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Register for the UCLA / SVS Symposium
Register today for the fourth annual UCLA / SVS Symposium. This year’s event, “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery,” will be held Aug. 24 to 26 at the Beverly Hilton in Beverly Hills, Calif. An internationally recognized faculty will present a comprehensive survey of generally accepted views. These will include basic science, pathogenesis, diagnosis and management of the broad spectrum of vascular disorders. Additionally, all speakers will address important new developments related to their topic that have taken place within the last year. Learn more and register today.
Register today for the fourth annual UCLA / SVS Symposium. This year’s event, “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery,” will be held Aug. 24 to 26 at the Beverly Hilton in Beverly Hills, Calif. An internationally recognized faculty will present a comprehensive survey of generally accepted views. These will include basic science, pathogenesis, diagnosis and management of the broad spectrum of vascular disorders. Additionally, all speakers will address important new developments related to their topic that have taken place within the last year. Learn more and register today.
Register today for the fourth annual UCLA / SVS Symposium. This year’s event, “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery,” will be held Aug. 24 to 26 at the Beverly Hilton in Beverly Hills, Calif. An internationally recognized faculty will present a comprehensive survey of generally accepted views. These will include basic science, pathogenesis, diagnosis and management of the broad spectrum of vascular disorders. Additionally, all speakers will address important new developments related to their topic that have taken place within the last year. Learn more and register today.
CHEST Clinical Perspectives explores the emerging field of precision medicine
For clinicians seeking to provide a pathway to treatment or diagnosis that is individualized to the patient, a recent study found that the issues go beyond awareness or a patient’s degree of comfort – there remains the question of something as simple as: what should we call it?
Clinicians remain uncertain whether to name the new field precision or personalized medicine according the new CHEST Clinical PerspectivesTM white paper, “Precision Medicine: Adoption of Emerging Methods of Evaluation and Therapy.” A survey of leading community clinicians from among CHEST membership found that only 35 % called tailoring medical treatment to the individual characteristics of each patient “precision medicine,” with 24% preferring “personalized” medicine. Thirty-six percent of respondents used the terms interchangeably.
Beyond the communication issues, the study found that most clinicians surveyed did not know enough about precision medicine to adopt it into their practice. Those surveyed reported that they wanted to see more published studies on the effectiveness of the newly available tools before discussing these options with their patients.
The majority of the respondents were general pulmonologists with intensivists and interventional pulmonologists also responding. The study was led by Nichole T. Tanner, MD, MSCR, FCCP, of the Medical University of South Carolina. Dr Tanner will be hosting a webinar to review the conclusions of this paper at 10:00 AM CT on Tuesday, July 30.
More information about CHEST Clinical PerspectivesTM, part of the CHEST Analytics program, can be found at insights.chestnet.org. To suggest a topic to be covered in a future issue, contact Linda Tomczynski, [email protected] or +1 (224) 521-9593. Register today at https://hubs.ly/H0jqCGb0.
For clinicians seeking to provide a pathway to treatment or diagnosis that is individualized to the patient, a recent study found that the issues go beyond awareness or a patient’s degree of comfort – there remains the question of something as simple as: what should we call it?
Clinicians remain uncertain whether to name the new field precision or personalized medicine according the new CHEST Clinical PerspectivesTM white paper, “Precision Medicine: Adoption of Emerging Methods of Evaluation and Therapy.” A survey of leading community clinicians from among CHEST membership found that only 35 % called tailoring medical treatment to the individual characteristics of each patient “precision medicine,” with 24% preferring “personalized” medicine. Thirty-six percent of respondents used the terms interchangeably.
Beyond the communication issues, the study found that most clinicians surveyed did not know enough about precision medicine to adopt it into their practice. Those surveyed reported that they wanted to see more published studies on the effectiveness of the newly available tools before discussing these options with their patients.
The majority of the respondents were general pulmonologists with intensivists and interventional pulmonologists also responding. The study was led by Nichole T. Tanner, MD, MSCR, FCCP, of the Medical University of South Carolina. Dr Tanner will be hosting a webinar to review the conclusions of this paper at 10:00 AM CT on Tuesday, July 30.
More information about CHEST Clinical PerspectivesTM, part of the CHEST Analytics program, can be found at insights.chestnet.org. To suggest a topic to be covered in a future issue, contact Linda Tomczynski, [email protected] or +1 (224) 521-9593. Register today at https://hubs.ly/H0jqCGb0.
For clinicians seeking to provide a pathway to treatment or diagnosis that is individualized to the patient, a recent study found that the issues go beyond awareness or a patient’s degree of comfort – there remains the question of something as simple as: what should we call it?
Clinicians remain uncertain whether to name the new field precision or personalized medicine according the new CHEST Clinical PerspectivesTM white paper, “Precision Medicine: Adoption of Emerging Methods of Evaluation and Therapy.” A survey of leading community clinicians from among CHEST membership found that only 35 % called tailoring medical treatment to the individual characteristics of each patient “precision medicine,” with 24% preferring “personalized” medicine. Thirty-six percent of respondents used the terms interchangeably.
Beyond the communication issues, the study found that most clinicians surveyed did not know enough about precision medicine to adopt it into their practice. Those surveyed reported that they wanted to see more published studies on the effectiveness of the newly available tools before discussing these options with their patients.
The majority of the respondents were general pulmonologists with intensivists and interventional pulmonologists also responding. The study was led by Nichole T. Tanner, MD, MSCR, FCCP, of the Medical University of South Carolina. Dr Tanner will be hosting a webinar to review the conclusions of this paper at 10:00 AM CT on Tuesday, July 30.
More information about CHEST Clinical PerspectivesTM, part of the CHEST Analytics program, can be found at insights.chestnet.org. To suggest a topic to be covered in a future issue, contact Linda Tomczynski, [email protected] or +1 (224) 521-9593. Register today at https://hubs.ly/H0jqCGb0.
Environmental Scan: Drivers of change in health care
CHEST Inspiration is a collection of programmatic initiatives developed by the American College of Chest Physicians leadership and aimed at stimulating and encouraging innovation within the association. One of the components of CHEST Inspiration is the Environmental Scan, a series of articles focusing on the internal and external environmental factors that bear on success currently and in the future. See “Envisioning the Future: the CHEST Environmental Scan,” CHEST Physician, June 2019, p. 44, for an introduction to the series.
Chest physicians are witnessing a revolution within the environment in which they practice. Information technology, changing consumer behavior, and the social imperative to contain costs are coming together to transform health care.
Innovation in the prevention, diagnosis, and treatment of health-related issues is being fueled by the emergence of accessible and affordable technology-based solutions and changes in patient approaches to health care. Consumers and employers are increasingly motivated to look for cost-effective options for health in care delivery and for economical access to innovations.1 Organizations will need to respond with a strategy that aligns with the changing environment and position physicians to lead these trends in the direction of improved patient care.2
Enabling technologies like electronic health records, blockchain, and artificial intelligence will increase connectivity among all the stakeholders in the health-care system. The exponential increase in connectivity means growing engagement of health systems, health plans, patients, and families in all aspects of health care. For health-care providers, these technologies will mean an acceleration of the requirement to generate data in clinical settings and utilize data for clinical decision making. Easily available data on outcomes and, most importantly, cost of treatment will be expected at point of service.3
Access to information will continue to empower consumers to take an active role in their own health care. More patients will be comfortable with delivery of some health care via digital devices, apps, and virtual access to treatment. The market will respond with technology that helps consumers navigate health-care systems, explore options, and communicate directly with providers. The use of apps and virtual encounters is expected to transform the role of primary care providers: patients will increasingly utilize nonphysician resources in outpatient settings, bypassing primary care physicians and reaching out to specialty care as needed.4
David A. Schulman, MD, FCCP, Professor of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, and Editor in Chief of CHEST Physician, has seen the transformation of patient behavior and attitudes in his own practice.
“In general, they have done far more research about their health problems before seeking my counsel than patients did previously. Many use the internet not just to read about their symptoms and diseases, but also to connect with others having similar issues, sharing experiences, treatments, outcomes, and emotions; in some ways, this is the new ‘crowdsourcing’ of medicine.”
Patients who do their own “research” can present a challenge for physicians. Dr. Schulman noted, “I am often surprised about the misconceptions about disease that derive from information gleaned from a web-based source. One need not look any farther than the groundswell of misinformation being spread about vaccinations to see the potential downside of the pervasive availability of medical ‘facts’ online. Since we are unlikely to convince our patients to avoid the online milieu entirely, our role as health-care providers is to help our patients process and appropriately weigh the information that they receive, potentially partnering with our national societies to help curate such information.”
Dr. Schulman’s approach to the potential of patient misinformation is to initiate almost all discussions with patients with the question “Have your read or seen anything about this condition?” He said, “It is rare for patients to answer negatively. And listening to them speak about their understanding of their disease provides me with invaluable information about how the remainder of our visit should be spent. Do we need to correct misunderstandings? Are there gaps in the explanation that I can fill? Can we move directly into a conversation about treatment options? Can I provide you with some additional resources that might help to further your knowledge about the condition?”
Generational factors will play a big role in health-care demand and delivery. Health-care companies are already building lower cost delivery models to capture the millennial market.4 Cost-saving digital tools and virtual contacts are currently most commonly used by younger patients.5 Physicians need to understand and be a part of this trend, Dr. Schulman argued. “We should embrace telemedicine and mobile applications to collect data from the patients in their day-to-day lives. While insurance coverage of telemedicine is far from universal at the moment, and the reliability of mobile applications is highly variable, we know that a growing number of our patients are already relying on their digital devices to manage their health. In much the same way that we will need to help patient evaluate online information, we should work with our national societies to support the creation of tools that will allow us to collect data in the home environment in a more robust and reliable fashion.”
The proportion of the US population over the age of 65 is increasing yearly.6 Six out of 10 Americans live with a chronic illness, such as heart disease or diabetes. These and other chronic diseases are the leading drivers of the $3.3 billion annual health-care costs.7 Cost containment for these older patients and those with chronic illness will involve a focus on quality and outcomes data, a drive to deliver treatment in lower cost outpatient settings, and an acceleration of the adoption of value-based models currently underway.8
Taken together, these trends will mean a growing digital interface between physician and patient, a more active consumer-patient, and the availability of a vast array of new tools to access and manage health-care data.
- Delivery of procedures and services will trend from physicians to other members of the health-care team and to lower cost, outpatient settings.9
- Health-care systems will ramp up investment in products and services that improve outcomes and cost effectiveness.10
- Increased regulatory requirements and new payment models mean an ever-growing utilization of information technology by providers to fulfill data imperatives.11
- Physicians will have an increased need for tools that prioritize costs and outcomes data at the point of care.12
- Integration of data from new technologies will touch every aspect of health-care delivery with the objective of improving outcomes and, in turn, reducing costs.13
- Changing consumer attitudes toward delivery of care will be based on a growing familiarity of patients with a digital or virtual interface with providers, facility with health-care apps, and preference for a menu of options for health-care delivery.14
Dr. Schulman concluded, “We can no more expect our patients to ignore the full panoply of medical information on the internet and digital tools on their mobile devices than we can tell the tide not to come in. The die is cast; this is the world within which we must ply our trade. By identifying best practices and sharing our successes, we can come through this revolution better for the experience.”
References
1. https://www.modernhealthcare.com/article/20181220/NEWS/181229992/number-of-outpatient-facilities-surges-as-industry-values-more
2. https://www.accenture.com/us-en/insights/health/digital-health-tech-vision-2018
3. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
4. PcW Health Research Institute: Top health industry issues of 2019
5. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
6. https://www.census.gov/newsroom/press-releases/2017/cb17-100.html
7. https://www.cdc.gov/chronicdisease/index.htm
8. https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/health-care-current-december4-2018.html
9. PcW Health Research Institute Top health industry issues of 2019: The New Health Economy comes of age
10. https://www.accenture.com/us-en/insights/health/digital-health-tech-vision-2018
11. https://www2.deloitte.com/insights/us/en/industry/life-sciences/medtech-research-and-development-innovation.html
12. https://www2.deloitte.com/insights/us/en/industry/health-care/volume-to-value-based-care.html
13. https://www2.deloitte.com/insights/us/en/industry/health-care/volume-to-value-based-care.html
14. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
CHEST Inspiration is a collection of programmatic initiatives developed by the American College of Chest Physicians leadership and aimed at stimulating and encouraging innovation within the association. One of the components of CHEST Inspiration is the Environmental Scan, a series of articles focusing on the internal and external environmental factors that bear on success currently and in the future. See “Envisioning the Future: the CHEST Environmental Scan,” CHEST Physician, June 2019, p. 44, for an introduction to the series.
Chest physicians are witnessing a revolution within the environment in which they practice. Information technology, changing consumer behavior, and the social imperative to contain costs are coming together to transform health care.
Innovation in the prevention, diagnosis, and treatment of health-related issues is being fueled by the emergence of accessible and affordable technology-based solutions and changes in patient approaches to health care. Consumers and employers are increasingly motivated to look for cost-effective options for health in care delivery and for economical access to innovations.1 Organizations will need to respond with a strategy that aligns with the changing environment and position physicians to lead these trends in the direction of improved patient care.2
Enabling technologies like electronic health records, blockchain, and artificial intelligence will increase connectivity among all the stakeholders in the health-care system. The exponential increase in connectivity means growing engagement of health systems, health plans, patients, and families in all aspects of health care. For health-care providers, these technologies will mean an acceleration of the requirement to generate data in clinical settings and utilize data for clinical decision making. Easily available data on outcomes and, most importantly, cost of treatment will be expected at point of service.3
Access to information will continue to empower consumers to take an active role in their own health care. More patients will be comfortable with delivery of some health care via digital devices, apps, and virtual access to treatment. The market will respond with technology that helps consumers navigate health-care systems, explore options, and communicate directly with providers. The use of apps and virtual encounters is expected to transform the role of primary care providers: patients will increasingly utilize nonphysician resources in outpatient settings, bypassing primary care physicians and reaching out to specialty care as needed.4
David A. Schulman, MD, FCCP, Professor of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, and Editor in Chief of CHEST Physician, has seen the transformation of patient behavior and attitudes in his own practice.
“In general, they have done far more research about their health problems before seeking my counsel than patients did previously. Many use the internet not just to read about their symptoms and diseases, but also to connect with others having similar issues, sharing experiences, treatments, outcomes, and emotions; in some ways, this is the new ‘crowdsourcing’ of medicine.”
Patients who do their own “research” can present a challenge for physicians. Dr. Schulman noted, “I am often surprised about the misconceptions about disease that derive from information gleaned from a web-based source. One need not look any farther than the groundswell of misinformation being spread about vaccinations to see the potential downside of the pervasive availability of medical ‘facts’ online. Since we are unlikely to convince our patients to avoid the online milieu entirely, our role as health-care providers is to help our patients process and appropriately weigh the information that they receive, potentially partnering with our national societies to help curate such information.”
Dr. Schulman’s approach to the potential of patient misinformation is to initiate almost all discussions with patients with the question “Have your read or seen anything about this condition?” He said, “It is rare for patients to answer negatively. And listening to them speak about their understanding of their disease provides me with invaluable information about how the remainder of our visit should be spent. Do we need to correct misunderstandings? Are there gaps in the explanation that I can fill? Can we move directly into a conversation about treatment options? Can I provide you with some additional resources that might help to further your knowledge about the condition?”
Generational factors will play a big role in health-care demand and delivery. Health-care companies are already building lower cost delivery models to capture the millennial market.4 Cost-saving digital tools and virtual contacts are currently most commonly used by younger patients.5 Physicians need to understand and be a part of this trend, Dr. Schulman argued. “We should embrace telemedicine and mobile applications to collect data from the patients in their day-to-day lives. While insurance coverage of telemedicine is far from universal at the moment, and the reliability of mobile applications is highly variable, we know that a growing number of our patients are already relying on their digital devices to manage their health. In much the same way that we will need to help patient evaluate online information, we should work with our national societies to support the creation of tools that will allow us to collect data in the home environment in a more robust and reliable fashion.”
The proportion of the US population over the age of 65 is increasing yearly.6 Six out of 10 Americans live with a chronic illness, such as heart disease or diabetes. These and other chronic diseases are the leading drivers of the $3.3 billion annual health-care costs.7 Cost containment for these older patients and those with chronic illness will involve a focus on quality and outcomes data, a drive to deliver treatment in lower cost outpatient settings, and an acceleration of the adoption of value-based models currently underway.8
Taken together, these trends will mean a growing digital interface between physician and patient, a more active consumer-patient, and the availability of a vast array of new tools to access and manage health-care data.
- Delivery of procedures and services will trend from physicians to other members of the health-care team and to lower cost, outpatient settings.9
- Health-care systems will ramp up investment in products and services that improve outcomes and cost effectiveness.10
- Increased regulatory requirements and new payment models mean an ever-growing utilization of information technology by providers to fulfill data imperatives.11
- Physicians will have an increased need for tools that prioritize costs and outcomes data at the point of care.12
- Integration of data from new technologies will touch every aspect of health-care delivery with the objective of improving outcomes and, in turn, reducing costs.13
- Changing consumer attitudes toward delivery of care will be based on a growing familiarity of patients with a digital or virtual interface with providers, facility with health-care apps, and preference for a menu of options for health-care delivery.14
Dr. Schulman concluded, “We can no more expect our patients to ignore the full panoply of medical information on the internet and digital tools on their mobile devices than we can tell the tide not to come in. The die is cast; this is the world within which we must ply our trade. By identifying best practices and sharing our successes, we can come through this revolution better for the experience.”
References
1. https://www.modernhealthcare.com/article/20181220/NEWS/181229992/number-of-outpatient-facilities-surges-as-industry-values-more
2. https://www.accenture.com/us-en/insights/health/digital-health-tech-vision-2018
3. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
4. PcW Health Research Institute: Top health industry issues of 2019
5. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
6. https://www.census.gov/newsroom/press-releases/2017/cb17-100.html
7. https://www.cdc.gov/chronicdisease/index.htm
8. https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/health-care-current-december4-2018.html
9. PcW Health Research Institute Top health industry issues of 2019: The New Health Economy comes of age
10. https://www.accenture.com/us-en/insights/health/digital-health-tech-vision-2018
11. https://www2.deloitte.com/insights/us/en/industry/life-sciences/medtech-research-and-development-innovation.html
12. https://www2.deloitte.com/insights/us/en/industry/health-care/volume-to-value-based-care.html
13. https://www2.deloitte.com/insights/us/en/industry/health-care/volume-to-value-based-care.html
14. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
CHEST Inspiration is a collection of programmatic initiatives developed by the American College of Chest Physicians leadership and aimed at stimulating and encouraging innovation within the association. One of the components of CHEST Inspiration is the Environmental Scan, a series of articles focusing on the internal and external environmental factors that bear on success currently and in the future. See “Envisioning the Future: the CHEST Environmental Scan,” CHEST Physician, June 2019, p. 44, for an introduction to the series.
Chest physicians are witnessing a revolution within the environment in which they practice. Information technology, changing consumer behavior, and the social imperative to contain costs are coming together to transform health care.
Innovation in the prevention, diagnosis, and treatment of health-related issues is being fueled by the emergence of accessible and affordable technology-based solutions and changes in patient approaches to health care. Consumers and employers are increasingly motivated to look for cost-effective options for health in care delivery and for economical access to innovations.1 Organizations will need to respond with a strategy that aligns with the changing environment and position physicians to lead these trends in the direction of improved patient care.2
Enabling technologies like electronic health records, blockchain, and artificial intelligence will increase connectivity among all the stakeholders in the health-care system. The exponential increase in connectivity means growing engagement of health systems, health plans, patients, and families in all aspects of health care. For health-care providers, these technologies will mean an acceleration of the requirement to generate data in clinical settings and utilize data for clinical decision making. Easily available data on outcomes and, most importantly, cost of treatment will be expected at point of service.3
Access to information will continue to empower consumers to take an active role in their own health care. More patients will be comfortable with delivery of some health care via digital devices, apps, and virtual access to treatment. The market will respond with technology that helps consumers navigate health-care systems, explore options, and communicate directly with providers. The use of apps and virtual encounters is expected to transform the role of primary care providers: patients will increasingly utilize nonphysician resources in outpatient settings, bypassing primary care physicians and reaching out to specialty care as needed.4
David A. Schulman, MD, FCCP, Professor of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, and Editor in Chief of CHEST Physician, has seen the transformation of patient behavior and attitudes in his own practice.
“In general, they have done far more research about their health problems before seeking my counsel than patients did previously. Many use the internet not just to read about their symptoms and diseases, but also to connect with others having similar issues, sharing experiences, treatments, outcomes, and emotions; in some ways, this is the new ‘crowdsourcing’ of medicine.”
Patients who do their own “research” can present a challenge for physicians. Dr. Schulman noted, “I am often surprised about the misconceptions about disease that derive from information gleaned from a web-based source. One need not look any farther than the groundswell of misinformation being spread about vaccinations to see the potential downside of the pervasive availability of medical ‘facts’ online. Since we are unlikely to convince our patients to avoid the online milieu entirely, our role as health-care providers is to help our patients process and appropriately weigh the information that they receive, potentially partnering with our national societies to help curate such information.”
Dr. Schulman’s approach to the potential of patient misinformation is to initiate almost all discussions with patients with the question “Have your read or seen anything about this condition?” He said, “It is rare for patients to answer negatively. And listening to them speak about their understanding of their disease provides me with invaluable information about how the remainder of our visit should be spent. Do we need to correct misunderstandings? Are there gaps in the explanation that I can fill? Can we move directly into a conversation about treatment options? Can I provide you with some additional resources that might help to further your knowledge about the condition?”
Generational factors will play a big role in health-care demand and delivery. Health-care companies are already building lower cost delivery models to capture the millennial market.4 Cost-saving digital tools and virtual contacts are currently most commonly used by younger patients.5 Physicians need to understand and be a part of this trend, Dr. Schulman argued. “We should embrace telemedicine and mobile applications to collect data from the patients in their day-to-day lives. While insurance coverage of telemedicine is far from universal at the moment, and the reliability of mobile applications is highly variable, we know that a growing number of our patients are already relying on their digital devices to manage their health. In much the same way that we will need to help patient evaluate online information, we should work with our national societies to support the creation of tools that will allow us to collect data in the home environment in a more robust and reliable fashion.”
The proportion of the US population over the age of 65 is increasing yearly.6 Six out of 10 Americans live with a chronic illness, such as heart disease or diabetes. These and other chronic diseases are the leading drivers of the $3.3 billion annual health-care costs.7 Cost containment for these older patients and those with chronic illness will involve a focus on quality and outcomes data, a drive to deliver treatment in lower cost outpatient settings, and an acceleration of the adoption of value-based models currently underway.8
Taken together, these trends will mean a growing digital interface between physician and patient, a more active consumer-patient, and the availability of a vast array of new tools to access and manage health-care data.
- Delivery of procedures and services will trend from physicians to other members of the health-care team and to lower cost, outpatient settings.9
- Health-care systems will ramp up investment in products and services that improve outcomes and cost effectiveness.10
- Increased regulatory requirements and new payment models mean an ever-growing utilization of information technology by providers to fulfill data imperatives.11
- Physicians will have an increased need for tools that prioritize costs and outcomes data at the point of care.12
- Integration of data from new technologies will touch every aspect of health-care delivery with the objective of improving outcomes and, in turn, reducing costs.13
- Changing consumer attitudes toward delivery of care will be based on a growing familiarity of patients with a digital or virtual interface with providers, facility with health-care apps, and preference for a menu of options for health-care delivery.14
Dr. Schulman concluded, “We can no more expect our patients to ignore the full panoply of medical information on the internet and digital tools on their mobile devices than we can tell the tide not to come in. The die is cast; this is the world within which we must ply our trade. By identifying best practices and sharing our successes, we can come through this revolution better for the experience.”
References
1. https://www.modernhealthcare.com/article/20181220/NEWS/181229992/number-of-outpatient-facilities-surges-as-industry-values-more
2. https://www.accenture.com/us-en/insights/health/digital-health-tech-vision-2018
3. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
4. PcW Health Research Institute: Top health industry issues of 2019
5. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
6. https://www.census.gov/newsroom/press-releases/2017/cb17-100.html
7. https://www.cdc.gov/chronicdisease/index.htm
8. https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/health-care-current-december4-2018.html
9. PcW Health Research Institute Top health industry issues of 2019: The New Health Economy comes of age
10. https://www.accenture.com/us-en/insights/health/digital-health-tech-vision-2018
11. https://www2.deloitte.com/insights/us/en/industry/life-sciences/medtech-research-and-development-innovation.html
12. https://www2.deloitte.com/insights/us/en/industry/health-care/volume-to-value-based-care.html
13. https://www2.deloitte.com/insights/us/en/industry/health-care/volume-to-value-based-care.html
14. https://www.accenture.com/us-en/insights/health/digital-health-primary-care
This month in the journal CHEST®
Editor’s picks
EDITORIAL
The CHEST Editorial Team: Serving Our Contributors and Readers
By Dr. P. J. Mazzone
ORIGINAL RESEARCH
Pulmonary Arterial Histologic Lesions in Patients With COPD With Severe Pulmonary Hypertension
By Dr. V. Bunel, et al.
Pulmonary Edema Following Initiation of Parenteral Prostacyclin Therapy for Pulmonary Arterial Hypertension: A Retrospective Study
By Dr. N. A. Khan, et al.
Lung Allocation Score Thresholds Prioritize Survival After Lung Transplantation
By Dr. S. S. Li, et al.
EVIDENCE-BASED MEDICINE
Chronic Cough and Gastroesophageal Reflux in Children: CHEST Guideline and Expert Panel Report
By Dr. A. B. Chang, et al.
Editor’s picks
Editor’s picks
EDITORIAL
The CHEST Editorial Team: Serving Our Contributors and Readers
By Dr. P. J. Mazzone
ORIGINAL RESEARCH
Pulmonary Arterial Histologic Lesions in Patients With COPD With Severe Pulmonary Hypertension
By Dr. V. Bunel, et al.
Pulmonary Edema Following Initiation of Parenteral Prostacyclin Therapy for Pulmonary Arterial Hypertension: A Retrospective Study
By Dr. N. A. Khan, et al.
Lung Allocation Score Thresholds Prioritize Survival After Lung Transplantation
By Dr. S. S. Li, et al.
EVIDENCE-BASED MEDICINE
Chronic Cough and Gastroesophageal Reflux in Children: CHEST Guideline and Expert Panel Report
By Dr. A. B. Chang, et al.
EDITORIAL
The CHEST Editorial Team: Serving Our Contributors and Readers
By Dr. P. J. Mazzone
ORIGINAL RESEARCH
Pulmonary Arterial Histologic Lesions in Patients With COPD With Severe Pulmonary Hypertension
By Dr. V. Bunel, et al.
Pulmonary Edema Following Initiation of Parenteral Prostacyclin Therapy for Pulmonary Arterial Hypertension: A Retrospective Study
By Dr. N. A. Khan, et al.
Lung Allocation Score Thresholds Prioritize Survival After Lung Transplantation
By Dr. S. S. Li, et al.
EVIDENCE-BASED MEDICINE
Chronic Cough and Gastroesophageal Reflux in Children: CHEST Guideline and Expert Panel Report
By Dr. A. B. Chang, et al.
Biologics. NetWork name change. Rapid sequence intubation. Competitive bidding. Genomic classifier.
Airways disorders
Asthma biologics: which patients?
Biologic therapies targeting specific inflammatory pathways promise “precision” medicine for severe asthma. Because these therapies are expensive and have different mechanisms of action, appropriate patient selection is crucial. To date, the biologics have been primarily used in severe asthma.
Severe asthma has been defined as “asthma which remains uncontrolled on high-dose inhaled corticosteroids plus a second controller for the previous year or systemic corticosteroids (for 50% or more of the previous year) to prevent it from becoming uncontrolled, or which remains uncontrolled despite this therapy” (Chung, et al. Eur Respir J. 2014;43:343).
Severe asthma is an infrequent to rare occurrence. Only 5% to 10 % of patients have severe asthma (Varsano, et al. Respir Med. 2017;123:131). Indeed, one study suggests that only 3.6% of patients meet criteria for it (Hekking, et al. J Allergy Clin Immunol. 2015;135[4]:896).
Not all difficult to control asthma is severe. With aggressive management of comorbidities and appropriate assessment of medication adherence/inhaler technique, up to 50% of uncontrolled asthmatics can reach therapeutic goals with traditional stepwise inhaler-based therapies (Tay, et al. J Allergy Clin Immunol Pract. 2017;5[4]:956; Hekking, et al. J Allergy Clin Immunol. 2015;135[4]:896). Yet, incorrect inhaler technique (MDI and DPI) is unacceptably frequent and has not improved over the past 40 years (Sanchis, et al. Chest. 2016;150[2]:394). Furthermore, correct inhaler technique was found in only 15.5% of health-care providers and has worsened in recent years (Plaza, et al. J Allergy Clin Immunol Pract. 2018;6[3]:987).
After establishing appropriate diagnosis, control of comorbidities, proper inhaler technique, and medication adherence, evaluation of a severe asthmatic’s inflammatory phenotype is necessary. Several phenotypes have emerged, including the severe allergic asthma phenotype and the severe eosinophilic asthma phenotype. Molecular phenotyping allows stratification into type–2–high vs type–2-low patients, which helps guide selection of the appropriate biologic. Options include: (1) anti-IgE (omalizumab); (2) anti-interleukin–5 (mepolizumab and reslizumab); (3) anti-interleukin-5 receptor alpha (benralizumab); and (4) anti-interleukin-4 receptor alpha and interleukin-13 (dupilumab).
Targeted biologics for specific severe asthma phenotypes may be cost effective long-term. However, long-term side effects need to be assessed and pharmaco-economic studies need to be performed.
Megan Conroy, MD
Steering Committee Fellow-in-Training
Stuart M. Garay, MD, FCCP
Steering Committee Chair
Clinical research and quality improvement
Anew, redefined, and enriched
CHEST Physician readers may not know that Clinical Research recently changed its name to include quality improvement (QI). Its new mission is “to provide a forum for clinical research, QI, research ethics, and regulatory aspects, as topics of multidisciplinary discussion and collaboration.” Medical education has become a natural addition to our NetWork’s scope, as this field of scholarly activity has emerged and grown tremendously in the past decade. Interestingly, the number of session submissions to CHEST 2019 increased by a whopping 32% vs 2018, while our NetWork saw an even more impressive increase of 42% in submissions deemed Clinical, Education Research, or QI.
The initial concept of a CHEST Clinical Research NetWork was narrower, aiming to fill gaps between our members’ interests and activities with those of pharmaceutical industry partners and equipment and device manufacturers. Its scope evolved, and our NetWork became the home of all clinical research endeavors not pinned to a specific condition, disease class, or membership category.
QI emerged in other industries long ago, using scientific methods and known to be foundational for any organization’s capacity to survive in competitive environments, become more efficient, satisfy customers, improve outcomes, and develop better work flows and conditions for employees and business partners.
If the QI world strives to achieve certainty with confidence levels less than 0.0001, it is interesting that in our scientific quest we settle for P less than .05. Self-indulgence? Simplistically speaking, are we tolerating “defect rates” of 5%, while others aim for 6 sigma thresholds? These are a few thoughts on how health care can learn from other industries and apply more stringent standards for scholarly activities in clinical research, education, and QI.
In conclusion, while it continues to strive to build the infrastructure of future CHEST clinical research nodes for randomized or observational multicentric studies, Clinical Research and QI NetWork enthusiastically embraces the fields of medical education and QI into its enriched activity scope and scale.
Octavian C. Ioachimescu, MD, PhD, FCCP
Steering Committee Member
Critical care
Rapid sequence intubation
Casey and colleagues recently published a study (N Engl J Med. 2019;380[9]:811) that challenges the long-held view that rapid sequence intubation (RSI) should not include ventilation attempts between induction and laryngoscopy. Airway management purists will say that true RSI is pre-oxygenate, give a sedation agent followed immediately by a paralytic agent, and immediate laryngoscopy as soon as the patient is paralyzed. However, RSI has come to mean the use of a sedation agent and a paralytic agent without specific timing of when to give the paralytic.
Purists would also say RSI is done for patients who are at a high risk for aspiration. In this study, the amount of subjectively reported aspiration was actually lower in the YES BVM group: 2.5% vs 4.0%. The presence of a new opacity on chest radiograph within 48 hours was 16% vs 15%, suggesting that there is no significant difference in the incidence of aspiration.
In this study, 40% in the NO BVM group and 30% in the YES BVM group had O2 desaturations below 90%. These statistics highlight the fact that it is imperative to pre-oxygenate all patients who will undergo intubation. Critically ill patients have little reserve. These patients are on the steep portion of the oxygen dissociation curve. The saturations will drop quickly. It is better to avoid any desaturation if possible.
This study demonstrates that bag-mask ventilation between induction and laryngoscopy can help prevent severe desaturation with a number needed to treat to prevent one severe hypoxic event is nine.
John Gaillard, MD, FCCP
Steering Committee Member
Home-based mechanical ventilation and neuromuscular disease
Pressures of competitive bidding process
Advancements in invasive and noninvasive ventilator technology have allowed patients with neuromuscular conditions and severe COPD to transition from institutional care to living at home. Ventilator support is reserved for severe or progressive respiratory impairment where interruption would lead to serious negative consequences. Access to this technology does entail significant cost, as monthly rental fees range from $660 to $1,352 and yearly ventilator claims for chronic respiratory failure have increased from 29% in 2009 to 85% in 2015 (US Dept HHS, OIG Data brief 2016). There is a current proposal to include home mechanical ventilators with oxygen and other services in competitive bidding programs (CBP). Since oxygen was included in CBP, access to liquid oxygen systems and payments for oxygen have decreased significantly. Of patients using home oxygen since July 1, 2016, 59% reported difficulties with access to oxygen-related equipment and services (American Association for Respiratory Care Comment on Federal policies, aarc.org).
Ventilator-dependent patients should not be subjected to the pressures of CBP when trying to obtain the equipment, supplies, and access to experienced medical providers that are necessary to remain in their homes. Beyond denying ventilatory support to some, CBP may also result in other unintended consequences, including the increased use of otherwise avoidable tracheostomies to ensure coverage for appropriate services. CHEST, including the Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork and other patient groups, has advocated that home mechanical ventilators should be permanently excluded from the CBP to protect these fragile and vulnerable patients.
Jeanette Brown, MD, PhD
Steering Committee Member
Interstitial and diffuse lung disease
New genomic classifier
A confident diagnosis of idiopathic pulmonary fibrosis (IPF) relies on the radiographic pattern of usual interstitial pneumonitis (UIP), although in some cases, histologic confirmation is warranted. Transbronchial biopsy (TBBx) does not provide adequate tissue for diagnosis, thus patients are subjected to the risk of a surgical biopsy. A promising new test can increase confidence in the diagnosis of IPF. The Envisia Genomic Classifier (Veracyte) is a recently approved test to aid in the diagnosis of IPF. It utilizes 190 genes and RNA sequencing, combined with machine learning, to create an algorithm that determines the presence of UIP on samples derived from TBBx.
A proof-of-principle study described the characteristics of the genomic classifier in distinguishing UIP for 53 training subjects and 31 test subjects. To ensure validation, this new test was compared with a diagnosis determined by histopathologic review from expert pathologists. Specificity was 86% and sensitivity 63% in distinguishing UIP vs non-UIP patterns. Although false-negatives were a concern due to IPFs heterogeneous involvement of the lung, combining multiple specimens from a single patient increased accuracy.
The recently-published BRAVE study was a validation and utilization study, proving the test’s success in identifying UIP on TBBx samples. The test was again compared with diagnostic histopathology, demonstrating 88% specificity and 70% sensitivity. In addition, two multidisciplinary teams had an 86% agreement on diagnoses when using pathology vs the genomic classifier. The classifier is commercially available and is covered by Medicare in the United States.
As with all new technology, it is expected that its use will increase in the future and that we will learn more about how, and in whom, to best utilize this tool.
Samantha D’Annunzio, MD
Steering Committee Member
References
Pankratz DG, et al. Ann Am Thorac Soc. 2017;14[11]1646.
Raghu G, et al. Lancet Respir Med. 2019 Jun;7(6):487.
Airways disorders
Asthma biologics: which patients?
Biologic therapies targeting specific inflammatory pathways promise “precision” medicine for severe asthma. Because these therapies are expensive and have different mechanisms of action, appropriate patient selection is crucial. To date, the biologics have been primarily used in severe asthma.
Severe asthma has been defined as “asthma which remains uncontrolled on high-dose inhaled corticosteroids plus a second controller for the previous year or systemic corticosteroids (for 50% or more of the previous year) to prevent it from becoming uncontrolled, or which remains uncontrolled despite this therapy” (Chung, et al. Eur Respir J. 2014;43:343).
Severe asthma is an infrequent to rare occurrence. Only 5% to 10 % of patients have severe asthma (Varsano, et al. Respir Med. 2017;123:131). Indeed, one study suggests that only 3.6% of patients meet criteria for it (Hekking, et al. J Allergy Clin Immunol. 2015;135[4]:896).
Not all difficult to control asthma is severe. With aggressive management of comorbidities and appropriate assessment of medication adherence/inhaler technique, up to 50% of uncontrolled asthmatics can reach therapeutic goals with traditional stepwise inhaler-based therapies (Tay, et al. J Allergy Clin Immunol Pract. 2017;5[4]:956; Hekking, et al. J Allergy Clin Immunol. 2015;135[4]:896). Yet, incorrect inhaler technique (MDI and DPI) is unacceptably frequent and has not improved over the past 40 years (Sanchis, et al. Chest. 2016;150[2]:394). Furthermore, correct inhaler technique was found in only 15.5% of health-care providers and has worsened in recent years (Plaza, et al. J Allergy Clin Immunol Pract. 2018;6[3]:987).
After establishing appropriate diagnosis, control of comorbidities, proper inhaler technique, and medication adherence, evaluation of a severe asthmatic’s inflammatory phenotype is necessary. Several phenotypes have emerged, including the severe allergic asthma phenotype and the severe eosinophilic asthma phenotype. Molecular phenotyping allows stratification into type–2–high vs type–2-low patients, which helps guide selection of the appropriate biologic. Options include: (1) anti-IgE (omalizumab); (2) anti-interleukin–5 (mepolizumab and reslizumab); (3) anti-interleukin-5 receptor alpha (benralizumab); and (4) anti-interleukin-4 receptor alpha and interleukin-13 (dupilumab).
Targeted biologics for specific severe asthma phenotypes may be cost effective long-term. However, long-term side effects need to be assessed and pharmaco-economic studies need to be performed.
Megan Conroy, MD
Steering Committee Fellow-in-Training
Stuart M. Garay, MD, FCCP
Steering Committee Chair
Clinical research and quality improvement
Anew, redefined, and enriched
CHEST Physician readers may not know that Clinical Research recently changed its name to include quality improvement (QI). Its new mission is “to provide a forum for clinical research, QI, research ethics, and regulatory aspects, as topics of multidisciplinary discussion and collaboration.” Medical education has become a natural addition to our NetWork’s scope, as this field of scholarly activity has emerged and grown tremendously in the past decade. Interestingly, the number of session submissions to CHEST 2019 increased by a whopping 32% vs 2018, while our NetWork saw an even more impressive increase of 42% in submissions deemed Clinical, Education Research, or QI.
The initial concept of a CHEST Clinical Research NetWork was narrower, aiming to fill gaps between our members’ interests and activities with those of pharmaceutical industry partners and equipment and device manufacturers. Its scope evolved, and our NetWork became the home of all clinical research endeavors not pinned to a specific condition, disease class, or membership category.
QI emerged in other industries long ago, using scientific methods and known to be foundational for any organization’s capacity to survive in competitive environments, become more efficient, satisfy customers, improve outcomes, and develop better work flows and conditions for employees and business partners.
If the QI world strives to achieve certainty with confidence levels less than 0.0001, it is interesting that in our scientific quest we settle for P less than .05. Self-indulgence? Simplistically speaking, are we tolerating “defect rates” of 5%, while others aim for 6 sigma thresholds? These are a few thoughts on how health care can learn from other industries and apply more stringent standards for scholarly activities in clinical research, education, and QI.
In conclusion, while it continues to strive to build the infrastructure of future CHEST clinical research nodes for randomized or observational multicentric studies, Clinical Research and QI NetWork enthusiastically embraces the fields of medical education and QI into its enriched activity scope and scale.
Octavian C. Ioachimescu, MD, PhD, FCCP
Steering Committee Member
Critical care
Rapid sequence intubation
Casey and colleagues recently published a study (N Engl J Med. 2019;380[9]:811) that challenges the long-held view that rapid sequence intubation (RSI) should not include ventilation attempts between induction and laryngoscopy. Airway management purists will say that true RSI is pre-oxygenate, give a sedation agent followed immediately by a paralytic agent, and immediate laryngoscopy as soon as the patient is paralyzed. However, RSI has come to mean the use of a sedation agent and a paralytic agent without specific timing of when to give the paralytic.
Purists would also say RSI is done for patients who are at a high risk for aspiration. In this study, the amount of subjectively reported aspiration was actually lower in the YES BVM group: 2.5% vs 4.0%. The presence of a new opacity on chest radiograph within 48 hours was 16% vs 15%, suggesting that there is no significant difference in the incidence of aspiration.
In this study, 40% in the NO BVM group and 30% in the YES BVM group had O2 desaturations below 90%. These statistics highlight the fact that it is imperative to pre-oxygenate all patients who will undergo intubation. Critically ill patients have little reserve. These patients are on the steep portion of the oxygen dissociation curve. The saturations will drop quickly. It is better to avoid any desaturation if possible.
This study demonstrates that bag-mask ventilation between induction and laryngoscopy can help prevent severe desaturation with a number needed to treat to prevent one severe hypoxic event is nine.
John Gaillard, MD, FCCP
Steering Committee Member
Home-based mechanical ventilation and neuromuscular disease
Pressures of competitive bidding process
Advancements in invasive and noninvasive ventilator technology have allowed patients with neuromuscular conditions and severe COPD to transition from institutional care to living at home. Ventilator support is reserved for severe or progressive respiratory impairment where interruption would lead to serious negative consequences. Access to this technology does entail significant cost, as monthly rental fees range from $660 to $1,352 and yearly ventilator claims for chronic respiratory failure have increased from 29% in 2009 to 85% in 2015 (US Dept HHS, OIG Data brief 2016). There is a current proposal to include home mechanical ventilators with oxygen and other services in competitive bidding programs (CBP). Since oxygen was included in CBP, access to liquid oxygen systems and payments for oxygen have decreased significantly. Of patients using home oxygen since July 1, 2016, 59% reported difficulties with access to oxygen-related equipment and services (American Association for Respiratory Care Comment on Federal policies, aarc.org).
Ventilator-dependent patients should not be subjected to the pressures of CBP when trying to obtain the equipment, supplies, and access to experienced medical providers that are necessary to remain in their homes. Beyond denying ventilatory support to some, CBP may also result in other unintended consequences, including the increased use of otherwise avoidable tracheostomies to ensure coverage for appropriate services. CHEST, including the Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork and other patient groups, has advocated that home mechanical ventilators should be permanently excluded from the CBP to protect these fragile and vulnerable patients.
Jeanette Brown, MD, PhD
Steering Committee Member
Interstitial and diffuse lung disease
New genomic classifier
A confident diagnosis of idiopathic pulmonary fibrosis (IPF) relies on the radiographic pattern of usual interstitial pneumonitis (UIP), although in some cases, histologic confirmation is warranted. Transbronchial biopsy (TBBx) does not provide adequate tissue for diagnosis, thus patients are subjected to the risk of a surgical biopsy. A promising new test can increase confidence in the diagnosis of IPF. The Envisia Genomic Classifier (Veracyte) is a recently approved test to aid in the diagnosis of IPF. It utilizes 190 genes and RNA sequencing, combined with machine learning, to create an algorithm that determines the presence of UIP on samples derived from TBBx.
A proof-of-principle study described the characteristics of the genomic classifier in distinguishing UIP for 53 training subjects and 31 test subjects. To ensure validation, this new test was compared with a diagnosis determined by histopathologic review from expert pathologists. Specificity was 86% and sensitivity 63% in distinguishing UIP vs non-UIP patterns. Although false-negatives were a concern due to IPFs heterogeneous involvement of the lung, combining multiple specimens from a single patient increased accuracy.
The recently-published BRAVE study was a validation and utilization study, proving the test’s success in identifying UIP on TBBx samples. The test was again compared with diagnostic histopathology, demonstrating 88% specificity and 70% sensitivity. In addition, two multidisciplinary teams had an 86% agreement on diagnoses when using pathology vs the genomic classifier. The classifier is commercially available and is covered by Medicare in the United States.
As with all new technology, it is expected that its use will increase in the future and that we will learn more about how, and in whom, to best utilize this tool.
Samantha D’Annunzio, MD
Steering Committee Member
References
Pankratz DG, et al. Ann Am Thorac Soc. 2017;14[11]1646.
Raghu G, et al. Lancet Respir Med. 2019 Jun;7(6):487.
Airways disorders
Asthma biologics: which patients?
Biologic therapies targeting specific inflammatory pathways promise “precision” medicine for severe asthma. Because these therapies are expensive and have different mechanisms of action, appropriate patient selection is crucial. To date, the biologics have been primarily used in severe asthma.
Severe asthma has been defined as “asthma which remains uncontrolled on high-dose inhaled corticosteroids plus a second controller for the previous year or systemic corticosteroids (for 50% or more of the previous year) to prevent it from becoming uncontrolled, or which remains uncontrolled despite this therapy” (Chung, et al. Eur Respir J. 2014;43:343).
Severe asthma is an infrequent to rare occurrence. Only 5% to 10 % of patients have severe asthma (Varsano, et al. Respir Med. 2017;123:131). Indeed, one study suggests that only 3.6% of patients meet criteria for it (Hekking, et al. J Allergy Clin Immunol. 2015;135[4]:896).
Not all difficult to control asthma is severe. With aggressive management of comorbidities and appropriate assessment of medication adherence/inhaler technique, up to 50% of uncontrolled asthmatics can reach therapeutic goals with traditional stepwise inhaler-based therapies (Tay, et al. J Allergy Clin Immunol Pract. 2017;5[4]:956; Hekking, et al. J Allergy Clin Immunol. 2015;135[4]:896). Yet, incorrect inhaler technique (MDI and DPI) is unacceptably frequent and has not improved over the past 40 years (Sanchis, et al. Chest. 2016;150[2]:394). Furthermore, correct inhaler technique was found in only 15.5% of health-care providers and has worsened in recent years (Plaza, et al. J Allergy Clin Immunol Pract. 2018;6[3]:987).
After establishing appropriate diagnosis, control of comorbidities, proper inhaler technique, and medication adherence, evaluation of a severe asthmatic’s inflammatory phenotype is necessary. Several phenotypes have emerged, including the severe allergic asthma phenotype and the severe eosinophilic asthma phenotype. Molecular phenotyping allows stratification into type–2–high vs type–2-low patients, which helps guide selection of the appropriate biologic. Options include: (1) anti-IgE (omalizumab); (2) anti-interleukin–5 (mepolizumab and reslizumab); (3) anti-interleukin-5 receptor alpha (benralizumab); and (4) anti-interleukin-4 receptor alpha and interleukin-13 (dupilumab).
Targeted biologics for specific severe asthma phenotypes may be cost effective long-term. However, long-term side effects need to be assessed and pharmaco-economic studies need to be performed.
Megan Conroy, MD
Steering Committee Fellow-in-Training
Stuart M. Garay, MD, FCCP
Steering Committee Chair
Clinical research and quality improvement
Anew, redefined, and enriched
CHEST Physician readers may not know that Clinical Research recently changed its name to include quality improvement (QI). Its new mission is “to provide a forum for clinical research, QI, research ethics, and regulatory aspects, as topics of multidisciplinary discussion and collaboration.” Medical education has become a natural addition to our NetWork’s scope, as this field of scholarly activity has emerged and grown tremendously in the past decade. Interestingly, the number of session submissions to CHEST 2019 increased by a whopping 32% vs 2018, while our NetWork saw an even more impressive increase of 42% in submissions deemed Clinical, Education Research, or QI.
The initial concept of a CHEST Clinical Research NetWork was narrower, aiming to fill gaps between our members’ interests and activities with those of pharmaceutical industry partners and equipment and device manufacturers. Its scope evolved, and our NetWork became the home of all clinical research endeavors not pinned to a specific condition, disease class, or membership category.
QI emerged in other industries long ago, using scientific methods and known to be foundational for any organization’s capacity to survive in competitive environments, become more efficient, satisfy customers, improve outcomes, and develop better work flows and conditions for employees and business partners.
If the QI world strives to achieve certainty with confidence levels less than 0.0001, it is interesting that in our scientific quest we settle for P less than .05. Self-indulgence? Simplistically speaking, are we tolerating “defect rates” of 5%, while others aim for 6 sigma thresholds? These are a few thoughts on how health care can learn from other industries and apply more stringent standards for scholarly activities in clinical research, education, and QI.
In conclusion, while it continues to strive to build the infrastructure of future CHEST clinical research nodes for randomized or observational multicentric studies, Clinical Research and QI NetWork enthusiastically embraces the fields of medical education and QI into its enriched activity scope and scale.
Octavian C. Ioachimescu, MD, PhD, FCCP
Steering Committee Member
Critical care
Rapid sequence intubation
Casey and colleagues recently published a study (N Engl J Med. 2019;380[9]:811) that challenges the long-held view that rapid sequence intubation (RSI) should not include ventilation attempts between induction and laryngoscopy. Airway management purists will say that true RSI is pre-oxygenate, give a sedation agent followed immediately by a paralytic agent, and immediate laryngoscopy as soon as the patient is paralyzed. However, RSI has come to mean the use of a sedation agent and a paralytic agent without specific timing of when to give the paralytic.
Purists would also say RSI is done for patients who are at a high risk for aspiration. In this study, the amount of subjectively reported aspiration was actually lower in the YES BVM group: 2.5% vs 4.0%. The presence of a new opacity on chest radiograph within 48 hours was 16% vs 15%, suggesting that there is no significant difference in the incidence of aspiration.
In this study, 40% in the NO BVM group and 30% in the YES BVM group had O2 desaturations below 90%. These statistics highlight the fact that it is imperative to pre-oxygenate all patients who will undergo intubation. Critically ill patients have little reserve. These patients are on the steep portion of the oxygen dissociation curve. The saturations will drop quickly. It is better to avoid any desaturation if possible.
This study demonstrates that bag-mask ventilation between induction and laryngoscopy can help prevent severe desaturation with a number needed to treat to prevent one severe hypoxic event is nine.
John Gaillard, MD, FCCP
Steering Committee Member
Home-based mechanical ventilation and neuromuscular disease
Pressures of competitive bidding process
Advancements in invasive and noninvasive ventilator technology have allowed patients with neuromuscular conditions and severe COPD to transition from institutional care to living at home. Ventilator support is reserved for severe or progressive respiratory impairment where interruption would lead to serious negative consequences. Access to this technology does entail significant cost, as monthly rental fees range from $660 to $1,352 and yearly ventilator claims for chronic respiratory failure have increased from 29% in 2009 to 85% in 2015 (US Dept HHS, OIG Data brief 2016). There is a current proposal to include home mechanical ventilators with oxygen and other services in competitive bidding programs (CBP). Since oxygen was included in CBP, access to liquid oxygen systems and payments for oxygen have decreased significantly. Of patients using home oxygen since July 1, 2016, 59% reported difficulties with access to oxygen-related equipment and services (American Association for Respiratory Care Comment on Federal policies, aarc.org).
Ventilator-dependent patients should not be subjected to the pressures of CBP when trying to obtain the equipment, supplies, and access to experienced medical providers that are necessary to remain in their homes. Beyond denying ventilatory support to some, CBP may also result in other unintended consequences, including the increased use of otherwise avoidable tracheostomies to ensure coverage for appropriate services. CHEST, including the Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork and other patient groups, has advocated that home mechanical ventilators should be permanently excluded from the CBP to protect these fragile and vulnerable patients.
Jeanette Brown, MD, PhD
Steering Committee Member
Interstitial and diffuse lung disease
New genomic classifier
A confident diagnosis of idiopathic pulmonary fibrosis (IPF) relies on the radiographic pattern of usual interstitial pneumonitis (UIP), although in some cases, histologic confirmation is warranted. Transbronchial biopsy (TBBx) does not provide adequate tissue for diagnosis, thus patients are subjected to the risk of a surgical biopsy. A promising new test can increase confidence in the diagnosis of IPF. The Envisia Genomic Classifier (Veracyte) is a recently approved test to aid in the diagnosis of IPF. It utilizes 190 genes and RNA sequencing, combined with machine learning, to create an algorithm that determines the presence of UIP on samples derived from TBBx.
A proof-of-principle study described the characteristics of the genomic classifier in distinguishing UIP for 53 training subjects and 31 test subjects. To ensure validation, this new test was compared with a diagnosis determined by histopathologic review from expert pathologists. Specificity was 86% and sensitivity 63% in distinguishing UIP vs non-UIP patterns. Although false-negatives were a concern due to IPFs heterogeneous involvement of the lung, combining multiple specimens from a single patient increased accuracy.
The recently-published BRAVE study was a validation and utilization study, proving the test’s success in identifying UIP on TBBx samples. The test was again compared with diagnostic histopathology, demonstrating 88% specificity and 70% sensitivity. In addition, two multidisciplinary teams had an 86% agreement on diagnoses when using pathology vs the genomic classifier. The classifier is commercially available and is covered by Medicare in the United States.
As with all new technology, it is expected that its use will increase in the future and that we will learn more about how, and in whom, to best utilize this tool.
Samantha D’Annunzio, MD
Steering Committee Member
References
Pankratz DG, et al. Ann Am Thorac Soc. 2017;14[11]1646.
Raghu G, et al. Lancet Respir Med. 2019 Jun;7(6):487.
From the EVP/CEO: Opportunities for CHEST to broaden its reach across the globe
Our recent congress in Bangkok, Thailand, was just the beginning of our plans to expand the CHEST brand and share our innovative education across the globe. The congress held this past April served as a successful launch pad that included attendance of over 1,000 delegates who represented 57 countries and featured innovative and diverse educational opportunities that incorporated the best of the CHEST Annual Meeting, including interactive lectures, recent advances in clinical practice and science, guided poster presentations, and hands-on simulation opportunities. The exceptional program is attributed to the partnership with the Thoracic Society of Thailand; the Chair, Dr. David Schulman; the faculty, for delivering such an innovative and engaging educational event; and many others who planned, supported, and participated in this impressive event.
In order to have a greater impact on the way that lung diseases, critical care conditions, and sleep disorders are diagnosed and treated, CHEST has been actively expanding its reach and the way it plans, develops, and executes its international educational strategy. This was CHEST’s first venture into a new model designed around hosting one large congress outside of the United States and one smaller regional congress each year. This year, Athens, Greece, followed in June as the site of the regional congress. In subsequent years, we will be increasing the offerings and the options for these regional international events.
Newly announced, we are planning a regional program in Singapore for late fall of 2020 or early 2021. This program will be conducted in collaboration with the National University Health System and Dr. Pyng Lee. Also, next year, the CHEST Congress will be held in Bologna, Italy, June 25-27, in collaboration with the CHEST delegation from Italy, led by Dr. Francesco de Blasio. The program chairs for this event are Drs. John Studdard and William Kelly.
We are excited to broaden our international educational reach through this plan. By refining, growing, and building upon this new model and developing more live learning, hands-on simulation, CHEST gamification, and other interactive components, we continually provide the most cutting-edge learning opportunities available across the globe. We are accomplishing this through partnering with global societies and CHEST delegations to identify unmet educational needs by region and patient base. Through this expansion, we hope to continue our fight to “Crush” lung disease wherever it exists.
Our recent congress in Bangkok, Thailand, was just the beginning of our plans to expand the CHEST brand and share our innovative education across the globe. The congress held this past April served as a successful launch pad that included attendance of over 1,000 delegates who represented 57 countries and featured innovative and diverse educational opportunities that incorporated the best of the CHEST Annual Meeting, including interactive lectures, recent advances in clinical practice and science, guided poster presentations, and hands-on simulation opportunities. The exceptional program is attributed to the partnership with the Thoracic Society of Thailand; the Chair, Dr. David Schulman; the faculty, for delivering such an innovative and engaging educational event; and many others who planned, supported, and participated in this impressive event.
In order to have a greater impact on the way that lung diseases, critical care conditions, and sleep disorders are diagnosed and treated, CHEST has been actively expanding its reach and the way it plans, develops, and executes its international educational strategy. This was CHEST’s first venture into a new model designed around hosting one large congress outside of the United States and one smaller regional congress each year. This year, Athens, Greece, followed in June as the site of the regional congress. In subsequent years, we will be increasing the offerings and the options for these regional international events.
Newly announced, we are planning a regional program in Singapore for late fall of 2020 or early 2021. This program will be conducted in collaboration with the National University Health System and Dr. Pyng Lee. Also, next year, the CHEST Congress will be held in Bologna, Italy, June 25-27, in collaboration with the CHEST delegation from Italy, led by Dr. Francesco de Blasio. The program chairs for this event are Drs. John Studdard and William Kelly.
We are excited to broaden our international educational reach through this plan. By refining, growing, and building upon this new model and developing more live learning, hands-on simulation, CHEST gamification, and other interactive components, we continually provide the most cutting-edge learning opportunities available across the globe. We are accomplishing this through partnering with global societies and CHEST delegations to identify unmet educational needs by region and patient base. Through this expansion, we hope to continue our fight to “Crush” lung disease wherever it exists.
Our recent congress in Bangkok, Thailand, was just the beginning of our plans to expand the CHEST brand and share our innovative education across the globe. The congress held this past April served as a successful launch pad that included attendance of over 1,000 delegates who represented 57 countries and featured innovative and diverse educational opportunities that incorporated the best of the CHEST Annual Meeting, including interactive lectures, recent advances in clinical practice and science, guided poster presentations, and hands-on simulation opportunities. The exceptional program is attributed to the partnership with the Thoracic Society of Thailand; the Chair, Dr. David Schulman; the faculty, for delivering such an innovative and engaging educational event; and many others who planned, supported, and participated in this impressive event.
In order to have a greater impact on the way that lung diseases, critical care conditions, and sleep disorders are diagnosed and treated, CHEST has been actively expanding its reach and the way it plans, develops, and executes its international educational strategy. This was CHEST’s first venture into a new model designed around hosting one large congress outside of the United States and one smaller regional congress each year. This year, Athens, Greece, followed in June as the site of the regional congress. In subsequent years, we will be increasing the offerings and the options for these regional international events.
Newly announced, we are planning a regional program in Singapore for late fall of 2020 or early 2021. This program will be conducted in collaboration with the National University Health System and Dr. Pyng Lee. Also, next year, the CHEST Congress will be held in Bologna, Italy, June 25-27, in collaboration with the CHEST delegation from Italy, led by Dr. Francesco de Blasio. The program chairs for this event are Drs. John Studdard and William Kelly.
We are excited to broaden our international educational reach through this plan. By refining, growing, and building upon this new model and developing more live learning, hands-on simulation, CHEST gamification, and other interactive components, we continually provide the most cutting-edge learning opportunities available across the globe. We are accomplishing this through partnering with global societies and CHEST delegations to identify unmet educational needs by region and patient base. Through this expansion, we hope to continue our fight to “Crush” lung disease wherever it exists.
In Memoriam
CHEST has been notified of the following deaths.
We extend our sincere condolences.
John W. Thomas, MD (2018)
Frederick J Curley, MD (2018)
CHEST has been notified of the following deaths.
We extend our sincere condolences.
John W. Thomas, MD (2018)
Frederick J Curley, MD (2018)
CHEST has been notified of the following deaths.
We extend our sincere condolences.
John W. Thomas, MD (2018)
Frederick J Curley, MD (2018)
Fill your day in New Orleans
No matter if you’re only in New Orleans during #CHEST2019 for a day or for the entire meeting, we’ve got you covered on how to spend your time in the Big Easy outside of sessions and CHEST events!
Rise and shine! If breakfast is the most important meal of the day, we’ve got the perfect way to start your morning before heading over to the Ernest N. Morial Convention Center to begin a day of learning. For a quick bite, try the ever popular Cafe du Monde Riverwalk next to the convention center for a light breakfast of beignets and café au lait, or Fulton Street Cafe.
Lunchtime: For something a little more hearty, head to Green Goddess in the French Quarter for southern comfort food. There’s something for everyone, as you’ll even find some vegan dishes on the menu. If you have time for a longer mid-day break, check out a Garden District Tour, Steam Boat on the River, or relax in Jackson Square.
Evening: You’ve had a long day of sessions, lectures, and exploring the exhibit hall, and now you want to wind down with a good meal (and maybe a drink!). For a slower vibe and space to linger and enjoy yourself, take an Uber/Lyft over to La Petite Grocery on Magazine Street for some tasty, traditional New Orleans dishes.
If you’re a night owl or looking for a late-night activity with a group of your friends and peers, there are plenty of places to find a cocktail on Bourbon Street, or listen to live jazz music along Frenchman Street.
There are many more things you can check out in New Orleans, and we hope you enjoy your stay during CHEST 2019.
*Note: If you’re staying in the hotel block near the convention center, many of the attractions, including the Convention Center, will be a short walking distance. Otherwise, we suggest taking an Uber or Lyft to reach your destination.
No matter if you’re only in New Orleans during #CHEST2019 for a day or for the entire meeting, we’ve got you covered on how to spend your time in the Big Easy outside of sessions and CHEST events!
Rise and shine! If breakfast is the most important meal of the day, we’ve got the perfect way to start your morning before heading over to the Ernest N. Morial Convention Center to begin a day of learning. For a quick bite, try the ever popular Cafe du Monde Riverwalk next to the convention center for a light breakfast of beignets and café au lait, or Fulton Street Cafe.
Lunchtime: For something a little more hearty, head to Green Goddess in the French Quarter for southern comfort food. There’s something for everyone, as you’ll even find some vegan dishes on the menu. If you have time for a longer mid-day break, check out a Garden District Tour, Steam Boat on the River, or relax in Jackson Square.
Evening: You’ve had a long day of sessions, lectures, and exploring the exhibit hall, and now you want to wind down with a good meal (and maybe a drink!). For a slower vibe and space to linger and enjoy yourself, take an Uber/Lyft over to La Petite Grocery on Magazine Street for some tasty, traditional New Orleans dishes.
If you’re a night owl or looking for a late-night activity with a group of your friends and peers, there are plenty of places to find a cocktail on Bourbon Street, or listen to live jazz music along Frenchman Street.
There are many more things you can check out in New Orleans, and we hope you enjoy your stay during CHEST 2019.
*Note: If you’re staying in the hotel block near the convention center, many of the attractions, including the Convention Center, will be a short walking distance. Otherwise, we suggest taking an Uber or Lyft to reach your destination.
No matter if you’re only in New Orleans during #CHEST2019 for a day or for the entire meeting, we’ve got you covered on how to spend your time in the Big Easy outside of sessions and CHEST events!
Rise and shine! If breakfast is the most important meal of the day, we’ve got the perfect way to start your morning before heading over to the Ernest N. Morial Convention Center to begin a day of learning. For a quick bite, try the ever popular Cafe du Monde Riverwalk next to the convention center for a light breakfast of beignets and café au lait, or Fulton Street Cafe.
Lunchtime: For something a little more hearty, head to Green Goddess in the French Quarter for southern comfort food. There’s something for everyone, as you’ll even find some vegan dishes on the menu. If you have time for a longer mid-day break, check out a Garden District Tour, Steam Boat on the River, or relax in Jackson Square.
Evening: You’ve had a long day of sessions, lectures, and exploring the exhibit hall, and now you want to wind down with a good meal (and maybe a drink!). For a slower vibe and space to linger and enjoy yourself, take an Uber/Lyft over to La Petite Grocery on Magazine Street for some tasty, traditional New Orleans dishes.
If you’re a night owl or looking for a late-night activity with a group of your friends and peers, there are plenty of places to find a cocktail on Bourbon Street, or listen to live jazz music along Frenchman Street.
There are many more things you can check out in New Orleans, and we hope you enjoy your stay during CHEST 2019.
*Note: If you’re staying in the hotel block near the convention center, many of the attractions, including the Convention Center, will be a short walking distance. Otherwise, we suggest taking an Uber or Lyft to reach your destination.
A distinguished 14-year editorship
In 1968, Richard S. Irwin, MD, Master FCCP, graduated from Tufts University School of Medicine. After completing medical residency training at the Tufts-New England Medical Center and pulmonary training at Columbia Presbyterian Medical Center, he has been practicing in pulmonary and critical care medicine for the last 50 years.
It was in 1979 that he became a CHEST member; in 2003-2004, he served as President of CHEST; and he has been actively involved as a CHEST leader throughout his career, serving on every major CHEST committee. But Dr. Irwin’s most beloved position has been as Editor in Chief of the journal CHEST®, a journey that began in 2005 – a position that he has filled for 14 years and that which he has recently stepped down from in June 2019. What better description of those 14 years at the helm of one of the most recognized and respected journals in chest medicine than to hear it straight from the Editor in Chief himself. In the June 2019 issue of the journal CHEST®, Dr. Irwin shares his thoughts in this Commentary: “On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.” Don’t miss it!
In 1968, Richard S. Irwin, MD, Master FCCP, graduated from Tufts University School of Medicine. After completing medical residency training at the Tufts-New England Medical Center and pulmonary training at Columbia Presbyterian Medical Center, he has been practicing in pulmonary and critical care medicine for the last 50 years.
It was in 1979 that he became a CHEST member; in 2003-2004, he served as President of CHEST; and he has been actively involved as a CHEST leader throughout his career, serving on every major CHEST committee. But Dr. Irwin’s most beloved position has been as Editor in Chief of the journal CHEST®, a journey that began in 2005 – a position that he has filled for 14 years and that which he has recently stepped down from in June 2019. What better description of those 14 years at the helm of one of the most recognized and respected journals in chest medicine than to hear it straight from the Editor in Chief himself. In the June 2019 issue of the journal CHEST®, Dr. Irwin shares his thoughts in this Commentary: “On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.” Don’t miss it!
In 1968, Richard S. Irwin, MD, Master FCCP, graduated from Tufts University School of Medicine. After completing medical residency training at the Tufts-New England Medical Center and pulmonary training at Columbia Presbyterian Medical Center, he has been practicing in pulmonary and critical care medicine for the last 50 years.
It was in 1979 that he became a CHEST member; in 2003-2004, he served as President of CHEST; and he has been actively involved as a CHEST leader throughout his career, serving on every major CHEST committee. But Dr. Irwin’s most beloved position has been as Editor in Chief of the journal CHEST®, a journey that began in 2005 – a position that he has filled for 14 years and that which he has recently stepped down from in June 2019. What better description of those 14 years at the helm of one of the most recognized and respected journals in chest medicine than to hear it straight from the Editor in Chief himself. In the June 2019 issue of the journal CHEST®, Dr. Irwin shares his thoughts in this Commentary: “On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.” Don’t miss it!
Updated Patient Fliers Available Now
The SVS Foundation’s patient fliers project is completed, and fliers are available free to members on the SVS website. Nine vascular topics are addressed in updated fliers, including Carotid Artery Disease, Diabetes, Peripheral Arterial Disease, and more. These were redesigned to be useful in a patient waiting room, or to hand to a patient during an office visit. They are available in both English and Spanish, and can be found on the SVS website here.
The SVS Foundation’s patient fliers project is completed, and fliers are available free to members on the SVS website. Nine vascular topics are addressed in updated fliers, including Carotid Artery Disease, Diabetes, Peripheral Arterial Disease, and more. These were redesigned to be useful in a patient waiting room, or to hand to a patient during an office visit. They are available in both English and Spanish, and can be found on the SVS website here.
The SVS Foundation’s patient fliers project is completed, and fliers are available free to members on the SVS website. Nine vascular topics are addressed in updated fliers, including Carotid Artery Disease, Diabetes, Peripheral Arterial Disease, and more. These were redesigned to be useful in a patient waiting room, or to hand to a patient during an office visit. They are available in both English and Spanish, and can be found on the SVS website here.