Society News

Disaster Response & Global Health Section

Responding to firearm violence in America

We think of disasters as sudden, calamitous events, but it does not take much imagination to recognize the loss of lives in America from firearm violence as a type of disaster. In 2020, 45,222 people died from gun-related injuries, an increase of 5,155 (14%) since 2019 (Kegler, et al. MMWR Morb Mortal Wkly Rep. 2022;71[19]:656). This is the highest death rate since 1994, and includes increases in both homicides and suicides. Mass shootings constitute a fraction of this total, but there have already been 530 deaths from mass shooting incidents in 2022.

Opinions about the appropriate degree of firearm regulations remain divided, but the need to improve our response as clinicians is clear. The National Center for Disaster Medicine and Public Health recently published consensus recommendations for healthcare response in mass shootings (Goolsby, et al. J Am Coll Surg. 2022; published online July 18, 2022). These recommendations address readiness training, triage, communications, public education, patient tracking, family reunification, and mental health services.

Stop the Bleed is a program originally based on the military’s Tactical Combat Casualty Care standards. It offers training on hemorrhage control for both the public and clinicians, similar to basic life support programs. It encourages bystanders to become trained and empowered to help in a bleeding emergency before professional help arrives. Opportunities for training are a frequent offering at the CHEST Annual Meeting, and additional information can be found at https://www.stopthebleed.org.

Stella Ogake, MD
Member-at-Large

Disaster Response & Global Health Section

Responding to firearm violence in America

We think of disasters as sudden, calamitous events, but it does not take much imagination to recognize the loss of lives in America from firearm violence as a type of disaster. In 2020, 45,222 people died from gun-related injuries, an increase of 5,155 (14%) since 2019 (Kegler, et al. MMWR Morb Mortal Wkly Rep. 2022;71[19]:656). This is the highest death rate since 1994, and includes increases in both homicides and suicides. Mass shootings constitute a fraction of this total, but there have already been 530 deaths from mass shooting incidents in 2022.

Opinions about the appropriate degree of firearm regulations remain divided, but the need to improve our response as clinicians is clear. The National Center for Disaster Medicine and Public Health recently published consensus recommendations for healthcare response in mass shootings (Goolsby, et al. J Am Coll Surg. 2022; published online July 18, 2022). These recommendations address readiness training, triage, communications, public education, patient tracking, family reunification, and mental health services.

Stop the Bleed is a program originally based on the military’s Tactical Combat Casualty Care standards. It offers training on hemorrhage control for both the public and clinicians, similar to basic life support programs. It encourages bystanders to become trained and empowered to help in a bleeding emergency before professional help arrives. Opportunities for training are a frequent offering at the CHEST Annual Meeting, and additional information can be found at https://www.stopthebleed.org.

Stella Ogake, MD
Member-at-Large

Disaster Response & Global Health Section

Responding to firearm violence in America

We think of disasters as sudden, calamitous events, but it does not take much imagination to recognize the loss of lives in America from firearm violence as a type of disaster. In 2020, 45,222 people died from gun-related injuries, an increase of 5,155 (14%) since 2019 (Kegler, et al. MMWR Morb Mortal Wkly Rep. 2022;71[19]:656). This is the highest death rate since 1994, and includes increases in both homicides and suicides. Mass shootings constitute a fraction of this total, but there have already been 530 deaths from mass shooting incidents in 2022.

Opinions about the appropriate degree of firearm regulations remain divided, but the need to improve our response as clinicians is clear. The National Center for Disaster Medicine and Public Health recently published consensus recommendations for healthcare response in mass shootings (Goolsby, et al. J Am Coll Surg. 2022; published online July 18, 2022). These recommendations address readiness training, triage, communications, public education, patient tracking, family reunification, and mental health services.

Stop the Bleed is a program originally based on the military’s Tactical Combat Casualty Care standards. It offers training on hemorrhage control for both the public and clinicians, similar to basic life support programs. It encourages bystanders to become trained and empowered to help in a bleeding emergency before professional help arrives. Opportunities for training are a frequent offering at the CHEST Annual Meeting, and additional information can be found at https://www.stopthebleed.org.

Stella Ogake, MD
Member-at-Large

This is an odd column for me to write. First, because of the nature of print publication, this writing for the November issue is being crafted just before the annual meeting is to be held in Nashville. Therefore, while I have a pretty good sense of what is in store for CHEST 2022, I have yet to see the final product, or the audience’s reaction to it. However, I will make some bold predictions as to what occurred therein:

• Even in the context of 3 years of separation, thousands CHEST members gathered in droves to rekindle friendships and to experience the best education in pulmonary, critical care, and sleep medicine that the world has to offer, leading to our second-biggest meeting ever.
• Neil Pasricha’s presentation helped attendees rekindle the “Art of Happiness.”
• Hundreds of attendees participated in, and successfully solved, our newest escape room, “Starship Relics.”
• Our valued CHEST members were able to successfully thwart Dr. Didactic and save the future of educational innovation.
• “CHEST After Hours” trended on social media and will become a normal and highly-anticipated part of the CHEST meeting moving forward.
• The most uncomfortable moment of the meeting centered on mayonnaise; for those of you who know what I am referencing, I am a little sorry…but only a little.
• Despite my best efforts, we were not able to recruit Neil Patrick Harris to participate.

Predicting the future of medical meetings is something we’ve spent a lot of time trying to do over the last year as we developed plans for CHEST 2022. But given the talented individuals involved in that planning, foreseeing the meeting’s success did not require any time travel; it was hardly a difficult task at all. Program Chair Subani Chandra and Vice-Chair Aneesa Das were exactly the people we needed at the helm for this all-important return to in-person meetings, and I cannot thank them enough for their creativity, effort, and leadership in bringing CHEST 2022 to fruition. And while I expect to have been seven-for-seven in my predictions above, I do hope I got that NPH one wrong.

The other reason that this column was a challenge to craft is because it represents my final formal presidential missive in these esteemed pages. And as I planned this final walk of the path, I gave careful consideration to the message with which I wanted to conclude my year. And as I put together my predictions for the future, my mind also turned to the past, considering things I wish I had known (or spent more time considering) as I started this journey. Some of this information may prove useful to the next generation of CHEST leaders, and some may be already well engrained for those of you with leadership experience. Here, in no particular order, are some thoughts for those of you in the audience who are considering future leadership opportunities at CHEST (or elsewhere in life; I suspect some of this advice is applicable to other venues). That said, the recommendations also come from yours truly, so take them with an appropriately large grain of salt, as your mileage may vary, and reasonable people could take issue here or there.

• The most important conversations should happen in person. The past 3 years have shown us the amazing things that modern technology can accomplish, but when it comes to providing important information, asking for input on a crucial issue, or providing feedback on a sensitive matter, there is no adequate substitute for a discussion in which all parties are in the same room.
• You are going to get things wrong sometimes; sometimes, this is because there wasn’t a way to get a right answer, and sometimes it will be because you tried something that didn’t work. You will learn far more from one of these experiences than from a dozen things that went as well as (or better than) expected.
• It is profoundly difficult to change someone’s mind if you aren’t interacting with them. I believe there is no gap so large that warrants breakdown of communication. Going that extra mile to talk to people who have a drastically different opinion than your own is the only way that you might be able to change someone’s mind and is a great way to ensure that your own opinion withstands pushback. With the growth of social media over the last decade, we’ve gotten very good at blocking people on social media; while this can sometimes be good (or even necessary) for emotional well-being, there can be value to interacting with such folks in a real-world environment.
• You do not have to bring everything to the table. The best leaders surround themselves with other really smart folks who, in aggregate, will provide support in areas in which you are deficient. That said, you need to know where these gaps in your knowledge and experience are, and when it is the right time to listen to those trusted advisors.
• When it comes time to identify folks for your “cabinet,” make sure to choose people who think differently than you and who may disagree with you on some fundamental things. Surrounding yourself with friends and close colleagues can lead to groupthink and poor decision making. The best results often stem from challenging and difficult decision-making processes.
• As a corollary to the above, every leader will bring their own sensibility and personality to the role. Make sure to bring yours, even if it involves silly jokes about holding a medical meeting in a former President’s basement or getting another former President to eat a big spoonful of the aforementioned condiment.
• Fun is important. Fun builds relationships, and teams, and trust. Make sure you are having it, as much as you possibly can, throughout your leadership tenure.

On that note, I will sign off for good, at least in these pages. I’ll still be bumbling around, proposing new educational experiences, hosting Pardon the Interruption, and serving as a sounding board for anyone who wants to chat. But I cannot wait to see what the next 3 years bring for our organization, under the leadership of Drs. Addrizzo-Harris, Buckley, and Howington. And for those of you who are just taking your first steps in leadership, and who will be following in their footsteps years down the road, I hope that you get just as much enjoyment from and fulfilment in the role of President as I have. #SchulmanOut

This is an odd column for me to write. First, because of the nature of print publication, this writing for the November issue is being crafted just before the annual meeting is to be held in Nashville. Therefore, while I have a pretty good sense of what is in store for CHEST 2022, I have yet to see the final product, or the audience’s reaction to it. However, I will make some bold predictions as to what occurred therein:

• Even in the context of 3 years of separation, thousands CHEST members gathered in droves to rekindle friendships and to experience the best education in pulmonary, critical care, and sleep medicine that the world has to offer, leading to our second-biggest meeting ever.
• Neil Pasricha’s presentation helped attendees rekindle the “Art of Happiness.”
• Hundreds of attendees participated in, and successfully solved, our newest escape room, “Starship Relics.”
• Our valued CHEST members were able to successfully thwart Dr. Didactic and save the future of educational innovation.
• “CHEST After Hours” trended on social media and will become a normal and highly-anticipated part of the CHEST meeting moving forward.
• The most uncomfortable moment of the meeting centered on mayonnaise; for those of you who know what I am referencing, I am a little sorry…but only a little.
• Despite my best efforts, we were not able to recruit Neil Patrick Harris to participate.

Predicting the future of medical meetings is something we’ve spent a lot of time trying to do over the last year as we developed plans for CHEST 2022. But given the talented individuals involved in that planning, foreseeing the meeting’s success did not require any time travel; it was hardly a difficult task at all. Program Chair Subani Chandra and Vice-Chair Aneesa Das were exactly the people we needed at the helm for this all-important return to in-person meetings, and I cannot thank them enough for their creativity, effort, and leadership in bringing CHEST 2022 to fruition. And while I expect to have been seven-for-seven in my predictions above, I do hope I got that NPH one wrong.

The other reason that this column was a challenge to craft is because it represents my final formal presidential missive in these esteemed pages. And as I planned this final walk of the path, I gave careful consideration to the message with which I wanted to conclude my year. And as I put together my predictions for the future, my mind also turned to the past, considering things I wish I had known (or spent more time considering) as I started this journey. Some of this information may prove useful to the next generation of CHEST leaders, and some may be already well engrained for those of you with leadership experience. Here, in no particular order, are some thoughts for those of you in the audience who are considering future leadership opportunities at CHEST (or elsewhere in life; I suspect some of this advice is applicable to other venues). That said, the recommendations also come from yours truly, so take them with an appropriately large grain of salt, as your mileage may vary, and reasonable people could take issue here or there.

• The most important conversations should happen in person. The past 3 years have shown us the amazing things that modern technology can accomplish, but when it comes to providing important information, asking for input on a crucial issue, or providing feedback on a sensitive matter, there is no adequate substitute for a discussion in which all parties are in the same room.
• You are going to get things wrong sometimes; sometimes, this is because there wasn’t a way to get a right answer, and sometimes it will be because you tried something that didn’t work. You will learn far more from one of these experiences than from a dozen things that went as well as (or better than) expected.
• It is profoundly difficult to change someone’s mind if you aren’t interacting with them. I believe there is no gap so large that warrants breakdown of communication. Going that extra mile to talk to people who have a drastically different opinion than your own is the only way that you might be able to change someone’s mind and is a great way to ensure that your own opinion withstands pushback. With the growth of social media over the last decade, we’ve gotten very good at blocking people on social media; while this can sometimes be good (or even necessary) for emotional well-being, there can be value to interacting with such folks in a real-world environment.
• You do not have to bring everything to the table. The best leaders surround themselves with other really smart folks who, in aggregate, will provide support in areas in which you are deficient. That said, you need to know where these gaps in your knowledge and experience are, and when it is the right time to listen to those trusted advisors.
• When it comes time to identify folks for your “cabinet,” make sure to choose people who think differently than you and who may disagree with you on some fundamental things. Surrounding yourself with friends and close colleagues can lead to groupthink and poor decision making. The best results often stem from challenging and difficult decision-making processes.
• As a corollary to the above, every leader will bring their own sensibility and personality to the role. Make sure to bring yours, even if it involves silly jokes about holding a medical meeting in a former President’s basement or getting another former President to eat a big spoonful of the aforementioned condiment.
• Fun is important. Fun builds relationships, and teams, and trust. Make sure you are having it, as much as you possibly can, throughout your leadership tenure.

On that note, I will sign off for good, at least in these pages. I’ll still be bumbling around, proposing new educational experiences, hosting Pardon the Interruption, and serving as a sounding board for anyone who wants to chat. But I cannot wait to see what the next 3 years bring for our organization, under the leadership of Drs. Addrizzo-Harris, Buckley, and Howington. And for those of you who are just taking your first steps in leadership, and who will be following in their footsteps years down the road, I hope that you get just as much enjoyment from and fulfilment in the role of President as I have. #SchulmanOut

This is an odd column for me to write. First, because of the nature of print publication, this writing for the November issue is being crafted just before the annual meeting is to be held in Nashville. Therefore, while I have a pretty good sense of what is in store for CHEST 2022, I have yet to see the final product, or the audience’s reaction to it. However, I will make some bold predictions as to what occurred therein:

• Even in the context of 3 years of separation, thousands CHEST members gathered in droves to rekindle friendships and to experience the best education in pulmonary, critical care, and sleep medicine that the world has to offer, leading to our second-biggest meeting ever.
• Neil Pasricha’s presentation helped attendees rekindle the “Art of Happiness.”
• Hundreds of attendees participated in, and successfully solved, our newest escape room, “Starship Relics.”
• Our valued CHEST members were able to successfully thwart Dr. Didactic and save the future of educational innovation.
• “CHEST After Hours” trended on social media and will become a normal and highly-anticipated part of the CHEST meeting moving forward.
• The most uncomfortable moment of the meeting centered on mayonnaise; for those of you who know what I am referencing, I am a little sorry…but only a little.
• Despite my best efforts, we were not able to recruit Neil Patrick Harris to participate.

Predicting the future of medical meetings is something we’ve spent a lot of time trying to do over the last year as we developed plans for CHEST 2022. But given the talented individuals involved in that planning, foreseeing the meeting’s success did not require any time travel; it was hardly a difficult task at all. Program Chair Subani Chandra and Vice-Chair Aneesa Das were exactly the people we needed at the helm for this all-important return to in-person meetings, and I cannot thank them enough for their creativity, effort, and leadership in bringing CHEST 2022 to fruition. And while I expect to have been seven-for-seven in my predictions above, I do hope I got that NPH one wrong.

The other reason that this column was a challenge to craft is because it represents my final formal presidential missive in these esteemed pages. And as I planned this final walk of the path, I gave careful consideration to the message with which I wanted to conclude my year. And as I put together my predictions for the future, my mind also turned to the past, considering things I wish I had known (or spent more time considering) as I started this journey. Some of this information may prove useful to the next generation of CHEST leaders, and some may be already well engrained for those of you with leadership experience. Here, in no particular order, are some thoughts for those of you in the audience who are considering future leadership opportunities at CHEST (or elsewhere in life; I suspect some of this advice is applicable to other venues). That said, the recommendations also come from yours truly, so take them with an appropriately large grain of salt, as your mileage may vary, and reasonable people could take issue here or there.

• The most important conversations should happen in person. The past 3 years have shown us the amazing things that modern technology can accomplish, but when it comes to providing important information, asking for input on a crucial issue, or providing feedback on a sensitive matter, there is no adequate substitute for a discussion in which all parties are in the same room.
• You are going to get things wrong sometimes; sometimes, this is because there wasn’t a way to get a right answer, and sometimes it will be because you tried something that didn’t work. You will learn far more from one of these experiences than from a dozen things that went as well as (or better than) expected.
• It is profoundly difficult to change someone’s mind if you aren’t interacting with them. I believe there is no gap so large that warrants breakdown of communication. Going that extra mile to talk to people who have a drastically different opinion than your own is the only way that you might be able to change someone’s mind and is a great way to ensure that your own opinion withstands pushback. With the growth of social media over the last decade, we’ve gotten very good at blocking people on social media; while this can sometimes be good (or even necessary) for emotional well-being, there can be value to interacting with such folks in a real-world environment.
• You do not have to bring everything to the table. The best leaders surround themselves with other really smart folks who, in aggregate, will provide support in areas in which you are deficient. That said, you need to know where these gaps in your knowledge and experience are, and when it is the right time to listen to those trusted advisors.
• When it comes time to identify folks for your “cabinet,” make sure to choose people who think differently than you and who may disagree with you on some fundamental things. Surrounding yourself with friends and close colleagues can lead to groupthink and poor decision making. The best results often stem from challenging and difficult decision-making processes.
• As a corollary to the above, every leader will bring their own sensibility and personality to the role. Make sure to bring yours, even if it involves silly jokes about holding a medical meeting in a former President’s basement or getting another former President to eat a big spoonful of the aforementioned condiment.
• Fun is important. Fun builds relationships, and teams, and trust. Make sure you are having it, as much as you possibly can, throughout your leadership tenure.

On that note, I will sign off for good, at least in these pages. I’ll still be bumbling around, proposing new educational experiences, hosting Pardon the Interruption, and serving as a sounding board for anyone who wants to chat. But I cannot wait to see what the next 3 years bring for our organization, under the leadership of Drs. Addrizzo-Harris, Buckley, and Howington. And for those of you who are just taking your first steps in leadership, and who will be following in their footsteps years down the road, I hope that you get just as much enjoyment from and fulfilment in the role of President as I have. #SchulmanOut

Estimates suggest that nearly 1 billion adults worldwide could have sleep apnea (Benjafield AV, et al. Lancet Respir Med. 2019;7[8]:687-698). Even with the current widespread use of portable sleep testing, cheap and innovative models of OSA care will need to be developed to address this growing epidemic. This fact is particularly true for communities with significant health disparities, as the evidence suggests diagnostic rates for OSA are extremely poor in these areas (Stansbury R, et al. J Clin Sleep Med. 2022;18[3]:817-824). Current models of care for OSA are predominantly outpatient based. Hospital sleep medicine offers a potential mechanism to capture patients with OSA who would otherwise go undiagnosed and potentially suffer adverse health outcomes from untreated disease.

What is hospital sleep medicine?

Hospital sleep medicine includes the evaluation and management of sleep disorders, including, but not limited to, insomnia, restless legs syndrome, and circadian rhythm disorders, in hospitalized patients. Our program centers around proactive screening and early recognition of sleep-disordered breathing (SDB). Patients at high risk for SDB are identified upon entry to the hospital. These individuals are educated about the disease process and how it impacts comorbid health conditions. Recommendations are provided to the primary team regarding the appropriate screening test for SDB; positive airway pressure trials; mask fitting and acclimation; and coordination with care management in the discharge process, including scheduling follow-up care and diagnostic sleep studies. This program has become an integral part of our comprehensive sleep program, which includes inpatient, outpatient, and sleep center care and utilizes a multidisciplinary team approach including sleep specialists, sleep technologists, respiratory therapists, nurses, information technology professionals, and discharge planners, as well as ambulatory sleep clinics and sleep laboratories.

Evidence for hospital sleep medicine

While there has been interest in hospital-based sleep medicine since 2000, the most well-validated clinical pathway was first described by Sharma and colleagues in 2015 (Sharma, et al. J Clin Sleep Med. 2015;11[7]:717-723). This initial application of a formal sleep program demonstrated a high prevalence of SDB in hospitalized adult patients and led to a substantial increase in SDB diagnoses in the system. Subsequent studies have demonstrated improved outcomes, particularly in patients with cardiopulmonary disease. For example, there are data to suggest that hospitalized patients with congestive heart failure or COPD have increased rates of readmission, and early diagnosis and intervention are associated with decreased rates of subsequent readmission and ED visits (Konikkara J, et al. Hosp Pract. 2016;44[1]:41-47; Sharma S, et al. Am J Cardiol. 2016;117[6]:940-945). Long-term data also suggest survival benefit (Sharma S, et al. Am J Med. 2017;130[10]:1184-1191). Adherence to inpatient PAP trials has also been shown to predict outpatient follow-up and adherence to PAP therapy (Sharma S, et al. Sleep Breath. 2022; published online June 18, 2022).

Establishing a team

Establishing a hospital sleep medicine program requires upfront investment and training and begins with educating key stakeholders. Support from executive administration and various departments including respiratory, sleep medicine, information technology, nursing, physicians, mid-level providers, and discharge planning is essential. Data are available, as outlined here, showing significant improvement in patient outcomes with a hospital sleep medicine program. This information can garner significant enthusiasm from leadership to support the initiation of a program. A more detailed account of key program elements, inpatient protocols, and technologies utilized is available in our recent review (Sharma S, Stansbury R. Chest. 2022;161[4]:1083-1091). Table 1 from this article is highlighted here and outlines the essential components (SEAT-COM) of our hospital sleep medicine model. While each component of this model is important, we stress the importance of care coordination, timely diagnostic testing, and treatment, as significant delays can lead to inadequate time for acclimatization and optimization of therapy. It is important to note that the practice of hospital sleep medicine does not supplant clinic-based approaches, but rather serves to facilitate and enhance outpatient diagnosis and treatment.

Current questions

Data to date suggest a hospital sleep medicine program positively influences important clinical endpoints in hospitalized patients identified to be at risk for SDB. However, much of the published research is based on retrospective and prospective analysis of established clinical programs. Further, most studies have been completed at large, urban-based academic medical centers. Our group has recently completed a validation study in our local rural population, but larger multicenter trials involving more diverse communities and health systems are needed to better understand outcomes and further refine the optimal timing of screening and intervention for SDB in hospitalized patients (Stansbury, et al. Sleep Breath. 2022; published online January 20, 2022).

A common question that arises is the program’s impact regarding payment for rendered service in the context of Medicare’s prospective payment system. Given that the program focuses on screening for SDB and does not utilize formal testing for diagnosis, there is no additional cost for diagnostic tests or procedural codes. Thus, the diagnosis-related group is not impacted (Sharma S, Stansbury R. Chest. 2022;161[4]:1083-1091). Importantly, hospital sleep medicine has the potential for cost savings given the reduction in hospital readmissions and decreased adverse events during a patient’s hospital stay. The economics of the initial investment in a hospital sleep program versus potential savings from improved patient outcomes warrants evaluation.
 

Conclusion

SDB is a prevalent disorder with potential deleterious impacts on a patient’s health. Despite this, it is underrecognized and, thus, undertreated. Hospital sleep medicine is a growing model of care that may expand our capability for early diagnosis and intervention. Studies have demonstrated benefits to patients, particularly those with cardiopulmonary disease. However, additional studies are required to further validate hospital-based sleep medicine in more diverse populations and environments.

Dr. Del Prado Rico and Dr. Stansbury are with the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Health Science Center North, West Virginia University. Dr. Stansbury is also with the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh.

Estimates suggest that nearly 1 billion adults worldwide could have sleep apnea (Benjafield AV, et al. Lancet Respir Med. 2019;7[8]:687-698). Even with the current widespread use of portable sleep testing, cheap and innovative models of OSA care will need to be developed to address this growing epidemic. This fact is particularly true for communities with significant health disparities, as the evidence suggests diagnostic rates for OSA are extremely poor in these areas (Stansbury R, et al. J Clin Sleep Med. 2022;18[3]:817-824). Current models of care for OSA are predominantly outpatient based. Hospital sleep medicine offers a potential mechanism to capture patients with OSA who would otherwise go undiagnosed and potentially suffer adverse health outcomes from untreated disease.

What is hospital sleep medicine?

Hospital sleep medicine includes the evaluation and management of sleep disorders, including, but not limited to, insomnia, restless legs syndrome, and circadian rhythm disorders, in hospitalized patients. Our program centers around proactive screening and early recognition of sleep-disordered breathing (SDB). Patients at high risk for SDB are identified upon entry to the hospital. These individuals are educated about the disease process and how it impacts comorbid health conditions. Recommendations are provided to the primary team regarding the appropriate screening test for SDB; positive airway pressure trials; mask fitting and acclimation; and coordination with care management in the discharge process, including scheduling follow-up care and diagnostic sleep studies. This program has become an integral part of our comprehensive sleep program, which includes inpatient, outpatient, and sleep center care and utilizes a multidisciplinary team approach including sleep specialists, sleep technologists, respiratory therapists, nurses, information technology professionals, and discharge planners, as well as ambulatory sleep clinics and sleep laboratories.

Evidence for hospital sleep medicine

While there has been interest in hospital-based sleep medicine since 2000, the most well-validated clinical pathway was first described by Sharma and colleagues in 2015 (Sharma, et al. J Clin Sleep Med. 2015;11[7]:717-723). This initial application of a formal sleep program demonstrated a high prevalence of SDB in hospitalized adult patients and led to a substantial increase in SDB diagnoses in the system. Subsequent studies have demonstrated improved outcomes, particularly in patients with cardiopulmonary disease. For example, there are data to suggest that hospitalized patients with congestive heart failure or COPD have increased rates of readmission, and early diagnosis and intervention are associated with decreased rates of subsequent readmission and ED visits (Konikkara J, et al. Hosp Pract. 2016;44[1]:41-47; Sharma S, et al. Am J Cardiol. 2016;117[6]:940-945). Long-term data also suggest survival benefit (Sharma S, et al. Am J Med. 2017;130[10]:1184-1191). Adherence to inpatient PAP trials has also been shown to predict outpatient follow-up and adherence to PAP therapy (Sharma S, et al. Sleep Breath. 2022; published online June 18, 2022).

Establishing a team

Establishing a hospital sleep medicine program requires upfront investment and training and begins with educating key stakeholders. Support from executive administration and various departments including respiratory, sleep medicine, information technology, nursing, physicians, mid-level providers, and discharge planning is essential. Data are available, as outlined here, showing significant improvement in patient outcomes with a hospital sleep medicine program. This information can garner significant enthusiasm from leadership to support the initiation of a program. A more detailed account of key program elements, inpatient protocols, and technologies utilized is available in our recent review (Sharma S, Stansbury R. Chest. 2022;161[4]:1083-1091). Table 1 from this article is highlighted here and outlines the essential components (SEAT-COM) of our hospital sleep medicine model. While each component of this model is important, we stress the importance of care coordination, timely diagnostic testing, and treatment, as significant delays can lead to inadequate time for acclimatization and optimization of therapy. It is important to note that the practice of hospital sleep medicine does not supplant clinic-based approaches, but rather serves to facilitate and enhance outpatient diagnosis and treatment.

Current questions

Data to date suggest a hospital sleep medicine program positively influences important clinical endpoints in hospitalized patients identified to be at risk for SDB. However, much of the published research is based on retrospective and prospective analysis of established clinical programs. Further, most studies have been completed at large, urban-based academic medical centers. Our group has recently completed a validation study in our local rural population, but larger multicenter trials involving more diverse communities and health systems are needed to better understand outcomes and further refine the optimal timing of screening and intervention for SDB in hospitalized patients (Stansbury, et al. Sleep Breath. 2022; published online January 20, 2022).

A common question that arises is the program’s impact regarding payment for rendered service in the context of Medicare’s prospective payment system. Given that the program focuses on screening for SDB and does not utilize formal testing for diagnosis, there is no additional cost for diagnostic tests or procedural codes. Thus, the diagnosis-related group is not impacted (Sharma S, Stansbury R. Chest. 2022;161[4]:1083-1091). Importantly, hospital sleep medicine has the potential for cost savings given the reduction in hospital readmissions and decreased adverse events during a patient’s hospital stay. The economics of the initial investment in a hospital sleep program versus potential savings from improved patient outcomes warrants evaluation.
 

Conclusion

SDB is a prevalent disorder with potential deleterious impacts on a patient’s health. Despite this, it is underrecognized and, thus, undertreated. Hospital sleep medicine is a growing model of care that may expand our capability for early diagnosis and intervention. Studies have demonstrated benefits to patients, particularly those with cardiopulmonary disease. However, additional studies are required to further validate hospital-based sleep medicine in more diverse populations and environments.

Dr. Del Prado Rico and Dr. Stansbury are with the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Health Science Center North, West Virginia University. Dr. Stansbury is also with the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh.

Estimates suggest that nearly 1 billion adults worldwide could have sleep apnea (Benjafield AV, et al. Lancet Respir Med. 2019;7[8]:687-698). Even with the current widespread use of portable sleep testing, cheap and innovative models of OSA care will need to be developed to address this growing epidemic. This fact is particularly true for communities with significant health disparities, as the evidence suggests diagnostic rates for OSA are extremely poor in these areas (Stansbury R, et al. J Clin Sleep Med. 2022;18[3]:817-824). Current models of care for OSA are predominantly outpatient based. Hospital sleep medicine offers a potential mechanism to capture patients with OSA who would otherwise go undiagnosed and potentially suffer adverse health outcomes from untreated disease.

What is hospital sleep medicine?

Hospital sleep medicine includes the evaluation and management of sleep disorders, including, but not limited to, insomnia, restless legs syndrome, and circadian rhythm disorders, in hospitalized patients. Our program centers around proactive screening and early recognition of sleep-disordered breathing (SDB). Patients at high risk for SDB are identified upon entry to the hospital. These individuals are educated about the disease process and how it impacts comorbid health conditions. Recommendations are provided to the primary team regarding the appropriate screening test for SDB; positive airway pressure trials; mask fitting and acclimation; and coordination with care management in the discharge process, including scheduling follow-up care and diagnostic sleep studies. This program has become an integral part of our comprehensive sleep program, which includes inpatient, outpatient, and sleep center care and utilizes a multidisciplinary team approach including sleep specialists, sleep technologists, respiratory therapists, nurses, information technology professionals, and discharge planners, as well as ambulatory sleep clinics and sleep laboratories.

Evidence for hospital sleep medicine

While there has been interest in hospital-based sleep medicine since 2000, the most well-validated clinical pathway was first described by Sharma and colleagues in 2015 (Sharma, et al. J Clin Sleep Med. 2015;11[7]:717-723). This initial application of a formal sleep program demonstrated a high prevalence of SDB in hospitalized adult patients and led to a substantial increase in SDB diagnoses in the system. Subsequent studies have demonstrated improved outcomes, particularly in patients with cardiopulmonary disease. For example, there are data to suggest that hospitalized patients with congestive heart failure or COPD have increased rates of readmission, and early diagnosis and intervention are associated with decreased rates of subsequent readmission and ED visits (Konikkara J, et al. Hosp Pract. 2016;44[1]:41-47; Sharma S, et al. Am J Cardiol. 2016;117[6]:940-945). Long-term data also suggest survival benefit (Sharma S, et al. Am J Med. 2017;130[10]:1184-1191). Adherence to inpatient PAP trials has also been shown to predict outpatient follow-up and adherence to PAP therapy (Sharma S, et al. Sleep Breath. 2022; published online June 18, 2022).

Establishing a team

Establishing a hospital sleep medicine program requires upfront investment and training and begins with educating key stakeholders. Support from executive administration and various departments including respiratory, sleep medicine, information technology, nursing, physicians, mid-level providers, and discharge planning is essential. Data are available, as outlined here, showing significant improvement in patient outcomes with a hospital sleep medicine program. This information can garner significant enthusiasm from leadership to support the initiation of a program. A more detailed account of key program elements, inpatient protocols, and technologies utilized is available in our recent review (Sharma S, Stansbury R. Chest. 2022;161[4]:1083-1091). Table 1 from this article is highlighted here and outlines the essential components (SEAT-COM) of our hospital sleep medicine model. While each component of this model is important, we stress the importance of care coordination, timely diagnostic testing, and treatment, as significant delays can lead to inadequate time for acclimatization and optimization of therapy. It is important to note that the practice of hospital sleep medicine does not supplant clinic-based approaches, but rather serves to facilitate and enhance outpatient diagnosis and treatment.

Current questions

Data to date suggest a hospital sleep medicine program positively influences important clinical endpoints in hospitalized patients identified to be at risk for SDB. However, much of the published research is based on retrospective and prospective analysis of established clinical programs. Further, most studies have been completed at large, urban-based academic medical centers. Our group has recently completed a validation study in our local rural population, but larger multicenter trials involving more diverse communities and health systems are needed to better understand outcomes and further refine the optimal timing of screening and intervention for SDB in hospitalized patients (Stansbury, et al. Sleep Breath. 2022; published online January 20, 2022).

A common question that arises is the program’s impact regarding payment for rendered service in the context of Medicare’s prospective payment system. Given that the program focuses on screening for SDB and does not utilize formal testing for diagnosis, there is no additional cost for diagnostic tests or procedural codes. Thus, the diagnosis-related group is not impacted (Sharma S, Stansbury R. Chest. 2022;161[4]:1083-1091). Importantly, hospital sleep medicine has the potential for cost savings given the reduction in hospital readmissions and decreased adverse events during a patient’s hospital stay. The economics of the initial investment in a hospital sleep program versus potential savings from improved patient outcomes warrants evaluation.
 

Conclusion

SDB is a prevalent disorder with potential deleterious impacts on a patient’s health. Despite this, it is underrecognized and, thus, undertreated. Hospital sleep medicine is a growing model of care that may expand our capability for early diagnosis and intervention. Studies have demonstrated benefits to patients, particularly those with cardiopulmonary disease. However, additional studies are required to further validate hospital-based sleep medicine in more diverse populations and environments.

Dr. Del Prado Rico and Dr. Stansbury are with the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Health Science Center North, West Virginia University. Dr. Stansbury is also with the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh.

Vaccine recommendations for your patients with IBD

It’s cold and flu season – are your patients with inflammatory bowel disease (IBD) properly informed about increased risk of infections?

It is especially important for patients with IBD to receive the flu vaccine every year. With IBD, you can only get the shot (and not the spray in the nose).

The AGA GI Patient Center provides additional recommendations about vaccines in adults with IBD. Talk to your patients with IBD about what vaccines are needed for their treatment regimen, age and sex.

Review vaccines and vaccine-preventable diseases the patient had when first diagnosed with IBD, no matter the age and continue discussing vaccines during regular health care visits.

Give patients vaccine(s) for infections they are not immune as soon as possible.

Make sure patients are up to date or receive any live vaccines prior to starting some immunosuppressive treatments, such as biologics.
 

Help drive HCV testing, treatment, and eradication

AGA has been working with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention to help drive the national priority for hepatitis C virus (HCV) testing, treatment and eradication.

Updates to QPP measure 400

In July 2022, CMS contacted AGA to modify measure 400 – to update the coverage for one-time screening for HCV to include a referral for treatment for patients with positive antibodies. CMS also advised that confirmation of eradication is a priority and we have started working with the CDC to modify AGA’s sustained virologic response measure for future consideration in the Quality Payment Program.

The modifications to measure 400 have been drafted and given the substantial changes to the measure specification, the measure needs to be retested and submitted to the National Quality Forum for consideration by the Measures Application Partnership. The CMS contractor for this project, Mathematica, will be leading this testing initiative and selected test sites will qualify for up to $2,000 to participate.

Additionally, there will be a second phase of testing to use deidentified patient-level data to assess the measure’s validity and reliability, which will be contracted separately. Our hope is that testing sites recruited for the first phase of testing will stay on through the second phase.

Participants in the second phase of testing are expected to have at least 2 years of patient data available containing data elements needed to calculate the measure. Ideally, each of the participating clinicians at the prospective testing sites would see at least 40 confirmed HCV-positive cases annually.

Vaccine recommendations for your patients with IBD

It’s cold and flu season – are your patients with inflammatory bowel disease (IBD) properly informed about increased risk of infections?

It is especially important for patients with IBD to receive the flu vaccine every year. With IBD, you can only get the shot (and not the spray in the nose).

The AGA GI Patient Center provides additional recommendations about vaccines in adults with IBD. Talk to your patients with IBD about what vaccines are needed for their treatment regimen, age and sex.

Review vaccines and vaccine-preventable diseases the patient had when first diagnosed with IBD, no matter the age and continue discussing vaccines during regular health care visits.

Give patients vaccine(s) for infections they are not immune as soon as possible.

Make sure patients are up to date or receive any live vaccines prior to starting some immunosuppressive treatments, such as biologics.
 

Help drive HCV testing, treatment, and eradication

AGA has been working with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention to help drive the national priority for hepatitis C virus (HCV) testing, treatment and eradication.

Updates to QPP measure 400

In July 2022, CMS contacted AGA to modify measure 400 – to update the coverage for one-time screening for HCV to include a referral for treatment for patients with positive antibodies. CMS also advised that confirmation of eradication is a priority and we have started working with the CDC to modify AGA’s sustained virologic response measure for future consideration in the Quality Payment Program.

The modifications to measure 400 have been drafted and given the substantial changes to the measure specification, the measure needs to be retested and submitted to the National Quality Forum for consideration by the Measures Application Partnership. The CMS contractor for this project, Mathematica, will be leading this testing initiative and selected test sites will qualify for up to $2,000 to participate.

Additionally, there will be a second phase of testing to use deidentified patient-level data to assess the measure’s validity and reliability, which will be contracted separately. Our hope is that testing sites recruited for the first phase of testing will stay on through the second phase.

Participants in the second phase of testing are expected to have at least 2 years of patient data available containing data elements needed to calculate the measure. Ideally, each of the participating clinicians at the prospective testing sites would see at least 40 confirmed HCV-positive cases annually.

Vaccine recommendations for your patients with IBD

It’s cold and flu season – are your patients with inflammatory bowel disease (IBD) properly informed about increased risk of infections?

It is especially important for patients with IBD to receive the flu vaccine every year. With IBD, you can only get the shot (and not the spray in the nose).

The AGA GI Patient Center provides additional recommendations about vaccines in adults with IBD. Talk to your patients with IBD about what vaccines are needed for their treatment regimen, age and sex.

Review vaccines and vaccine-preventable diseases the patient had when first diagnosed with IBD, no matter the age and continue discussing vaccines during regular health care visits.

Give patients vaccine(s) for infections they are not immune as soon as possible.

Make sure patients are up to date or receive any live vaccines prior to starting some immunosuppressive treatments, such as biologics.
 

Help drive HCV testing, treatment, and eradication

AGA has been working with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention to help drive the national priority for hepatitis C virus (HCV) testing, treatment and eradication.

Updates to QPP measure 400

In July 2022, CMS contacted AGA to modify measure 400 – to update the coverage for one-time screening for HCV to include a referral for treatment for patients with positive antibodies. CMS also advised that confirmation of eradication is a priority and we have started working with the CDC to modify AGA’s sustained virologic response measure for future consideration in the Quality Payment Program.

The modifications to measure 400 have been drafted and given the substantial changes to the measure specification, the measure needs to be retested and submitted to the National Quality Forum for consideration by the Measures Application Partnership. The CMS contractor for this project, Mathematica, will be leading this testing initiative and selected test sites will qualify for up to $2,000 to participate.

Additionally, there will be a second phase of testing to use deidentified patient-level data to assess the measure’s validity and reliability, which will be contracted separately. Our hope is that testing sites recruited for the first phase of testing will stay on through the second phase.

Participants in the second phase of testing are expected to have at least 2 years of patient data available containing data elements needed to calculate the measure. Ideally, each of the participating clinicians at the prospective testing sites would see at least 40 confirmed HCV-positive cases annually.

Each year, the AGA Research Foundation provides research funding to transform the lives of talented investigators.

What will the practice of gastroenterology look like in 20 years? It is our hope that physicians have an abundance of new tools and treatments to care for their patients suffering from digestive disorders.

How will we get there? New treatments and devices are the result of years of research.

To help make this dream a reality, AGA – through the AGA Research Foundation – has made a commitment to support investigators in GI and hepatology with its Research Awards Program. In the past year, the AGA Research Foundation provided $2.5 million in research funding to 61 highly qualified investigators. These diverse researchers range from young investigators to more seasoned leaders in GI, all embarking on novel research projects that will advance our understanding of digestive conditions and pave the way for future discoveries in the field.

The AGA Research Foundation sincerely thanks all of its donors – without their contributions, this work wouldn’t be possible.

You can help spark the scientific breakthroughs of today so clinicians will have the tools to improve care tomorrow. Donate your tax-deductible gift today at www.gastro.org/donateonline.

Each year, the AGA Research Foundation provides research funding to transform the lives of talented investigators.

What will the practice of gastroenterology look like in 20 years? It is our hope that physicians have an abundance of new tools and treatments to care for their patients suffering from digestive disorders.

How will we get there? New treatments and devices are the result of years of research.

To help make this dream a reality, AGA – through the AGA Research Foundation – has made a commitment to support investigators in GI and hepatology with its Research Awards Program. In the past year, the AGA Research Foundation provided $2.5 million in research funding to 61 highly qualified investigators. These diverse researchers range from young investigators to more seasoned leaders in GI, all embarking on novel research projects that will advance our understanding of digestive conditions and pave the way for future discoveries in the field.

The AGA Research Foundation sincerely thanks all of its donors – without their contributions, this work wouldn’t be possible.

You can help spark the scientific breakthroughs of today so clinicians will have the tools to improve care tomorrow. Donate your tax-deductible gift today at www.gastro.org/donateonline.

Each year, the AGA Research Foundation provides research funding to transform the lives of talented investigators.

What will the practice of gastroenterology look like in 20 years? It is our hope that physicians have an abundance of new tools and treatments to care for their patients suffering from digestive disorders.

How will we get there? New treatments and devices are the result of years of research.

To help make this dream a reality, AGA – through the AGA Research Foundation – has made a commitment to support investigators in GI and hepatology with its Research Awards Program. In the past year, the AGA Research Foundation provided $2.5 million in research funding to 61 highly qualified investigators. These diverse researchers range from young investigators to more seasoned leaders in GI, all embarking on novel research projects that will advance our understanding of digestive conditions and pave the way for future discoveries in the field.

The AGA Research Foundation sincerely thanks all of its donors – without their contributions, this work wouldn’t be possible.

You can help spark the scientific breakthroughs of today so clinicians will have the tools to improve care tomorrow. Donate your tax-deductible gift today at www.gastro.org/donateonline.

The Intersociety Group on Diversity, in partnership with researchers at the University of California, Los Angeles, released results of the first study of its kind to explore perspectives on workforce diversity and health equity among practicing GI and hepatology professionals.

The report — Diversity, Equity, and Inclusion in GI and Hepatology: A Survey of Where We Stand — was published jointly in Gastroenterology, Gastrointestinal Endoscopy, HEPATOLOGY, and The American Journal of Gastroenterology. An executive summary is also available in the Journal of Pediatric Gastroenterology and Nutrition.
 

Key findings:

1. Many are complacent with current levels of diversity. Despite the well-recognized under-representation of certain racial and ethnic groups in GI/hepatology, a small proportion of survey participants (one-third or fewer) felt that racial/ethnic representation was insufficient in the educational/training pipeline, among practicing professionals, or in GI/hepatology leadership. There was a clear discrepancy in satisfaction with workplace diversity among GI and hepatology physicians by race and ethnicity: Overall, 63% of Black physicians were very or somewhat unsatisfied with workplace diversity, whereas 78% of White physicians were very or somewhat satisfied.

2. Interventions are needed. Among those who recommended interventions to enhance racial and gender diversity in the profession, the most common suggestions were to increase the following:

• Mentorship opportunities for resident and medical students who are women or from racial and ethnic populations underrepresented in medicine relative to their numbers in the general population. These groups have traditionally included Latino (i.e., Latino/a/x), Black/African American, Native American individuals (namely, American Indians, Alaska Natives, and Native Hawaiians), Pacific Islanders, and mainland Puerto Ricans.
• Representation of underrepresented in medicine GI/hepatology professionals in academic and professional society leadership.

More than 1,200 individuals participated in this nationwide, cross-sectional, 33-question survey. The survey was developed by University of California, Los Angeles investigators Folasade P. May, MD, PhD, MPhil; Harman Rahal, MD; James H. Tabibian, MD, PhD; and Liu Yang, PhD. The IGD, co-chaired at the time by Darrell M. Gray, II, MD, MPH, and Rachel Issaka, MD, MAS, provided input and facilitated survey distribution.


 

The Intersociety Group on Diversity, in partnership with researchers at the University of California, Los Angeles, released results of the first study of its kind to explore perspectives on workforce diversity and health equity among practicing GI and hepatology professionals.

The report — Diversity, Equity, and Inclusion in GI and Hepatology: A Survey of Where We Stand — was published jointly in Gastroenterology, Gastrointestinal Endoscopy, HEPATOLOGY, and The American Journal of Gastroenterology. An executive summary is also available in the Journal of Pediatric Gastroenterology and Nutrition.
 

Key findings:

1. Many are complacent with current levels of diversity. Despite the well-recognized under-representation of certain racial and ethnic groups in GI/hepatology, a small proportion of survey participants (one-third or fewer) felt that racial/ethnic representation was insufficient in the educational/training pipeline, among practicing professionals, or in GI/hepatology leadership. There was a clear discrepancy in satisfaction with workplace diversity among GI and hepatology physicians by race and ethnicity: Overall, 63% of Black physicians were very or somewhat unsatisfied with workplace diversity, whereas 78% of White physicians were very or somewhat satisfied.

2. Interventions are needed. Among those who recommended interventions to enhance racial and gender diversity in the profession, the most common suggestions were to increase the following:

• Mentorship opportunities for resident and medical students who are women or from racial and ethnic populations underrepresented in medicine relative to their numbers in the general population. These groups have traditionally included Latino (i.e., Latino/a/x), Black/African American, Native American individuals (namely, American Indians, Alaska Natives, and Native Hawaiians), Pacific Islanders, and mainland Puerto Ricans.
• Representation of underrepresented in medicine GI/hepatology professionals in academic and professional society leadership.

More than 1,200 individuals participated in this nationwide, cross-sectional, 33-question survey. The survey was developed by University of California, Los Angeles investigators Folasade P. May, MD, PhD, MPhil; Harman Rahal, MD; James H. Tabibian, MD, PhD; and Liu Yang, PhD. The IGD, co-chaired at the time by Darrell M. Gray, II, MD, MPH, and Rachel Issaka, MD, MAS, provided input and facilitated survey distribution.


 

The Intersociety Group on Diversity, in partnership with researchers at the University of California, Los Angeles, released results of the first study of its kind to explore perspectives on workforce diversity and health equity among practicing GI and hepatology professionals.

The report — Diversity, Equity, and Inclusion in GI and Hepatology: A Survey of Where We Stand — was published jointly in Gastroenterology, Gastrointestinal Endoscopy, HEPATOLOGY, and The American Journal of Gastroenterology. An executive summary is also available in the Journal of Pediatric Gastroenterology and Nutrition.
 

Key findings:

1. Many are complacent with current levels of diversity. Despite the well-recognized under-representation of certain racial and ethnic groups in GI/hepatology, a small proportion of survey participants (one-third or fewer) felt that racial/ethnic representation was insufficient in the educational/training pipeline, among practicing professionals, or in GI/hepatology leadership. There was a clear discrepancy in satisfaction with workplace diversity among GI and hepatology physicians by race and ethnicity: Overall, 63% of Black physicians were very or somewhat unsatisfied with workplace diversity, whereas 78% of White physicians were very or somewhat satisfied.

2. Interventions are needed. Among those who recommended interventions to enhance racial and gender diversity in the profession, the most common suggestions were to increase the following:

• Mentorship opportunities for resident and medical students who are women or from racial and ethnic populations underrepresented in medicine relative to their numbers in the general population. These groups have traditionally included Latino (i.e., Latino/a/x), Black/African American, Native American individuals (namely, American Indians, Alaska Natives, and Native Hawaiians), Pacific Islanders, and mainland Puerto Ricans.
• Representation of underrepresented in medicine GI/hepatology professionals in academic and professional society leadership.

More than 1,200 individuals participated in this nationwide, cross-sectional, 33-question survey. The survey was developed by University of California, Los Angeles investigators Folasade P. May, MD, PhD, MPhil; Harman Rahal, MD; James H. Tabibian, MD, PhD; and Liu Yang, PhD. The IGD, co-chaired at the time by Darrell M. Gray, II, MD, MPH, and Rachel Issaka, MD, MAS, provided input and facilitated survey distribution.


 

Everyone at AGA sends our congratulations to AGA President John Carethers, MD, AGAF, on his appointment as the vice chancellor for health sciences at the University of California San Diego.

Dr. Carethers, who began his term as the 117th president of the AGA Institute on June 1, 2022, is returning to UC San Diego after a 13-year tenure at the University of Michigan. He will report directly to the chancellor and serve as a part of the leadership team, effective Jan. 1, 2023.

Aside from his new role at UCSD, Dr. Carethers has been an active member of AGA for more than 20 years and has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee.

We wish him well in this new chapter!

Everyone at AGA sends our congratulations to AGA President John Carethers, MD, AGAF, on his appointment as the vice chancellor for health sciences at the University of California San Diego.

Dr. Carethers, who began his term as the 117th president of the AGA Institute on June 1, 2022, is returning to UC San Diego after a 13-year tenure at the University of Michigan. He will report directly to the chancellor and serve as a part of the leadership team, effective Jan. 1, 2023.

Aside from his new role at UCSD, Dr. Carethers has been an active member of AGA for more than 20 years and has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee.

We wish him well in this new chapter!

Everyone at AGA sends our congratulations to AGA President John Carethers, MD, AGAF, on his appointment as the vice chancellor for health sciences at the University of California San Diego.

Dr. Carethers, who began his term as the 117th president of the AGA Institute on June 1, 2022, is returning to UC San Diego after a 13-year tenure at the University of Michigan. He will report directly to the chancellor and serve as a part of the leadership team, effective Jan. 1, 2023.

Aside from his new role at UCSD, Dr. Carethers has been an active member of AGA for more than 20 years and has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee.

We wish him well in this new chapter!

Bronchiectasis Section

Antibiotics in non–cystic fibrosis bronchiectasis: new perspectives

The clearest benefit of antibiotics in managing non-cystic fibrosis bronchiectasis is for treatment of exacerbations and for chronic azithromycin use. There is a paucity of high-quality evidence for prophylactic antibiotics, though guidelines support this practice, particularly for adults with three or more exacerbations a year. A recent Cochrane database review (Spencer, et al. Cochrane Database Syst Rev. 2022;1[1]:CD013254) examined eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2,180 adults and found little net benefit for prophylactic cycled antibiotics (fluoroquinolones, beta-lactams, and aminoglycosides) in terms of outcomes viz time-to-first-exacerbation and duration of exacerbations, but more than doubled the risk of emerging resistance.

Clinical equipoise exists regarding the duration of antibiotics during exacerbations. Guidelines favor 14 days. A recent RCT (Pallavi, et al. Eur Respir J. 2021;58:2004388) examined the feasibility of bacterial load-guided therapy in 47 participants with bronchiectasis requiring IV antibiotics.

Patients were randomized to either 14 days of antibiotics or treatment guided by bacterial load (BLGG). The 88% of participants in the BLGG group were able to stop antibiotics by day 8, and potentially 81% of participants in the 14-day group could have stopped antibiotics at day 8. Median time to next exacerbation was much longer – 60 days (18-110 days) in the in BLGG group vs 27.5 days (12.5-60 days) in the 14-day group vs (P = .0034). A larger multicenter RCT may clarify the benefits of this approach to shortening duration of antibiotic therapy in patients with bronchiectasis exacerbations.

O’Neil Green, MBBS, FCCP
Member-at-Large

Bronchiectasis Section

Antibiotics in non–cystic fibrosis bronchiectasis: new perspectives

The clearest benefit of antibiotics in managing non-cystic fibrosis bronchiectasis is for treatment of exacerbations and for chronic azithromycin use. There is a paucity of high-quality evidence for prophylactic antibiotics, though guidelines support this practice, particularly for adults with three or more exacerbations a year. A recent Cochrane database review (Spencer, et al. Cochrane Database Syst Rev. 2022;1[1]:CD013254) examined eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2,180 adults and found little net benefit for prophylactic cycled antibiotics (fluoroquinolones, beta-lactams, and aminoglycosides) in terms of outcomes viz time-to-first-exacerbation and duration of exacerbations, but more than doubled the risk of emerging resistance.

Clinical equipoise exists regarding the duration of antibiotics during exacerbations. Guidelines favor 14 days. A recent RCT (Pallavi, et al. Eur Respir J. 2021;58:2004388) examined the feasibility of bacterial load-guided therapy in 47 participants with bronchiectasis requiring IV antibiotics.

Patients were randomized to either 14 days of antibiotics or treatment guided by bacterial load (BLGG). The 88% of participants in the BLGG group were able to stop antibiotics by day 8, and potentially 81% of participants in the 14-day group could have stopped antibiotics at day 8. Median time to next exacerbation was much longer – 60 days (18-110 days) in the in BLGG group vs 27.5 days (12.5-60 days) in the 14-day group vs (P = .0034). A larger multicenter RCT may clarify the benefits of this approach to shortening duration of antibiotic therapy in patients with bronchiectasis exacerbations.

O’Neil Green, MBBS, FCCP
Member-at-Large

Bronchiectasis Section

Antibiotics in non–cystic fibrosis bronchiectasis: new perspectives

The clearest benefit of antibiotics in managing non-cystic fibrosis bronchiectasis is for treatment of exacerbations and for chronic azithromycin use. There is a paucity of high-quality evidence for prophylactic antibiotics, though guidelines support this practice, particularly for adults with three or more exacerbations a year. A recent Cochrane database review (Spencer, et al. Cochrane Database Syst Rev. 2022;1[1]:CD013254) examined eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2,180 adults and found little net benefit for prophylactic cycled antibiotics (fluoroquinolones, beta-lactams, and aminoglycosides) in terms of outcomes viz time-to-first-exacerbation and duration of exacerbations, but more than doubled the risk of emerging resistance.

Clinical equipoise exists regarding the duration of antibiotics during exacerbations. Guidelines favor 14 days. A recent RCT (Pallavi, et al. Eur Respir J. 2021;58:2004388) examined the feasibility of bacterial load-guided therapy in 47 participants with bronchiectasis requiring IV antibiotics.

Patients were randomized to either 14 days of antibiotics or treatment guided by bacterial load (BLGG). The 88% of participants in the BLGG group were able to stop antibiotics by day 8, and potentially 81% of participants in the 14-day group could have stopped antibiotics at day 8. Median time to next exacerbation was much longer – 60 days (18-110 days) in the in BLGG group vs 27.5 days (12.5-60 days) in the 14-day group vs (P = .0034). A larger multicenter RCT may clarify the benefits of this approach to shortening duration of antibiotic therapy in patients with bronchiectasis exacerbations.

O’Neil Green, MBBS, FCCP
Member-at-Large

Intensive care telemedicine was first described in 1982 after implementation in a seven-bed, inner-city ICU using 19-inch television screens connected with intensivists at the University Hospitals of Cleveland (Grundy, et al. Crit Care Med. 1982;10[7]:471). After this proof-of-concept report, however, ICU telemedicine gained little traction for nearly 20 years, until Johns Hopkins Hospital established a continuously monitored ICU telemedicine service in a nonintensivist staffed surgical ICU. Their pre/post analysis suggested a 64% decrease in severity-adjusted ICU mortality and greater than 30% decrease in ICU length of stay, ICU complications, and costs (Rosenfeld, et al. Crit Care Med. 2000;28[12]:3925).

Along with better and less costly telemedicine technology, rapid adoption of electronic medical records, and a nationwide intensivist shortage, this and other evidence for the service’s clinical and cost effectiveness has spurred explosive growth in ICU telemedicine in the succeeding 2 decades, with at least 18% of hospitals and 28% of ICU beds supported by ICU telemedicine by 2018 (Ofoma, et al. Crit Care Explor. 2021;4[3]:e0468).

Importantly, what “ICU telemedicine” represents varies substantially across hospitals and even across ICUs within systems. Two-way audiovisual technology is the defining feature, and at a minimum, programs provide intensivists and/or nurses who respond to consultation requests. Commonly, telemedicine clinicians directly connect with patients; monitor labs, hemodynamics, and alarms; and proactively contact on-site clinicians with recommendations or place orders directly into the electronic health record depending on whether the clinician acts as the patients’ primary, co-managing, or consultant provider. A centralized hub and spoke model with telemedicine personnel located at a single, remote center is the most common and best studied ICU telemedicine design. Additional staffing may include respiratory therapists, pharmacists, and advanced practice clinicians in coverage models that range from 24/7 to nocturnal and can also differ in whether patients are monitored continuously or on an as needed basis, triggered by alarms or clinician/nursing concerns.

On-demand services may extend to support for teams responding to medical emergencies inside and sometimes outside the ICU. Another equally important role that ICU telemedicine can provide is helping ensure facilities adhere to ICU quality metrics, such as ventilator bundles, DVT prophylaxis, and daily SAT/SBT.

Unsurprisingly, integrating ICU telemedicine into an existing system is very costly and complex, requiring substantial and thoughtful process redesign to maximize fiscal and clinical return on investment. One vendor of proprietary telemedicine technology, Philips eICU, estimates an implementation cost of $50,000 to $100,000 per bed with annual overhead, software maintenance, and IT staffing of ~20% of implementation costs in addition to clinician staffing of $1-2 million per 100 beds. However, some (but not all) evidence suggests that ICU telemedicine programs pay for themselves over time. An influential report from Sentara Healthcare, an early adopter of ICU telemedicine, described equipment costs of more than $1 million for a total of 103 critical care beds but attributed savings of $460,000 per month to decreased length of stay (Coustasse, et al. The Permanente Journal. 2014;18[4]:76).

Cost savings are great, of course, but ICU telemedicine’s potential to improve clinical outcomes is the real priority. While Sentara’s early report included a 27% decrease in ICU mortality after telemedicine adoption, a 2011 meta-analysis of 13 studies, including 35 ICUs and over 40,000 patients, suggested decreased ICU mortality and LOS with a statistically significant effect on overall hospital mortality and LOS (Young, et al. Arch Intern Med. 2011;171[6]:498). This highlights the Achilles heel of ICU telemedicine evidence: the pretest/posttest studies that dominate this field and likely contribute substantially to the inconsistencies in the evidence base.

In the absence of risk adjustment and control groups, many studies observed postimplementation changes that may reflect trends in patient mix or the effects of unrelated practice changes rather than the causal influence of ICU telemedicine. In fact, in studies using more robust methods, ICU telemedicine’s effect size has been smaller or nonexistent. For example, in 2016, Kahn and colleagues used CMS data to evaluate 132 ICU telemedicine programs using 389 matched controlled hospitals. There was a slight reduction in 90-day mortality (OR=0.96, CI 0.94-0.98) with only 12% showing a statistically significant reduction in mortality. Interestingly, hospitals in urban areas demonstrated greater benefit than rural facilities (Kahn, et al. Medical Care. 2016;54[3]:319).

The heterogeneity of the studied programs (e.g., primary vs consultative role, on-demand vs proactive involvement) and recipient ICUs (e.g., rural vs tertiary care facility, presence of bedside intensivists) further hinders a clear answer to the key question: Would ICU telemedicine benefit my hospital? Fortunately, some recent, well-designed studies have attempted to understand which attributes of ICU telemedicine programs provide results and which ICUs will see the most benefit. In a cohort of 118,990 patients across 56 ICUs, four interventions were associated with lower mortality and reduced LOS: (1) evaluation of patients within 1 hour of ICU admission, (2) frequent leadership review of performance data, (3) ICU best practice compliance, and (4) prompt response to alerts (Lilly, et al. Chest. 2014;145[3]:500). Kahn and colleagues have also investigated this issue, conducting an in-depth ethnographic evaluation of 10 hospitals identified in their 2016 study to have positive, neutral, or negative outcomes after ICU telemedicine implementation (Kahn, et al. Am J Respir Crit Care Med. 2019;199[8]:970). They found that successful programs:

(1) provided consistent services matched to recipient needs;

(2) provided services both proactively and reactively without being obtrusive;

(3) embedded routine engagements unobtrusively into usual routines;

(4) had engaged leadership who set clear expectations and mediated conflicts; and

(5) had bedside clinicians who valued and sought out telemedicine participation in care.

The authors concluded that, “the true value of ICU telemedicine lies not in whether the technology exists but in how it is applied.” However, another recent analysis also suggested that, rather than telemedicine or recipient ICU design, targeting underperforming recipient ICU performance may be the key determinant of whether ICU telemedicine implementation improves outcomes (Fusaro, et al. Crit Care Med. 2019; 47[4]:501). While the finding may reflect regression to the mean, the idea that ICUs with above-expected mortality derive greater benefit from ICU telemedicine support than already well-performing ICUs is certainly logical.

As COVID-19 strained health care systems across the country, we and others found ways to use ICU telemedicine to preserve optimal care delivery for critically ill patients. Our program at Intermountain Healthcare – already supporting 17 ICUs within our 24-hospital health system, as well as 10 external ICUs with experienced critical care physicians, nurses, respiratory therapists, and pharmacists – took on increased responsibility for ICU load balancing and interhospital transfers.

Leveraging telemedicine services also helped community ICUs care for sicker, more complex patients than usual and aided nonintensivist physicians called upon to manage critically ill patients in ad hoc ICUs at referral hospitals. While the pandemic certainly stressed ICU staff, we suspect that telemedicine’s ability to balance caseloads and distribute clinical tasks helped mitigate these stresses. At age 40, ICU telemedicine is both mature and still growing, with continued expansion of bed coverage and the range of services available. Looking ahead, as we confront a national shortage of intensivists, ICU telemedicine likely represents a cost effective and efficient strategy to maintain critical care capacity with the potential to ensure low-cost, high-quality care for all, regardless of location.
 

Dr. Graham and Dr. Peltan are with the Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and Dr. Peltan is also with the Division of Pulmonary & Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah.

Intensive care telemedicine was first described in 1982 after implementation in a seven-bed, inner-city ICU using 19-inch television screens connected with intensivists at the University Hospitals of Cleveland (Grundy, et al. Crit Care Med. 1982;10[7]:471). After this proof-of-concept report, however, ICU telemedicine gained little traction for nearly 20 years, until Johns Hopkins Hospital established a continuously monitored ICU telemedicine service in a nonintensivist staffed surgical ICU. Their pre/post analysis suggested a 64% decrease in severity-adjusted ICU mortality and greater than 30% decrease in ICU length of stay, ICU complications, and costs (Rosenfeld, et al. Crit Care Med. 2000;28[12]:3925).

Along with better and less costly telemedicine technology, rapid adoption of electronic medical records, and a nationwide intensivist shortage, this and other evidence for the service’s clinical and cost effectiveness has spurred explosive growth in ICU telemedicine in the succeeding 2 decades, with at least 18% of hospitals and 28% of ICU beds supported by ICU telemedicine by 2018 (Ofoma, et al. Crit Care Explor. 2021;4[3]:e0468).

Importantly, what “ICU telemedicine” represents varies substantially across hospitals and even across ICUs within systems. Two-way audiovisual technology is the defining feature, and at a minimum, programs provide intensivists and/or nurses who respond to consultation requests. Commonly, telemedicine clinicians directly connect with patients; monitor labs, hemodynamics, and alarms; and proactively contact on-site clinicians with recommendations or place orders directly into the electronic health record depending on whether the clinician acts as the patients’ primary, co-managing, or consultant provider. A centralized hub and spoke model with telemedicine personnel located at a single, remote center is the most common and best studied ICU telemedicine design. Additional staffing may include respiratory therapists, pharmacists, and advanced practice clinicians in coverage models that range from 24/7 to nocturnal and can also differ in whether patients are monitored continuously or on an as needed basis, triggered by alarms or clinician/nursing concerns.

On-demand services may extend to support for teams responding to medical emergencies inside and sometimes outside the ICU. Another equally important role that ICU telemedicine can provide is helping ensure facilities adhere to ICU quality metrics, such as ventilator bundles, DVT prophylaxis, and daily SAT/SBT.

Unsurprisingly, integrating ICU telemedicine into an existing system is very costly and complex, requiring substantial and thoughtful process redesign to maximize fiscal and clinical return on investment. One vendor of proprietary telemedicine technology, Philips eICU, estimates an implementation cost of $50,000 to $100,000 per bed with annual overhead, software maintenance, and IT staffing of ~20% of implementation costs in addition to clinician staffing of $1-2 million per 100 beds. However, some (but not all) evidence suggests that ICU telemedicine programs pay for themselves over time. An influential report from Sentara Healthcare, an early adopter of ICU telemedicine, described equipment costs of more than $1 million for a total of 103 critical care beds but attributed savings of $460,000 per month to decreased length of stay (Coustasse, et al. The Permanente Journal. 2014;18[4]:76).

Cost savings are great, of course, but ICU telemedicine’s potential to improve clinical outcomes is the real priority. While Sentara’s early report included a 27% decrease in ICU mortality after telemedicine adoption, a 2011 meta-analysis of 13 studies, including 35 ICUs and over 40,000 patients, suggested decreased ICU mortality and LOS with a statistically significant effect on overall hospital mortality and LOS (Young, et al. Arch Intern Med. 2011;171[6]:498). This highlights the Achilles heel of ICU telemedicine evidence: the pretest/posttest studies that dominate this field and likely contribute substantially to the inconsistencies in the evidence base.

In the absence of risk adjustment and control groups, many studies observed postimplementation changes that may reflect trends in patient mix or the effects of unrelated practice changes rather than the causal influence of ICU telemedicine. In fact, in studies using more robust methods, ICU telemedicine’s effect size has been smaller or nonexistent. For example, in 2016, Kahn and colleagues used CMS data to evaluate 132 ICU telemedicine programs using 389 matched controlled hospitals. There was a slight reduction in 90-day mortality (OR=0.96, CI 0.94-0.98) with only 12% showing a statistically significant reduction in mortality. Interestingly, hospitals in urban areas demonstrated greater benefit than rural facilities (Kahn, et al. Medical Care. 2016;54[3]:319).

The heterogeneity of the studied programs (e.g., primary vs consultative role, on-demand vs proactive involvement) and recipient ICUs (e.g., rural vs tertiary care facility, presence of bedside intensivists) further hinders a clear answer to the key question: Would ICU telemedicine benefit my hospital? Fortunately, some recent, well-designed studies have attempted to understand which attributes of ICU telemedicine programs provide results and which ICUs will see the most benefit. In a cohort of 118,990 patients across 56 ICUs, four interventions were associated with lower mortality and reduced LOS: (1) evaluation of patients within 1 hour of ICU admission, (2) frequent leadership review of performance data, (3) ICU best practice compliance, and (4) prompt response to alerts (Lilly, et al. Chest. 2014;145[3]:500). Kahn and colleagues have also investigated this issue, conducting an in-depth ethnographic evaluation of 10 hospitals identified in their 2016 study to have positive, neutral, or negative outcomes after ICU telemedicine implementation (Kahn, et al. Am J Respir Crit Care Med. 2019;199[8]:970). They found that successful programs:

(1) provided consistent services matched to recipient needs;

(2) provided services both proactively and reactively without being obtrusive;

(3) embedded routine engagements unobtrusively into usual routines;

(4) had engaged leadership who set clear expectations and mediated conflicts; and

(5) had bedside clinicians who valued and sought out telemedicine participation in care.

The authors concluded that, “the true value of ICU telemedicine lies not in whether the technology exists but in how it is applied.” However, another recent analysis also suggested that, rather than telemedicine or recipient ICU design, targeting underperforming recipient ICU performance may be the key determinant of whether ICU telemedicine implementation improves outcomes (Fusaro, et al. Crit Care Med. 2019; 47[4]:501). While the finding may reflect regression to the mean, the idea that ICUs with above-expected mortality derive greater benefit from ICU telemedicine support than already well-performing ICUs is certainly logical.

As COVID-19 strained health care systems across the country, we and others found ways to use ICU telemedicine to preserve optimal care delivery for critically ill patients. Our program at Intermountain Healthcare – already supporting 17 ICUs within our 24-hospital health system, as well as 10 external ICUs with experienced critical care physicians, nurses, respiratory therapists, and pharmacists – took on increased responsibility for ICU load balancing and interhospital transfers.

Leveraging telemedicine services also helped community ICUs care for sicker, more complex patients than usual and aided nonintensivist physicians called upon to manage critically ill patients in ad hoc ICUs at referral hospitals. While the pandemic certainly stressed ICU staff, we suspect that telemedicine’s ability to balance caseloads and distribute clinical tasks helped mitigate these stresses. At age 40, ICU telemedicine is both mature and still growing, with continued expansion of bed coverage and the range of services available. Looking ahead, as we confront a national shortage of intensivists, ICU telemedicine likely represents a cost effective and efficient strategy to maintain critical care capacity with the potential to ensure low-cost, high-quality care for all, regardless of location.
 

Dr. Graham and Dr. Peltan are with the Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and Dr. Peltan is also with the Division of Pulmonary & Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah.

Intensive care telemedicine was first described in 1982 after implementation in a seven-bed, inner-city ICU using 19-inch television screens connected with intensivists at the University Hospitals of Cleveland (Grundy, et al. Crit Care Med. 1982;10[7]:471). After this proof-of-concept report, however, ICU telemedicine gained little traction for nearly 20 years, until Johns Hopkins Hospital established a continuously monitored ICU telemedicine service in a nonintensivist staffed surgical ICU. Their pre/post analysis suggested a 64% decrease in severity-adjusted ICU mortality and greater than 30% decrease in ICU length of stay, ICU complications, and costs (Rosenfeld, et al. Crit Care Med. 2000;28[12]:3925).

Along with better and less costly telemedicine technology, rapid adoption of electronic medical records, and a nationwide intensivist shortage, this and other evidence for the service’s clinical and cost effectiveness has spurred explosive growth in ICU telemedicine in the succeeding 2 decades, with at least 18% of hospitals and 28% of ICU beds supported by ICU telemedicine by 2018 (Ofoma, et al. Crit Care Explor. 2021;4[3]:e0468).

Importantly, what “ICU telemedicine” represents varies substantially across hospitals and even across ICUs within systems. Two-way audiovisual technology is the defining feature, and at a minimum, programs provide intensivists and/or nurses who respond to consultation requests. Commonly, telemedicine clinicians directly connect with patients; monitor labs, hemodynamics, and alarms; and proactively contact on-site clinicians with recommendations or place orders directly into the electronic health record depending on whether the clinician acts as the patients’ primary, co-managing, or consultant provider. A centralized hub and spoke model with telemedicine personnel located at a single, remote center is the most common and best studied ICU telemedicine design. Additional staffing may include respiratory therapists, pharmacists, and advanced practice clinicians in coverage models that range from 24/7 to nocturnal and can also differ in whether patients are monitored continuously or on an as needed basis, triggered by alarms or clinician/nursing concerns.

On-demand services may extend to support for teams responding to medical emergencies inside and sometimes outside the ICU. Another equally important role that ICU telemedicine can provide is helping ensure facilities adhere to ICU quality metrics, such as ventilator bundles, DVT prophylaxis, and daily SAT/SBT.

Unsurprisingly, integrating ICU telemedicine into an existing system is very costly and complex, requiring substantial and thoughtful process redesign to maximize fiscal and clinical return on investment. One vendor of proprietary telemedicine technology, Philips eICU, estimates an implementation cost of $50,000 to $100,000 per bed with annual overhead, software maintenance, and IT staffing of ~20% of implementation costs in addition to clinician staffing of $1-2 million per 100 beds. However, some (but not all) evidence suggests that ICU telemedicine programs pay for themselves over time. An influential report from Sentara Healthcare, an early adopter of ICU telemedicine, described equipment costs of more than $1 million for a total of 103 critical care beds but attributed savings of $460,000 per month to decreased length of stay (Coustasse, et al. The Permanente Journal. 2014;18[4]:76).

Cost savings are great, of course, but ICU telemedicine’s potential to improve clinical outcomes is the real priority. While Sentara’s early report included a 27% decrease in ICU mortality after telemedicine adoption, a 2011 meta-analysis of 13 studies, including 35 ICUs and over 40,000 patients, suggested decreased ICU mortality and LOS with a statistically significant effect on overall hospital mortality and LOS (Young, et al. Arch Intern Med. 2011;171[6]:498). This highlights the Achilles heel of ICU telemedicine evidence: the pretest/posttest studies that dominate this field and likely contribute substantially to the inconsistencies in the evidence base.

In the absence of risk adjustment and control groups, many studies observed postimplementation changes that may reflect trends in patient mix or the effects of unrelated practice changes rather than the causal influence of ICU telemedicine. In fact, in studies using more robust methods, ICU telemedicine’s effect size has been smaller or nonexistent. For example, in 2016, Kahn and colleagues used CMS data to evaluate 132 ICU telemedicine programs using 389 matched controlled hospitals. There was a slight reduction in 90-day mortality (OR=0.96, CI 0.94-0.98) with only 12% showing a statistically significant reduction in mortality. Interestingly, hospitals in urban areas demonstrated greater benefit than rural facilities (Kahn, et al. Medical Care. 2016;54[3]:319).

The heterogeneity of the studied programs (e.g., primary vs consultative role, on-demand vs proactive involvement) and recipient ICUs (e.g., rural vs tertiary care facility, presence of bedside intensivists) further hinders a clear answer to the key question: Would ICU telemedicine benefit my hospital? Fortunately, some recent, well-designed studies have attempted to understand which attributes of ICU telemedicine programs provide results and which ICUs will see the most benefit. In a cohort of 118,990 patients across 56 ICUs, four interventions were associated with lower mortality and reduced LOS: (1) evaluation of patients within 1 hour of ICU admission, (2) frequent leadership review of performance data, (3) ICU best practice compliance, and (4) prompt response to alerts (Lilly, et al. Chest. 2014;145[3]:500). Kahn and colleagues have also investigated this issue, conducting an in-depth ethnographic evaluation of 10 hospitals identified in their 2016 study to have positive, neutral, or negative outcomes after ICU telemedicine implementation (Kahn, et al. Am J Respir Crit Care Med. 2019;199[8]:970). They found that successful programs:

(1) provided consistent services matched to recipient needs;

(2) provided services both proactively and reactively without being obtrusive;

(3) embedded routine engagements unobtrusively into usual routines;

(4) had engaged leadership who set clear expectations and mediated conflicts; and

(5) had bedside clinicians who valued and sought out telemedicine participation in care.

The authors concluded that, “the true value of ICU telemedicine lies not in whether the technology exists but in how it is applied.” However, another recent analysis also suggested that, rather than telemedicine or recipient ICU design, targeting underperforming recipient ICU performance may be the key determinant of whether ICU telemedicine implementation improves outcomes (Fusaro, et al. Crit Care Med. 2019; 47[4]:501). While the finding may reflect regression to the mean, the idea that ICUs with above-expected mortality derive greater benefit from ICU telemedicine support than already well-performing ICUs is certainly logical.

As COVID-19 strained health care systems across the country, we and others found ways to use ICU telemedicine to preserve optimal care delivery for critically ill patients. Our program at Intermountain Healthcare – already supporting 17 ICUs within our 24-hospital health system, as well as 10 external ICUs with experienced critical care physicians, nurses, respiratory therapists, and pharmacists – took on increased responsibility for ICU load balancing and interhospital transfers.

Leveraging telemedicine services also helped community ICUs care for sicker, more complex patients than usual and aided nonintensivist physicians called upon to manage critically ill patients in ad hoc ICUs at referral hospitals. While the pandemic certainly stressed ICU staff, we suspect that telemedicine’s ability to balance caseloads and distribute clinical tasks helped mitigate these stresses. At age 40, ICU telemedicine is both mature and still growing, with continued expansion of bed coverage and the range of services available. Looking ahead, as we confront a national shortage of intensivists, ICU telemedicine likely represents a cost effective and efficient strategy to maintain critical care capacity with the potential to ensure low-cost, high-quality care for all, regardless of location.
 

Dr. Graham and Dr. Peltan are with the Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and Dr. Peltan is also with the Division of Pulmonary & Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah.

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”