limitation

The researchers say a limitation of this analysis is that symptom data were collected only during the acute phase of infection, which limits the ability to compare long-term physiologic and behavioral changes with long-term symptoms.

“In the future, with larger sample sizes and more comprehensive participant-reported outcomes, it will be possible to better understand factors associated with inter-individualized variability in COVID-19 recovery,” they concluded.

Earlier data from the DETECT study showed that pairing wearable tracker data with self-reported symptoms can improve COVID-19 prediction.

As previously reported by this news organization, DETECT investigators found that associating participant-reported symptoms with personal sensor data, such as deviation from normal sleep duration and RHR, resulted in an area under the curve of 0.80 for differentiating between symptomatic individuals who were positive and those who were negative for COVID-19.

Funding for the current study was provided by a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

People infected with SARS-CoV-2 can experience lingering physiologic effects after they recover, according to early data from an ongoing study that is harnessing the power of Fitbits and other wearable trackers to gauge long-term effects of COVID-19.

“To our knowledge, this is the first study to examine longer duration wearable sensor data. We found a prolonged physiological impact of COVID-19 infection, lasting approximately 2-3 months, on average, but with substantial intra-individual variability,” report Jennifer Radin, PhD, MPH, and colleagues with the Scripps Research Translational Institute, San Diego.

The study was published online July 7 in JAMA Network Open.

The DETECT study is enrolling adults from all over the United States and is collecting their health data from different wearable devices to better understand changes associated with viral illness, including COVID-19.

The current analysis focuses on a subset of 875 device wearers who reported symptoms of an acute respiratory illness and underwent testing for SARS-CoV-2. A total of 234 individuals tested positive for SARS-CoV-2; 641 were presumed to have other viral infections (COVID-19-negative symptomatic individuals).

The investigators found that among people with COVID-19, it took longer to return to baseline status with respect to resting heart rate (RHR), sleep, and activity compared with those who had symptoms of viral illness but who did not have COVID-19.

“This difference was most marked for RHR, with COVID-19-positive individuals initially experiencing a transient bradycardia followed by a prolonged relative tachycardia that did not return to baseline, on average, until 79 days after symptom onset,” Dr. Radin and colleagues reported.

Step count and sleep quantity returned to baseline values sooner than RHR, at 32 days and 24 days, respectively.

Among people with COVID-19, during recovery, trajectories differed with respect to return of RHR to normal in comparison with persons who did not have COVID-19.

The RHR of 32 COVID-19–positive participants (13.7%) remained 5 beats/min greater than their baseline RHR for more than 133 days, on average. During the acute phase of COVID-19, these individuals were more apt to report cough, body ache, and shortness of breath compared with other groups.
 

Limitation

The researchers say a limitation of this analysis is that symptom data were collected only during the acute phase of infection, which limits the ability to compare long-term physiologic and behavioral changes with long-term symptoms.

“In the future, with larger sample sizes and more comprehensive participant-reported outcomes, it will be possible to better understand factors associated with inter-individualized variability in COVID-19 recovery,” they concluded.

Earlier data from the DETECT study showed that pairing wearable tracker data with self-reported symptoms can improve COVID-19 prediction.

As previously reported by this news organization, DETECT investigators found that associating participant-reported symptoms with personal sensor data, such as deviation from normal sleep duration and RHR, resulted in an area under the curve of 0.80 for differentiating between symptomatic individuals who were positive and those who were negative for COVID-19.

Funding for the current study was provided by a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

People infected with SARS-CoV-2 can experience lingering physiologic effects after they recover, according to early data from an ongoing study that is harnessing the power of Fitbits and other wearable trackers to gauge long-term effects of COVID-19.

“To our knowledge, this is the first study to examine longer duration wearable sensor data. We found a prolonged physiological impact of COVID-19 infection, lasting approximately 2-3 months, on average, but with substantial intra-individual variability,” report Jennifer Radin, PhD, MPH, and colleagues with the Scripps Research Translational Institute, San Diego.

The study was published online July 7 in JAMA Network Open.

The DETECT study is enrolling adults from all over the United States and is collecting their health data from different wearable devices to better understand changes associated with viral illness, including COVID-19.

The current analysis focuses on a subset of 875 device wearers who reported symptoms of an acute respiratory illness and underwent testing for SARS-CoV-2. A total of 234 individuals tested positive for SARS-CoV-2; 641 were presumed to have other viral infections (COVID-19-negative symptomatic individuals).

The investigators found that among people with COVID-19, it took longer to return to baseline status with respect to resting heart rate (RHR), sleep, and activity compared with those who had symptoms of viral illness but who did not have COVID-19.

“This difference was most marked for RHR, with COVID-19-positive individuals initially experiencing a transient bradycardia followed by a prolonged relative tachycardia that did not return to baseline, on average, until 79 days after symptom onset,” Dr. Radin and colleagues reported.

Step count and sleep quantity returned to baseline values sooner than RHR, at 32 days and 24 days, respectively.

Among people with COVID-19, during recovery, trajectories differed with respect to return of RHR to normal in comparison with persons who did not have COVID-19.

The RHR of 32 COVID-19–positive participants (13.7%) remained 5 beats/min greater than their baseline RHR for more than 133 days, on average. During the acute phase of COVID-19, these individuals were more apt to report cough, body ache, and shortness of breath compared with other groups.
 

Limitation

The researchers say a limitation of this analysis is that symptom data were collected only during the acute phase of infection, which limits the ability to compare long-term physiologic and behavioral changes with long-term symptoms.

“In the future, with larger sample sizes and more comprehensive participant-reported outcomes, it will be possible to better understand factors associated with inter-individualized variability in COVID-19 recovery,” they concluded.

Earlier data from the DETECT study showed that pairing wearable tracker data with self-reported symptoms can improve COVID-19 prediction.

As previously reported by this news organization, DETECT investigators found that associating participant-reported symptoms with personal sensor data, such as deviation from normal sleep duration and RHR, resulted in an area under the curve of 0.80 for differentiating between symptomatic individuals who were positive and those who were negative for COVID-19.

Funding for the current study was provided by a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Adults with limited English skills receive far less health care than do those proficient in English, according to a new study in Health Affairs.

Jessica Himmelstein, MD, a Harvard research fellow and primary care physician at Cambridge Health Alliance in Cambridge, Mass., led a study of more than 120,000 adults published July 6, 2021. The study population included 17,776 Hispanic adults with limited English proficiency, 14,936 Hispanic adults proficient in English and 87,834 non-Hispanic, English-proficient adults.

Researchers compared several measures of care usage from information in the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey from 1998 to 2018.

They found that, in adjusted analyses, total use of care per capita from 2014-2018, measured by health care expenditures, was $1,463 lower (98% confidence interval, $1,030-$1,897), or 35% lower for primary-Spanish speakers than for Hispanic adults who were English proficient and $2,802 lower (98% CI, $2,356-$3,247), or 42% lower versus non-Hispanic adults who were English proficient.

Spanish speakers also had 36% fewer outpatient visits and 48% fewer prescription medications than non-Hispanic adults, and 35% fewer outpatient visits and 37% fewer prescription medications than English-proficient Hispanic adults.

Even when accounting for differences in health, age, sex, income and insurance, adults with language barriers fared worse.
 

Gaps span all types of care

The services that those with limited English skills are missing are “the types of care people need to lead a healthy life,” from routine visits and medications to urgent or emergency care, Dr. Himmelstein said in an interview.

She said the gaps were greater in outpatient care and in medication use, compared with emergency department visits and inpatient care, but the inequities were present in all the categories she and her coinvestigators studied.

Underlying causes for having less care may include that people who struggle with English may not feel comfortable accessing the health system or may feel unwelcome or discriminated against.

“An undercurrent of biases, including racism, could also be contributing,” she said.

The data show that, despite several federal policy changes aimed at promoting language services in hospitals and clinics, several language-based disparities have not improved over 2 decades.

Some of the changes have included an executive order in 2000 requiring interpreters to be available in federally funded health facilities. In 2010, the Affordable Care Act enhanced the definition of meaningful access to language services and setting standards for qualified interpreters.
 

Gap widened over 2 decades

The adjusted gap in annual health care expenditures per capita between adults with limited English skills and non-Hispanic, English-proficient adults widened by $1,596 (98% CI, $837-$2,356) between 1999-2000 and 2017-2018, after accounting for inflation.

Dr. Himmelstein said that though this study period predated COVID-19, its findings may help explain the disproportionate burden the pandemic placed on the Hispanic population.

“This is a community that traditionally wasn’t getting access to care and then suddenly something like COVID-19 comes and they were even more devastated,” she noted.

Telehealth, which proved an important way to access care during the pandemic, also added a degree of communication difficulty for those with fewer English skills, she said.

Many of the telehealth changes are here to stay, and it will be important to ask: “Are we ensuring equity in telehealth use for individuals who face language barriers?” Dr. Himmelstein said.

Olga Garcia-Bedoya, MD, an associate professor at University of Illinois at Chicago’s department of medicine and medical director of UIC’s Institute for Minority Health Research, said having access to interpreters with high accuracy is key to narrowing the gaps.

“The literature is very clear that access to professional medical interpreters is associated with decreased health disparities for patients with limited English proficiency,” she said.

More cultural training for clinicians is needed surrounding beliefs about illness and that some care may be declined not because of a person’s limited English proficiency, but because their beliefs may keep them from getting care, Dr. Garcia-Bedoya added. When it comes to getting a flu shot, for example, sometimes belief systems, rather than English proficiency, keep people from accessing care.
 

What can be done?

Addressing barriers caused by lack of English proficiency will likely take change in policies, including one related reimbursement for medical interpreters, Dr. Himmelstein said.

Currently, only 15 states’ Medicaid programs or Children’s Health Insurance Programs reimburse providers for language services, the paper notes, and neither Medicare nor private insurers routinely pay for those services.

Recruiting bilingual providers and staff at health care facilities and in medical and nursing schools will also be important to narrow the gaps, Dr. Himmelstein said.

Strengthening standards for interpreters also will help. “Currently such standards vary by state or by institution and are not necessarily enforced,” she explained.

It will also be important to make sure patients know that they are entitled by law to care, free of discriminatory practices and to have certain language services including qualified interpreters, Dr. Himmelstein said.

Dr. Garcia-Bedoya said changes need to come from health systems working in combination with clinicians, providing resources so that quality interpreters can be accessed and making sure that equipment supports clear communication in telehealth. Patients’ language preferences should also be noted as soon as they make the appointment.

The findings of the study may have large significance as one in seven people in the United States speak Spanish at home, and 25 million people in the United States have limited English proficiency, the authors noted.

Dr. Himmelstein receives funding support from an Institutional National Research Service Award. Dr. Garcia-Bedoya reports no relevant financial relationships.

Adults with limited English skills receive far less health care than do those proficient in English, according to a new study in Health Affairs.

Jessica Himmelstein, MD, a Harvard research fellow and primary care physician at Cambridge Health Alliance in Cambridge, Mass., led a study of more than 120,000 adults published July 6, 2021. The study population included 17,776 Hispanic adults with limited English proficiency, 14,936 Hispanic adults proficient in English and 87,834 non-Hispanic, English-proficient adults.

Researchers compared several measures of care usage from information in the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey from 1998 to 2018.

They found that, in adjusted analyses, total use of care per capita from 2014-2018, measured by health care expenditures, was $1,463 lower (98% confidence interval, $1,030-$1,897), or 35% lower for primary-Spanish speakers than for Hispanic adults who were English proficient and $2,802 lower (98% CI, $2,356-$3,247), or 42% lower versus non-Hispanic adults who were English proficient.

Spanish speakers also had 36% fewer outpatient visits and 48% fewer prescription medications than non-Hispanic adults, and 35% fewer outpatient visits and 37% fewer prescription medications than English-proficient Hispanic adults.

Even when accounting for differences in health, age, sex, income and insurance, adults with language barriers fared worse.
 

Gaps span all types of care

The services that those with limited English skills are missing are “the types of care people need to lead a healthy life,” from routine visits and medications to urgent or emergency care, Dr. Himmelstein said in an interview.

She said the gaps were greater in outpatient care and in medication use, compared with emergency department visits and inpatient care, but the inequities were present in all the categories she and her coinvestigators studied.

Underlying causes for having less care may include that people who struggle with English may not feel comfortable accessing the health system or may feel unwelcome or discriminated against.

“An undercurrent of biases, including racism, could also be contributing,” she said.

The data show that, despite several federal policy changes aimed at promoting language services in hospitals and clinics, several language-based disparities have not improved over 2 decades.

Some of the changes have included an executive order in 2000 requiring interpreters to be available in federally funded health facilities. In 2010, the Affordable Care Act enhanced the definition of meaningful access to language services and setting standards for qualified interpreters.
 

Gap widened over 2 decades

The adjusted gap in annual health care expenditures per capita between adults with limited English skills and non-Hispanic, English-proficient adults widened by $1,596 (98% CI, $837-$2,356) between 1999-2000 and 2017-2018, after accounting for inflation.

Dr. Himmelstein said that though this study period predated COVID-19, its findings may help explain the disproportionate burden the pandemic placed on the Hispanic population.

“This is a community that traditionally wasn’t getting access to care and then suddenly something like COVID-19 comes and they were even more devastated,” she noted.

Telehealth, which proved an important way to access care during the pandemic, also added a degree of communication difficulty for those with fewer English skills, she said.

Many of the telehealth changes are here to stay, and it will be important to ask: “Are we ensuring equity in telehealth use for individuals who face language barriers?” Dr. Himmelstein said.

Olga Garcia-Bedoya, MD, an associate professor at University of Illinois at Chicago’s department of medicine and medical director of UIC’s Institute for Minority Health Research, said having access to interpreters with high accuracy is key to narrowing the gaps.

“The literature is very clear that access to professional medical interpreters is associated with decreased health disparities for patients with limited English proficiency,” she said.

More cultural training for clinicians is needed surrounding beliefs about illness and that some care may be declined not because of a person’s limited English proficiency, but because their beliefs may keep them from getting care, Dr. Garcia-Bedoya added. When it comes to getting a flu shot, for example, sometimes belief systems, rather than English proficiency, keep people from accessing care.
 

What can be done?

Addressing barriers caused by lack of English proficiency will likely take change in policies, including one related reimbursement for medical interpreters, Dr. Himmelstein said.

Currently, only 15 states’ Medicaid programs or Children’s Health Insurance Programs reimburse providers for language services, the paper notes, and neither Medicare nor private insurers routinely pay for those services.

Recruiting bilingual providers and staff at health care facilities and in medical and nursing schools will also be important to narrow the gaps, Dr. Himmelstein said.

Strengthening standards for interpreters also will help. “Currently such standards vary by state or by institution and are not necessarily enforced,” she explained.

It will also be important to make sure patients know that they are entitled by law to care, free of discriminatory practices and to have certain language services including qualified interpreters, Dr. Himmelstein said.

Dr. Garcia-Bedoya said changes need to come from health systems working in combination with clinicians, providing resources so that quality interpreters can be accessed and making sure that equipment supports clear communication in telehealth. Patients’ language preferences should also be noted as soon as they make the appointment.

The findings of the study may have large significance as one in seven people in the United States speak Spanish at home, and 25 million people in the United States have limited English proficiency, the authors noted.

Dr. Himmelstein receives funding support from an Institutional National Research Service Award. Dr. Garcia-Bedoya reports no relevant financial relationships.

Adults with limited English skills receive far less health care than do those proficient in English, according to a new study in Health Affairs.

Jessica Himmelstein, MD, a Harvard research fellow and primary care physician at Cambridge Health Alliance in Cambridge, Mass., led a study of more than 120,000 adults published July 6, 2021. The study population included 17,776 Hispanic adults with limited English proficiency, 14,936 Hispanic adults proficient in English and 87,834 non-Hispanic, English-proficient adults.

Researchers compared several measures of care usage from information in the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey from 1998 to 2018.

They found that, in adjusted analyses, total use of care per capita from 2014-2018, measured by health care expenditures, was $1,463 lower (98% confidence interval, $1,030-$1,897), or 35% lower for primary-Spanish speakers than for Hispanic adults who were English proficient and $2,802 lower (98% CI, $2,356-$3,247), or 42% lower versus non-Hispanic adults who were English proficient.

Spanish speakers also had 36% fewer outpatient visits and 48% fewer prescription medications than non-Hispanic adults, and 35% fewer outpatient visits and 37% fewer prescription medications than English-proficient Hispanic adults.

Even when accounting for differences in health, age, sex, income and insurance, adults with language barriers fared worse.
 

Gaps span all types of care

The services that those with limited English skills are missing are “the types of care people need to lead a healthy life,” from routine visits and medications to urgent or emergency care, Dr. Himmelstein said in an interview.

She said the gaps were greater in outpatient care and in medication use, compared with emergency department visits and inpatient care, but the inequities were present in all the categories she and her coinvestigators studied.

Underlying causes for having less care may include that people who struggle with English may not feel comfortable accessing the health system or may feel unwelcome or discriminated against.

“An undercurrent of biases, including racism, could also be contributing,” she said.

The data show that, despite several federal policy changes aimed at promoting language services in hospitals and clinics, several language-based disparities have not improved over 2 decades.

Some of the changes have included an executive order in 2000 requiring interpreters to be available in federally funded health facilities. In 2010, the Affordable Care Act enhanced the definition of meaningful access to language services and setting standards for qualified interpreters.
 

Gap widened over 2 decades

The adjusted gap in annual health care expenditures per capita between adults with limited English skills and non-Hispanic, English-proficient adults widened by $1,596 (98% CI, $837-$2,356) between 1999-2000 and 2017-2018, after accounting for inflation.

Dr. Himmelstein said that though this study period predated COVID-19, its findings may help explain the disproportionate burden the pandemic placed on the Hispanic population.

“This is a community that traditionally wasn’t getting access to care and then suddenly something like COVID-19 comes and they were even more devastated,” she noted.

Telehealth, which proved an important way to access care during the pandemic, also added a degree of communication difficulty for those with fewer English skills, she said.

Many of the telehealth changes are here to stay, and it will be important to ask: “Are we ensuring equity in telehealth use for individuals who face language barriers?” Dr. Himmelstein said.

Olga Garcia-Bedoya, MD, an associate professor at University of Illinois at Chicago’s department of medicine and medical director of UIC’s Institute for Minority Health Research, said having access to interpreters with high accuracy is key to narrowing the gaps.

“The literature is very clear that access to professional medical interpreters is associated with decreased health disparities for patients with limited English proficiency,” she said.

More cultural training for clinicians is needed surrounding beliefs about illness and that some care may be declined not because of a person’s limited English proficiency, but because their beliefs may keep them from getting care, Dr. Garcia-Bedoya added. When it comes to getting a flu shot, for example, sometimes belief systems, rather than English proficiency, keep people from accessing care.
 

What can be done?

Addressing barriers caused by lack of English proficiency will likely take change in policies, including one related reimbursement for medical interpreters, Dr. Himmelstein said.

Currently, only 15 states’ Medicaid programs or Children’s Health Insurance Programs reimburse providers for language services, the paper notes, and neither Medicare nor private insurers routinely pay for those services.

Recruiting bilingual providers and staff at health care facilities and in medical and nursing schools will also be important to narrow the gaps, Dr. Himmelstein said.

Strengthening standards for interpreters also will help. “Currently such standards vary by state or by institution and are not necessarily enforced,” she explained.

It will also be important to make sure patients know that they are entitled by law to care, free of discriminatory practices and to have certain language services including qualified interpreters, Dr. Himmelstein said.

Dr. Garcia-Bedoya said changes need to come from health systems working in combination with clinicians, providing resources so that quality interpreters can be accessed and making sure that equipment supports clear communication in telehealth. Patients’ language preferences should also be noted as soon as they make the appointment.

The findings of the study may have large significance as one in seven people in the United States speak Spanish at home, and 25 million people in the United States have limited English proficiency, the authors noted.

Dr. Himmelstein receives funding support from an Institutional National Research Service Award. Dr. Garcia-Bedoya reports no relevant financial relationships.