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Chest Sep 2017The introduction of new technologies offers the promise to advance medicine. This occurs alongside improved efforts to control costs of health care by hospital... (Review)
Review
The introduction of new technologies offers the promise to advance medicine. This occurs alongside improved efforts to control costs of health care by hospital administrators, the Centers for Medicare & Medicaid Services' (CMS) pivot to value programs, and commercial payers' efforts to reduce reimbursement. These trends present a challenge for the pulmonologist, among others, who must navigate increasingly complex and highly scrutinized evaluation processes used to secure new technology (NT). Health-care providers are turning toward value assessments while simultaneously tasked with the mission of offering state of the art technologies and services. Pulmonologists desiring NT are thus faced with increased scrutiny in their evaluation of costs and clinical data to support investments. Consideration of this scrutiny and further evidence to temper the evaluation will improve the likelihood of adoption and patient access to clinically impactful technology. The identification of this evidence may provide a comprehensive view of the clinical and economic benefits of such technologies to both administrators and pulmonary clinicians. It is imperative that all parties involved in the decision process work collaboratively to deploy value added and clinically impactful technologies. Although a physician group might invest in such NT, the capital required often leads such decisions to a larger organization such as a hospital, health-care system, or privately owned entity. This article aims to provide a framework for pulmonary clinicians to better understand the processes that purchasers use to evaluate NT, the pressures that influence their consideration, and what resources may be leveraged toward success.
Topics: Biomedical Technology; Diffusion of Innovation; Humans; Investments; Pulmonary Medicine
PubMed: 28642108
DOI: 10.1016/j.chest.2017.06.014 -
The Journal of Allergy and Clinical... Oct 2020Little is known about specialist-specific variations in guideline agreement and adoption.
BACKGROUND
Little is known about specialist-specific variations in guideline agreement and adoption.
OBJECTIVE
To assess similarities and differences between allergists and pulmonologists in adherence to cornerstone components of the National Asthma Education and Prevention Program's Third Expert Panel Report.
METHODS
Self-reported guideline agreement, self-efficacy, and adherence were assessed in allergists (n = 134) and pulmonologists (n = 99) in the 2012 National Asthma Survey of Physicians. Multivariate models were used to assess if physician and practice characteristics explained bivariate associations between specialty and "almost always" adhering to recommendations (ie, ≥75% of the time).
RESULTS
Allergists and pulmonologists reported high guideline self-efficacy and moderate guideline agreement. Both groups "almost always" assessed asthma control (66.2%, standard error [SE] 4.3), assessed school/work asthma triggers (71.3%, SE, 3.9), and endorsed inhaled corticosteroids use (95.5%, SE 2.0). Repeated assessment of the inhaler technique, use of asthma action/treatment plans, and spirometry were lower (39.7%, SE 4.0; 30.6%, SE 3.6; 44.7%, SE 4.1, respectively). Compared with pulmonologists, more allergists almost always performed spirometry (56.6% vs 38.6%, P = .06), asked about nighttime awakening (91.9% vs 76.5%, P = .03) and emergency department visits (92.2% vs 76.5%, P = .03), assessed home triggers (70.5% vs 52.6%, P = .06), and performed allergy testing (61.8% vs 21.3%, P < .001). In multivariate analyses, practice-specific characteristics explained differences except for allergy testing.
CONCLUSIONS
Overall, allergists and pulmonologists adhere to the asthma guidelines with notable exceptions, including asthma action plan use and inhaler technique assessment. Recommendations with low implementation offer opportunities for further exploration and could serve as targets for increasing guideline uptake.
Topics: Allergists; Asthma; Guideline Adherence; Humans; Practice Patterns, Physicians'; Pulmonologists; Spirometry
PubMed: 32344187
DOI: 10.1016/j.jaip.2020.04.026 -
Medicina (Kaunas, Lithuania) Aug 2020Data about pulmonologist adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines showed a great variability and cannot be... (Observational Study)
Observational Study
Data about pulmonologist adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines showed a great variability and cannot be extrapolated. The present study investigates the current pharmacological prescribing practices in the treatment of chronic obstructive pulmonary disease (COPD) according to the 2017 GOLD guidelines, to determine the level of pulmonologist adherence and to identify possible factors that influence physician adherence. This retrospective study took place between 1 February and 30 April 2018 in Pneumophtysiology Clinical Hospital Cluj-Napoca. We included 348 stable COPD outpatients classified according to the 2017 GOLD strategy in the ABCD risk groups. Pulmonologist adherence was defined as appropriate if the recommended pharmacological therapy was the first- or alternative-choice drug according to the guidelines, and inappropriate (overtreatment, undertreatment) if it was not in line with these recommendations. The most prescribed treatment was the combination long-acting beta agonist (LABA) + long-acting antimuscarinic agent (LAMA) (34.77%), followed by LAMA + LABA + inhaled corticosteroid (ICS). Overall, pneumologist adherence was 79.02%. The most inappropriate therapies were in Group B (33.57%), followed by 33.33% in Group A. Compared to Groups C and D (analyzed together), Groups A and B had a 4.65 times higher chance ( = 0.0000001) of receiving an inappropriate therapy. Patients with cardiovascular comorbidities had a 1.89 times higher risk of receiving an inappropriate therapy ( = 0.021). ICS overprescription was the most common type of inappropriateness (17.81%). Groups C and D had a 3.12 times higher chance of being prescribed ICS compared to Groups A and B ( = 0.0000004). Pulmonologist adherence to the GOLD guidelines is not optimal and needs to be improved. Among the factors that influence the inappropriateness of COPD treatments, cardiovascular comorbidities and low-risk Groups A and B are important. ICS represent the most prescribed overtreatment. Further multicentric studies are needed to evaluate all factors that might influence the adherence rate.
Topics: Adrenal Cortex Hormones; Adrenergic beta-Agonists; Aged; Female; Goals; Guideline Adherence; Humans; Male; Medical Overuse; Muscarinic Antagonists; Practice Guidelines as Topic; Practice Patterns, Physicians'; Pulmonary Disease, Chronic Obstructive; Pulmonologists; Retrospective Studies; Risk Factors
PubMed: 32825456
DOI: 10.3390/medicina56090422 -
European Respiratory Review : An... Jun 2018http://ow.ly/pXNW30knUzl
http://ow.ly/pXNW30knUzl
Topics: Connective Tissue Diseases; Humans; Lung Diseases, Interstitial; Retrospective Studies
PubMed: 29950308
DOI: 10.1183/16000617.0047-2018 -
Respirology (Carlton, Vic.) Jan 2022In Australia, little is known about delivery of care for people with idiopathic pulmonary fibrosis (IPF). This study examined the organization of IPF care across...
BACKGROUND AND OBJECTIVE
In Australia, little is known about delivery of care for people with idiopathic pulmonary fibrosis (IPF). This study examined the organization of IPF care across Australia, how it aligns with guidance for best practice, and identified barriers and facilitators to best care.
METHODS
Data on the organization of IPF care in Australia were collected from public hospitals using a study-specific questionnaire between February and July 2020. Semi-structured telephone interviews were conducted with respiratory physicians from around Australia between April and December 2020. Interviews were transcribed verbatim and thematic analysis was undertaken.
RESULTS
Almost all hospitals (n = 38, 97%) held multidisciplinary meetings (MDMs) for diagnosing IPF, with 90% of multidisciplinary teams including expert respiratory physicians and radiologists; however, rheumatologists, interstitial lung disease nurses and a histopathologist were often not available. More than 90% of institutions had access to oxygen therapy, pulmonary rehabilitation and advanced care planning, but access to psychological support and clinical trials was limited (53% and 58%, respectively). Fifteen respiratory physicians (27% regional) were interviewed. Approaches to diagnosis, treatment and access to referral services were generally consistent with best practice guidance; however, regional respondents reported barriers related to inadequate staffing, lack of a nurse coordinator, inadequate access to clinical trials and funding models. Telehealth technologies were perceived as facilitators to best care.
CONCLUSION
Clinical management of IPF in Australia generally aligns with best practice guidance, but there may be some inequity of access to specialist services, particularly in regional areas, that should be addressed to ensure optimal care for all.
Topics: Australia; Hospitals; Humans; Idiopathic Pulmonary Fibrosis; Pulmonologists; Referral and Consultation
PubMed: 34783108
DOI: 10.1111/resp.14185 -
Chest Apr 2019There is limited knowledge on what proportions of patients with COPD receive ambulatory care from primary care physicians, pulmonologists, or other specialists. We...
BACKGROUND
There is limited knowledge on what proportions of patients with COPD receive ambulatory care from primary care physicians, pulmonologists, or other specialists. We evaluated the types and combinations of physicians who provide ambulatory care to patients with COPD.
METHODS
We conducted a population-based cross-sectional study using health administrative datasets from Ontario, Canada between April 1, 2014 and March 31, 2015. Individuals age 35 years and older with physician-diagnosed COPD were identified, using a previously validated COPD case definition. The primary outcomes were ambulatory visits to primary care physicians, pulmonologists, and all other specialists within a 1-year period.
RESULTS
There were 895,155 individuals identified as having physician-diagnosed COPD. Of those, 56,533 individuals (6.3%) had no ambulatory care visits, 802,327 (89.6%) saw primary care physicians, and 95,782 (10.7%) consulted pulmonologists. By comparison, 736,496 (82.3%) saw other specialists, and 218,997 (24.5%) saw cardiologists. There were 32,473 individuals (3.6%) who underwent COPD-related hospitalizations. Of those in the subcohort with one hospitalization, about 30.0% saw pulmonologists; 43.7% of those who underwent two or more hospitalizations saw pulmonologists, and 9.9% with no hospitalization consulted pulmonologists.
CONCLUSIONS
Primary care physicians play a substantial role in caring for patients with COPD. But only one-half as many patients with COPD saw pulmonologists than cardiologists, suggesting that COPD may receive less specialty care compared with other chronic medical conditions. This information can help inform COPD care strategies to improve COPD care and minimize exacerbations and associated health-care costs. It also suggests a need for more research to provide guidance on when patients with COPD should be referred to pulmonologists.
Topics: Adult; Aged; Ambulatory Care; Cross-Sectional Studies; Female; Humans; Male; Middle Aged; Morbidity; Ontario; Physician's Role; Physicians, Primary Care; Pulmonary Disease, Chronic Obstructive; Pulmonologists; Retrospective Studies
PubMed: 30664858
DOI: 10.1016/j.chest.2018.12.018 -
Clinics in Chest Medicine Jun 2024The pericardium comprises a double-walled fibrous-serosal sac that encloses the heart. Reflections of the serosal layer form sinuses and recesses. With advances in... (Review)
Review
The pericardium comprises a double-walled fibrous-serosal sac that encloses the heart. Reflections of the serosal layer form sinuses and recesses. With advances in multidetector computed tomography (CT) technology, pericardial recesses are frequently detected with thin-section CT. Knowledge of pericardial anatomy on imaging is crucial to avoid misinterpretation of fluid-filled pericardial sinuses and recesses as adenopathy/pericardial metastasis or aortic dissection, which can impact patient management and treatment decisions. The authors offer a comprehensive review of pericardial anatomy and its variations observed on CT, potential pitfalls in image interpretation, and implications for the pulmonologist with respect to unnecessary diagnostic procedures or interventions.
Topics: Humans; Pericardium; Tomography, X-Ray Computed; Pulmonologists; Multidetector Computed Tomography
PubMed: 38816085
DOI: 10.1016/j.ccm.2024.02.002 -
Intractable & Rare Diseases Research May 2015Idiopathic pulmonary fibrosis (IPF) accounts for the majority of lung diseases classified as idiopathic interstitial pneumonia (IIP). It is considered to be lethal... (Review)
Review
Idiopathic pulmonary fibrosis (IPF) accounts for the majority of lung diseases classified as idiopathic interstitial pneumonia (IIP). It is considered to be lethal because prognosis is very poor and far worse than other types of IIP. An early and accurate diagnosis of IPF is critical. The diagnostic process is complex and requires a multidisciplinary approach involving a pulmonologist, radiologist and pathologist.
PubMed: 25984423
DOI: 10.5582/irdr.2015.01009 -
Annals of the American Thoracic Society May 2015Up to 80% of patients with lung cancer have comorbid chronic obstructive pulmonary disease (COPD). Many of them are poor candidates for stage-specific lung cancer...
RATIONALE
Up to 80% of patients with lung cancer have comorbid chronic obstructive pulmonary disease (COPD). Many of them are poor candidates for stage-specific lung cancer treatment due to diminished lung function and poor functional status, and many forego treatment. The negative effect of COPD may be moderated by pulmonologist-guided management.
OBJECTIVES
This study examined the association between pulmonologist management and the probability of receiving the recommended stage-specific treatment modality and overall survival among patients with non-small cell lung cancer (NSCLC) with preexisting COPD.
METHODS
Early- and advanced-stage NSCLC cases diagnosed between 2002 and 2005 with a prior COPD diagnosis (3-24 months before NSCLC diagnosis) were identified in Surveillance, Epidemiology, and End Results tumor registry data linked to Medicare claims. Study outcomes included receipt of recommended stage-specific treatment (surgical resection for early-stage NSCLC and chemotherapy for advanced-stage NSCLC [advNSCLC]) and overall survival. Pulmonologist management was considered present if one or more Evaluation and Management visit claims with pulmonologist specialty were observed within 6 months after NSCLC diagnosis. Stage-specific multivariate logistic regression tested association between pulmonologist management and treatment received. Cox proportional hazard models examined the independent association between pulmonologist care and mortality. Two-stage residual inclusion instrumental variable (2SRI-IV) analyses tested and adjusted for potential confounding based on unobserved factors or measurement error.
MEASUREMENTS AND MAIN RESULTS
The cohorts included 5,488 patients with early-stage NSCLC and 6,426 patients with advNSCLC disease with preexisting COPD. Pulmonologist management was recorded for 54.9% of patients with early stage NSCLC and 35.7% of patients with advNSCLC. Of those patients with pulmonologist involvement, 58.5% of patients with early NSCLC received surgical resection, and 43.6% of patients with advNSCLC received chemotherapy. Pulmonologist management post NSCLC diagnosis was associated with increased surgical resection rates (odds ratio, 1.26; 95% confidence interval, 1.11-1.45) for early NSCLC and increased chemotherapy rates (odds ratio, 1.88; 95% confidence interval, 1.67-2.10) for advNSCLC. Pulmonologist management was also associated with reduced mortality risk for patients with early-stage NSCLC but not AdvNSCLC.
CONCLUSIONS
Pulmonologist management had a positive association with rates of stage-specific treatment in both groups and overall survival in early-stage NSCLC. These results provide preliminary support for the recently published guidelines emphasizing the role of pulmonologists in lung cancer management.
Topics: Aged; Aged, 80 and over; Carcinoma, Non-Small-Cell Lung; Clinical Competence; Disease Management; Female; Follow-Up Studies; Humans; Lung Neoplasms; Male; Neoplasm Staging; Odds Ratio; Proportional Hazards Models; Pulmonary Disease, Chronic Obstructive; Pulmonary Medicine; Retrospective Studies; Risk Factors; SEER Program; Treatment Outcome; United States; Workforce
PubMed: 25760983
DOI: 10.1513/AnnalsATS.201406-230OC -
Respiratory Care May 2024Inhaler education for patients with asthma and patients with COPD is typically provided by non-pulmonologists. We studied inhaler education by pulmonologists to...
BACKGROUND
Inhaler education for patients with asthma and patients with COPD is typically provided by non-pulmonologists. We studied inhaler education by pulmonologists to determine changes in clinical outcomes and inhaler use.
METHODS
This was a retrospective study of 296 subjects diagnosed with asthma, COPD, or both that evaluated use of inhaler technique education and its impact on (1) inhaler/dosage change consisting of dosage change in the same class of inhaler and/or change in number of inhalers, (2) forced expiratory volume in one second/forced vital capacity (FEV/FVC%), (3) disease symptom control, (4) out-patient visits, (5) urgent care visits (6) emergency department visits, and (7) hospital admissions. One group received inhaler technique education by a pulmonologist while the other group did not.
RESULTS
The pulmonologist inhaler technique-educated group had significantly decreased relative risk for inhaler/dosage increase (relative risk 0.57 [95% CI 0.34-0.96], = .03) and significantly increased odds for symptom control (odds ratio 2.15 [95% CI 1.24-3.74], = .01) at 1-y follow-up as compared to the no education group. No differences occurred for FEV/FVC%, out-patient visits, urgent care visits, emergency department visits, and hospital admissions.
CONCLUSIONS
Pulmonologist education of inhaler technique for patients with asthma and patients with COPD was associated with decreased relative risk for inhaler/dosage increase and increased odds for symptom control. We recommend pulmonologists provide education of inhaler technique to patients with asthma and patients with COPD and not rely on non-pulmonologist education alone. Prospective research is needed to confirm the importance of proper inhaler techniques.
PubMed: 38688545
DOI: 10.4187/respcare.11478