In August of 2014, the Pediatric Hospital Medicine (PHM) community petitioned the American Board of Pediatrics (ABP) for a subspecialty certificate in PHM. A lengthy vetting process ensued during which the ABP consulted with a wide array of stakeholders. The ABP Board of Directors approved the request from the PHM community for a subspecialty certificate in December 2015 and published the results of the vetting process.¹

The ABP received a second petition posted on PHM listserv, which opened with the following statement:

“We submit this petition letter to register a formal complaint, demand immediate action, and request a formal response from the ABP regarding the practice pathway criteria and the application of these criteria for the Pediatric Hospital Medicine specialty exam. Recently there has been considerable discussion on the Pediatric Hospital Medicine ListServ suggesting that the ABP’s implementation of the career pathway criteria has failed to respect and fairly assess the diverse career paths of numerous experienced pediatric hospitalists, which may impede their opportunities for professional advancement. Anecdotal reports on the ListServ also suggest that the use of the current practice pathway criteria to evaluate exam applicants disadvantages women, though sufficient data is not available at this time to evaluate this assertion objectively.”

The ABP response to the PHM community’s concerns regarding the practice pathway for the first certifying exam in PHM is as follows.

ABP thanks the PHM community for the opportunity to respond to the attached petition. Our approach and response are grounded in our mission:

“Advancing child health by certifying pediatricians who meet standards of excellence and are committed to continuous learning and improvement.” 

Transparency is one of the ABP’s core values, which underpins this response. The ABP acknowledges that the petitioners did not find the guidance on the ABP website sufficiently transparent. We regret the distress this may have caused, will do our best to answer the questions forthrightly, and have revised the website language for greater clarity.

Some posts on the PHM listserv alleged gender (sex) bias against women in the ABP application process and outcomes. This allegation is not supported by the facts. A peer group of pediatric hospitalists constitutes the ABP PHM subboard which determined the eligibility criteria. The subboard thoughtfully developed these criteria and the American Board of Medical Specialties (ABMS) approved the broad eligibility criteria. The PHM subboard is composed of practicing pediatric hospitalists with a diversity of practice location, age, gender, and race. The majority of ABP PHM subboard members and medical editors are women.

Making unbiased decisions is also a core value of the ABP. Among the 1,627 applicants for the exam, the ABP has approved 1,515 (93%) as of August 15, 2019. Seventy percent of applications were from women, which mirrors the demographics of the pediatric workforce. There was no significant difference between the percentage of women (4.0%) and men (3.7%) who were denied admission to the exam (Table 1). As of August 15, 2019, the credentials committee of the PHM subboard is still reviewing 48 applications, including 35 appeals, of which 60% (N = 21) were from women and 40% (N = 14) were from men. Thirteen (N = 13) remaining applications are under review but not in the appeals process.

PHM is the 15^th pediatric subspecialty to begin the certification process with a practice pathway. In none of the prior cases was it possible to do a detailed implementation study to understand the myriad of ways in which individual pediatricians arrange their professional and personal time. This reality has led to the publication of only general, rather than specific practice pathway criteria at the start of the application process for PHM and every other pediatric subspecialty. Rather, in each case, a well-informed and diverse peer group of subspecialists (the subboard) has reviewed the applications to get a sense of the variations of practice and then decided on the criteria that a subspecialist must meet to be considered eligible to sit for the certifying exam. Clear-cut criteria were used consistently in adjudicating all applications. Although the ABP has not done this for other subspecialties, we agree that publishing the specific criteria once they had been decided upon would have improved the process. We commit to doing so in the future.

The eligibility criteria were designed to be true to the mission of the ABP and seek parity with the requirements used by other subspecialties and by the PHM training pathway. The assumption is that competent PHM practice of sufficient duration and breadth, attested to by a supervisor, would allow the ABP to represent to the public that the candidate is qualified to sit for the exam. The eligibility criteria focused on seven practice characteristics (Table 2):

The ABP recognizes that the use of %FTE, work hours, and leave exceptions led to unintended confusion among applicants. The intent had been to acknowledge the many valid reasons for interruption of practice, including parental leave. This response to the petition clarifies that the critical question from the public’s perspective is whether the candidate has accumulated enough hours of sustained practice to be considered competent in the field of PHM and specifically caring for hospitalized children (as defined above). Upon review, the ABP believes the workhours criteria (items 3 and 4) accomplish this critical goal and make the %FTE and practice interruption criteria largely redundant. Table 3 reflects the clarified and streamlined requirements. Re-examination of all the denied applications showed that using the criteria in Table 3 did not have a significant impact on the outcomes. One additional applicant’s appeal was granted, and this applicant has been so notified.

The right to appeal and the Appellate Review Procedure are included in a denial letter. The applicant is given a deadline of 14 days to notify the ABP of the intent to appeal. There is no appellate fee. Within one to three days, the ABP acknowledges receipt of the applicant’s intent to appeal and sends the applicant a date by which additional supporting information should be provided.

The appeal material is shared with the subboard credentials committee and each member individually reviews and votes on the appeal. The application is approved if a majority votes in favor of the applicant’s appeal. If there is no majority, the credentials committee discusses the case to reach a decision. The results of the appeal are final according to the ABP Appellate Review Procedure. We remain in the appeal process for several PHM applicants as of the date of this response.

Thank you for the opportunity to respond to the petition. The ABP is committed to dialogue, transparency, and continuously improving its processes.

Acknowledgment

The authors thank the ABP board of directors and the ABP PHM subboard for their review and thoughtful contributions.

Disclosures

Dr. Nichols reports other from The American Board of Pediatrics, during the conduct of the work. Dr. Woods has nothing to disclose.

In August of 2014, the Pediatric Hospital Medicine (PHM) community petitioned the American Board of Pediatrics (ABP) for a subspecialty certificate in PHM. A lengthy vetting process ensued during which the ABP consulted with a wide array of stakeholders. The ABP Board of Directors approved the request from the PHM community for a subspecialty certificate in December 2015 and published the results of the vetting process.¹

The ABP received a second petition posted on PHM listserv, which opened with the following statement:

“We submit this petition letter to register a formal complaint, demand immediate action, and request a formal response from the ABP regarding the practice pathway criteria and the application of these criteria for the Pediatric Hospital Medicine specialty exam. Recently there has been considerable discussion on the Pediatric Hospital Medicine ListServ suggesting that the ABP’s implementation of the career pathway criteria has failed to respect and fairly assess the diverse career paths of numerous experienced pediatric hospitalists, which may impede their opportunities for professional advancement. Anecdotal reports on the ListServ also suggest that the use of the current practice pathway criteria to evaluate exam applicants disadvantages women, though sufficient data is not available at this time to evaluate this assertion objectively.”

The ABP response to the PHM community’s concerns regarding the practice pathway for the first certifying exam in PHM is as follows.

ABP thanks the PHM community for the opportunity to respond to the attached petition. Our approach and response are grounded in our mission:

“Advancing child health by certifying pediatricians who meet standards of excellence and are committed to continuous learning and improvement.” 

Transparency is one of the ABP’s core values, which underpins this response. The ABP acknowledges that the petitioners did not find the guidance on the ABP website sufficiently transparent. We regret the distress this may have caused, will do our best to answer the questions forthrightly, and have revised the website language for greater clarity.

Some posts on the PHM listserv alleged gender (sex) bias against women in the ABP application process and outcomes. This allegation is not supported by the facts. A peer group of pediatric hospitalists constitutes the ABP PHM subboard which determined the eligibility criteria. The subboard thoughtfully developed these criteria and the American Board of Medical Specialties (ABMS) approved the broad eligibility criteria. The PHM subboard is composed of practicing pediatric hospitalists with a diversity of practice location, age, gender, and race. The majority of ABP PHM subboard members and medical editors are women.

Making unbiased decisions is also a core value of the ABP. Among the 1,627 applicants for the exam, the ABP has approved 1,515 (93%) as of August 15, 2019. Seventy percent of applications were from women, which mirrors the demographics of the pediatric workforce. There was no significant difference between the percentage of women (4.0%) and men (3.7%) who were denied admission to the exam (Table 1). As of August 15, 2019, the credentials committee of the PHM subboard is still reviewing 48 applications, including 35 appeals, of which 60% (N = 21) were from women and 40% (N = 14) were from men. Thirteen (N = 13) remaining applications are under review but not in the appeals process.

PHM is the 15^th pediatric subspecialty to begin the certification process with a practice pathway. In none of the prior cases was it possible to do a detailed implementation study to understand the myriad of ways in which individual pediatricians arrange their professional and personal time. This reality has led to the publication of only general, rather than specific practice pathway criteria at the start of the application process for PHM and every other pediatric subspecialty. Rather, in each case, a well-informed and diverse peer group of subspecialists (the subboard) has reviewed the applications to get a sense of the variations of practice and then decided on the criteria that a subspecialist must meet to be considered eligible to sit for the certifying exam. Clear-cut criteria were used consistently in adjudicating all applications. Although the ABP has not done this for other subspecialties, we agree that publishing the specific criteria once they had been decided upon would have improved the process. We commit to doing so in the future.

The eligibility criteria were designed to be true to the mission of the ABP and seek parity with the requirements used by other subspecialties and by the PHM training pathway. The assumption is that competent PHM practice of sufficient duration and breadth, attested to by a supervisor, would allow the ABP to represent to the public that the candidate is qualified to sit for the exam. The eligibility criteria focused on seven practice characteristics (Table 2):

The ABP recognizes that the use of %FTE, work hours, and leave exceptions led to unintended confusion among applicants. The intent had been to acknowledge the many valid reasons for interruption of practice, including parental leave. This response to the petition clarifies that the critical question from the public’s perspective is whether the candidate has accumulated enough hours of sustained practice to be considered competent in the field of PHM and specifically caring for hospitalized children (as defined above). Upon review, the ABP believes the workhours criteria (items 3 and 4) accomplish this critical goal and make the %FTE and practice interruption criteria largely redundant. Table 3 reflects the clarified and streamlined requirements. Re-examination of all the denied applications showed that using the criteria in Table 3 did not have a significant impact on the outcomes. One additional applicant’s appeal was granted, and this applicant has been so notified.

The right to appeal and the Appellate Review Procedure are included in a denial letter. The applicant is given a deadline of 14 days to notify the ABP of the intent to appeal. There is no appellate fee. Within one to three days, the ABP acknowledges receipt of the applicant’s intent to appeal and sends the applicant a date by which additional supporting information should be provided.

The appeal material is shared with the subboard credentials committee and each member individually reviews and votes on the appeal. The application is approved if a majority votes in favor of the applicant’s appeal. If there is no majority, the credentials committee discusses the case to reach a decision. The results of the appeal are final according to the ABP Appellate Review Procedure. We remain in the appeal process for several PHM applicants as of the date of this response.

Thank you for the opportunity to respond to the petition. The ABP is committed to dialogue, transparency, and continuously improving its processes.

Acknowledgment

The authors thank the ABP board of directors and the ABP PHM subboard for their review and thoughtful contributions.

Disclosures

Dr. Nichols reports other from The American Board of Pediatrics, during the conduct of the work. Dr. Woods has nothing to disclose.

In August of 2014, the Pediatric Hospital Medicine (PHM) community petitioned the American Board of Pediatrics (ABP) for a subspecialty certificate in PHM. A lengthy vetting process ensued during which the ABP consulted with a wide array of stakeholders. The ABP Board of Directors approved the request from the PHM community for a subspecialty certificate in December 2015 and published the results of the vetting process.¹

The ABP received a second petition posted on PHM listserv, which opened with the following statement:

“We submit this petition letter to register a formal complaint, demand immediate action, and request a formal response from the ABP regarding the practice pathway criteria and the application of these criteria for the Pediatric Hospital Medicine specialty exam. Recently there has been considerable discussion on the Pediatric Hospital Medicine ListServ suggesting that the ABP’s implementation of the career pathway criteria has failed to respect and fairly assess the diverse career paths of numerous experienced pediatric hospitalists, which may impede their opportunities for professional advancement. Anecdotal reports on the ListServ also suggest that the use of the current practice pathway criteria to evaluate exam applicants disadvantages women, though sufficient data is not available at this time to evaluate this assertion objectively.”

The ABP response to the PHM community’s concerns regarding the practice pathway for the first certifying exam in PHM is as follows.

ABP thanks the PHM community for the opportunity to respond to the attached petition. Our approach and response are grounded in our mission:

“Advancing child health by certifying pediatricians who meet standards of excellence and are committed to continuous learning and improvement.” 

Transparency is one of the ABP’s core values, which underpins this response. The ABP acknowledges that the petitioners did not find the guidance on the ABP website sufficiently transparent. We regret the distress this may have caused, will do our best to answer the questions forthrightly, and have revised the website language for greater clarity.

Some posts on the PHM listserv alleged gender (sex) bias against women in the ABP application process and outcomes. This allegation is not supported by the facts. A peer group of pediatric hospitalists constitutes the ABP PHM subboard which determined the eligibility criteria. The subboard thoughtfully developed these criteria and the American Board of Medical Specialties (ABMS) approved the broad eligibility criteria. The PHM subboard is composed of practicing pediatric hospitalists with a diversity of practice location, age, gender, and race. The majority of ABP PHM subboard members and medical editors are women.

Making unbiased decisions is also a core value of the ABP. Among the 1,627 applicants for the exam, the ABP has approved 1,515 (93%) as of August 15, 2019. Seventy percent of applications were from women, which mirrors the demographics of the pediatric workforce. There was no significant difference between the percentage of women (4.0%) and men (3.7%) who were denied admission to the exam (Table 1). As of August 15, 2019, the credentials committee of the PHM subboard is still reviewing 48 applications, including 35 appeals, of which 60% (N = 21) were from women and 40% (N = 14) were from men. Thirteen (N = 13) remaining applications are under review but not in the appeals process.

PHM is the 15^th pediatric subspecialty to begin the certification process with a practice pathway. In none of the prior cases was it possible to do a detailed implementation study to understand the myriad of ways in which individual pediatricians arrange their professional and personal time. This reality has led to the publication of only general, rather than specific practice pathway criteria at the start of the application process for PHM and every other pediatric subspecialty. Rather, in each case, a well-informed and diverse peer group of subspecialists (the subboard) has reviewed the applications to get a sense of the variations of practice and then decided on the criteria that a subspecialist must meet to be considered eligible to sit for the certifying exam. Clear-cut criteria were used consistently in adjudicating all applications. Although the ABP has not done this for other subspecialties, we agree that publishing the specific criteria once they had been decided upon would have improved the process. We commit to doing so in the future.

The eligibility criteria were designed to be true to the mission of the ABP and seek parity with the requirements used by other subspecialties and by the PHM training pathway. The assumption is that competent PHM practice of sufficient duration and breadth, attested to by a supervisor, would allow the ABP to represent to the public that the candidate is qualified to sit for the exam. The eligibility criteria focused on seven practice characteristics (Table 2):

The ABP recognizes that the use of %FTE, work hours, and leave exceptions led to unintended confusion among applicants. The intent had been to acknowledge the many valid reasons for interruption of practice, including parental leave. This response to the petition clarifies that the critical question from the public’s perspective is whether the candidate has accumulated enough hours of sustained practice to be considered competent in the field of PHM and specifically caring for hospitalized children (as defined above). Upon review, the ABP believes the workhours criteria (items 3 and 4) accomplish this critical goal and make the %FTE and practice interruption criteria largely redundant. Table 3 reflects the clarified and streamlined requirements. Re-examination of all the denied applications showed that using the criteria in Table 3 did not have a significant impact on the outcomes. One additional applicant’s appeal was granted, and this applicant has been so notified.

The right to appeal and the Appellate Review Procedure are included in a denial letter. The applicant is given a deadline of 14 days to notify the ABP of the intent to appeal. There is no appellate fee. Within one to three days, the ABP acknowledges receipt of the applicant’s intent to appeal and sends the applicant a date by which additional supporting information should be provided.

The appeal material is shared with the subboard credentials committee and each member individually reviews and votes on the appeal. The application is approved if a majority votes in favor of the applicant’s appeal. If there is no majority, the credentials committee discusses the case to reach a decision. The results of the appeal are final according to the ABP Appellate Review Procedure. We remain in the appeal process for several PHM applicants as of the date of this response.

Thank you for the opportunity to respond to the petition. The ABP is committed to dialogue, transparency, and continuously improving its processes.

Acknowledgment

The authors thank the ABP board of directors and the ABP PHM subboard for their review and thoughtful contributions.

Disclosures

Dr. Nichols reports other from The American Board of Pediatrics, during the conduct of the work. Dr. Woods has nothing to disclose.

Is there a single intervention more important to hospitalized patients than vascular access? Since their advent in the 1950s, small plastic tubes have revolutionized medication administration and become a mainstay of modern medicine. Yet, for much of the last 60 years, nurses and doctors have used the same landmark-guided approaches to acquire peripheral and, more specifically, central access.¹ Minor improvements to the Seldinger technique and sterile preparation have been reported.² However, for such a vital and common procedure, the complication rates of landmark-based approaches to central venous access remain unacceptably high.³

In the position statement released by the Society of Hospital Medicine (SHM), Franco–Sadud et al. outline the transformative effects ultrasound can have in obtaining adult vascular access.⁴ The authors cite comprehensive evidence, leaving little doubt of the technique’s benefits compared with landmark-based approaches. However, several questions remain: Is vascular access the domain of the hospitalist? If so, how can hospitalists pursue and afford ultrasound training? Finally, how will this shift toward ultrasound-guided vascular access affect patients in resource-limited settings?

Through an expert-driven literature review, the authors present 29 succinct recommendations for ultrasound use in vascular access. Supporting data consistently illustrate the association of ultrasound with increased successful vessel cannulation rates and decreased complication rates for all types of vascular access; including central venous access (internal jugular, subclavian, femoral), arterial line placement, peripherally inserted central catheters, and difficult peripheral venous access. Despite this compelling evidence, however, 20%-55% of all central venous catheters are still placed without ultrasound.⁵ How, then, can hospitalists expand ultrasound use for vascular access or perform these procedures in general?

Hospitalists likely fall into one of three categories in terms of vascular access: (1) they are proficient in ultrasound use for vascular access, (2) they still routinely use traditional landmark-based approaches, or (3) they have little to no involvement in vascular access and defer to intensivists, interventional radiologists, or nurse specialists. Franco-Sadud et al.’s position statement acknowledges the wide range of hospitalist practices and only asserts that, if providers perform vascular access, they should be trained and use ultrasound to do them. We would advocate further that, regardless of their practice, hospitalists have a role in expanding ultrasound use for vascular access given its direct impact on the patients they care for. Hospitalists who do not directly practice vascular access can still leverage the skills that have established hospital medicine’s reputation as leaders in patient safety and quality improvement. Hospitalists can partner with proceduralists in their institutions to ensure that they are supported and trained in the most evidence-based approaches to vascular access and that their patients have access to the highest quality of care.

For the individual hospitalist, the investment of time and resources to incorporate ultrasound into routine practice can seem daunting. In previous position statements, the SHM has advocated for the robust use of simulation and directly observed assessment in credentialing for all bedside procedures.⁶ However, the Society also acknowledges that this degree of training and monitoring can constitute significant barriers and has argued that the onus for change lies not only with providers but with healthcare institutions at large. How, then, can hospitalists approach their institutions to successfully solicit support? While the evidence is not yet conclusive, Cohen et al. have shown promising data for potential long-term cost savings through ultrasound-guided vascular access.⁷ Due to decreased complication rates, downstream benefits of lower resource use, higher patient satisfaction, and, theoretically, even lower clinician burnout rates have been attained. These effects, combined with hospitalists acquiring ultrasound skills translatable to other bedside procedures and fundamentals of diagnostic point of care ultrasound, form a compelling argument for institutional support. Many academic medical centers, typically with increased resources and training programs, have been early adopters; but, how will the shift from landmark-based to ultrasound-guided vascular access affect those in resource-limited settings?

While incredible strides have been made in care quality and patient safety over the last 15 years, improvements clearly do not always benefit patients, clinicians, or institutions equally.⁸ In fact, those in resource-limited settings often experience disproportionately reduced benefits. While focus on the “quality gap” has transformed the culture of the quality improvement and patient safety fields, an “equity gap” has long undermined and limited the impact of those very improvements. Unfortunately, changes in care driven by costly technological advances such as ultrasound are particularly likely to widen this “equity gap.” While ultrasound technology is rapidly becoming more affordable, a lack of access to machines and appropriate training remain significant barriers in the resource-limited settings that hospitalists are most likely to be performing these procedures. Without a focus on equity, the benefits offered by ultrasound will continue to be limited in their reach.

The SHM position statement by Franco-Sadud et al. is an important step in expanding evidence-based ultrasound use for vascular access and improving patient care. While the recommendations are, at times, aspirational and the barriers are real, hospitalists have shown time and again their ability to overcome these challenges and advance the standard of care for all.

Is there a single intervention more important to hospitalized patients than vascular access? Since their advent in the 1950s, small plastic tubes have revolutionized medication administration and become a mainstay of modern medicine. Yet, for much of the last 60 years, nurses and doctors have used the same landmark-guided approaches to acquire peripheral and, more specifically, central access.¹ Minor improvements to the Seldinger technique and sterile preparation have been reported.² However, for such a vital and common procedure, the complication rates of landmark-based approaches to central venous access remain unacceptably high.³

In the position statement released by the Society of Hospital Medicine (SHM), Franco–Sadud et al. outline the transformative effects ultrasound can have in obtaining adult vascular access.⁴ The authors cite comprehensive evidence, leaving little doubt of the technique’s benefits compared with landmark-based approaches. However, several questions remain: Is vascular access the domain of the hospitalist? If so, how can hospitalists pursue and afford ultrasound training? Finally, how will this shift toward ultrasound-guided vascular access affect patients in resource-limited settings?

Through an expert-driven literature review, the authors present 29 succinct recommendations for ultrasound use in vascular access. Supporting data consistently illustrate the association of ultrasound with increased successful vessel cannulation rates and decreased complication rates for all types of vascular access; including central venous access (internal jugular, subclavian, femoral), arterial line placement, peripherally inserted central catheters, and difficult peripheral venous access. Despite this compelling evidence, however, 20%-55% of all central venous catheters are still placed without ultrasound.⁵ How, then, can hospitalists expand ultrasound use for vascular access or perform these procedures in general?

Hospitalists likely fall into one of three categories in terms of vascular access: (1) they are proficient in ultrasound use for vascular access, (2) they still routinely use traditional landmark-based approaches, or (3) they have little to no involvement in vascular access and defer to intensivists, interventional radiologists, or nurse specialists. Franco-Sadud et al.’s position statement acknowledges the wide range of hospitalist practices and only asserts that, if providers perform vascular access, they should be trained and use ultrasound to do them. We would advocate further that, regardless of their practice, hospitalists have a role in expanding ultrasound use for vascular access given its direct impact on the patients they care for. Hospitalists who do not directly practice vascular access can still leverage the skills that have established hospital medicine’s reputation as leaders in patient safety and quality improvement. Hospitalists can partner with proceduralists in their institutions to ensure that they are supported and trained in the most evidence-based approaches to vascular access and that their patients have access to the highest quality of care.

For the individual hospitalist, the investment of time and resources to incorporate ultrasound into routine practice can seem daunting. In previous position statements, the SHM has advocated for the robust use of simulation and directly observed assessment in credentialing for all bedside procedures.⁶ However, the Society also acknowledges that this degree of training and monitoring can constitute significant barriers and has argued that the onus for change lies not only with providers but with healthcare institutions at large. How, then, can hospitalists approach their institutions to successfully solicit support? While the evidence is not yet conclusive, Cohen et al. have shown promising data for potential long-term cost savings through ultrasound-guided vascular access.⁷ Due to decreased complication rates, downstream benefits of lower resource use, higher patient satisfaction, and, theoretically, even lower clinician burnout rates have been attained. These effects, combined with hospitalists acquiring ultrasound skills translatable to other bedside procedures and fundamentals of diagnostic point of care ultrasound, form a compelling argument for institutional support. Many academic medical centers, typically with increased resources and training programs, have been early adopters; but, how will the shift from landmark-based to ultrasound-guided vascular access affect those in resource-limited settings?

While incredible strides have been made in care quality and patient safety over the last 15 years, improvements clearly do not always benefit patients, clinicians, or institutions equally.⁸ In fact, those in resource-limited settings often experience disproportionately reduced benefits. While focus on the “quality gap” has transformed the culture of the quality improvement and patient safety fields, an “equity gap” has long undermined and limited the impact of those very improvements. Unfortunately, changes in care driven by costly technological advances such as ultrasound are particularly likely to widen this “equity gap.” While ultrasound technology is rapidly becoming more affordable, a lack of access to machines and appropriate training remain significant barriers in the resource-limited settings that hospitalists are most likely to be performing these procedures. Without a focus on equity, the benefits offered by ultrasound will continue to be limited in their reach.

The SHM position statement by Franco-Sadud et al. is an important step in expanding evidence-based ultrasound use for vascular access and improving patient care. While the recommendations are, at times, aspirational and the barriers are real, hospitalists have shown time and again their ability to overcome these challenges and advance the standard of care for all.

Is there a single intervention more important to hospitalized patients than vascular access? Since their advent in the 1950s, small plastic tubes have revolutionized medication administration and become a mainstay of modern medicine. Yet, for much of the last 60 years, nurses and doctors have used the same landmark-guided approaches to acquire peripheral and, more specifically, central access.¹ Minor improvements to the Seldinger technique and sterile preparation have been reported.² However, for such a vital and common procedure, the complication rates of landmark-based approaches to central venous access remain unacceptably high.³

In the position statement released by the Society of Hospital Medicine (SHM), Franco–Sadud et al. outline the transformative effects ultrasound can have in obtaining adult vascular access.⁴ The authors cite comprehensive evidence, leaving little doubt of the technique’s benefits compared with landmark-based approaches. However, several questions remain: Is vascular access the domain of the hospitalist? If so, how can hospitalists pursue and afford ultrasound training? Finally, how will this shift toward ultrasound-guided vascular access affect patients in resource-limited settings?

Through an expert-driven literature review, the authors present 29 succinct recommendations for ultrasound use in vascular access. Supporting data consistently illustrate the association of ultrasound with increased successful vessel cannulation rates and decreased complication rates for all types of vascular access; including central venous access (internal jugular, subclavian, femoral), arterial line placement, peripherally inserted central catheters, and difficult peripheral venous access. Despite this compelling evidence, however, 20%-55% of all central venous catheters are still placed without ultrasound.⁵ How, then, can hospitalists expand ultrasound use for vascular access or perform these procedures in general?

Hospitalists likely fall into one of three categories in terms of vascular access: (1) they are proficient in ultrasound use for vascular access, (2) they still routinely use traditional landmark-based approaches, or (3) they have little to no involvement in vascular access and defer to intensivists, interventional radiologists, or nurse specialists. Franco-Sadud et al.’s position statement acknowledges the wide range of hospitalist practices and only asserts that, if providers perform vascular access, they should be trained and use ultrasound to do them. We would advocate further that, regardless of their practice, hospitalists have a role in expanding ultrasound use for vascular access given its direct impact on the patients they care for. Hospitalists who do not directly practice vascular access can still leverage the skills that have established hospital medicine’s reputation as leaders in patient safety and quality improvement. Hospitalists can partner with proceduralists in their institutions to ensure that they are supported and trained in the most evidence-based approaches to vascular access and that their patients have access to the highest quality of care.

For the individual hospitalist, the investment of time and resources to incorporate ultrasound into routine practice can seem daunting. In previous position statements, the SHM has advocated for the robust use of simulation and directly observed assessment in credentialing for all bedside procedures.⁶ However, the Society also acknowledges that this degree of training and monitoring can constitute significant barriers and has argued that the onus for change lies not only with providers but with healthcare institutions at large. How, then, can hospitalists approach their institutions to successfully solicit support? While the evidence is not yet conclusive, Cohen et al. have shown promising data for potential long-term cost savings through ultrasound-guided vascular access.⁷ Due to decreased complication rates, downstream benefits of lower resource use, higher patient satisfaction, and, theoretically, even lower clinician burnout rates have been attained. These effects, combined with hospitalists acquiring ultrasound skills translatable to other bedside procedures and fundamentals of diagnostic point of care ultrasound, form a compelling argument for institutional support. Many academic medical centers, typically with increased resources and training programs, have been early adopters; but, how will the shift from landmark-based to ultrasound-guided vascular access affect those in resource-limited settings?

While incredible strides have been made in care quality and patient safety over the last 15 years, improvements clearly do not always benefit patients, clinicians, or institutions equally.⁸ In fact, those in resource-limited settings often experience disproportionately reduced benefits. While focus on the “quality gap” has transformed the culture of the quality improvement and patient safety fields, an “equity gap” has long undermined and limited the impact of those very improvements. Unfortunately, changes in care driven by costly technological advances such as ultrasound are particularly likely to widen this “equity gap.” While ultrasound technology is rapidly becoming more affordable, a lack of access to machines and appropriate training remain significant barriers in the resource-limited settings that hospitalists are most likely to be performing these procedures. Without a focus on equity, the benefits offered by ultrasound will continue to be limited in their reach.

The SHM position statement by Franco-Sadud et al. is an important step in expanding evidence-based ultrasound use for vascular access and improving patient care. While the recommendations are, at times, aspirational and the barriers are real, hospitalists have shown time and again their ability to overcome these challenges and advance the standard of care for all.

Emerging technology has long been a driver of change in health care, and the pace of technological change has accelerated dramatically in the past decade. Physicians are being challenged to incorporate blockchain technology, virtual health care, artificial intelligence, gamification of learning, and the rapidly developing Internet of Things into their work and into their interactions with patients.

Blockchain in health care

Blockchain is a log of activity that is time stamped, tamper proof, and shared across a network of computers. Each transaction that goes into the log of activity is enclosed in a block and linked together in chronological order to form a chain, now called blockchain.

The potential applications of this emerging technology in health-care delivery are almost limitless.¹ Shared, secure, and linked data that can be accessed by all can give rise to the automation of complex problems, community-generated solutions to problems that empower patients, and an increase in trust, transparency, and incentive alignment. Currently, insurance claims, prescriptions, and payments mostly reside in sequestered computer systems, but a blockchain of the transactions among them would open up a wealth of learning and efficiency possibilities.² Hospitals, medical centers, insurance companies, clinical trials, and large practices can collaborate to create a blockchain of transactions in which all members can view access, share, and analyze the data.

Burton Lesnick, MD, FCCP, has given the topic of technology change and the practice of medicine some thought. He is a member of the CHEST Board of Regents and the former founding medical director of The Children’s Care Network, a pediatric accountable care organization of 1,800 providers in metro Atlanta area. Dr. Lesnick notes that blockchain is still in its early phases, partly because it is expensive in terms of computing power and electricity to adequately maintain a distributed ledger.

“I would see it being used in the next decade for high-value public registries, especially where the authenticity of data is critical. For instance, in Europe, we are already seeing a lot of effort to prevent counterfeit drugs from entering the pharmacy chain. We may soon see blockchain being used to track expensive drugs in our health-care system, thus ensuring chain of possession and preventing fraud,” he said.
 

Virtual care

Some traditional face-to-face encounters between doctor and patient will be replaced by virtual care of different types. Telemedicine is growing, thanks in part to advocacy from Medicare and Medicaid, although the lack of federal guidance on coverage and reimbursement could be a barrier.³ mHealth, the delivery of care via mobile devices, is being utilized for preventive services, appointment confirmation, and follow-up information, but the future of this technology will probably expand into transmission of data from patients and health devices, as well as health alerts.

According to a report by the World Health Organization, an increasing proportion of the population is accessing health information and services through mobile phones.⁴ According to the Physicians Practice 2018 Mobile Health Survey, a majority of practices that participated in the study stated they use mobile health in their practice on a weekly basis.⁵ Those still not using mHealth cite concerns over HIPAA compliance. Dr. Lesnick offers some cautionary perspectives.

“Many of us can already download data from medical devices such as CPAP machines and home ventilators. A prominent pharmaceutical company has recently gained FDA approval for an inhaler that date and time stamps when and how the inhaler has been used. Wearable health devices, such as fitness monitors and watches that can alert users about life-threatening arrhythmias are wonderful. But the potential for physicians being overwhelmed by the incoming data flow is concerning. This is especially true when physicians are already reporting high levels of burnout associated with frustration using electronic medical record systems. We can only hope that algorithms will be developed to sift the precious stones from the digital effluent.”

Despite the security concerns, health-care providers, along with the Centers for Medicare & Medicaid Services and the insurance industry, are planning to address the projected shortages in the health-care workforce with virtual care.³

Dr. Lesnick added, “Doctors need to be engaged at the level of their health-care systems and national organizations. Providers are needed to provide context and balance to ensure that new technology utilizes appropriate scope of practice, optimizes care, and reduces costs, while reducing burdens on caregivers.”
 

Artificial intelligence and the Internet of Things

Artificial intelligence (AI) in health care is the use of complex algorithms and software to approximate human analysis of complicated medical data. The applications in medicine are potentially limitless given the rapid accumulation of data related to health care.

According to Forbes, AI for health-care IT application will cross $1.7 billion by 2019.² By operationalizing AI platforms across select health-care workflows, organizations could see significant productivity gains during the next few years. Forbes also predicts more AI solutions will be used in imaging diagnostics, drug discovery, and risk-analytics applications.²

At the Icahn School of Medicine at Mount Sinai, New York, researchers use an in-house AI system known as Deep Patient, to predict risk factors for 78 different diseases. Doctors use the system to aid in diagnoses.⁹ AI is being used to diagnose patient wounds via smartphones, remotely monitor the elderly, and help health systems to digitally verify a patient’s insurance information.

Dr. Lesnick observed that chess computers started beating grand masters more than 20 years ago. However, the best chess players, in combination with a computer, can still reliably beat a computer alone. We need organizations like CHEST to help us become more adept at using technology. AI is a powerful tool but just another instrument to be employed in care of patients.

Big data and AI will combine to create a new ways of practicing medicine in the coming years, but what this trend will mean to individual clinicians remains to seen.

An area of rapid development is the Internet of Things, the extension of internet connectivity into everyday objects and devices designed to monitor and send information. Health-care devices now incorporate AI, real-time analytics, machine learning, physiologic sensors, and embedded systems.¹⁰ Physicians will increasingly have access to real-time data on individual patients. For physicians, managing, storing, and analyzing data from the personalized health-care devices of their patients will be a major challenge as the Internet of Things continues to expand into health care.

Dr. Lesnick noted, “In my collaboration with Georgia Tech [in Atlanta], one area I’m really excited about is process mining. Instead of sorting individual data points for statistical correlation, process mining looks at groups of actions and decisions. We’ve applied this to our local emergency room. I’m hoping we can find the most efficient processes and hardwire them in order sets. If we can eventually apply process mining to the health-care system as a whole, we might start to see gains in efficiencies.”
 

Gamification

Gamification is the term used to describe any tool or platform that applies game mechanics to nongame initiatives in order to encourage and increase engagement. Elements of gamification often include the use of badges, reward points, prizes, social interaction, and leaderboards. Gamification is frequently used by sales teams, marketers, employee training and performance management, onboarding, learning management, and health and wellness.¹¹

The rise in smartphone ownership and wearable technology will likely increase the adoption of gamification technologies to manage health-related concerns and issues. Patient education via gamification is a potentially powerful tool to enhance engagement around disease management. Maintenance of certification and CME are also growth areas for gamification.
 

Cybersecurity and data breaches

The rapid development of mobile devices and the Internet of Things, in addition to the transmission of health data on a massive scale, will mean more health data will be stolen for a variety of illegal purposes. Hacking and unauthorized access are now common occurrences. Privacy breaches, potential HIPAA violations, and financial damage to patients and institutions are all areas of concern that accompany technological changes.¹²

Dr. Lesnick stressed that all health-care professionals must be accountable for safeguarding patient information and using the latest security software. “Physicians can be advocates for their patients by cautioning them about the risks of placing their private medical information into public spaces, such as social media. Patients should also know that they may be waiving their privacy rights when they utilize commercial entities that collect and store DNA analyses for purposes of ancestry tracking or medical screening,” he concluded.
 

References

1. Dhillon V et al. “Blockchain in healthcare: Innovations that empower patients, connect professionals and improve care.” (New York: CRC Press, 2019).

2. Das R. Top 8 healthcare predictions for 2019. Forbes. 2018 Nov 13.

3. 2019 Predictions. Teladoc Health. 2019. http://go.teladochealth.com/predictions/3/.

4. Director-General. “mHealth: Use of appropriate digital technologies for public health.” World Health Organization. 2018 Mar 26.

5. Physicians Practice Staff. 2018 Mobile Health Survey Results. Physicians Practice. 2018 Feb 20.

6. Trend 1: Citizen AI. Accenture. 2018 May 24.

7. Siwicki B. Zocdoc appointment booking app now verifies insurance with AI. Healthcare IT News. 2017 Oct 25

8. Schepke J. What’s your healthcare gamification strategy? Becker’s Healthcare. 2018 May 31.

9. November 2018 healthcare data breach report. HIPAA Journal. 2018 Dec 20.

10. Siwicki, B. Zocdoc appointment booking app now verifies insurance with AI. HeathcareITNews. 2017 Oct 25.

11. Schepke, J. What’s your healthcare gamification strategy? Becker’s Health IT & CIO Report. 2018. May 31.

12. November 2018 healthcare data breach report. HIPAA Journal. 2018 Dec 20.
Note: Background research performed by Avenue M Group.

Emerging technology has long been a driver of change in health care, and the pace of technological change has accelerated dramatically in the past decade. Physicians are being challenged to incorporate blockchain technology, virtual health care, artificial intelligence, gamification of learning, and the rapidly developing Internet of Things into their work and into their interactions with patients.

Blockchain in health care

Blockchain is a log of activity that is time stamped, tamper proof, and shared across a network of computers. Each transaction that goes into the log of activity is enclosed in a block and linked together in chronological order to form a chain, now called blockchain.

The potential applications of this emerging technology in health-care delivery are almost limitless.¹ Shared, secure, and linked data that can be accessed by all can give rise to the automation of complex problems, community-generated solutions to problems that empower patients, and an increase in trust, transparency, and incentive alignment. Currently, insurance claims, prescriptions, and payments mostly reside in sequestered computer systems, but a blockchain of the transactions among them would open up a wealth of learning and efficiency possibilities.² Hospitals, medical centers, insurance companies, clinical trials, and large practices can collaborate to create a blockchain of transactions in which all members can view access, share, and analyze the data.

Burton Lesnick, MD, FCCP, has given the topic of technology change and the practice of medicine some thought. He is a member of the CHEST Board of Regents and the former founding medical director of The Children’s Care Network, a pediatric accountable care organization of 1,800 providers in metro Atlanta area. Dr. Lesnick notes that blockchain is still in its early phases, partly because it is expensive in terms of computing power and electricity to adequately maintain a distributed ledger.

“I would see it being used in the next decade for high-value public registries, especially where the authenticity of data is critical. For instance, in Europe, we are already seeing a lot of effort to prevent counterfeit drugs from entering the pharmacy chain. We may soon see blockchain being used to track expensive drugs in our health-care system, thus ensuring chain of possession and preventing fraud,” he said.
 

Virtual care

Some traditional face-to-face encounters between doctor and patient will be replaced by virtual care of different types. Telemedicine is growing, thanks in part to advocacy from Medicare and Medicaid, although the lack of federal guidance on coverage and reimbursement could be a barrier.³ mHealth, the delivery of care via mobile devices, is being utilized for preventive services, appointment confirmation, and follow-up information, but the future of this technology will probably expand into transmission of data from patients and health devices, as well as health alerts.

According to a report by the World Health Organization, an increasing proportion of the population is accessing health information and services through mobile phones.⁴ According to the Physicians Practice 2018 Mobile Health Survey, a majority of practices that participated in the study stated they use mobile health in their practice on a weekly basis.⁵ Those still not using mHealth cite concerns over HIPAA compliance. Dr. Lesnick offers some cautionary perspectives.

“Many of us can already download data from medical devices such as CPAP machines and home ventilators. A prominent pharmaceutical company has recently gained FDA approval for an inhaler that date and time stamps when and how the inhaler has been used. Wearable health devices, such as fitness monitors and watches that can alert users about life-threatening arrhythmias are wonderful. But the potential for physicians being overwhelmed by the incoming data flow is concerning. This is especially true when physicians are already reporting high levels of burnout associated with frustration using electronic medical record systems. We can only hope that algorithms will be developed to sift the precious stones from the digital effluent.”

Despite the security concerns, health-care providers, along with the Centers for Medicare & Medicaid Services and the insurance industry, are planning to address the projected shortages in the health-care workforce with virtual care.³

Dr. Lesnick added, “Doctors need to be engaged at the level of their health-care systems and national organizations. Providers are needed to provide context and balance to ensure that new technology utilizes appropriate scope of practice, optimizes care, and reduces costs, while reducing burdens on caregivers.”
 

Artificial intelligence and the Internet of Things

Artificial intelligence (AI) in health care is the use of complex algorithms and software to approximate human analysis of complicated medical data. The applications in medicine are potentially limitless given the rapid accumulation of data related to health care.

According to Forbes, AI for health-care IT application will cross $1.7 billion by 2019.² By operationalizing AI platforms across select health-care workflows, organizations could see significant productivity gains during the next few years. Forbes also predicts more AI solutions will be used in imaging diagnostics, drug discovery, and risk-analytics applications.²

At the Icahn School of Medicine at Mount Sinai, New York, researchers use an in-house AI system known as Deep Patient, to predict risk factors for 78 different diseases. Doctors use the system to aid in diagnoses.⁹ AI is being used to diagnose patient wounds via smartphones, remotely monitor the elderly, and help health systems to digitally verify a patient’s insurance information.

Dr. Lesnick observed that chess computers started beating grand masters more than 20 years ago. However, the best chess players, in combination with a computer, can still reliably beat a computer alone. We need organizations like CHEST to help us become more adept at using technology. AI is a powerful tool but just another instrument to be employed in care of patients.

Big data and AI will combine to create a new ways of practicing medicine in the coming years, but what this trend will mean to individual clinicians remains to seen.

An area of rapid development is the Internet of Things, the extension of internet connectivity into everyday objects and devices designed to monitor and send information. Health-care devices now incorporate AI, real-time analytics, machine learning, physiologic sensors, and embedded systems.¹⁰ Physicians will increasingly have access to real-time data on individual patients. For physicians, managing, storing, and analyzing data from the personalized health-care devices of their patients will be a major challenge as the Internet of Things continues to expand into health care.

Dr. Lesnick noted, “In my collaboration with Georgia Tech [in Atlanta], one area I’m really excited about is process mining. Instead of sorting individual data points for statistical correlation, process mining looks at groups of actions and decisions. We’ve applied this to our local emergency room. I’m hoping we can find the most efficient processes and hardwire them in order sets. If we can eventually apply process mining to the health-care system as a whole, we might start to see gains in efficiencies.”
 

Gamification

Gamification is the term used to describe any tool or platform that applies game mechanics to nongame initiatives in order to encourage and increase engagement. Elements of gamification often include the use of badges, reward points, prizes, social interaction, and leaderboards. Gamification is frequently used by sales teams, marketers, employee training and performance management, onboarding, learning management, and health and wellness.¹¹

The rise in smartphone ownership and wearable technology will likely increase the adoption of gamification technologies to manage health-related concerns and issues. Patient education via gamification is a potentially powerful tool to enhance engagement around disease management. Maintenance of certification and CME are also growth areas for gamification.
 

Cybersecurity and data breaches

The rapid development of mobile devices and the Internet of Things, in addition to the transmission of health data on a massive scale, will mean more health data will be stolen for a variety of illegal purposes. Hacking and unauthorized access are now common occurrences. Privacy breaches, potential HIPAA violations, and financial damage to patients and institutions are all areas of concern that accompany technological changes.¹²

Dr. Lesnick stressed that all health-care professionals must be accountable for safeguarding patient information and using the latest security software. “Physicians can be advocates for their patients by cautioning them about the risks of placing their private medical information into public spaces, such as social media. Patients should also know that they may be waiving their privacy rights when they utilize commercial entities that collect and store DNA analyses for purposes of ancestry tracking or medical screening,” he concluded.
 

References

1. Dhillon V et al. “Blockchain in healthcare: Innovations that empower patients, connect professionals and improve care.” (New York: CRC Press, 2019).

2. Das R. Top 8 healthcare predictions for 2019. Forbes. 2018 Nov 13.

3. 2019 Predictions. Teladoc Health. 2019. http://go.teladochealth.com/predictions/3/.

4. Director-General. “mHealth: Use of appropriate digital technologies for public health.” World Health Organization. 2018 Mar 26.

5. Physicians Practice Staff. 2018 Mobile Health Survey Results. Physicians Practice. 2018 Feb 20.

6. Trend 1: Citizen AI. Accenture. 2018 May 24.

7. Siwicki B. Zocdoc appointment booking app now verifies insurance with AI. Healthcare IT News. 2017 Oct 25

8. Schepke J. What’s your healthcare gamification strategy? Becker’s Healthcare. 2018 May 31.

9. November 2018 healthcare data breach report. HIPAA Journal. 2018 Dec 20.

10. Siwicki, B. Zocdoc appointment booking app now verifies insurance with AI. HeathcareITNews. 2017 Oct 25.

11. Schepke, J. What’s your healthcare gamification strategy? Becker’s Health IT & CIO Report. 2018. May 31.

12. November 2018 healthcare data breach report. HIPAA Journal. 2018 Dec 20.
Note: Background research performed by Avenue M Group.

Emerging technology has long been a driver of change in health care, and the pace of technological change has accelerated dramatically in the past decade. Physicians are being challenged to incorporate blockchain technology, virtual health care, artificial intelligence, gamification of learning, and the rapidly developing Internet of Things into their work and into their interactions with patients.

Blockchain in health care

Blockchain is a log of activity that is time stamped, tamper proof, and shared across a network of computers. Each transaction that goes into the log of activity is enclosed in a block and linked together in chronological order to form a chain, now called blockchain.

The potential applications of this emerging technology in health-care delivery are almost limitless.¹ Shared, secure, and linked data that can be accessed by all can give rise to the automation of complex problems, community-generated solutions to problems that empower patients, and an increase in trust, transparency, and incentive alignment. Currently, insurance claims, prescriptions, and payments mostly reside in sequestered computer systems, but a blockchain of the transactions among them would open up a wealth of learning and efficiency possibilities.² Hospitals, medical centers, insurance companies, clinical trials, and large practices can collaborate to create a blockchain of transactions in which all members can view access, share, and analyze the data.

Burton Lesnick, MD, FCCP, has given the topic of technology change and the practice of medicine some thought. He is a member of the CHEST Board of Regents and the former founding medical director of The Children’s Care Network, a pediatric accountable care organization of 1,800 providers in metro Atlanta area. Dr. Lesnick notes that blockchain is still in its early phases, partly because it is expensive in terms of computing power and electricity to adequately maintain a distributed ledger.

“I would see it being used in the next decade for high-value public registries, especially where the authenticity of data is critical. For instance, in Europe, we are already seeing a lot of effort to prevent counterfeit drugs from entering the pharmacy chain. We may soon see blockchain being used to track expensive drugs in our health-care system, thus ensuring chain of possession and preventing fraud,” he said.
 

Virtual care

Some traditional face-to-face encounters between doctor and patient will be replaced by virtual care of different types. Telemedicine is growing, thanks in part to advocacy from Medicare and Medicaid, although the lack of federal guidance on coverage and reimbursement could be a barrier.³ mHealth, the delivery of care via mobile devices, is being utilized for preventive services, appointment confirmation, and follow-up information, but the future of this technology will probably expand into transmission of data from patients and health devices, as well as health alerts.

According to a report by the World Health Organization, an increasing proportion of the population is accessing health information and services through mobile phones.⁴ According to the Physicians Practice 2018 Mobile Health Survey, a majority of practices that participated in the study stated they use mobile health in their practice on a weekly basis.⁵ Those still not using mHealth cite concerns over HIPAA compliance. Dr. Lesnick offers some cautionary perspectives.

“Many of us can already download data from medical devices such as CPAP machines and home ventilators. A prominent pharmaceutical company has recently gained FDA approval for an inhaler that date and time stamps when and how the inhaler has been used. Wearable health devices, such as fitness monitors and watches that can alert users about life-threatening arrhythmias are wonderful. But the potential for physicians being overwhelmed by the incoming data flow is concerning. This is especially true when physicians are already reporting high levels of burnout associated with frustration using electronic medical record systems. We can only hope that algorithms will be developed to sift the precious stones from the digital effluent.”

Despite the security concerns, health-care providers, along with the Centers for Medicare & Medicaid Services and the insurance industry, are planning to address the projected shortages in the health-care workforce with virtual care.³

Dr. Lesnick added, “Doctors need to be engaged at the level of their health-care systems and national organizations. Providers are needed to provide context and balance to ensure that new technology utilizes appropriate scope of practice, optimizes care, and reduces costs, while reducing burdens on caregivers.”
 

Artificial intelligence and the Internet of Things

Artificial intelligence (AI) in health care is the use of complex algorithms and software to approximate human analysis of complicated medical data. The applications in medicine are potentially limitless given the rapid accumulation of data related to health care.

According to Forbes, AI for health-care IT application will cross $1.7 billion by 2019.² By operationalizing AI platforms across select health-care workflows, organizations could see significant productivity gains during the next few years. Forbes also predicts more AI solutions will be used in imaging diagnostics, drug discovery, and risk-analytics applications.²

At the Icahn School of Medicine at Mount Sinai, New York, researchers use an in-house AI system known as Deep Patient, to predict risk factors for 78 different diseases. Doctors use the system to aid in diagnoses.⁹ AI is being used to diagnose patient wounds via smartphones, remotely monitor the elderly, and help health systems to digitally verify a patient’s insurance information.

Dr. Lesnick observed that chess computers started beating grand masters more than 20 years ago. However, the best chess players, in combination with a computer, can still reliably beat a computer alone. We need organizations like CHEST to help us become more adept at using technology. AI is a powerful tool but just another instrument to be employed in care of patients.

Big data and AI will combine to create a new ways of practicing medicine in the coming years, but what this trend will mean to individual clinicians remains to seen.

An area of rapid development is the Internet of Things, the extension of internet connectivity into everyday objects and devices designed to monitor and send information. Health-care devices now incorporate AI, real-time analytics, machine learning, physiologic sensors, and embedded systems.¹⁰ Physicians will increasingly have access to real-time data on individual patients. For physicians, managing, storing, and analyzing data from the personalized health-care devices of their patients will be a major challenge as the Internet of Things continues to expand into health care.

Dr. Lesnick noted, “In my collaboration with Georgia Tech [in Atlanta], one area I’m really excited about is process mining. Instead of sorting individual data points for statistical correlation, process mining looks at groups of actions and decisions. We’ve applied this to our local emergency room. I’m hoping we can find the most efficient processes and hardwire them in order sets. If we can eventually apply process mining to the health-care system as a whole, we might start to see gains in efficiencies.”
 

Gamification

Gamification is the term used to describe any tool or platform that applies game mechanics to nongame initiatives in order to encourage and increase engagement. Elements of gamification often include the use of badges, reward points, prizes, social interaction, and leaderboards. Gamification is frequently used by sales teams, marketers, employee training and performance management, onboarding, learning management, and health and wellness.¹¹

The rise in smartphone ownership and wearable technology will likely increase the adoption of gamification technologies to manage health-related concerns and issues. Patient education via gamification is a potentially powerful tool to enhance engagement around disease management. Maintenance of certification and CME are also growth areas for gamification.
 

Cybersecurity and data breaches

The rapid development of mobile devices and the Internet of Things, in addition to the transmission of health data on a massive scale, will mean more health data will be stolen for a variety of illegal purposes. Hacking and unauthorized access are now common occurrences. Privacy breaches, potential HIPAA violations, and financial damage to patients and institutions are all areas of concern that accompany technological changes.¹²

Dr. Lesnick stressed that all health-care professionals must be accountable for safeguarding patient information and using the latest security software. “Physicians can be advocates for their patients by cautioning them about the risks of placing their private medical information into public spaces, such as social media. Patients should also know that they may be waiving their privacy rights when they utilize commercial entities that collect and store DNA analyses for purposes of ancestry tracking or medical screening,” he concluded.
 

References

1. Dhillon V et al. “Blockchain in healthcare: Innovations that empower patients, connect professionals and improve care.” (New York: CRC Press, 2019).

2. Das R. Top 8 healthcare predictions for 2019. Forbes. 2018 Nov 13.

3. 2019 Predictions. Teladoc Health. 2019. http://go.teladochealth.com/predictions/3/.

4. Director-General. “mHealth: Use of appropriate digital technologies for public health.” World Health Organization. 2018 Mar 26.

5. Physicians Practice Staff. 2018 Mobile Health Survey Results. Physicians Practice. 2018 Feb 20.

6. Trend 1: Citizen AI. Accenture. 2018 May 24.

7. Siwicki B. Zocdoc appointment booking app now verifies insurance with AI. Healthcare IT News. 2017 Oct 25

8. Schepke J. What’s your healthcare gamification strategy? Becker’s Healthcare. 2018 May 31.

9. November 2018 healthcare data breach report. HIPAA Journal. 2018 Dec 20.

10. Siwicki, B. Zocdoc appointment booking app now verifies insurance with AI. HeathcareITNews. 2017 Oct 25.

11. Schepke, J. What’s your healthcare gamification strategy? Becker’s Health IT & CIO Report. 2018. May 31.

12. November 2018 healthcare data breach report. HIPAA Journal. 2018 Dec 20.
Note: Background research performed by Avenue M Group.

By now, most of you know that the CHEST family lost one of our dearest members and leaders in early July, Past President Mark Rosen. This loss has been felt deeply by many, not only because he was taken so suddenly, but because of who Mark was and what he meant to us. We did not get the chance to say goodbye. We shared Mark’s official obituary last month in CHEST Physician. This month, we thought it important to share something more personal.

When I think of Mark, so many words come to mind: master educator, astute and caring clinician, researcher, mentor, leader. So many qualities come to mind: generous, kind, honest, brilliant, and funny. Mark loved CHEST. He gave so much to the organization and was happy to do so. He was one of the Past Presidents who contributed even more after his presidency than during or before. Mark left an enormous footprint on our educational programs, including the annual meeting, Pulmonary Board Review, and SEEK. He was instrumental in building our international educational programs and a key player in assisting our Chinese colleagues in establishing pulmonary fellowships in their country.

When I think of my own journey with Mark, I think back to the first time I saw him. I was a senior fellow taking the Pulmonary Board Review course in Chicago. I don’t remember much from that course – except for Mark’s presentations. They included everything you needed to know, in a very logical outline. More importantly, he had a presence on stage that was larger than life. He made you laugh throughout the entire talk! Mark’s humor was self-deprecating, and he made you feel like you had been best friends forever---even if he’d never met you. From that first encounter, he became a giant in chest medicine to me. It wasn’t too many years later that, as a junior volunteer leader in the organization, I was able to finally meet Mark. He could not have been more welcoming or humble, and he instantly took on the role of mentor. I was so lucky; not only did that mentorship grow, but so did our friendship. I quickly got to the point that I looked forward to the times I would travel for CHEST events, because I knew I would see Mark. I did establish one rule, however, when we started teaching together. I refused to follow Mark in the agenda, as there was no way I could ever live up to his presentation style and humor. I didn’t want to be a let down to the crowd!

Much of what I and others have accomplished with CHEST and in pulmonary medicine is directly related to the wonderful mentors we have had in the organization, and Mark was certainly one of the most prominent. He introduced me to so many additional friends and mentors. And, Mark did this for hundreds of trainees and junior faculty throughout his career. If I were to guess, I would say that this is the thing that made him most proud. Yes, he was an established international expert in several areas of pulmonary medicine; he held several prominent positions in academic medicine and at CHEST. But, what made him most happy was seeing his trainees and mentees succeed – you would have thought we were one of his kids (whom he was also very proud of and loved dearly). Mark was THE example of an outstanding mentor.

The memory I will carry forever of Mark, however, is when he got on stage and was the Master of Ceremonies for the CHEST Challenge Championship. He was in his element as an educator, interacting with the next generation of chest medicine physicians. He spent the entire time making the contestants, and the audience, laugh. People came to the final round to see Mark, even if they had no dog in the fight. I will always fondly recall that way he would look over at me and the other judges if he wasn’t sure about a team’s answer and then have an immediate witty comeback. Many of my CHEST friends have said that Mark was the Jerry Seinfeld of CHEST. I’ve never watched a single episode of Seinfeld, but if this description is true, I plan to!

Mark kept his sense of humor until the very end, telling me in his final days that he chose to focus on “humor markers,” rather than “tumor markers” – he said that always worked out better for him! Mark, we all miss you friend. We can’t wait to share a Chopin Martini with a twist of lemon when we see you on the other side. Thank you for all you did for your family, your patients, your trainees, your colleagues, and CHEST.

By now, most of you know that the CHEST family lost one of our dearest members and leaders in early July, Past President Mark Rosen. This loss has been felt deeply by many, not only because he was taken so suddenly, but because of who Mark was and what he meant to us. We did not get the chance to say goodbye. We shared Mark’s official obituary last month in CHEST Physician. This month, we thought it important to share something more personal.

When I think of Mark, so many words come to mind: master educator, astute and caring clinician, researcher, mentor, leader. So many qualities come to mind: generous, kind, honest, brilliant, and funny. Mark loved CHEST. He gave so much to the organization and was happy to do so. He was one of the Past Presidents who contributed even more after his presidency than during or before. Mark left an enormous footprint on our educational programs, including the annual meeting, Pulmonary Board Review, and SEEK. He was instrumental in building our international educational programs and a key player in assisting our Chinese colleagues in establishing pulmonary fellowships in their country.

When I think of my own journey with Mark, I think back to the first time I saw him. I was a senior fellow taking the Pulmonary Board Review course in Chicago. I don’t remember much from that course – except for Mark’s presentations. They included everything you needed to know, in a very logical outline. More importantly, he had a presence on stage that was larger than life. He made you laugh throughout the entire talk! Mark’s humor was self-deprecating, and he made you feel like you had been best friends forever---even if he’d never met you. From that first encounter, he became a giant in chest medicine to me. It wasn’t too many years later that, as a junior volunteer leader in the organization, I was able to finally meet Mark. He could not have been more welcoming or humble, and he instantly took on the role of mentor. I was so lucky; not only did that mentorship grow, but so did our friendship. I quickly got to the point that I looked forward to the times I would travel for CHEST events, because I knew I would see Mark. I did establish one rule, however, when we started teaching together. I refused to follow Mark in the agenda, as there was no way I could ever live up to his presentation style and humor. I didn’t want to be a let down to the crowd!

Much of what I and others have accomplished with CHEST and in pulmonary medicine is directly related to the wonderful mentors we have had in the organization, and Mark was certainly one of the most prominent. He introduced me to so many additional friends and mentors. And, Mark did this for hundreds of trainees and junior faculty throughout his career. If I were to guess, I would say that this is the thing that made him most proud. Yes, he was an established international expert in several areas of pulmonary medicine; he held several prominent positions in academic medicine and at CHEST. But, what made him most happy was seeing his trainees and mentees succeed – you would have thought we were one of his kids (whom he was also very proud of and loved dearly). Mark was THE example of an outstanding mentor.

The memory I will carry forever of Mark, however, is when he got on stage and was the Master of Ceremonies for the CHEST Challenge Championship. He was in his element as an educator, interacting with the next generation of chest medicine physicians. He spent the entire time making the contestants, and the audience, laugh. People came to the final round to see Mark, even if they had no dog in the fight. I will always fondly recall that way he would look over at me and the other judges if he wasn’t sure about a team’s answer and then have an immediate witty comeback. Many of my CHEST friends have said that Mark was the Jerry Seinfeld of CHEST. I’ve never watched a single episode of Seinfeld, but if this description is true, I plan to!

Mark kept his sense of humor until the very end, telling me in his final days that he chose to focus on “humor markers,” rather than “tumor markers” – he said that always worked out better for him! Mark, we all miss you friend. We can’t wait to share a Chopin Martini with a twist of lemon when we see you on the other side. Thank you for all you did for your family, your patients, your trainees, your colleagues, and CHEST.

By now, most of you know that the CHEST family lost one of our dearest members and leaders in early July, Past President Mark Rosen. This loss has been felt deeply by many, not only because he was taken so suddenly, but because of who Mark was and what he meant to us. We did not get the chance to say goodbye. We shared Mark’s official obituary last month in CHEST Physician. This month, we thought it important to share something more personal.

When I think of Mark, so many words come to mind: master educator, astute and caring clinician, researcher, mentor, leader. So many qualities come to mind: generous, kind, honest, brilliant, and funny. Mark loved CHEST. He gave so much to the organization and was happy to do so. He was one of the Past Presidents who contributed even more after his presidency than during or before. Mark left an enormous footprint on our educational programs, including the annual meeting, Pulmonary Board Review, and SEEK. He was instrumental in building our international educational programs and a key player in assisting our Chinese colleagues in establishing pulmonary fellowships in their country.

When I think of my own journey with Mark, I think back to the first time I saw him. I was a senior fellow taking the Pulmonary Board Review course in Chicago. I don’t remember much from that course – except for Mark’s presentations. They included everything you needed to know, in a very logical outline. More importantly, he had a presence on stage that was larger than life. He made you laugh throughout the entire talk! Mark’s humor was self-deprecating, and he made you feel like you had been best friends forever---even if he’d never met you. From that first encounter, he became a giant in chest medicine to me. It wasn’t too many years later that, as a junior volunteer leader in the organization, I was able to finally meet Mark. He could not have been more welcoming or humble, and he instantly took on the role of mentor. I was so lucky; not only did that mentorship grow, but so did our friendship. I quickly got to the point that I looked forward to the times I would travel for CHEST events, because I knew I would see Mark. I did establish one rule, however, when we started teaching together. I refused to follow Mark in the agenda, as there was no way I could ever live up to his presentation style and humor. I didn’t want to be a let down to the crowd!

Much of what I and others have accomplished with CHEST and in pulmonary medicine is directly related to the wonderful mentors we have had in the organization, and Mark was certainly one of the most prominent. He introduced me to so many additional friends and mentors. And, Mark did this for hundreds of trainees and junior faculty throughout his career. If I were to guess, I would say that this is the thing that made him most proud. Yes, he was an established international expert in several areas of pulmonary medicine; he held several prominent positions in academic medicine and at CHEST. But, what made him most happy was seeing his trainees and mentees succeed – you would have thought we were one of his kids (whom he was also very proud of and loved dearly). Mark was THE example of an outstanding mentor.

The memory I will carry forever of Mark, however, is when he got on stage and was the Master of Ceremonies for the CHEST Challenge Championship. He was in his element as an educator, interacting with the next generation of chest medicine physicians. He spent the entire time making the contestants, and the audience, laugh. People came to the final round to see Mark, even if they had no dog in the fight. I will always fondly recall that way he would look over at me and the other judges if he wasn’t sure about a team’s answer and then have an immediate witty comeback. Many of my CHEST friends have said that Mark was the Jerry Seinfeld of CHEST. I’ve never watched a single episode of Seinfeld, but if this description is true, I plan to!

Mark kept his sense of humor until the very end, telling me in his final days that he chose to focus on “humor markers,” rather than “tumor markers” – he said that always worked out better for him! Mark, we all miss you friend. We can’t wait to share a Chopin Martini with a twist of lemon when we see you on the other side. Thank you for all you did for your family, your patients, your trainees, your colleagues, and CHEST.

As we put summer in our rear-view mirror and look ahead to the switch of seasons and the vivid colors of fall and prepare to indulge and learn at CHEST 2019, it is evident change is in the air. Fall is a time of change and learning about the many opportunities the CHEST 2019 meeting offers our members, and it is also the launch of all that is changing and new for you to be a part of the CHEST Foundation.

At CHEST 2019 this year, the CHEST Foundation will be holding their 3rd Annual Women & Pulmonary Luncheon on Monday, October 21. This annual luncheon has brought over 350 attendees together to not only collaborate on patient care while focusing on gender differences but also to discuss better ways to advocate for career advancements for women pulmonologists. A new change for this year is the addition of a networking hour following the luncheon, creating an open environment to discuss empowerment, education, and resources.

The CHEST Foundation continues to help young clinicians come to the CHEST Annual Meeting. As of today, more than $250,000 has been awarded by the Foundation in travel grants and complimentary registrations to more than 125 early career clinicians. YOU can have an impact and make a change for an individual by supporting travel grants this year.

The Foundation’s most noteworthy change, and one we hope all of our membership and donors will be a part of, is the launch of our new endowment in 2019/2020. The Erin Popovich Endowment will enable access to resources for patients and families, empower patients to take charge, find support groups, seek second opinions, and more, and will support research to advance patient care and improve treatment options and outcomes. This endowment will change and improve quality of life for patients and families affected by interstitial lung disease, and we encourage you to join us at the Donor Lounge to learn more.

As you embrace the changing of the season and prepare your highlights for CHEST 2019 in NOLA, we invite you to come and discover all the changes and impact the CHEST Foundation is making and why you are so important in all we do!

As we put summer in our rear-view mirror and look ahead to the switch of seasons and the vivid colors of fall and prepare to indulge and learn at CHEST 2019, it is evident change is in the air. Fall is a time of change and learning about the many opportunities the CHEST 2019 meeting offers our members, and it is also the launch of all that is changing and new for you to be a part of the CHEST Foundation.

At CHEST 2019 this year, the CHEST Foundation will be holding their 3rd Annual Women & Pulmonary Luncheon on Monday, October 21. This annual luncheon has brought over 350 attendees together to not only collaborate on patient care while focusing on gender differences but also to discuss better ways to advocate for career advancements for women pulmonologists. A new change for this year is the addition of a networking hour following the luncheon, creating an open environment to discuss empowerment, education, and resources.

The CHEST Foundation continues to help young clinicians come to the CHEST Annual Meeting. As of today, more than $250,000 has been awarded by the Foundation in travel grants and complimentary registrations to more than 125 early career clinicians. YOU can have an impact and make a change for an individual by supporting travel grants this year.

The Foundation’s most noteworthy change, and one we hope all of our membership and donors will be a part of, is the launch of our new endowment in 2019/2020. The Erin Popovich Endowment will enable access to resources for patients and families, empower patients to take charge, find support groups, seek second opinions, and more, and will support research to advance patient care and improve treatment options and outcomes. This endowment will change and improve quality of life for patients and families affected by interstitial lung disease, and we encourage you to join us at the Donor Lounge to learn more.

As you embrace the changing of the season and prepare your highlights for CHEST 2019 in NOLA, we invite you to come and discover all the changes and impact the CHEST Foundation is making and why you are so important in all we do!

As we put summer in our rear-view mirror and look ahead to the switch of seasons and the vivid colors of fall and prepare to indulge and learn at CHEST 2019, it is evident change is in the air. Fall is a time of change and learning about the many opportunities the CHEST 2019 meeting offers our members, and it is also the launch of all that is changing and new for you to be a part of the CHEST Foundation.

At CHEST 2019 this year, the CHEST Foundation will be holding their 3rd Annual Women & Pulmonary Luncheon on Monday, October 21. This annual luncheon has brought over 350 attendees together to not only collaborate on patient care while focusing on gender differences but also to discuss better ways to advocate for career advancements for women pulmonologists. A new change for this year is the addition of a networking hour following the luncheon, creating an open environment to discuss empowerment, education, and resources.

The CHEST Foundation continues to help young clinicians come to the CHEST Annual Meeting. As of today, more than $250,000 has been awarded by the Foundation in travel grants and complimentary registrations to more than 125 early career clinicians. YOU can have an impact and make a change for an individual by supporting travel grants this year.

The Foundation’s most noteworthy change, and one we hope all of our membership and donors will be a part of, is the launch of our new endowment in 2019/2020. The Erin Popovich Endowment will enable access to resources for patients and families, empower patients to take charge, find support groups, seek second opinions, and more, and will support research to advance patient care and improve treatment options and outcomes. This endowment will change and improve quality of life for patients and families affected by interstitial lung disease, and we encourage you to join us at the Donor Lounge to learn more.

As you embrace the changing of the season and prepare your highlights for CHEST 2019 in NOLA, we invite you to come and discover all the changes and impact the CHEST Foundation is making and why you are so important in all we do!

This year, in conjunction with CHEST Annual Meeting, CHEST is piloting self-study bundles that will allow attendees to earn additional Continuing Medical Education/Continuing Education credits and American Board of Internal Medicine Maintenance of Certification points, apart from the total credits available for the overall meeting. Attendees will receive complimentary access to the eight self-study bundles, in which they will read articles and answer questions related to the articles, in the following areas:

• Pulmonary Hypertension

• Critical Care

• Sleep

• COPD

• Asthma

• Lung Cancer

• Interstitial Lung Disease

• Transplant

This value-added addition will offer the opportunity to earn three credits CME/CE and the corresponding number of ABIM MOC points for each bundle; if someone completes all eight bundles, they can earn up to 24 credits.

The deadline for completion of and claiming CME/CE for the self-study bundles is the same as the claiming deadline for the CHEST Annual Meeting, February 29, 2020.

This year, in conjunction with CHEST Annual Meeting, CHEST is piloting self-study bundles that will allow attendees to earn additional Continuing Medical Education/Continuing Education credits and American Board of Internal Medicine Maintenance of Certification points, apart from the total credits available for the overall meeting. Attendees will receive complimentary access to the eight self-study bundles, in which they will read articles and answer questions related to the articles, in the following areas:

• Pulmonary Hypertension

• Critical Care

• Sleep

• COPD

• Asthma

• Lung Cancer

• Interstitial Lung Disease

• Transplant

This value-added addition will offer the opportunity to earn three credits CME/CE and the corresponding number of ABIM MOC points for each bundle; if someone completes all eight bundles, they can earn up to 24 credits.

The deadline for completion of and claiming CME/CE for the self-study bundles is the same as the claiming deadline for the CHEST Annual Meeting, February 29, 2020.

This year, in conjunction with CHEST Annual Meeting, CHEST is piloting self-study bundles that will allow attendees to earn additional Continuing Medical Education/Continuing Education credits and American Board of Internal Medicine Maintenance of Certification points, apart from the total credits available for the overall meeting. Attendees will receive complimentary access to the eight self-study bundles, in which they will read articles and answer questions related to the articles, in the following areas:

• Pulmonary Hypertension

• Critical Care

• Sleep

• COPD

• Asthma

• Lung Cancer

• Interstitial Lung Disease

• Transplant

This value-added addition will offer the opportunity to earn three credits CME/CE and the corresponding number of ABIM MOC points for each bundle; if someone completes all eight bundles, they can earn up to 24 credits.

The deadline for completion of and claiming CME/CE for the self-study bundles is the same as the claiming deadline for the CHEST Annual Meeting, February 29, 2020.

Noninvasive ventilation (NIV) supports patient’s breathing without the immediate need for tracheotomy or intubation. The Center for Medicare and Medicaid Services (CMS) defines respiratory assist devices (RAD) as bi-level devices with back-up respiratory rate capability, which provide noninvasive modes of ventilation for respiratory insufficiency or sleep-related respiratory disorders in a home or hospital setting (21 CFR 868.5895). These devices are smaller in size with provision of the external battery (if needed) but limited by inability to offer daytime ventilatory mode (ie, mouthpiece ventilation). Currently, respiratory assist devices have been in DMEPOS Competitive Bidding Program since 2011, (similar to PAP devices for sleep apnea syndromes), which puts a 13-month capped rental in which the patient gets the device, supplies, and services for 13 months subsequent to which patient owns the device and supplies are paid separately by CMS (https://www.dmecompetitivebid.com/cbic/cbic.nsf/DocsCat/Home).

On the other hand, CMS defines home mechanical ventilators (HMV) as life supporting/sustaining devices for patients of all age groups used in various settings, included but not limited to home, hospital, institutional setting, transportation, or wherever portability is needed. The ventilators have increased portability due to external and internal battery, provision of mouthpiece ventilation, and at least six pressure modes and three volumes modes. Currently, the ventilators are under the frequently and substantially serviced act [42 U.S.C. § 1395m(a)(3)]. Under this act, the patient never owns the device but the device, ancillary supplies, clinical support (trained respiratory therapists), and servicing of the device are included in the monthly payments, which can last indefinitely. Thus, ventilators have both higher reimbursement rates and uncapped rental periods; beneficiaries not only pay higher monthly co-payments for these devices but also pay over a longer rental period. Nonetheless, these services are vital in keeping a certain subset of patients comfortable at home and out of higher cost settings. The current populations that directly benefit from this service are patients with polio, amyotrophic lateral sclerosis, muscular dystrophies, spinal muscle atrophy, thoracic restrictive disorder, and chronic hypercapnic respiratory failure due to COPD, to name a few. Thus, HMV has been vital in “freeing” these frail and vulnerable patient populations from their hospital beds, improving the quality of life, as well as mortality.

With the advent of technologic advancements, HMV, especially the noninvasive pressure support ventilator, is now capable of doing multiple modes, including CPAP, RAD modes, and ventilator modes. This could create a potential of abuse when the durable medical equipment supplier bills CMS for the ventilator but clinically, a lower cost CPAP, auto bi-level PAP, or RAD is indicated. The 2016 report from the Office of Inspector General (OIG) noted that CMS paid 85 times more claims for noninvasive pressure support ventilators in 2015 than in 2009 (from $3.8 million to $340 million). [https://tinyurl.com/y3ckskrb]. Expenditure increased from 2014 to 2015 alone accounted for 47% of the entire $337 million increase from 2009 to 2015. But, the report could not implicate reduced prices for CPAP devices and RADs under the Competitive Bidding Program to be driving increased billing for ventilators. They did find that the diagnoses used for these claims have shifted dramatically from neuromuscular diseases to other chronic respiratory conditions.

Since then, in January 2016, CMS consolidated billing codes for ventilators, and also reduced the reimbursement amount for noninvasive pressure support ventilators. After this change, between 2015 and 2016, median monthly rental rate of products decreased from $1,561 to $1,055; a reduction of 32% [https://tinyurl.com/y3ckskrb]. CMS presently is proposing to include HMV in the competitive bidding program to help with misuse and cost reduction. But proposed addition of the home ventilators in competitive bidding risks elimination of the vital services that are so important to keep a very “vulnerable and frail” population out of higher cost facilities. Because of this, CMS would see increased costs due to frequent emergency rooms visits, frequent intubations, intensive care unit stays, and admissions to long-term care at skilled nursing on one hand, but negatively impacting the quality of life of these patients on the other hand. This addition would have serious unintended consequences on Medicaid recipients, especially the pediatric population.

As a clinical guide, RADs are used for similar clinical conditions as HMV, but are meant for less severe respiratory conditions. Ideally, getting a RAD device for a patient should be governed by the physician’s clinical judgment rather than rigorous qualification criteria, nonetheless current RAD coverage policy in not only difficult but includes unnecessary qualification criteria, and as a result pushing the patient towards more costly ventilators. Unfortunately, CMS policies have not kept up with the technological advances of noninvasive ventilation. This has led to increased costs and utilization of noninvasive ventilators. In our opinion, including noninvasive ventilators in competitive bidding to reduce cost utilization is not the solution.

CMS needs to work with medical providers, beneficiaries, and various stakeholders to revise the current respiratory assist device and home mechanical ventilator guidelines in order to ensure that the appropriate patient is eligible for the correct device, without putting a very vulnerable patient population at risk.
 

Dr. Sahni is Clinical Assistant Professor, Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Illinois at Chicago; Dr. Wolfe is Associate Professor of Medicine (Pulmonary & Critical Care) and Neurology (Sleep Medicine), Northwestern University, Chicago, Illinois.

Noninvasive ventilation (NIV) supports patient’s breathing without the immediate need for tracheotomy or intubation. The Center for Medicare and Medicaid Services (CMS) defines respiratory assist devices (RAD) as bi-level devices with back-up respiratory rate capability, which provide noninvasive modes of ventilation for respiratory insufficiency or sleep-related respiratory disorders in a home or hospital setting (21 CFR 868.5895). These devices are smaller in size with provision of the external battery (if needed) but limited by inability to offer daytime ventilatory mode (ie, mouthpiece ventilation). Currently, respiratory assist devices have been in DMEPOS Competitive Bidding Program since 2011, (similar to PAP devices for sleep apnea syndromes), which puts a 13-month capped rental in which the patient gets the device, supplies, and services for 13 months subsequent to which patient owns the device and supplies are paid separately by CMS (https://www.dmecompetitivebid.com/cbic/cbic.nsf/DocsCat/Home).

On the other hand, CMS defines home mechanical ventilators (HMV) as life supporting/sustaining devices for patients of all age groups used in various settings, included but not limited to home, hospital, institutional setting, transportation, or wherever portability is needed. The ventilators have increased portability due to external and internal battery, provision of mouthpiece ventilation, and at least six pressure modes and three volumes modes. Currently, the ventilators are under the frequently and substantially serviced act [42 U.S.C. § 1395m(a)(3)]. Under this act, the patient never owns the device but the device, ancillary supplies, clinical support (trained respiratory therapists), and servicing of the device are included in the monthly payments, which can last indefinitely. Thus, ventilators have both higher reimbursement rates and uncapped rental periods; beneficiaries not only pay higher monthly co-payments for these devices but also pay over a longer rental period. Nonetheless, these services are vital in keeping a certain subset of patients comfortable at home and out of higher cost settings. The current populations that directly benefit from this service are patients with polio, amyotrophic lateral sclerosis, muscular dystrophies, spinal muscle atrophy, thoracic restrictive disorder, and chronic hypercapnic respiratory failure due to COPD, to name a few. Thus, HMV has been vital in “freeing” these frail and vulnerable patient populations from their hospital beds, improving the quality of life, as well as mortality.

With the advent of technologic advancements, HMV, especially the noninvasive pressure support ventilator, is now capable of doing multiple modes, including CPAP, RAD modes, and ventilator modes. This could create a potential of abuse when the durable medical equipment supplier bills CMS for the ventilator but clinically, a lower cost CPAP, auto bi-level PAP, or RAD is indicated. The 2016 report from the Office of Inspector General (OIG) noted that CMS paid 85 times more claims for noninvasive pressure support ventilators in 2015 than in 2009 (from $3.8 million to $340 million). [https://tinyurl.com/y3ckskrb]. Expenditure increased from 2014 to 2015 alone accounted for 47% of the entire $337 million increase from 2009 to 2015. But, the report could not implicate reduced prices for CPAP devices and RADs under the Competitive Bidding Program to be driving increased billing for ventilators. They did find that the diagnoses used for these claims have shifted dramatically from neuromuscular diseases to other chronic respiratory conditions.

Since then, in January 2016, CMS consolidated billing codes for ventilators, and also reduced the reimbursement amount for noninvasive pressure support ventilators. After this change, between 2015 and 2016, median monthly rental rate of products decreased from $1,561 to $1,055; a reduction of 32% [https://tinyurl.com/y3ckskrb]. CMS presently is proposing to include HMV in the competitive bidding program to help with misuse and cost reduction. But proposed addition of the home ventilators in competitive bidding risks elimination of the vital services that are so important to keep a very “vulnerable and frail” population out of higher cost facilities. Because of this, CMS would see increased costs due to frequent emergency rooms visits, frequent intubations, intensive care unit stays, and admissions to long-term care at skilled nursing on one hand, but negatively impacting the quality of life of these patients on the other hand. This addition would have serious unintended consequences on Medicaid recipients, especially the pediatric population.

As a clinical guide, RADs are used for similar clinical conditions as HMV, but are meant for less severe respiratory conditions. Ideally, getting a RAD device for a patient should be governed by the physician’s clinical judgment rather than rigorous qualification criteria, nonetheless current RAD coverage policy in not only difficult but includes unnecessary qualification criteria, and as a result pushing the patient towards more costly ventilators. Unfortunately, CMS policies have not kept up with the technological advances of noninvasive ventilation. This has led to increased costs and utilization of noninvasive ventilators. In our opinion, including noninvasive ventilators in competitive bidding to reduce cost utilization is not the solution.

CMS needs to work with medical providers, beneficiaries, and various stakeholders to revise the current respiratory assist device and home mechanical ventilator guidelines in order to ensure that the appropriate patient is eligible for the correct device, without putting a very vulnerable patient population at risk.
 

Dr. Sahni is Clinical Assistant Professor, Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Illinois at Chicago; Dr. Wolfe is Associate Professor of Medicine (Pulmonary & Critical Care) and Neurology (Sleep Medicine), Northwestern University, Chicago, Illinois.

Noninvasive ventilation (NIV) supports patient’s breathing without the immediate need for tracheotomy or intubation. The Center for Medicare and Medicaid Services (CMS) defines respiratory assist devices (RAD) as bi-level devices with back-up respiratory rate capability, which provide noninvasive modes of ventilation for respiratory insufficiency or sleep-related respiratory disorders in a home or hospital setting (21 CFR 868.5895). These devices are smaller in size with provision of the external battery (if needed) but limited by inability to offer daytime ventilatory mode (ie, mouthpiece ventilation). Currently, respiratory assist devices have been in DMEPOS Competitive Bidding Program since 2011, (similar to PAP devices for sleep apnea syndromes), which puts a 13-month capped rental in which the patient gets the device, supplies, and services for 13 months subsequent to which patient owns the device and supplies are paid separately by CMS (https://www.dmecompetitivebid.com/cbic/cbic.nsf/DocsCat/Home).

On the other hand, CMS defines home mechanical ventilators (HMV) as life supporting/sustaining devices for patients of all age groups used in various settings, included but not limited to home, hospital, institutional setting, transportation, or wherever portability is needed. The ventilators have increased portability due to external and internal battery, provision of mouthpiece ventilation, and at least six pressure modes and three volumes modes. Currently, the ventilators are under the frequently and substantially serviced act [42 U.S.C. § 1395m(a)(3)]. Under this act, the patient never owns the device but the device, ancillary supplies, clinical support (trained respiratory therapists), and servicing of the device are included in the monthly payments, which can last indefinitely. Thus, ventilators have both higher reimbursement rates and uncapped rental periods; beneficiaries not only pay higher monthly co-payments for these devices but also pay over a longer rental period. Nonetheless, these services are vital in keeping a certain subset of patients comfortable at home and out of higher cost settings. The current populations that directly benefit from this service are patients with polio, amyotrophic lateral sclerosis, muscular dystrophies, spinal muscle atrophy, thoracic restrictive disorder, and chronic hypercapnic respiratory failure due to COPD, to name a few. Thus, HMV has been vital in “freeing” these frail and vulnerable patient populations from their hospital beds, improving the quality of life, as well as mortality.

With the advent of technologic advancements, HMV, especially the noninvasive pressure support ventilator, is now capable of doing multiple modes, including CPAP, RAD modes, and ventilator modes. This could create a potential of abuse when the durable medical equipment supplier bills CMS for the ventilator but clinically, a lower cost CPAP, auto bi-level PAP, or RAD is indicated. The 2016 report from the Office of Inspector General (OIG) noted that CMS paid 85 times more claims for noninvasive pressure support ventilators in 2015 than in 2009 (from $3.8 million to $340 million). [https://tinyurl.com/y3ckskrb]. Expenditure increased from 2014 to 2015 alone accounted for 47% of the entire $337 million increase from 2009 to 2015. But, the report could not implicate reduced prices for CPAP devices and RADs under the Competitive Bidding Program to be driving increased billing for ventilators. They did find that the diagnoses used for these claims have shifted dramatically from neuromuscular diseases to other chronic respiratory conditions.

Since then, in January 2016, CMS consolidated billing codes for ventilators, and also reduced the reimbursement amount for noninvasive pressure support ventilators. After this change, between 2015 and 2016, median monthly rental rate of products decreased from $1,561 to $1,055; a reduction of 32% [https://tinyurl.com/y3ckskrb]. CMS presently is proposing to include HMV in the competitive bidding program to help with misuse and cost reduction. But proposed addition of the home ventilators in competitive bidding risks elimination of the vital services that are so important to keep a very “vulnerable and frail” population out of higher cost facilities. Because of this, CMS would see increased costs due to frequent emergency rooms visits, frequent intubations, intensive care unit stays, and admissions to long-term care at skilled nursing on one hand, but negatively impacting the quality of life of these patients on the other hand. This addition would have serious unintended consequences on Medicaid recipients, especially the pediatric population.

As a clinical guide, RADs are used for similar clinical conditions as HMV, but are meant for less severe respiratory conditions. Ideally, getting a RAD device for a patient should be governed by the physician’s clinical judgment rather than rigorous qualification criteria, nonetheless current RAD coverage policy in not only difficult but includes unnecessary qualification criteria, and as a result pushing the patient towards more costly ventilators. Unfortunately, CMS policies have not kept up with the technological advances of noninvasive ventilation. This has led to increased costs and utilization of noninvasive ventilators. In our opinion, including noninvasive ventilators in competitive bidding to reduce cost utilization is not the solution.

CMS needs to work with medical providers, beneficiaries, and various stakeholders to revise the current respiratory assist device and home mechanical ventilator guidelines in order to ensure that the appropriate patient is eligible for the correct device, without putting a very vulnerable patient population at risk.
 

Dr. Sahni is Clinical Assistant Professor, Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Illinois at Chicago; Dr. Wolfe is Associate Professor of Medicine (Pulmonary & Critical Care) and Neurology (Sleep Medicine), Northwestern University, Chicago, Illinois.

COMMENTARY

Rare Lung Disease Research: National Heart, Lung, and Blood Institute’s Commitment to Partnership and Progress.
By L. J. Vuga, et al



ORIGINAL RESEARCH

Validation of Predictive Metabolic Syndrome Biomarkers of World Trade Center Lung Injury: A 16-Year Longitudinal Study
By S. Kwon, et al.
 

Association of Short Sleep Duration and Atrial Fibrillation
By M. W. Genuardi, et al.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of 7 or More Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study 
By M. Hamilton, et al.

TOPICS IN PRACTICE MANAGEMENT

Clinician Strategies to Improve the Care of Patients Using Supplemental Oxygen
By S. S. Jacobs

COMMENTARY

Rare Lung Disease Research: National Heart, Lung, and Blood Institute’s Commitment to Partnership and Progress.
By L. J. Vuga, et al



ORIGINAL RESEARCH

Validation of Predictive Metabolic Syndrome Biomarkers of World Trade Center Lung Injury: A 16-Year Longitudinal Study
By S. Kwon, et al.
 

Association of Short Sleep Duration and Atrial Fibrillation
By M. W. Genuardi, et al.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of 7 or More Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study 
By M. Hamilton, et al.

TOPICS IN PRACTICE MANAGEMENT

Clinician Strategies to Improve the Care of Patients Using Supplemental Oxygen
By S. S. Jacobs

COMMENTARY

Rare Lung Disease Research: National Heart, Lung, and Blood Institute’s Commitment to Partnership and Progress.
By L. J. Vuga, et al



ORIGINAL RESEARCH

Validation of Predictive Metabolic Syndrome Biomarkers of World Trade Center Lung Injury: A 16-Year Longitudinal Study
By S. Kwon, et al.
 

Association of Short Sleep Duration and Atrial Fibrillation
By M. W. Genuardi, et al.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of 7 or More Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study 
By M. Hamilton, et al.

TOPICS IN PRACTICE MANAGEMENT

Clinician Strategies to Improve the Care of Patients Using Supplemental Oxygen
By S. S. Jacobs

Working as a clinician doesn’t always allow for extra time to focus on the wellness of your body and mind. After taking care of patients all day, it’s important to find the time to also take care of yourself.

This year’s CHEST’s Annual Meeting is introducing a new interactive experience that aims to provide physicians with the necessary tools to decompress from the stressors of work. Visit the CHEST Wellness Zone at CHEST Annual Meeting 2019 to learn easy methods to handle stress and relax after a long day at work.

CHEST 2019 attendees will learn tips and tricks geared toward improving health, and consultants will provide attendees with personalized methods to maintain a healthy lifestyle in the workplace and at home. For those who have yet to register for the annual meeting, this new initiative might change your mind.

At the Wellness Zone, you can relax while getting your feet massaged at one of the four massage machine stations. Clinicians are always on the go, and this station will help to relieve the pressures of being on your feet all day at work.

Essential oils will also be on display for you to smell. Experts will show you the best oil combinations to use in and out of the office.

With a daily strenuous workload, clinicians often forget about their own health, which can lead to poor posture. The Wellness Zone is equipped with consultants who will examine your posture to provide you with feedback to improve your stance. You will walk away after an evaluation with before and after pictures from your consult and a full posture analysis report.

Do you want to try meditation? There is a space dedicated to guiding you through a first-time practice equipped with headphones. You can visit this area to learn about guided meditation apps that make it easy to follow along when meditating at work and home.

The Wellness Zone will feature a variety of 15- to 30-minute sessions focused on providing you with the resources to create a new wellness routine after the annual meeting’s conclusion.

Geared toward improving both one’s physical and mental health, these sessions will dive deeper into maintaining a healthy lifestyle while at work and home. You will walk away from the Wellness Zone with new habits that you are encouraged to incorporate into your daily life to keep your stress levels down to avoid burnout.

The Wellness Zone will be located in the lobby/foyer space inside the New Orleans Ernest N. Morial Convention Center and will be open all day October 20-23, except for during the Opening Sessions. Attendees can visit the Wellness Zone at any time with no appointment necessary.

Visit chestmeeting.chestnet.org for a list of sessions that are offered in the Wellness Zone, including Creating Well-Being in the Workplace and more. Plan your visit now to enjoy all the benefits CHEST 2019 has to offer.

Working as a clinician doesn’t always allow for extra time to focus on the wellness of your body and mind. After taking care of patients all day, it’s important to find the time to also take care of yourself.

This year’s CHEST’s Annual Meeting is introducing a new interactive experience that aims to provide physicians with the necessary tools to decompress from the stressors of work. Visit the CHEST Wellness Zone at CHEST Annual Meeting 2019 to learn easy methods to handle stress and relax after a long day at work.

CHEST 2019 attendees will learn tips and tricks geared toward improving health, and consultants will provide attendees with personalized methods to maintain a healthy lifestyle in the workplace and at home. For those who have yet to register for the annual meeting, this new initiative might change your mind.

At the Wellness Zone, you can relax while getting your feet massaged at one of the four massage machine stations. Clinicians are always on the go, and this station will help to relieve the pressures of being on your feet all day at work.

Essential oils will also be on display for you to smell. Experts will show you the best oil combinations to use in and out of the office.

With a daily strenuous workload, clinicians often forget about their own health, which can lead to poor posture. The Wellness Zone is equipped with consultants who will examine your posture to provide you with feedback to improve your stance. You will walk away after an evaluation with before and after pictures from your consult and a full posture analysis report.

Do you want to try meditation? There is a space dedicated to guiding you through a first-time practice equipped with headphones. You can visit this area to learn about guided meditation apps that make it easy to follow along when meditating at work and home.

The Wellness Zone will feature a variety of 15- to 30-minute sessions focused on providing you with the resources to create a new wellness routine after the annual meeting’s conclusion.

Geared toward improving both one’s physical and mental health, these sessions will dive deeper into maintaining a healthy lifestyle while at work and home. You will walk away from the Wellness Zone with new habits that you are encouraged to incorporate into your daily life to keep your stress levels down to avoid burnout.

The Wellness Zone will be located in the lobby/foyer space inside the New Orleans Ernest N. Morial Convention Center and will be open all day October 20-23, except for during the Opening Sessions. Attendees can visit the Wellness Zone at any time with no appointment necessary.

Visit chestmeeting.chestnet.org for a list of sessions that are offered in the Wellness Zone, including Creating Well-Being in the Workplace and more. Plan your visit now to enjoy all the benefits CHEST 2019 has to offer.

Working as a clinician doesn’t always allow for extra time to focus on the wellness of your body and mind. After taking care of patients all day, it’s important to find the time to also take care of yourself.

This year’s CHEST’s Annual Meeting is introducing a new interactive experience that aims to provide physicians with the necessary tools to decompress from the stressors of work. Visit the CHEST Wellness Zone at CHEST Annual Meeting 2019 to learn easy methods to handle stress and relax after a long day at work.

CHEST 2019 attendees will learn tips and tricks geared toward improving health, and consultants will provide attendees with personalized methods to maintain a healthy lifestyle in the workplace and at home. For those who have yet to register for the annual meeting, this new initiative might change your mind.

At the Wellness Zone, you can relax while getting your feet massaged at one of the four massage machine stations. Clinicians are always on the go, and this station will help to relieve the pressures of being on your feet all day at work.

Essential oils will also be on display for you to smell. Experts will show you the best oil combinations to use in and out of the office.

With a daily strenuous workload, clinicians often forget about their own health, which can lead to poor posture. The Wellness Zone is equipped with consultants who will examine your posture to provide you with feedback to improve your stance. You will walk away after an evaluation with before and after pictures from your consult and a full posture analysis report.

Do you want to try meditation? There is a space dedicated to guiding you through a first-time practice equipped with headphones. You can visit this area to learn about guided meditation apps that make it easy to follow along when meditating at work and home.

The Wellness Zone will feature a variety of 15- to 30-minute sessions focused on providing you with the resources to create a new wellness routine after the annual meeting’s conclusion.

Geared toward improving both one’s physical and mental health, these sessions will dive deeper into maintaining a healthy lifestyle while at work and home. You will walk away from the Wellness Zone with new habits that you are encouraged to incorporate into your daily life to keep your stress levels down to avoid burnout.

The Wellness Zone will be located in the lobby/foyer space inside the New Orleans Ernest N. Morial Convention Center and will be open all day October 20-23, except for during the Opening Sessions. Attendees can visit the Wellness Zone at any time with no appointment necessary.

Visit chestmeeting.chestnet.org for a list of sessions that are offered in the Wellness Zone, including Creating Well-Being in the Workplace and more. Plan your visit now to enjoy all the benefits CHEST 2019 has to offer.

Occupational and Environmental Health

New guidelines for latent TB testing in health-care personnel

Latent infection with Mycobacterium tuberculosis (TB) infection is of public health concern because of the lifetime risk of reactivation, a risk highest in the first 2 years after TB infection. Treatment of latent TB infection (LTBI) reduces the risk of reactivation by as much as 90%, and, thus, screening for LTBI in high-risk populations can identify patients eligible for treatment (Horsburgh & Rubin. N Engl J Med. 2011;364[15]:1441). The Centers for Disease Control and Prevention (CDC) previously recommended annual testing for LTBI in health-care personnel (HCP) as a high-risk group for developing LTBI (Jensen et al. MMWR Recomm Rep. 2005;54[No. RR-17]).

The annual national TB rate in the United States has decreased by 73% since 1991 (Stewart et al. MMWR Morb Mortal Wkly Rep. 2018;67[11]:317), and surveillance data show that TB incidence among HCPs does not differ significantly from the general population. The CDC thus formed the National Tuberculosis Controllers Association (NTCA)-CDC work group to revisit the recommendations for LTBI screening in HCPs. A systematic evidence review of all studies of LTBI testing in HCPs since 2005 was performed. Analysis of data from identified studies showed that less than 5% of HCPs converted from baseline negative to positive on routine annual screening.

Based on this, the CDC updated their recommendations from the 2005 guidelines: (1) Serial annual LTBI testing is no longer routinely recommended for all HCPs but may be considered for select HCPs (eg, pulmonologists, infectious disease specialists, respiratory therapists); (2) Treatment is encouraged for all HCPs with positive LTBI testing, unless medically contraindicated; (3) The recommendations for baseline LTBI and postexposure testing in all HCPs remain unchanged (Sosa et al. MMWR Morb Mortal Wkly Rep. 2019;68[19]:439).

Sujith Cherian, MD, FCCP
Steering Committee Member

Amy Ahasic, MD, MPH, FCCP
Chair
 

Respiratory Care

Aerosol drug delivery via high-flow nasal cannula

As a noninvasive, easy-to-use oxygen device, high-flow nasal cannula (HFNC) meets patients’ inspiratory demands, increases functional residual capacity, and decreases the need for intubation (Rochwerg, et al. Intensive Care Med. 2019;45[5]:563).

Using HFNC for aerosol drug delivery is an innovative approach (Ari, et al. Pediatr Pulmonol. 2011;46[8]:795) and the seven most important things about aerosol delivery via HFNC are listed below for clinicians:

1. Aerosols can be delivered via HFNC in the treatment of patients with respiratory distress through all age groups.

2. Delivery efficiency of mesh nebulizers is greater than jet nebulizers during HFNC. Unlike jet nebulizers, they do not interfere with FiO2 and the function of HFNC by adding extra gas flow to the system.

3. Placing mesh nebulizers before the humidifier improves aerosol delivery via HFNC.

4. Higher inspiratory flow rates with HFNC decreases aerosol delivery due to increased turbulence and impactive loss of aerosols during therapy.

5. While aerosol deposition is greater with the larger prong sizes, its size should not block more than 50% of the cross-sectional area of each nostril to allow gas leakage around the cannula.

6. Although oxygen is commonly used with HFNC, administering aerosolized medications with heliox during HFNC improves lung deposition more than oxygen.

7. Training patients on the closed mouth technique and nasal breathing during therapy may improve aerosol drug delivery via HFNC.

HFNC is a promising tool in aerosol therapy, and developing clinical guidelines on aerosol delivery via HFNC is needed to improve its effectiveness in drug delivery.

Arzu Ari, PhD, RRT
Steering Committee Member

Jessica Overgoner, RRT
NetWork Member
 

Sleep Medicine

Statins in OSA

Obstructive sleep apnea is linked with cardiovascular disease (CVD) (Wolk R, et al. Circulation. 2003;108[1]:9), and the primary treatment of OSA, ie, continuous positive airway pressure (CPAP), may reverse the adverse CVD sequelae associated with OSA. However, recent randomized controlled trials, including SAVE and RICCADSA, fail to show significant reductions in CVD events with CPAP therapy (McEvoy RD, et al. J Thorac Dis. 2010;2[3]:138; Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613). Although numerous reasons are postulated for these unexpected trial findings, one potential explanation is that individuals in these trials were already on CVD protective drugs. One such drug category is statins. Statins are prescribed for their lipid lowering effects; however, they have pleiotropic properties including reduction in vascular inflammation and oxidative stress. Statins also enhance endothelial function and improve blood pressure. In animal studies, statins prevented the adverse effects of chronic intermittent hypoxemia on systolic blood pressure, endothelial function, and carotid artery compliance. Human studies confirm some of the aforementioned animal study findings. In a study of patients with OSA, statin therapy preserved the anti-inflammatory cell surface proteins that are typically reduced in these patients (Emin M, et al. Sci Transl Med. 2016;8[320]:320ra1). In a randomized controlled trial of patients with OSA, statin therapy significantly improved systolic blood pressure but did not improve reactive hyperemia index, which is a marker of endothelial dysfunction (Joyeux-Faure M, et al. Mediators Inflamm. 2014 Aug 25. doi: 10.1155/2014/423120).

Therefore, the jury is still out regarding the independent impact of statin therapy on CVD risk reduction in patients with OSA. Yet, there is select evidence suggesting there may be a role for statins in patients with OSA to mitigate the CVD risk associated with OSA. It remains unknown whether statins work synergistically with CPAP to further reduce CVD risk.

Neomi Shah, MD
Steering Committee Member

Occupational and Environmental Health

New guidelines for latent TB testing in health-care personnel

Latent infection with Mycobacterium tuberculosis (TB) infection is of public health concern because of the lifetime risk of reactivation, a risk highest in the first 2 years after TB infection. Treatment of latent TB infection (LTBI) reduces the risk of reactivation by as much as 90%, and, thus, screening for LTBI in high-risk populations can identify patients eligible for treatment (Horsburgh & Rubin. N Engl J Med. 2011;364[15]:1441). The Centers for Disease Control and Prevention (CDC) previously recommended annual testing for LTBI in health-care personnel (HCP) as a high-risk group for developing LTBI (Jensen et al. MMWR Recomm Rep. 2005;54[No. RR-17]).

The annual national TB rate in the United States has decreased by 73% since 1991 (Stewart et al. MMWR Morb Mortal Wkly Rep. 2018;67[11]:317), and surveillance data show that TB incidence among HCPs does not differ significantly from the general population. The CDC thus formed the National Tuberculosis Controllers Association (NTCA)-CDC work group to revisit the recommendations for LTBI screening in HCPs. A systematic evidence review of all studies of LTBI testing in HCPs since 2005 was performed. Analysis of data from identified studies showed that less than 5% of HCPs converted from baseline negative to positive on routine annual screening.

Based on this, the CDC updated their recommendations from the 2005 guidelines: (1) Serial annual LTBI testing is no longer routinely recommended for all HCPs but may be considered for select HCPs (eg, pulmonologists, infectious disease specialists, respiratory therapists); (2) Treatment is encouraged for all HCPs with positive LTBI testing, unless medically contraindicated; (3) The recommendations for baseline LTBI and postexposure testing in all HCPs remain unchanged (Sosa et al. MMWR Morb Mortal Wkly Rep. 2019;68[19]:439).

Sujith Cherian, MD, FCCP
Steering Committee Member

Amy Ahasic, MD, MPH, FCCP
Chair
 

Respiratory Care

Aerosol drug delivery via high-flow nasal cannula

As a noninvasive, easy-to-use oxygen device, high-flow nasal cannula (HFNC) meets patients’ inspiratory demands, increases functional residual capacity, and decreases the need for intubation (Rochwerg, et al. Intensive Care Med. 2019;45[5]:563).

Using HFNC for aerosol drug delivery is an innovative approach (Ari, et al. Pediatr Pulmonol. 2011;46[8]:795) and the seven most important things about aerosol delivery via HFNC are listed below for clinicians:

1. Aerosols can be delivered via HFNC in the treatment of patients with respiratory distress through all age groups.

2. Delivery efficiency of mesh nebulizers is greater than jet nebulizers during HFNC. Unlike jet nebulizers, they do not interfere with FiO2 and the function of HFNC by adding extra gas flow to the system.

3. Placing mesh nebulizers before the humidifier improves aerosol delivery via HFNC.

4. Higher inspiratory flow rates with HFNC decreases aerosol delivery due to increased turbulence and impactive loss of aerosols during therapy.

5. While aerosol deposition is greater with the larger prong sizes, its size should not block more than 50% of the cross-sectional area of each nostril to allow gas leakage around the cannula.

6. Although oxygen is commonly used with HFNC, administering aerosolized medications with heliox during HFNC improves lung deposition more than oxygen.

7. Training patients on the closed mouth technique and nasal breathing during therapy may improve aerosol drug delivery via HFNC.

HFNC is a promising tool in aerosol therapy, and developing clinical guidelines on aerosol delivery via HFNC is needed to improve its effectiveness in drug delivery.

Arzu Ari, PhD, RRT
Steering Committee Member

Jessica Overgoner, RRT
NetWork Member
 

Sleep Medicine

Statins in OSA

Obstructive sleep apnea is linked with cardiovascular disease (CVD) (Wolk R, et al. Circulation. 2003;108[1]:9), and the primary treatment of OSA, ie, continuous positive airway pressure (CPAP), may reverse the adverse CVD sequelae associated with OSA. However, recent randomized controlled trials, including SAVE and RICCADSA, fail to show significant reductions in CVD events with CPAP therapy (McEvoy RD, et al. J Thorac Dis. 2010;2[3]:138; Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613). Although numerous reasons are postulated for these unexpected trial findings, one potential explanation is that individuals in these trials were already on CVD protective drugs. One such drug category is statins. Statins are prescribed for their lipid lowering effects; however, they have pleiotropic properties including reduction in vascular inflammation and oxidative stress. Statins also enhance endothelial function and improve blood pressure. In animal studies, statins prevented the adverse effects of chronic intermittent hypoxemia on systolic blood pressure, endothelial function, and carotid artery compliance. Human studies confirm some of the aforementioned animal study findings. In a study of patients with OSA, statin therapy preserved the anti-inflammatory cell surface proteins that are typically reduced in these patients (Emin M, et al. Sci Transl Med. 2016;8[320]:320ra1). In a randomized controlled trial of patients with OSA, statin therapy significantly improved systolic blood pressure but did not improve reactive hyperemia index, which is a marker of endothelial dysfunction (Joyeux-Faure M, et al. Mediators Inflamm. 2014 Aug 25. doi: 10.1155/2014/423120).

Therefore, the jury is still out regarding the independent impact of statin therapy on CVD risk reduction in patients with OSA. Yet, there is select evidence suggesting there may be a role for statins in patients with OSA to mitigate the CVD risk associated with OSA. It remains unknown whether statins work synergistically with CPAP to further reduce CVD risk.

Neomi Shah, MD
Steering Committee Member

Occupational and Environmental Health

New guidelines for latent TB testing in health-care personnel

Latent infection with Mycobacterium tuberculosis (TB) infection is of public health concern because of the lifetime risk of reactivation, a risk highest in the first 2 years after TB infection. Treatment of latent TB infection (LTBI) reduces the risk of reactivation by as much as 90%, and, thus, screening for LTBI in high-risk populations can identify patients eligible for treatment (Horsburgh & Rubin. N Engl J Med. 2011;364[15]:1441). The Centers for Disease Control and Prevention (CDC) previously recommended annual testing for LTBI in health-care personnel (HCP) as a high-risk group for developing LTBI (Jensen et al. MMWR Recomm Rep. 2005;54[No. RR-17]).

The annual national TB rate in the United States has decreased by 73% since 1991 (Stewart et al. MMWR Morb Mortal Wkly Rep. 2018;67[11]:317), and surveillance data show that TB incidence among HCPs does not differ significantly from the general population. The CDC thus formed the National Tuberculosis Controllers Association (NTCA)-CDC work group to revisit the recommendations for LTBI screening in HCPs. A systematic evidence review of all studies of LTBI testing in HCPs since 2005 was performed. Analysis of data from identified studies showed that less than 5% of HCPs converted from baseline negative to positive on routine annual screening.

Based on this, the CDC updated their recommendations from the 2005 guidelines: (1) Serial annual LTBI testing is no longer routinely recommended for all HCPs but may be considered for select HCPs (eg, pulmonologists, infectious disease specialists, respiratory therapists); (2) Treatment is encouraged for all HCPs with positive LTBI testing, unless medically contraindicated; (3) The recommendations for baseline LTBI and postexposure testing in all HCPs remain unchanged (Sosa et al. MMWR Morb Mortal Wkly Rep. 2019;68[19]:439).

Sujith Cherian, MD, FCCP
Steering Committee Member

Amy Ahasic, MD, MPH, FCCP
Chair
 

Respiratory Care

Aerosol drug delivery via high-flow nasal cannula

As a noninvasive, easy-to-use oxygen device, high-flow nasal cannula (HFNC) meets patients’ inspiratory demands, increases functional residual capacity, and decreases the need for intubation (Rochwerg, et al. Intensive Care Med. 2019;45[5]:563).

Using HFNC for aerosol drug delivery is an innovative approach (Ari, et al. Pediatr Pulmonol. 2011;46[8]:795) and the seven most important things about aerosol delivery via HFNC are listed below for clinicians:

1. Aerosols can be delivered via HFNC in the treatment of patients with respiratory distress through all age groups.

2. Delivery efficiency of mesh nebulizers is greater than jet nebulizers during HFNC. Unlike jet nebulizers, they do not interfere with FiO2 and the function of HFNC by adding extra gas flow to the system.

3. Placing mesh nebulizers before the humidifier improves aerosol delivery via HFNC.

4. Higher inspiratory flow rates with HFNC decreases aerosol delivery due to increased turbulence and impactive loss of aerosols during therapy.

5. While aerosol deposition is greater with the larger prong sizes, its size should not block more than 50% of the cross-sectional area of each nostril to allow gas leakage around the cannula.

6. Although oxygen is commonly used with HFNC, administering aerosolized medications with heliox during HFNC improves lung deposition more than oxygen.

7. Training patients on the closed mouth technique and nasal breathing during therapy may improve aerosol drug delivery via HFNC.

HFNC is a promising tool in aerosol therapy, and developing clinical guidelines on aerosol delivery via HFNC is needed to improve its effectiveness in drug delivery.

Arzu Ari, PhD, RRT
Steering Committee Member

Jessica Overgoner, RRT
NetWork Member
 

Sleep Medicine

Statins in OSA

Obstructive sleep apnea is linked with cardiovascular disease (CVD) (Wolk R, et al. Circulation. 2003;108[1]:9), and the primary treatment of OSA, ie, continuous positive airway pressure (CPAP), may reverse the adverse CVD sequelae associated with OSA. However, recent randomized controlled trials, including SAVE and RICCADSA, fail to show significant reductions in CVD events with CPAP therapy (McEvoy RD, et al. J Thorac Dis. 2010;2[3]:138; Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613). Although numerous reasons are postulated for these unexpected trial findings, one potential explanation is that individuals in these trials were already on CVD protective drugs. One such drug category is statins. Statins are prescribed for their lipid lowering effects; however, they have pleiotropic properties including reduction in vascular inflammation and oxidative stress. Statins also enhance endothelial function and improve blood pressure. In animal studies, statins prevented the adverse effects of chronic intermittent hypoxemia on systolic blood pressure, endothelial function, and carotid artery compliance. Human studies confirm some of the aforementioned animal study findings. In a study of patients with OSA, statin therapy preserved the anti-inflammatory cell surface proteins that are typically reduced in these patients (Emin M, et al. Sci Transl Med. 2016;8[320]:320ra1). In a randomized controlled trial of patients with OSA, statin therapy significantly improved systolic blood pressure but did not improve reactive hyperemia index, which is a marker of endothelial dysfunction (Joyeux-Faure M, et al. Mediators Inflamm. 2014 Aug 25. doi: 10.1155/2014/423120).

Therefore, the jury is still out regarding the independent impact of statin therapy on CVD risk reduction in patients with OSA. Yet, there is select evidence suggesting there may be a role for statins in patients with OSA to mitigate the CVD risk associated with OSA. It remains unknown whether statins work synergistically with CPAP to further reduce CVD risk.

Neomi Shah, MD
Steering Committee Member