Airways Disorders

Quadrupling the inhaled glucocorticoid dose in those with deteriorating asthma control: Zone 2 asthma

Asthma exacerbations account for most asthma-associated health-care costs and are a key outcome for successful asthma management programs. Inhaled corticosteroid (ICS) forms the cornerstone of asthma maintenance therapy.

Previously published data show that:

Most therapeutic benefit of budesonide was achieved at dose range of 400-1000 µg/day (Masoli et al. Eur Respir J. 2004;23:552).

Doubling ICS dose was ineffective in preventing acute asthma exacerbations (Harrison et al. Lancet. 2004;363:271. FitzGerald et al. Thorax. 2004;59: 550).

Increasing ICS dose was unlikely to reduce systemic glucocorticoid use or hospitalization for asthma exacerbations(Kew et al. Cochrane Database Syst Rev. 2016;6:CD007524).

A recent open-label pragmatic study, published in the New England Journal of Medicine, included 1,922 adolescents and adults with asthma. The authors observed a small reduction in severe asthma exacerbations (Hazard ratio 0.81 for time to first severe exacerbation) by quadrupling the dose of ICS during periods of worsening asthma control (McKeever et al. N Engl J Med. 2018;378:902).

This study does create opportunities for cost-benefit by decreasing health-care utilization, decrease in systemic steroid exposure in some patients, and increase in patient awareness of asthma control allowing self-management. Although statistically significant, the treatment effect was small, with 45% of subjects in the ‘quadrupling dose’ arm still experiencing severe exacerbations. Intervention arm also experienced increased rate of adverse effects.

Additional studies are needed before this strategy can be broadly applied. In the same issue of NEJM, quintupling the dose of ICS in children was not associated with decrease in exacerbations (Jackson et al. N Engl J Med. 2018;378:891). The fact that nearly half of asthmatics who quadrupled ICS dose had exacerbations is disconcerting. This highlights an urgent need to understand treatment-responsive phenotypes, mechanisms of steroid sensitivity, and modalities to improve them, if we are to reduce asthma morbidity in the community.

Clinical Research

Informed consent: Do we need to change our practice?

Informed consent is the keystone of clinical research and helps respect and protect the rights of the participants/subjects. While the informed consent process has been standardized, some challenges still remain, such as pieces of information that should be disclosed, how to disclose information and document understanding of participants, and how detailed that disclosure should be (Grady, N Engl J Med. 2015;372:855). Digital technology can and has been used to improve the process of obtaining informed consent.

Substituting long and complex written forms with electronic consent (e-consent), however, has issues. Few people read through online agreements before clicking “agree,” which may lead to participants consenting without a clear understanding of what they are consenting to. On the other hand, it is also possible to use e-consent to improve comprehension by including videos and graphics. Interactive quizzes can assess the understanding of the participants, embedded links to audios or videos can further enhance the grasp of information. With e-consents, queries from participants can be answered via phone call or email. When e-consent is obtained remotely, the identity can be confirmed by electronic signatures, username, password, or biometrics.

E-consent has advantages, can be done remotely, no paper is needed, etc. It has potential disadvantages like being costly, videos can add time to the process, and multicenter international trials can be difficult (Grady, et al. N Engl J Med, 2017; 376:e43). Studying e-consents to identify gaps in communication between the researcher and the participant in the digitalized world may help improve the process and allow research to proceed with better understanding of the risks and benefits of involvement in clinical research.

Critical Care

Fluid Resuscitation in ICU Patients With Sepsis

Appropriate fluid resuscitation is a major goal in sepsis management. Debate remains regarding fluid choice and the impact on acute kidney injury (AKI), renal replacement therapy (RRT), and mortality. Normal saline solution (NS) may be associated with hyperchloremic metabolic acidosis, AKI, and death, but study results have been inconsistent. A large before-after study revealed that balanced crystalloids (BC) were associated with lower rates of AKI and RRT but did not impact mortality (Yunos et al. JAMA. 2012;308:1566). A meta-analysis specifically examining patients with sepsis failed to find a significant difference in RRT or mortality, although this conclusion was of low certainty (Rochwerg, et al., Intensive Care Med. 2015;41:1561).

Earlier this year, a large RCT comparing NS vs BC demonstrated a reduction in major adverse kidney events using BC. Independent rates of new RRT, mortality, and persistent renal dysfunction were not significant, but when combined as a composite outcome, the difference was significant. A 30-day mortality reduction was significant in patients with sepsis (25.2% BC vs 29.4% NS) and in patients with large infusions of NS (Semler et al., N Engl J Med. 2018;378:829). Given these results, a move toward a “balanced approach” to fluid resuscitation seems prudent and may be the next step toward improving outcomes in sepsis. These results are likely related to the large infusions of fluid in patients with sepsis or to the inflammatory effects of the disease. Finally, the applicability of these outcomes to the overall critically ill population is still open to debate.

Home-Based Mechanical Ventilation and Neuromuscular Disease

Transcutaneous Carbon Dioxide Monitoring: New Era for Home Ventilation

A primary objective of noninvasive home ventilation is normalization of arterial blood gas tensions, night and day. Pulse oximetry has long enabled estimation of arterial oxygen saturation (SpO₂) in outpatient offices and overnight at home; however, until recently, measurement of the partial pressure of carbon dioxide (PCO₂) has been limited to invasive arterial blood gas testing (PaCO2) or end-tidal CO2 (PetCO2) measurements. Assessment of PetCO2 has been limited by challenges in accessing true end-tidal exhaled gas under a face mask during noninvasive ventilation, particularly for patients with parenchymal lung diseases such as COPD.

Thanks to recent technological advances, transcutaneous measurement of carbon dioxide (PtcCO₂) is emerging as the method of choice for assessing the adequacy of noninvasive ventilation. PtcCO₂ monitoring is a standard assessment for pediatric patients in the sleep lab, and it is increasingly being utilized in adults to complement diagnostic and treatment purposes. The transcutaneous CO₂ sensors work by heating underlying skin to approximately 43° C, increasing blood flow through the underlying dermal capillary bed. Within 2 to 5 minutes, the “arteriolized” capillary PtcCO₂ approximates PaCO₂. Commercially available devices for measuring PtcCO₂ reliably estimate PaCO₂ in patients undergoing noninvasive ventilation to within 5 mm Hg (95% CI) (Storre et al. Respir Med. 2010;105:143).

PtcCO₂ measurement has limitations. Measured PtcCO₂ can drift upward (i.e., technical drift) during continuous monitoring; however, currently available devices adequately adjust for this phenomenon. Arterialization may be limited by thickened skin, edema, or hypoperfusion.

Currently, U.S. insurance companies do not accept PtcCO₂ for documentation of hypercapnia, and the cost of measuring PtcCO₂ is not reimbursed. Nevertheless, PtcCO₂ technology promises a new era for home mechanical ventilation guided by accurate and practical assessment of PCO₂, in particular for chronic respiratory failure syndromes. In this setting, home PtcCO₂ monitoring potentially can be utilized in place of in-laboratory sleep studies for assessment of nocturnal hypoventilation and optimizing home mechanical ventilation.

Interstitial and Diffuse Lung Disease

Electronic Patient Education

The management of patients with an interstitial lung disease (ILD) is challenging. A provider must examine the fine details about current and prior medication history, explore various occupational and environmental exposures, perform a thorough physical examination that includes a careful dermatologic and rheumatologic review, and peruse the objective data, such as the high-resolution CT scan of the chest and pulmonary function tests. Then, the pulmonologist and the patient (plus often multiple family members) discuss diagnostic possibilities, any future testing for confirmation, and prognostic implications. Understandably, the patient may leave the office bewildered, overwhelmed, and in search of clarification.

Bewilderment may lead to the internet. In 2001, 4.5% of all internet searches were determined to be health-care-related (Eysenbach et al. AMIA Annu Symp Proc. 2003;225). It is reasonable to presume the percentage is higher today. Just as with any nonmedical website, the choices for digital health-care information are sometimes not contemporaneous and vary in quality. By exploring the most common “hits” on popular search engines when searching for idiopathic pulmonary fibrosis, a 2016 study found that not only is information presented at a high reading level – 12th grade – but often outdated or simply wrong (Fisher, et al. Am J Respir Crit Care Med. 2016;194[2)]:218). Adding to a patient’s possible confusion is that websites expected to be the most helpful, foundation or advocacy websites, were more likely to suggest disproven and even harmful therapies years after those conclusions were published.

CHEST and the Interstitial and Diffuse Lung Disease NetWork are committed to patient education both in and out of the clinical setting. An ongoing redesign of ILD patient education on the CHEST Foundation website is nearing completion and will ensure patients have the most accurate and understandable information available.

Airways Disorders

Quadrupling the inhaled glucocorticoid dose in those with deteriorating asthma control: Zone 2 asthma

Asthma exacerbations account for most asthma-associated health-care costs and are a key outcome for successful asthma management programs. Inhaled corticosteroid (ICS) forms the cornerstone of asthma maintenance therapy.

Previously published data show that:

Most therapeutic benefit of budesonide was achieved at dose range of 400-1000 µg/day (Masoli et al. Eur Respir J. 2004;23:552).

Doubling ICS dose was ineffective in preventing acute asthma exacerbations (Harrison et al. Lancet. 2004;363:271. FitzGerald et al. Thorax. 2004;59: 550).

Increasing ICS dose was unlikely to reduce systemic glucocorticoid use or hospitalization for asthma exacerbations(Kew et al. Cochrane Database Syst Rev. 2016;6:CD007524).

A recent open-label pragmatic study, published in the New England Journal of Medicine, included 1,922 adolescents and adults with asthma. The authors observed a small reduction in severe asthma exacerbations (Hazard ratio 0.81 for time to first severe exacerbation) by quadrupling the dose of ICS during periods of worsening asthma control (McKeever et al. N Engl J Med. 2018;378:902).

This study does create opportunities for cost-benefit by decreasing health-care utilization, decrease in systemic steroid exposure in some patients, and increase in patient awareness of asthma control allowing self-management. Although statistically significant, the treatment effect was small, with 45% of subjects in the ‘quadrupling dose’ arm still experiencing severe exacerbations. Intervention arm also experienced increased rate of adverse effects.

Additional studies are needed before this strategy can be broadly applied. In the same issue of NEJM, quintupling the dose of ICS in children was not associated with decrease in exacerbations (Jackson et al. N Engl J Med. 2018;378:891). The fact that nearly half of asthmatics who quadrupled ICS dose had exacerbations is disconcerting. This highlights an urgent need to understand treatment-responsive phenotypes, mechanisms of steroid sensitivity, and modalities to improve them, if we are to reduce asthma morbidity in the community.

Clinical Research

Informed consent: Do we need to change our practice?

Informed consent is the keystone of clinical research and helps respect and protect the rights of the participants/subjects. While the informed consent process has been standardized, some challenges still remain, such as pieces of information that should be disclosed, how to disclose information and document understanding of participants, and how detailed that disclosure should be (Grady, N Engl J Med. 2015;372:855). Digital technology can and has been used to improve the process of obtaining informed consent.

Substituting long and complex written forms with electronic consent (e-consent), however, has issues. Few people read through online agreements before clicking “agree,” which may lead to participants consenting without a clear understanding of what they are consenting to. On the other hand, it is also possible to use e-consent to improve comprehension by including videos and graphics. Interactive quizzes can assess the understanding of the participants, embedded links to audios or videos can further enhance the grasp of information. With e-consents, queries from participants can be answered via phone call or email. When e-consent is obtained remotely, the identity can be confirmed by electronic signatures, username, password, or biometrics.

E-consent has advantages, can be done remotely, no paper is needed, etc. It has potential disadvantages like being costly, videos can add time to the process, and multicenter international trials can be difficult (Grady, et al. N Engl J Med, 2017; 376:e43). Studying e-consents to identify gaps in communication between the researcher and the participant in the digitalized world may help improve the process and allow research to proceed with better understanding of the risks and benefits of involvement in clinical research.

Critical Care

Fluid Resuscitation in ICU Patients With Sepsis

Appropriate fluid resuscitation is a major goal in sepsis management. Debate remains regarding fluid choice and the impact on acute kidney injury (AKI), renal replacement therapy (RRT), and mortality. Normal saline solution (NS) may be associated with hyperchloremic metabolic acidosis, AKI, and death, but study results have been inconsistent. A large before-after study revealed that balanced crystalloids (BC) were associated with lower rates of AKI and RRT but did not impact mortality (Yunos et al. JAMA. 2012;308:1566). A meta-analysis specifically examining patients with sepsis failed to find a significant difference in RRT or mortality, although this conclusion was of low certainty (Rochwerg, et al., Intensive Care Med. 2015;41:1561).

Earlier this year, a large RCT comparing NS vs BC demonstrated a reduction in major adverse kidney events using BC. Independent rates of new RRT, mortality, and persistent renal dysfunction were not significant, but when combined as a composite outcome, the difference was significant. A 30-day mortality reduction was significant in patients with sepsis (25.2% BC vs 29.4% NS) and in patients with large infusions of NS (Semler et al., N Engl J Med. 2018;378:829). Given these results, a move toward a “balanced approach” to fluid resuscitation seems prudent and may be the next step toward improving outcomes in sepsis. These results are likely related to the large infusions of fluid in patients with sepsis or to the inflammatory effects of the disease. Finally, the applicability of these outcomes to the overall critically ill population is still open to debate.

Home-Based Mechanical Ventilation and Neuromuscular Disease

Transcutaneous Carbon Dioxide Monitoring: New Era for Home Ventilation

A primary objective of noninvasive home ventilation is normalization of arterial blood gas tensions, night and day. Pulse oximetry has long enabled estimation of arterial oxygen saturation (SpO₂) in outpatient offices and overnight at home; however, until recently, measurement of the partial pressure of carbon dioxide (PCO₂) has been limited to invasive arterial blood gas testing (PaCO2) or end-tidal CO2 (PetCO2) measurements. Assessment of PetCO2 has been limited by challenges in accessing true end-tidal exhaled gas under a face mask during noninvasive ventilation, particularly for patients with parenchymal lung diseases such as COPD.

Thanks to recent technological advances, transcutaneous measurement of carbon dioxide (PtcCO₂) is emerging as the method of choice for assessing the adequacy of noninvasive ventilation. PtcCO₂ monitoring is a standard assessment for pediatric patients in the sleep lab, and it is increasingly being utilized in adults to complement diagnostic and treatment purposes. The transcutaneous CO₂ sensors work by heating underlying skin to approximately 43° C, increasing blood flow through the underlying dermal capillary bed. Within 2 to 5 minutes, the “arteriolized” capillary PtcCO₂ approximates PaCO₂. Commercially available devices for measuring PtcCO₂ reliably estimate PaCO₂ in patients undergoing noninvasive ventilation to within 5 mm Hg (95% CI) (Storre et al. Respir Med. 2010;105:143).

PtcCO₂ measurement has limitations. Measured PtcCO₂ can drift upward (i.e., technical drift) during continuous monitoring; however, currently available devices adequately adjust for this phenomenon. Arterialization may be limited by thickened skin, edema, or hypoperfusion.

Currently, U.S. insurance companies do not accept PtcCO₂ for documentation of hypercapnia, and the cost of measuring PtcCO₂ is not reimbursed. Nevertheless, PtcCO₂ technology promises a new era for home mechanical ventilation guided by accurate and practical assessment of PCO₂, in particular for chronic respiratory failure syndromes. In this setting, home PtcCO₂ monitoring potentially can be utilized in place of in-laboratory sleep studies for assessment of nocturnal hypoventilation and optimizing home mechanical ventilation.

Interstitial and Diffuse Lung Disease

Electronic Patient Education

The management of patients with an interstitial lung disease (ILD) is challenging. A provider must examine the fine details about current and prior medication history, explore various occupational and environmental exposures, perform a thorough physical examination that includes a careful dermatologic and rheumatologic review, and peruse the objective data, such as the high-resolution CT scan of the chest and pulmonary function tests. Then, the pulmonologist and the patient (plus often multiple family members) discuss diagnostic possibilities, any future testing for confirmation, and prognostic implications. Understandably, the patient may leave the office bewildered, overwhelmed, and in search of clarification.

Bewilderment may lead to the internet. In 2001, 4.5% of all internet searches were determined to be health-care-related (Eysenbach et al. AMIA Annu Symp Proc. 2003;225). It is reasonable to presume the percentage is higher today. Just as with any nonmedical website, the choices for digital health-care information are sometimes not contemporaneous and vary in quality. By exploring the most common “hits” on popular search engines when searching for idiopathic pulmonary fibrosis, a 2016 study found that not only is information presented at a high reading level – 12th grade – but often outdated or simply wrong (Fisher, et al. Am J Respir Crit Care Med. 2016;194[2)]:218). Adding to a patient’s possible confusion is that websites expected to be the most helpful, foundation or advocacy websites, were more likely to suggest disproven and even harmful therapies years after those conclusions were published.

CHEST and the Interstitial and Diffuse Lung Disease NetWork are committed to patient education both in and out of the clinical setting. An ongoing redesign of ILD patient education on the CHEST Foundation website is nearing completion and will ensure patients have the most accurate and understandable information available.

Airways Disorders

Quadrupling the inhaled glucocorticoid dose in those with deteriorating asthma control: Zone 2 asthma

Asthma exacerbations account for most asthma-associated health-care costs and are a key outcome for successful asthma management programs. Inhaled corticosteroid (ICS) forms the cornerstone of asthma maintenance therapy.

Previously published data show that:

Most therapeutic benefit of budesonide was achieved at dose range of 400-1000 µg/day (Masoli et al. Eur Respir J. 2004;23:552).

Doubling ICS dose was ineffective in preventing acute asthma exacerbations (Harrison et al. Lancet. 2004;363:271. FitzGerald et al. Thorax. 2004;59: 550).

Increasing ICS dose was unlikely to reduce systemic glucocorticoid use or hospitalization for asthma exacerbations(Kew et al. Cochrane Database Syst Rev. 2016;6:CD007524).

A recent open-label pragmatic study, published in the New England Journal of Medicine, included 1,922 adolescents and adults with asthma. The authors observed a small reduction in severe asthma exacerbations (Hazard ratio 0.81 for time to first severe exacerbation) by quadrupling the dose of ICS during periods of worsening asthma control (McKeever et al. N Engl J Med. 2018;378:902).

This study does create opportunities for cost-benefit by decreasing health-care utilization, decrease in systemic steroid exposure in some patients, and increase in patient awareness of asthma control allowing self-management. Although statistically significant, the treatment effect was small, with 45% of subjects in the ‘quadrupling dose’ arm still experiencing severe exacerbations. Intervention arm also experienced increased rate of adverse effects.

Additional studies are needed before this strategy can be broadly applied. In the same issue of NEJM, quintupling the dose of ICS in children was not associated with decrease in exacerbations (Jackson et al. N Engl J Med. 2018;378:891). The fact that nearly half of asthmatics who quadrupled ICS dose had exacerbations is disconcerting. This highlights an urgent need to understand treatment-responsive phenotypes, mechanisms of steroid sensitivity, and modalities to improve them, if we are to reduce asthma morbidity in the community.

Clinical Research

Informed consent: Do we need to change our practice?

Informed consent is the keystone of clinical research and helps respect and protect the rights of the participants/subjects. While the informed consent process has been standardized, some challenges still remain, such as pieces of information that should be disclosed, how to disclose information and document understanding of participants, and how detailed that disclosure should be (Grady, N Engl J Med. 2015;372:855). Digital technology can and has been used to improve the process of obtaining informed consent.

Substituting long and complex written forms with electronic consent (e-consent), however, has issues. Few people read through online agreements before clicking “agree,” which may lead to participants consenting without a clear understanding of what they are consenting to. On the other hand, it is also possible to use e-consent to improve comprehension by including videos and graphics. Interactive quizzes can assess the understanding of the participants, embedded links to audios or videos can further enhance the grasp of information. With e-consents, queries from participants can be answered via phone call or email. When e-consent is obtained remotely, the identity can be confirmed by electronic signatures, username, password, or biometrics.

E-consent has advantages, can be done remotely, no paper is needed, etc. It has potential disadvantages like being costly, videos can add time to the process, and multicenter international trials can be difficult (Grady, et al. N Engl J Med, 2017; 376:e43). Studying e-consents to identify gaps in communication between the researcher and the participant in the digitalized world may help improve the process and allow research to proceed with better understanding of the risks and benefits of involvement in clinical research.

Critical Care

Fluid Resuscitation in ICU Patients With Sepsis

Appropriate fluid resuscitation is a major goal in sepsis management. Debate remains regarding fluid choice and the impact on acute kidney injury (AKI), renal replacement therapy (RRT), and mortality. Normal saline solution (NS) may be associated with hyperchloremic metabolic acidosis, AKI, and death, but study results have been inconsistent. A large before-after study revealed that balanced crystalloids (BC) were associated with lower rates of AKI and RRT but did not impact mortality (Yunos et al. JAMA. 2012;308:1566). A meta-analysis specifically examining patients with sepsis failed to find a significant difference in RRT or mortality, although this conclusion was of low certainty (Rochwerg, et al., Intensive Care Med. 2015;41:1561).

Earlier this year, a large RCT comparing NS vs BC demonstrated a reduction in major adverse kidney events using BC. Independent rates of new RRT, mortality, and persistent renal dysfunction were not significant, but when combined as a composite outcome, the difference was significant. A 30-day mortality reduction was significant in patients with sepsis (25.2% BC vs 29.4% NS) and in patients with large infusions of NS (Semler et al., N Engl J Med. 2018;378:829). Given these results, a move toward a “balanced approach” to fluid resuscitation seems prudent and may be the next step toward improving outcomes in sepsis. These results are likely related to the large infusions of fluid in patients with sepsis or to the inflammatory effects of the disease. Finally, the applicability of these outcomes to the overall critically ill population is still open to debate.

Home-Based Mechanical Ventilation and Neuromuscular Disease

Transcutaneous Carbon Dioxide Monitoring: New Era for Home Ventilation

A primary objective of noninvasive home ventilation is normalization of arterial blood gas tensions, night and day. Pulse oximetry has long enabled estimation of arterial oxygen saturation (SpO₂) in outpatient offices and overnight at home; however, until recently, measurement of the partial pressure of carbon dioxide (PCO₂) has been limited to invasive arterial blood gas testing (PaCO2) or end-tidal CO2 (PetCO2) measurements. Assessment of PetCO2 has been limited by challenges in accessing true end-tidal exhaled gas under a face mask during noninvasive ventilation, particularly for patients with parenchymal lung diseases such as COPD.

Thanks to recent technological advances, transcutaneous measurement of carbon dioxide (PtcCO₂) is emerging as the method of choice for assessing the adequacy of noninvasive ventilation. PtcCO₂ monitoring is a standard assessment for pediatric patients in the sleep lab, and it is increasingly being utilized in adults to complement diagnostic and treatment purposes. The transcutaneous CO₂ sensors work by heating underlying skin to approximately 43° C, increasing blood flow through the underlying dermal capillary bed. Within 2 to 5 minutes, the “arteriolized” capillary PtcCO₂ approximates PaCO₂. Commercially available devices for measuring PtcCO₂ reliably estimate PaCO₂ in patients undergoing noninvasive ventilation to within 5 mm Hg (95% CI) (Storre et al. Respir Med. 2010;105:143).

PtcCO₂ measurement has limitations. Measured PtcCO₂ can drift upward (i.e., technical drift) during continuous monitoring; however, currently available devices adequately adjust for this phenomenon. Arterialization may be limited by thickened skin, edema, or hypoperfusion.

Currently, U.S. insurance companies do not accept PtcCO₂ for documentation of hypercapnia, and the cost of measuring PtcCO₂ is not reimbursed. Nevertheless, PtcCO₂ technology promises a new era for home mechanical ventilation guided by accurate and practical assessment of PCO₂, in particular for chronic respiratory failure syndromes. In this setting, home PtcCO₂ monitoring potentially can be utilized in place of in-laboratory sleep studies for assessment of nocturnal hypoventilation and optimizing home mechanical ventilation.

Interstitial and Diffuse Lung Disease

Electronic Patient Education

The management of patients with an interstitial lung disease (ILD) is challenging. A provider must examine the fine details about current and prior medication history, explore various occupational and environmental exposures, perform a thorough physical examination that includes a careful dermatologic and rheumatologic review, and peruse the objective data, such as the high-resolution CT scan of the chest and pulmonary function tests. Then, the pulmonologist and the patient (plus often multiple family members) discuss diagnostic possibilities, any future testing for confirmation, and prognostic implications. Understandably, the patient may leave the office bewildered, overwhelmed, and in search of clarification.

Bewilderment may lead to the internet. In 2001, 4.5% of all internet searches were determined to be health-care-related (Eysenbach et al. AMIA Annu Symp Proc. 2003;225). It is reasonable to presume the percentage is higher today. Just as with any nonmedical website, the choices for digital health-care information are sometimes not contemporaneous and vary in quality. By exploring the most common “hits” on popular search engines when searching for idiopathic pulmonary fibrosis, a 2016 study found that not only is information presented at a high reading level – 12th grade – but often outdated or simply wrong (Fisher, et al. Am J Respir Crit Care Med. 2016;194[2)]:218). Adding to a patient’s possible confusion is that websites expected to be the most helpful, foundation or advocacy websites, were more likely to suggest disproven and even harmful therapies years after those conclusions were published.

CHEST and the Interstitial and Diffuse Lung Disease NetWork are committed to patient education both in and out of the clinical setting. An ongoing redesign of ILD patient education on the CHEST Foundation website is nearing completion and will ensure patients have the most accurate and understandable information available.

Upon wrapping up a successful 2018 NetWorks Challenge Giving campaign – supporting travel grants to CHEST 2018 for early career and diverse clinicians, CHEST Foundation staff sat down with one of our champions, Demondes Haynes, MD, FCCP. Our conversation focused heavily on the role of mentorship in the development of early career clinicians and his own experience as both a mentor and mentee.

Dr. Haynes has had several mentors over the course of his career, but one stands out to him in particular: Doug Campbell, MD, FCCP. Dr. Campbell is a pulmonary and critical care physician who was the division chief at the University of Mississippi Medical Center in Jackson. “When I was finishing my chief residency, the entire pulmonary division imploded. All of the faculty left, except one or two professors, and all those who were going to become fellows here started looking for other places to go. I was actively looking as well…planning to leave my home state, which was not my initial plan. Dr. Campbell came in about that time and promised me that if I gave him some time, we could rebuild the division. He told me if I stayed for my fellowship, I could really help rebuild it. From that day forward, he was my mentor. I stayed for my fellowship under Dr. Campbell.

He delivered on all of those promises. He taught pulmonary medicine extremely well. Not only was a he a great clinician, but he built up the faculty – started a telemedicine program for the ICU and brought in a diverse set of faculty who had all trained at other institutions. He really helped build the program up to be a strong program. I was very happy I chose to stay and learn under his leadership.”

Doug Campbell not only had an impact on Dr. Haynes’ professional life, but also his personal life. “When I agreed to stay for my fellowship, he sent a beautiful handwritten note to my mother, thanking her for raising me to be respectful. She was amazed.” Dr. Haynes mother passed 10 years ago. The night before the funeral at the visitation, Dr. Campbell brought the card his mother sent back – an exchange that Dr. Haynes never knew took place. “It really meant the world to me, not only had he mentored me in my academic career, but he made those personal touches. Those moments are very special to me.”

Dr. Haynes is now mentoring residents and feels it is even more rewarding being a mentor. “You actually get to invest in others, and when you invest in others, the best comes out in them. Sometimes, in this mentoring role, you’re helping people uncover what their qualities are. Sometimes they don’t even know what they are capable of until you push them just a little bit. That’s been so rewarding. I have been blessed, my mentors have invested so much in me, and I am able to pay it forward and give back.”

Dr. Haynes chose to honor Dr. Campbell through giving during the NetWorks Challenge Giving Month. “The NetWork Challenge is great because part of our mission as an organization is philanthropy. We are an education organization, and, in medicine in general, we should support philanthropy. We talk a lot about empathy for our patients… and giving back is just a small part of that. There is a scripture that says, ‘To whom much is given, much is required.’ I truly believe that. I believe that it should just be an ingrained part of our calling as physicians.”

Your generosity funds young clinicians’ learning opportunities that will change the future of patient outcomes and lung diseases. Thank you for making these opportunities possible.

Your continued support will support the next generation of mentees launching their careers (with the proper hands-on training). You can be a Champion for Lung Health and DONATE today through a new gift to the CHEST Foundation by going to  chestfoundation.org/donate or calling 224/521-9527.

Again, thank you for all you do to improve patient outcomes. You are the lung health champions who patients and families count on to positively impact lung health.

Upon wrapping up a successful 2018 NetWorks Challenge Giving campaign – supporting travel grants to CHEST 2018 for early career and diverse clinicians, CHEST Foundation staff sat down with one of our champions, Demondes Haynes, MD, FCCP. Our conversation focused heavily on the role of mentorship in the development of early career clinicians and his own experience as both a mentor and mentee.

Dr. Haynes has had several mentors over the course of his career, but one stands out to him in particular: Doug Campbell, MD, FCCP. Dr. Campbell is a pulmonary and critical care physician who was the division chief at the University of Mississippi Medical Center in Jackson. “When I was finishing my chief residency, the entire pulmonary division imploded. All of the faculty left, except one or two professors, and all those who were going to become fellows here started looking for other places to go. I was actively looking as well…planning to leave my home state, which was not my initial plan. Dr. Campbell came in about that time and promised me that if I gave him some time, we could rebuild the division. He told me if I stayed for my fellowship, I could really help rebuild it. From that day forward, he was my mentor. I stayed for my fellowship under Dr. Campbell.

He delivered on all of those promises. He taught pulmonary medicine extremely well. Not only was a he a great clinician, but he built up the faculty – started a telemedicine program for the ICU and brought in a diverse set of faculty who had all trained at other institutions. He really helped build the program up to be a strong program. I was very happy I chose to stay and learn under his leadership.”

Doug Campbell not only had an impact on Dr. Haynes’ professional life, but also his personal life. “When I agreed to stay for my fellowship, he sent a beautiful handwritten note to my mother, thanking her for raising me to be respectful. She was amazed.” Dr. Haynes mother passed 10 years ago. The night before the funeral at the visitation, Dr. Campbell brought the card his mother sent back – an exchange that Dr. Haynes never knew took place. “It really meant the world to me, not only had he mentored me in my academic career, but he made those personal touches. Those moments are very special to me.”

Dr. Haynes is now mentoring residents and feels it is even more rewarding being a mentor. “You actually get to invest in others, and when you invest in others, the best comes out in them. Sometimes, in this mentoring role, you’re helping people uncover what their qualities are. Sometimes they don’t even know what they are capable of until you push them just a little bit. That’s been so rewarding. I have been blessed, my mentors have invested so much in me, and I am able to pay it forward and give back.”

Dr. Haynes chose to honor Dr. Campbell through giving during the NetWorks Challenge Giving Month. “The NetWork Challenge is great because part of our mission as an organization is philanthropy. We are an education organization, and, in medicine in general, we should support philanthropy. We talk a lot about empathy for our patients… and giving back is just a small part of that. There is a scripture that says, ‘To whom much is given, much is required.’ I truly believe that. I believe that it should just be an ingrained part of our calling as physicians.”

Your generosity funds young clinicians’ learning opportunities that will change the future of patient outcomes and lung diseases. Thank you for making these opportunities possible.

Your continued support will support the next generation of mentees launching their careers (with the proper hands-on training). You can be a Champion for Lung Health and DONATE today through a new gift to the CHEST Foundation by going to  chestfoundation.org/donate or calling 224/521-9527.

Again, thank you for all you do to improve patient outcomes. You are the lung health champions who patients and families count on to positively impact lung health.

Upon wrapping up a successful 2018 NetWorks Challenge Giving campaign – supporting travel grants to CHEST 2018 for early career and diverse clinicians, CHEST Foundation staff sat down with one of our champions, Demondes Haynes, MD, FCCP. Our conversation focused heavily on the role of mentorship in the development of early career clinicians and his own experience as both a mentor and mentee.

Dr. Haynes has had several mentors over the course of his career, but one stands out to him in particular: Doug Campbell, MD, FCCP. Dr. Campbell is a pulmonary and critical care physician who was the division chief at the University of Mississippi Medical Center in Jackson. “When I was finishing my chief residency, the entire pulmonary division imploded. All of the faculty left, except one or two professors, and all those who were going to become fellows here started looking for other places to go. I was actively looking as well…planning to leave my home state, which was not my initial plan. Dr. Campbell came in about that time and promised me that if I gave him some time, we could rebuild the division. He told me if I stayed for my fellowship, I could really help rebuild it. From that day forward, he was my mentor. I stayed for my fellowship under Dr. Campbell.

He delivered on all of those promises. He taught pulmonary medicine extremely well. Not only was a he a great clinician, but he built up the faculty – started a telemedicine program for the ICU and brought in a diverse set of faculty who had all trained at other institutions. He really helped build the program up to be a strong program. I was very happy I chose to stay and learn under his leadership.”

Doug Campbell not only had an impact on Dr. Haynes’ professional life, but also his personal life. “When I agreed to stay for my fellowship, he sent a beautiful handwritten note to my mother, thanking her for raising me to be respectful. She was amazed.” Dr. Haynes mother passed 10 years ago. The night before the funeral at the visitation, Dr. Campbell brought the card his mother sent back – an exchange that Dr. Haynes never knew took place. “It really meant the world to me, not only had he mentored me in my academic career, but he made those personal touches. Those moments are very special to me.”

Dr. Haynes is now mentoring residents and feels it is even more rewarding being a mentor. “You actually get to invest in others, and when you invest in others, the best comes out in them. Sometimes, in this mentoring role, you’re helping people uncover what their qualities are. Sometimes they don’t even know what they are capable of until you push them just a little bit. That’s been so rewarding. I have been blessed, my mentors have invested so much in me, and I am able to pay it forward and give back.”

Dr. Haynes chose to honor Dr. Campbell through giving during the NetWorks Challenge Giving Month. “The NetWork Challenge is great because part of our mission as an organization is philanthropy. We are an education organization, and, in medicine in general, we should support philanthropy. We talk a lot about empathy for our patients… and giving back is just a small part of that. There is a scripture that says, ‘To whom much is given, much is required.’ I truly believe that. I believe that it should just be an ingrained part of our calling as physicians.”

Your generosity funds young clinicians’ learning opportunities that will change the future of patient outcomes and lung diseases. Thank you for making these opportunities possible.

Your continued support will support the next generation of mentees launching their careers (with the proper hands-on training). You can be a Champion for Lung Health and DONATE today through a new gift to the CHEST Foundation by going to  chestfoundation.org/donate or calling 224/521-9527.

Again, thank you for all you do to improve patient outcomes. You are the lung health champions who patients and families count on to positively impact lung health.

Editor’s Picks

Editor in Chief, CHEST

Giants in CHEST Medicine –Arthur S. Slutsky, MD, MASc, BASc

By Dr. Eliot A. Phillipson



Original Research

A Longitudinal Cohort Study of Aspirin Use and Progression of Emphysema-like Lung

Characteristics on CT Imaging: The MESA Lung Study

By Dr. C. P. Aaron, et al.



The Effect of Alcohol Consumption on the Risk of ARDS: A Systematic Review and

Meta-analysis

By Dr. E. Simou, et al.



The Relationship Between COPD and Frailty: A Systematic Review and Meta-Analysis of

Observational Studies

By Dr. A. Marengoni, et al.

Editor’s Picks

Editor in Chief, CHEST

Giants in CHEST Medicine –Arthur S. Slutsky, MD, MASc, BASc

By Dr. Eliot A. Phillipson



Original Research

A Longitudinal Cohort Study of Aspirin Use and Progression of Emphysema-like Lung

Characteristics on CT Imaging: The MESA Lung Study

By Dr. C. P. Aaron, et al.



The Effect of Alcohol Consumption on the Risk of ARDS: A Systematic Review and

Meta-analysis

By Dr. E. Simou, et al.



The Relationship Between COPD and Frailty: A Systematic Review and Meta-Analysis of

Observational Studies

By Dr. A. Marengoni, et al.

Editor’s Picks

Editor in Chief, CHEST

Giants in CHEST Medicine –Arthur S. Slutsky, MD, MASc, BASc

By Dr. Eliot A. Phillipson



Original Research

A Longitudinal Cohort Study of Aspirin Use and Progression of Emphysema-like Lung

Characteristics on CT Imaging: The MESA Lung Study

By Dr. C. P. Aaron, et al.



The Effect of Alcohol Consumption on the Risk of ARDS: A Systematic Review and

Meta-analysis

By Dr. E. Simou, et al.



The Relationship Between COPD and Frailty: A Systematic Review and Meta-Analysis of

Observational Studies

By Dr. A. Marengoni, et al.

Planning on bringing your family with you to CHEST 2018 in San Antonio? Well, we’ve got you covered on ways to have some family fun when you’re not immersed in learning at the convention center. Here are a few activities you can take part in:



San Antonio Missions National Historical Park

There are four San Antonio Missions you can visit: San José, Espada, Concepción, and San Juan. Explore the missions on your own, or join a park ranger or volunteer for a free, 45- to 60- minute guided tour of your chosen mission. While Mission San José is the most popular tour with ranger-led tours between 10:00 am and 3:00 pm, make sure to stop at the visitor center or information center of the other missions you want to tour to check available tour times.



World’s Largest Cowboy Boots

Just outside Saks Fifth Avenue at North Star Mall, you can take a selfie next to the World’s Largest Cowboy Boots. These 35-foot tall and 30-foot long boots shouldn’t be too hard to spot. Originally the boots were built by Bob “Daddy-O” Wade in Washington, DC, in 1979 and moved to San Antonio just 1 year later.



Natural Bridge Caverns

Explore the Natural Bridge Caverns, the largest caverns in Texas. This family-owned and family-operated attraction offers guided and adventure tours, and outdoor maze, mining for gems and fossils, and more! When you’re done, you can visit the Shops of Discovery Village where you’ll find treats, a general store, and souvenirs to take home.



The Alamo Trolley

Need a captivating-yet-low impact activity? Ride the Alamo Trolley. This “hop-on, hop-off” trolley allows you to explore San Antonio at your own pace. With 10 stops around town, this entirely narrated tour includes The Alamo, Hemisfair Park, River Walk, the Mission Trail, and more.



Clyde and Seamore’s Sea Lion High

If you go to SeaWorld San Antonio, kids will love attending the sea lion show called “Clyde and Seamore’s Sea Lion High.” The sea lions perform tricks and interact with the audience as Clyde and Seamore go back to school in search of their diplomas.



Cool Off at a Waterpark

While October weather in San Antonio may be slightly cooler than in the summer, it still averages in the mid-80 degrees Fahrenheit, so you’ll want to cool off at the pool or a waterpark. Take some downtime with the family and head to one of the several waterparks in the area, including Schlitterbahn, Splashtown San Antonio, and Aquatica at SeaWorld.



Brackenridge Park

Spend the day at one of San Antonio’s most popular parks, Brackenridge Park. Hike or bike along one of the nature trails, have a picnic, play with your kids at the Kiddie Park, or find the Japanese Tea Garden. Want to add something a little more exciting to your day? The San Antonio Zoo is also on the grounds, where there are lots of animals, experiences, and events.

Planning on bringing your family with you to CHEST 2018 in San Antonio? Well, we’ve got you covered on ways to have some family fun when you’re not immersed in learning at the convention center. Here are a few activities you can take part in:



San Antonio Missions National Historical Park

There are four San Antonio Missions you can visit: San José, Espada, Concepción, and San Juan. Explore the missions on your own, or join a park ranger or volunteer for a free, 45- to 60- minute guided tour of your chosen mission. While Mission San José is the most popular tour with ranger-led tours between 10:00 am and 3:00 pm, make sure to stop at the visitor center or information center of the other missions you want to tour to check available tour times.



World’s Largest Cowboy Boots

Just outside Saks Fifth Avenue at North Star Mall, you can take a selfie next to the World’s Largest Cowboy Boots. These 35-foot tall and 30-foot long boots shouldn’t be too hard to spot. Originally the boots were built by Bob “Daddy-O” Wade in Washington, DC, in 1979 and moved to San Antonio just 1 year later.



Natural Bridge Caverns

Explore the Natural Bridge Caverns, the largest caverns in Texas. This family-owned and family-operated attraction offers guided and adventure tours, and outdoor maze, mining for gems and fossils, and more! When you’re done, you can visit the Shops of Discovery Village where you’ll find treats, a general store, and souvenirs to take home.



The Alamo Trolley

Need a captivating-yet-low impact activity? Ride the Alamo Trolley. This “hop-on, hop-off” trolley allows you to explore San Antonio at your own pace. With 10 stops around town, this entirely narrated tour includes The Alamo, Hemisfair Park, River Walk, the Mission Trail, and more.



Clyde and Seamore’s Sea Lion High

If you go to SeaWorld San Antonio, kids will love attending the sea lion show called “Clyde and Seamore’s Sea Lion High.” The sea lions perform tricks and interact with the audience as Clyde and Seamore go back to school in search of their diplomas.



Cool Off at a Waterpark

While October weather in San Antonio may be slightly cooler than in the summer, it still averages in the mid-80 degrees Fahrenheit, so you’ll want to cool off at the pool or a waterpark. Take some downtime with the family and head to one of the several waterparks in the area, including Schlitterbahn, Splashtown San Antonio, and Aquatica at SeaWorld.



Brackenridge Park

Spend the day at one of San Antonio’s most popular parks, Brackenridge Park. Hike or bike along one of the nature trails, have a picnic, play with your kids at the Kiddie Park, or find the Japanese Tea Garden. Want to add something a little more exciting to your day? The San Antonio Zoo is also on the grounds, where there are lots of animals, experiences, and events.

Planning on bringing your family with you to CHEST 2018 in San Antonio? Well, we’ve got you covered on ways to have some family fun when you’re not immersed in learning at the convention center. Here are a few activities you can take part in:



San Antonio Missions National Historical Park

There are four San Antonio Missions you can visit: San José, Espada, Concepción, and San Juan. Explore the missions on your own, or join a park ranger or volunteer for a free, 45- to 60- minute guided tour of your chosen mission. While Mission San José is the most popular tour with ranger-led tours between 10:00 am and 3:00 pm, make sure to stop at the visitor center or information center of the other missions you want to tour to check available tour times.



World’s Largest Cowboy Boots

Just outside Saks Fifth Avenue at North Star Mall, you can take a selfie next to the World’s Largest Cowboy Boots. These 35-foot tall and 30-foot long boots shouldn’t be too hard to spot. Originally the boots were built by Bob “Daddy-O” Wade in Washington, DC, in 1979 and moved to San Antonio just 1 year later.



Natural Bridge Caverns

Explore the Natural Bridge Caverns, the largest caverns in Texas. This family-owned and family-operated attraction offers guided and adventure tours, and outdoor maze, mining for gems and fossils, and more! When you’re done, you can visit the Shops of Discovery Village where you’ll find treats, a general store, and souvenirs to take home.



The Alamo Trolley

Need a captivating-yet-low impact activity? Ride the Alamo Trolley. This “hop-on, hop-off” trolley allows you to explore San Antonio at your own pace. With 10 stops around town, this entirely narrated tour includes The Alamo, Hemisfair Park, River Walk, the Mission Trail, and more.



Clyde and Seamore’s Sea Lion High

If you go to SeaWorld San Antonio, kids will love attending the sea lion show called “Clyde and Seamore’s Sea Lion High.” The sea lions perform tricks and interact with the audience as Clyde and Seamore go back to school in search of their diplomas.



Cool Off at a Waterpark

While October weather in San Antonio may be slightly cooler than in the summer, it still averages in the mid-80 degrees Fahrenheit, so you’ll want to cool off at the pool or a waterpark. Take some downtime with the family and head to one of the several waterparks in the area, including Schlitterbahn, Splashtown San Antonio, and Aquatica at SeaWorld.



Brackenridge Park

Spend the day at one of San Antonio’s most popular parks, Brackenridge Park. Hike or bike along one of the nature trails, have a picnic, play with your kids at the Kiddie Park, or find the Japanese Tea Garden. Want to add something a little more exciting to your day? The San Antonio Zoo is also on the grounds, where there are lots of animals, experiences, and events.

The American College of Chest Physicians (CHEST) announces a new partnership with Medscape focused on supporting physicians in addressing the challenges of diagnosing and treating moderate to severe asthma. The Moderate to Severe Asthma Center of Excellence (https://www.medscape.com/resource/moderate-severe-asthma) will provide news, expert commentary, and insights on challenging cases to physicians specializing in chest medicine, allergy, primary care, pediatrics, and emergency medicine.

Medscape is a leading source of clinical news, health information, and point-of-care tools for physicians and health-care professionals. This new Center of Excellence available on Medscape.com will explore the diagnostic, therapeutic, and prevention strategies associated with moderate to severe asthma, including the latest research and breakthroughs. Topics will include challenges in classifying and diagnosing disease; risks, benefits, and barriers to treatment; and impact on patients’ quality of life.

“We look forward to working with Medscape on the Center of Excellence to ensure that all physicians treating patients with asthma have access to the latest information and research on managing this pervasive and challenging disease,” said John Studdard, MD, FCCP, President, American College of Chest Physicians.

“The Moderate to Severe Asthma Center of Excellence with CHEST provides a new, accessible channel for information, practical insights, and commentary to the thousands of physicians and health-care professionals who visit Medscape daily,” said Jo-Ann Strangis, Senior Vice President, Editorial for Medscape. “We are privileged to be working with CHEST and look forward to the Center of Excellence making a meaningful difference in patient care.”

Don’t miss Dr. Aaron Holley’s video on “Diagnosing Severe Asthma: ‘Not as Easy as It Sounds” (https://www.medscape.com/viewarticle/896135?src=dpcs).

Visit the Moderate to Severe Asthma Center of Excellence: https://www.medscape.com/resource/moderate-severe-asthma

The American College of Chest Physicians (CHEST) announces a new partnership with Medscape focused on supporting physicians in addressing the challenges of diagnosing and treating moderate to severe asthma. The Moderate to Severe Asthma Center of Excellence (https://www.medscape.com/resource/moderate-severe-asthma) will provide news, expert commentary, and insights on challenging cases to physicians specializing in chest medicine, allergy, primary care, pediatrics, and emergency medicine.

Medscape is a leading source of clinical news, health information, and point-of-care tools for physicians and health-care professionals. This new Center of Excellence available on Medscape.com will explore the diagnostic, therapeutic, and prevention strategies associated with moderate to severe asthma, including the latest research and breakthroughs. Topics will include challenges in classifying and diagnosing disease; risks, benefits, and barriers to treatment; and impact on patients’ quality of life.

“We look forward to working with Medscape on the Center of Excellence to ensure that all physicians treating patients with asthma have access to the latest information and research on managing this pervasive and challenging disease,” said John Studdard, MD, FCCP, President, American College of Chest Physicians.

“The Moderate to Severe Asthma Center of Excellence with CHEST provides a new, accessible channel for information, practical insights, and commentary to the thousands of physicians and health-care professionals who visit Medscape daily,” said Jo-Ann Strangis, Senior Vice President, Editorial for Medscape. “We are privileged to be working with CHEST and look forward to the Center of Excellence making a meaningful difference in patient care.”

Don’t miss Dr. Aaron Holley’s video on “Diagnosing Severe Asthma: ‘Not as Easy as It Sounds” (https://www.medscape.com/viewarticle/896135?src=dpcs).

Visit the Moderate to Severe Asthma Center of Excellence: https://www.medscape.com/resource/moderate-severe-asthma

The American College of Chest Physicians (CHEST) announces a new partnership with Medscape focused on supporting physicians in addressing the challenges of diagnosing and treating moderate to severe asthma. The Moderate to Severe Asthma Center of Excellence (https://www.medscape.com/resource/moderate-severe-asthma) will provide news, expert commentary, and insights on challenging cases to physicians specializing in chest medicine, allergy, primary care, pediatrics, and emergency medicine.

Medscape is a leading source of clinical news, health information, and point-of-care tools for physicians and health-care professionals. This new Center of Excellence available on Medscape.com will explore the diagnostic, therapeutic, and prevention strategies associated with moderate to severe asthma, including the latest research and breakthroughs. Topics will include challenges in classifying and diagnosing disease; risks, benefits, and barriers to treatment; and impact on patients’ quality of life.

“We look forward to working with Medscape on the Center of Excellence to ensure that all physicians treating patients with asthma have access to the latest information and research on managing this pervasive and challenging disease,” said John Studdard, MD, FCCP, President, American College of Chest Physicians.

“The Moderate to Severe Asthma Center of Excellence with CHEST provides a new, accessible channel for information, practical insights, and commentary to the thousands of physicians and health-care professionals who visit Medscape daily,” said Jo-Ann Strangis, Senior Vice President, Editorial for Medscape. “We are privileged to be working with CHEST and look forward to the Center of Excellence making a meaningful difference in patient care.”

Don’t miss Dr. Aaron Holley’s video on “Diagnosing Severe Asthma: ‘Not as Easy as It Sounds” (https://www.medscape.com/viewarticle/896135?src=dpcs).

Visit the Moderate to Severe Asthma Center of Excellence: https://www.medscape.com/resource/moderate-severe-asthma

Hard work may be its own reward, but there may be an added, but unwelcome, bonus lurking for women who work more than 40 hours a week: diabetes.

Men have a higher risk overall for developing diabetes, 12.2%, compared with 7.5% for women, but the risk for women increases as they work more hours per week, which is not the case for men, according to the results of a 12-year Canadian study that included over 7,000 workers.

Among the 3,502 women in the study, those who worked 45 or more hours per week had a cumulative diabetes incidence of 8.5% over the median 11.7 years of follow-up. Diabetes incidence was 7.2% for women who worked 41-44 hours a week, 6.8% for those who worked 35-40 hours, and 7.9% among women who worked 15-34 hours weekly, Mahée Gilbert-Ouimet, PhD, of the Institute for Work & Health, Toronto, and her associates reported in BMJ Open Diabetes Research & Care.

For the 3,563 men included in the study, diabetes incidence was 9.5% for those who worked at least 45 hours a week versus 12% for those who worked 41-44 hours, 14.6% for men working 35-40 hours weekly, and 17.6% among those who put in 15-34 hours, the investigators wrote.

Hazard ratios for working 45 or more hours, compared with 35-40 hours, were 1.63 for women and 0.81 for men after adjustment for age, level of education, working conditions, and other factors, although the effect was significant only for women, they noted.

“Considering the rapid and substantial increase of diabetes prevalence in Canada and worldwide, identifying modifiable risk factors, such as long work hours, is of major importance to improve prevention and orient policy making as it could prevent numerous cases of diabetes and diabetes-related chronic diseases,” Dr. Gilbert-Ouimet and her associates wrote.

The study was supported by the Canadian Institutes of Health Research and by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. None of the investigators declared any conflicts of interest.

rfranki@mdedge.com

SOURCE: Gilbert-Ouimet M et al. BMJ Open Diab Res Care. 2018. doi: 10.1136/bmjdrc-2017-000496.

Hard work may be its own reward, but there may be an added, but unwelcome, bonus lurking for women who work more than 40 hours a week: diabetes.

Men have a higher risk overall for developing diabetes, 12.2%, compared with 7.5% for women, but the risk for women increases as they work more hours per week, which is not the case for men, according to the results of a 12-year Canadian study that included over 7,000 workers.

Among the 3,502 women in the study, those who worked 45 or more hours per week had a cumulative diabetes incidence of 8.5% over the median 11.7 years of follow-up. Diabetes incidence was 7.2% for women who worked 41-44 hours a week, 6.8% for those who worked 35-40 hours, and 7.9% among women who worked 15-34 hours weekly, Mahée Gilbert-Ouimet, PhD, of the Institute for Work & Health, Toronto, and her associates reported in BMJ Open Diabetes Research & Care.

For the 3,563 men included in the study, diabetes incidence was 9.5% for those who worked at least 45 hours a week versus 12% for those who worked 41-44 hours, 14.6% for men working 35-40 hours weekly, and 17.6% among those who put in 15-34 hours, the investigators wrote.

Hazard ratios for working 45 or more hours, compared with 35-40 hours, were 1.63 for women and 0.81 for men after adjustment for age, level of education, working conditions, and other factors, although the effect was significant only for women, they noted.

“Considering the rapid and substantial increase of diabetes prevalence in Canada and worldwide, identifying modifiable risk factors, such as long work hours, is of major importance to improve prevention and orient policy making as it could prevent numerous cases of diabetes and diabetes-related chronic diseases,” Dr. Gilbert-Ouimet and her associates wrote.

The study was supported by the Canadian Institutes of Health Research and by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. None of the investigators declared any conflicts of interest.

rfranki@mdedge.com

SOURCE: Gilbert-Ouimet M et al. BMJ Open Diab Res Care. 2018. doi: 10.1136/bmjdrc-2017-000496.

Hard work may be its own reward, but there may be an added, but unwelcome, bonus lurking for women who work more than 40 hours a week: diabetes.

Men have a higher risk overall for developing diabetes, 12.2%, compared with 7.5% for women, but the risk for women increases as they work more hours per week, which is not the case for men, according to the results of a 12-year Canadian study that included over 7,000 workers.

Among the 3,502 women in the study, those who worked 45 or more hours per week had a cumulative diabetes incidence of 8.5% over the median 11.7 years of follow-up. Diabetes incidence was 7.2% for women who worked 41-44 hours a week, 6.8% for those who worked 35-40 hours, and 7.9% among women who worked 15-34 hours weekly, Mahée Gilbert-Ouimet, PhD, of the Institute for Work & Health, Toronto, and her associates reported in BMJ Open Diabetes Research & Care.

For the 3,563 men included in the study, diabetes incidence was 9.5% for those who worked at least 45 hours a week versus 12% for those who worked 41-44 hours, 14.6% for men working 35-40 hours weekly, and 17.6% among those who put in 15-34 hours, the investigators wrote.

Hazard ratios for working 45 or more hours, compared with 35-40 hours, were 1.63 for women and 0.81 for men after adjustment for age, level of education, working conditions, and other factors, although the effect was significant only for women, they noted.

“Considering the rapid and substantial increase of diabetes prevalence in Canada and worldwide, identifying modifiable risk factors, such as long work hours, is of major importance to improve prevention and orient policy making as it could prevent numerous cases of diabetes and diabetes-related chronic diseases,” Dr. Gilbert-Ouimet and her associates wrote.

The study was supported by the Canadian Institutes of Health Research and by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. None of the investigators declared any conflicts of interest.

rfranki@mdedge.com

SOURCE: Gilbert-Ouimet M et al. BMJ Open Diab Res Care. 2018. doi: 10.1136/bmjdrc-2017-000496.

ORLANDO – Researchers have been able to sustain a dramatic reduction in hypoglycemia incidents at nine St. Louis–area hospitals, thanks to a computer algorithm that warns medical staff when patients appear to be on the road to dangerously low blood sugar levels.

Robert Lodge/MDedge Medical News

SOURCE: Tobin G et al. ADA 2018. Abstract 397-P.

ORLANDO – Researchers have been able to sustain a dramatic reduction in hypoglycemia incidents at nine St. Louis–area hospitals, thanks to a computer algorithm that warns medical staff when patients appear to be on the road to dangerously low blood sugar levels.

Robert Lodge/MDedge Medical News

SOURCE: Tobin G et al. ADA 2018. Abstract 397-P.

ORLANDO – Researchers have been able to sustain a dramatic reduction in hypoglycemia incidents at nine St. Louis–area hospitals, thanks to a computer algorithm that warns medical staff when patients appear to be on the road to dangerously low blood sugar levels.

Robert Lodge/MDedge Medical News

SOURCE: Tobin G et al. ADA 2018. Abstract 397-P.

LOS ANGELES—Variables such as age, sex, race, and insurance status predict whether a patient with ischemic stroke will receive IV t-PA, according to an analysis presented at the 70th Annual Meeting of the American Academy of Neurology. The results provide “compelling evidence” of disparities, despite increased use of IV thrombolysis over time, said F. Stephen Benesh, MD, Chief Resident at the University of Alabama at Birmingham School of Medicine.

Stroke is the leading cause of mortality and morbidity in the United States and has an economic impact of more than $34 billion annually, said Dr. Benesh. IV t-PA has been available since the 1990s, but not all eligible patients have access to this treatment. Dr. Benesh and colleagues examined data from the National Inpatient Sample to find emerging trends and predictors of IV t-PA administration in the clinical setting.

The National Inpatient Sample is a stratified sample of all discharges from US community hospitals. The investigators analyzed data from 2003 through 2013 and identified 1,168,847 patients who had been discharged with a primary diagnosis of ischemic stroke. They ascertained whether patients had received thrombolytic infusion by looking at medical coding. A bimodal logistic regression analysis was performed to identify differences between patients who received t-PA and those who did not. Variables included age, sex, race, teaching status of the treating institution, and patient’s insurance type.

During the period examined, 3.2% of patients with ischemic stroke received thrombolytic treatment. The annual rate of IV t-PA administration increased during the period to approximately 6% in 2013.

Women were slightly more likely to receive IV t-PA than men (odds ratio [OR], 1.036). African Americans (OR, 0.884) were less likely than Caucasians to receive IV t-PA.

Patients insured with Medicare were less likely to receive t-PA than patients insured with Medicaid (OR, 1.128), patients with private insurance (OR, 1.216), and self-paying patients (OR, 1.162). Dr. Benesh and colleagues found no statistically significant difference in the rate of t-PA administration between patients with Medicaid, those with private insurance, and self-paying patients.

In addition, teaching hospitals were more likely than nonteaching hospitals to administer IV t-PA (OR, 1.685).

Various factors may account for the discrepancies in IV t-PA administration. For example, a recent study found that African Americans are more likely to refuse t-PA than patients of other ethnicities. This research reveals “ongoing problems with education and socioeconomic disparities,” said Dr. Benesh.

—Erik Greb

LOS ANGELES—Variables such as age, sex, race, and insurance status predict whether a patient with ischemic stroke will receive IV t-PA, according to an analysis presented at the 70th Annual Meeting of the American Academy of Neurology. The results provide “compelling evidence” of disparities, despite increased use of IV thrombolysis over time, said F. Stephen Benesh, MD, Chief Resident at the University of Alabama at Birmingham School of Medicine.

Stroke is the leading cause of mortality and morbidity in the United States and has an economic impact of more than $34 billion annually, said Dr. Benesh. IV t-PA has been available since the 1990s, but not all eligible patients have access to this treatment. Dr. Benesh and colleagues examined data from the National Inpatient Sample to find emerging trends and predictors of IV t-PA administration in the clinical setting.

The National Inpatient Sample is a stratified sample of all discharges from US community hospitals. The investigators analyzed data from 2003 through 2013 and identified 1,168,847 patients who had been discharged with a primary diagnosis of ischemic stroke. They ascertained whether patients had received thrombolytic infusion by looking at medical coding. A bimodal logistic regression analysis was performed to identify differences between patients who received t-PA and those who did not. Variables included age, sex, race, teaching status of the treating institution, and patient’s insurance type.

During the period examined, 3.2% of patients with ischemic stroke received thrombolytic treatment. The annual rate of IV t-PA administration increased during the period to approximately 6% in 2013.

Women were slightly more likely to receive IV t-PA than men (odds ratio [OR], 1.036). African Americans (OR, 0.884) were less likely than Caucasians to receive IV t-PA.

Patients insured with Medicare were less likely to receive t-PA than patients insured with Medicaid (OR, 1.128), patients with private insurance (OR, 1.216), and self-paying patients (OR, 1.162). Dr. Benesh and colleagues found no statistically significant difference in the rate of t-PA administration between patients with Medicaid, those with private insurance, and self-paying patients.

In addition, teaching hospitals were more likely than nonteaching hospitals to administer IV t-PA (OR, 1.685).

Various factors may account for the discrepancies in IV t-PA administration. For example, a recent study found that African Americans are more likely to refuse t-PA than patients of other ethnicities. This research reveals “ongoing problems with education and socioeconomic disparities,” said Dr. Benesh.

—Erik Greb

LOS ANGELES—Variables such as age, sex, race, and insurance status predict whether a patient with ischemic stroke will receive IV t-PA, according to an analysis presented at the 70th Annual Meeting of the American Academy of Neurology. The results provide “compelling evidence” of disparities, despite increased use of IV thrombolysis over time, said F. Stephen Benesh, MD, Chief Resident at the University of Alabama at Birmingham School of Medicine.

Stroke is the leading cause of mortality and morbidity in the United States and has an economic impact of more than $34 billion annually, said Dr. Benesh. IV t-PA has been available since the 1990s, but not all eligible patients have access to this treatment. Dr. Benesh and colleagues examined data from the National Inpatient Sample to find emerging trends and predictors of IV t-PA administration in the clinical setting.

The National Inpatient Sample is a stratified sample of all discharges from US community hospitals. The investigators analyzed data from 2003 through 2013 and identified 1,168,847 patients who had been discharged with a primary diagnosis of ischemic stroke. They ascertained whether patients had received thrombolytic infusion by looking at medical coding. A bimodal logistic regression analysis was performed to identify differences between patients who received t-PA and those who did not. Variables included age, sex, race, teaching status of the treating institution, and patient’s insurance type.

During the period examined, 3.2% of patients with ischemic stroke received thrombolytic treatment. The annual rate of IV t-PA administration increased during the period to approximately 6% in 2013.

Women were slightly more likely to receive IV t-PA than men (odds ratio [OR], 1.036). African Americans (OR, 0.884) were less likely than Caucasians to receive IV t-PA.

Patients insured with Medicare were less likely to receive t-PA than patients insured with Medicaid (OR, 1.128), patients with private insurance (OR, 1.216), and self-paying patients (OR, 1.162). Dr. Benesh and colleagues found no statistically significant difference in the rate of t-PA administration between patients with Medicaid, those with private insurance, and self-paying patients.

In addition, teaching hospitals were more likely than nonteaching hospitals to administer IV t-PA (OR, 1.685).

Various factors may account for the discrepancies in IV t-PA administration. For example, a recent study found that African Americans are more likely to refuse t-PA than patients of other ethnicities. This research reveals “ongoing problems with education and socioeconomic disparities,” said Dr. Benesh.

—Erik Greb

LOS ANGELES—Sodium oxybate reduces cataplexy and excessive sleepiness in children with narcolepsy type 1, according to a study described at the 70th Annual Meeting of the American Academy of Neurology. The treatment’s safety profile in this population is similar to that in adults.

Although symptoms of narcolepsy often begin during childhood or adolescence, few studies have evaluated treatments for narcolepsy in pediatric patients. Sodium oxybate is approved for the treatment of cataplexy and excessive daytime sleepiness in adults with narcolepsy, but it had not previously been studied in a large pediatric narcolepsy trial. Chad Ruoff, MD, Clinical Assistant Professor of Psychiatry and Behavioral Sciences at the Stanford Center for Sleep Sciences and Medicine in California, and colleagues conducted a double-blind, placebo-controlled, randomized-withdrawal study to evaluate the efficacy and safety of sodium oxybate in pediatric patients with narcolepsy type 1.

A Randomized-Withdrawal Study

Eligible participants were children and adolescents between ages 7 and 16 who had been diagnosed with narcolepsy type 1 and had cataplexy. Patients who were on stable doses of sodium oxybate and patients who were sodium-oxybate-naïve were included. Patients with evidence of sleep-disordered breathing were excluded.

Sodium-oxybate-naïve participants were titrated to a stable dose. After a stable-dose period, all participants began a two-week, double-blind, placebo-controlled withdrawal period. The investigators randomized participants in equal groups to continue sodium oxybate or to be switched to placebo. At the end of the double-blind period, all participants received open-label sodium oxybate treatment. Efficacy assessments compared measurements during or at the end of the double-blind period with those taken the last two weeks of the stable-dose period. The study’s primary end point was change in weekly number of cataplexy attacks.

Study Was Terminated Early

Dr. Ruoff and colleagues randomized 63 participants. Approximately 41% of the population was between ages 7 and 11, 44% was female, and 38% was receiving sodium oxybate at baseline. A preplanned interim analysis of 35 participants indicated that sodium oxybate was effective, based on the primary end point result. The double-blind, randomized-withdrawal period thus was terminated early.

For the total group of 63 randomized participants, weekly cataplexy attacks were significantly increased in the placebo group (median, 12.7/week), compared with the sodium-oxybate-treated group (median, 0.3/week). Cataplexy severity, assessed using the Clinical Global Impression of Change (CGI-C), was worse in the placebo group than in the sodium-oxybate group. For 65% of participants in the placebo group, cataplexy was rated “much worse” or “very much worse,” compared with 17% of the sodium-oxybate group. Excessive sleepiness, assessed using the Epworth Sleepiness Scale for Children and Adolescents, also was worse in the placebo group (median increase, 3.0 points) than in the sodium-oxybate group (no change). In addition, the CGI-C for narcolepsy overall was worse in the placebo group.

Treatment-emergent adverse events occurring in more than 10% of the overall sample were enuresis, nausea, vomiting, headache, and decreased weight. These adverse events had been reported in previous trials of sodium oxybate in adults with narcolepsy.

The study was sponsored by Jazz Pharmaceuticals.

LOS ANGELES—Sodium oxybate reduces cataplexy and excessive sleepiness in children with narcolepsy type 1, according to a study described at the 70th Annual Meeting of the American Academy of Neurology. The treatment’s safety profile in this population is similar to that in adults.

Although symptoms of narcolepsy often begin during childhood or adolescence, few studies have evaluated treatments for narcolepsy in pediatric patients. Sodium oxybate is approved for the treatment of cataplexy and excessive daytime sleepiness in adults with narcolepsy, but it had not previously been studied in a large pediatric narcolepsy trial. Chad Ruoff, MD, Clinical Assistant Professor of Psychiatry and Behavioral Sciences at the Stanford Center for Sleep Sciences and Medicine in California, and colleagues conducted a double-blind, placebo-controlled, randomized-withdrawal study to evaluate the efficacy and safety of sodium oxybate in pediatric patients with narcolepsy type 1.

A Randomized-Withdrawal Study

Eligible participants were children and adolescents between ages 7 and 16 who had been diagnosed with narcolepsy type 1 and had cataplexy. Patients who were on stable doses of sodium oxybate and patients who were sodium-oxybate-naïve were included. Patients with evidence of sleep-disordered breathing were excluded.

Sodium-oxybate-naïve participants were titrated to a stable dose. After a stable-dose period, all participants began a two-week, double-blind, placebo-controlled withdrawal period. The investigators randomized participants in equal groups to continue sodium oxybate or to be switched to placebo. At the end of the double-blind period, all participants received open-label sodium oxybate treatment. Efficacy assessments compared measurements during or at the end of the double-blind period with those taken the last two weeks of the stable-dose period. The study’s primary end point was change in weekly number of cataplexy attacks.

Study Was Terminated Early

Dr. Ruoff and colleagues randomized 63 participants. Approximately 41% of the population was between ages 7 and 11, 44% was female, and 38% was receiving sodium oxybate at baseline. A preplanned interim analysis of 35 participants indicated that sodium oxybate was effective, based on the primary end point result. The double-blind, randomized-withdrawal period thus was terminated early.

For the total group of 63 randomized participants, weekly cataplexy attacks were significantly increased in the placebo group (median, 12.7/week), compared with the sodium-oxybate-treated group (median, 0.3/week). Cataplexy severity, assessed using the Clinical Global Impression of Change (CGI-C), was worse in the placebo group than in the sodium-oxybate group. For 65% of participants in the placebo group, cataplexy was rated “much worse” or “very much worse,” compared with 17% of the sodium-oxybate group. Excessive sleepiness, assessed using the Epworth Sleepiness Scale for Children and Adolescents, also was worse in the placebo group (median increase, 3.0 points) than in the sodium-oxybate group (no change). In addition, the CGI-C for narcolepsy overall was worse in the placebo group.

Treatment-emergent adverse events occurring in more than 10% of the overall sample were enuresis, nausea, vomiting, headache, and decreased weight. These adverse events had been reported in previous trials of sodium oxybate in adults with narcolepsy.

The study was sponsored by Jazz Pharmaceuticals.

LOS ANGELES—Sodium oxybate reduces cataplexy and excessive sleepiness in children with narcolepsy type 1, according to a study described at the 70th Annual Meeting of the American Academy of Neurology. The treatment’s safety profile in this population is similar to that in adults.

Although symptoms of narcolepsy often begin during childhood or adolescence, few studies have evaluated treatments for narcolepsy in pediatric patients. Sodium oxybate is approved for the treatment of cataplexy and excessive daytime sleepiness in adults with narcolepsy, but it had not previously been studied in a large pediatric narcolepsy trial. Chad Ruoff, MD, Clinical Assistant Professor of Psychiatry and Behavioral Sciences at the Stanford Center for Sleep Sciences and Medicine in California, and colleagues conducted a double-blind, placebo-controlled, randomized-withdrawal study to evaluate the efficacy and safety of sodium oxybate in pediatric patients with narcolepsy type 1.

A Randomized-Withdrawal Study

Eligible participants were children and adolescents between ages 7 and 16 who had been diagnosed with narcolepsy type 1 and had cataplexy. Patients who were on stable doses of sodium oxybate and patients who were sodium-oxybate-naïve were included. Patients with evidence of sleep-disordered breathing were excluded.

Sodium-oxybate-naïve participants were titrated to a stable dose. After a stable-dose period, all participants began a two-week, double-blind, placebo-controlled withdrawal period. The investigators randomized participants in equal groups to continue sodium oxybate or to be switched to placebo. At the end of the double-blind period, all participants received open-label sodium oxybate treatment. Efficacy assessments compared measurements during or at the end of the double-blind period with those taken the last two weeks of the stable-dose period. The study’s primary end point was change in weekly number of cataplexy attacks.

Study Was Terminated Early

Dr. Ruoff and colleagues randomized 63 participants. Approximately 41% of the population was between ages 7 and 11, 44% was female, and 38% was receiving sodium oxybate at baseline. A preplanned interim analysis of 35 participants indicated that sodium oxybate was effective, based on the primary end point result. The double-blind, randomized-withdrawal period thus was terminated early.

For the total group of 63 randomized participants, weekly cataplexy attacks were significantly increased in the placebo group (median, 12.7/week), compared with the sodium-oxybate-treated group (median, 0.3/week). Cataplexy severity, assessed using the Clinical Global Impression of Change (CGI-C), was worse in the placebo group than in the sodium-oxybate group. For 65% of participants in the placebo group, cataplexy was rated “much worse” or “very much worse,” compared with 17% of the sodium-oxybate group. Excessive sleepiness, assessed using the Epworth Sleepiness Scale for Children and Adolescents, also was worse in the placebo group (median increase, 3.0 points) than in the sodium-oxybate group (no change). In addition, the CGI-C for narcolepsy overall was worse in the placebo group.

Treatment-emergent adverse events occurring in more than 10% of the overall sample were enuresis, nausea, vomiting, headache, and decreased weight. These adverse events had been reported in previous trials of sodium oxybate in adults with narcolepsy.

The study was sponsored by Jazz Pharmaceuticals.

Telemedicine is defined broadly by the World Health Organization as the delivery of health care services at a distance using electronic means for “the diagnosis of treatment, and prevention of disease and injuries, research and evaluation, education of health care providers”¹ to improve health. Although no single accepted definition exists, telehealth often is used as the umbrella term to encompass telemedicine (health care delivery) in addition to other activities such as education, research, health surveillance, and public health promotion.² These various terms often are used interchangeably throughout the literature, leading to confusion.^1,3 For the purpose of this review, we will use the term telemedicine to describe any care delivery model whereby patient care is provided at a distance using information technology such as cellphones, computers, or other electronic devices.

Use of telemedicine in chronic liver disease: A literature review

We performed a systematic review of telemedicine in chronic liver disease. In consultation with a biomedical librarian, we searched for English-language articles for relevant studies with adult participants from July 1984 to May 2017 in PubMed, OVID Medline, American Association for the Study of Liver Disease, EMBASE, Web of Science, ClinicalTrials.gov, Elsevier/Science Direct, and the Cochrane Library (the search strategy is shown in the Supplementary Material at https://doi.org/10.1016/j.cgh.2017.10.004). The references of original publications and of review articles additionally were screened for potentially relevant studies. Abstracts that later resulted in no publications and studies in which telemedicine was used to deliver care, but was neither an exposure nor outcome, were excluded. Social media studies were not considered telemedicine if no patient care was involved. Studies of purely medical education interventions or those that evaluated the accuracy of technology to aid in diagnosis also were excluded.

Supplementary Table 1 (https://doi.org/10.1016/j.cgh.2017.10.004) shows the 20 published articles of telemedicine studies. Among these, there were 9 prospective trials, 3 retrospective studies, 2 case reports, and 6 small case series. One of the studies was randomized prospectively and 10 were uncontrolled.
 

Telemedicine in hepatitis C treatment

Telemedicine to aid in procedural/surgical management

A few reports have been published in the use of synchronous video and digital technology to aid in periprocedural management in liver disease. A case report highlighted a successful example of gastroenterologist-led teleproctoring using basic video technology to enable a surgeon to perform sclerotherapy for hemostasis in the setting of a variceal bleed.⁹ Another case report described the transmission of smart phone images from surgical trainees to an attending physician to make a real-time decision regarding a possibly questionable liver procurement, which took place 545 km away from the university hospital.¹⁰ A retrospective case series described the feasibility and successful use of high-resolution digital macroscopic photography and electronic transmission between liver transplant centers in the United Kingdom to increase the utilization of split liver transplantation, a setting in which detailed knowledge of vessel anatomy is needed for advanced surgical planning.¹¹ Similarly, an uncontrolled case series from Greece reported on the feasibility and reliability of macroscopic image transmission to aid in the evaluation of liver grafts for transplantation.¹²

Telemedicine to support evaluation and management of hepatocellular carcinoma

One recent abstract reported on the use of asynchronous store-and-forward telemedicine for screening and management of hepatocellular carcinoma and evaluated process outcomes of specialty care access for newly diagnosed patients.¹³ A multifaceted approach included live video teleconferencing and centralized radiology review, which was conducted by a multidisciplinary tumor board at an expert hub site, which provided expert opinion and subsequent care (e.g., locoregional therapy, liver transplant evaluation) to spoke sites. As a result of the initiative, the time to specialty evaluation and receipt of hepatocellular carcinoma therapy decreased by 23 and 25 days, respectively.

Remote monitoring interventions

Proposed framework for advancing telemedicine in liver disease: The case for more research and policy changes

Telemedicine can serve two main goals in liver disease: improve access to specialty care, and improve care between visits. For the first goal, the technology is straightforward and limited research is required; the main barriers are regulatory and reimbursement. As an example, one of the authors (M.L.V.) uses telemedicine to perform liver transplant evaluations in Las Vegas, N.V., a state without a liver transplant program. Patients are seen initially by a nurse practitioner who resides in Las Vegas, and those patients needing transplant evaluation are scheduled for a video visit with the attending physician who is physically in California. This works well and patients love it; however, the business model is dependent on the downstream financial incentive of transplantation. In addition, various regulatory requirements must be satisfied such as monthly in-person visits. For the second goal, a number of exciting possibilities exist such as remote monitoring and patient disease management, but more research is needed.

Research

According to the Pew Research Center, 95% of American adults own a cellphone and 77% own a smartphone. These devices passively gather an extraordinary amount of data that could be harnessed to identify early warning signs of complications (remote monitoring). Another potentially fruitful area of research is patient disease management. This includes using technology (e.g., reminder texts) to effect behavior change such as with medication adherence, lifestyle modification, education, or peer mentoring. As an example, the coauthor (M.S.) is leading a study to promote physical activity among liver transplant recipients by using an online web portal developed by researchers at the University of Pennsylvania (Way to Health), which interfaces with patient cell phones and digital accelerometer devices. Participants receive daily feedback through text messages with their step counts, and small financial incentives are provided for adequate levels of physical activity. Technology also can facilitate the development of disease management platforms, which could improve both access and in-between visit monitoring, especially in remote areas. One of the authors (M.L.V.) currently is leading the development of a remote disease management program with funding from the American Association for the Study of Liver Diseases.

Despite the tremendous promise, traditional research methods in telemedicine may be challenging given the rapid and increasing uptake of health technology among patients and health systems. As such, the classic paradigm of randomized controlled trials to evaluate the success of an intervention or change in care delivery often is not feasible. We believe there is a need to recalibrate the definition of what constitutes a high-quality telemedicine study. For example, pragmatic trials and those designed within an implementation science framework that evaluate feasibility, scalability, and cost, in parallel with traditional clinical outcomes, may be better suited and should be accepted more widely.¹⁷



Policy

Even when the technology is available and research shows efficacy, the implementation of telemedicine in clinical practice faces regulatory and reimbursement barriers. The first regulatory question is whether a patient–provider relationship is being established (with the exception of limited provider–provider curbside consultation, the answer usually is yes). If so, the practice then is subject to all the usual regulatory concerns. The provider needs to be licensed at the site of origin (where the patient is located) and hold malpractice coverage for that location, and the video and medical record transmission should be compliant with the Health Insurance Portability and Accountability Act. The next challenge is reimbursement. Medicare only pays for video consultation if the patient lives in a designated rural Health Professional Shortage Area (www.cms.gov), and reimbursement by private payers varies. Even this is dependent on ever-changing state laws. Reimbursement for remote patient monitoring is even more limited (the National Telehealth Policy Research Center publishes a useful handbook: http://www.cchpca.org/sites/default/files/resources/50%20State%20FINAL%20April%202016.pdf). Absent a bipartisan Congressional effort to remedy this situation, the best hope for removing reimbursement barriers lies with payment reform. The Medicare Access and CHIP Reauthorization Act of 2015 mandates that the Centers for Medicare and Medicaid Services shift from fee-for-service to alternative payment models in the coming years. In these alternate payment models, providers are responsible for the overall quality and total cost of care for a population of patients. In this scenario, there may be a financial incentive for telemedicine, especially remote monitoring, to keep patients out of the hospital. Until then, under current payment models, reimbursement is limited and the barriers to widespread implementation are high.
 

Conclusions

Telemedicine has continued to increase in uptake and shows tremendous promise in expanding access to health care, promoting patient disease management, and facilitating in-between health care visit monitoring. Although the future is bright, more research is needed to determine optimal ways to integrate telemedicine — especially remote monitoring — into routine clinical care. We call on our specialty societies to send a clear political advocacy message that policy changes are needed to overcome regulatory and reimbursement challenges.

Acknowledgments

The authors would like to thank Lauren Jones and Mackenzie McDougal for their assistance with the literature review.

Supplementary materials and methods

The telemedicine interventions PubMed literature search strategy was as follows: ((“liver diseases”[MeSH Terms] OR (“liver”[All Fields] AND “diseases”[All Fields]) OR “liver diseases”[All Fields] OR (“liver”[All Fields] AND “disease”[All Fields]) OR “liver disease”[All Fields] OR liver dysfunction OR liver dysfunctions)) OR “liver transplantation”[MeSH Terms] OR “liver transplantation” [All Fields] AND (((“telemedicine”[MeSH Terms] OR “telemedicine”[All Fields] OR mobile health OR mhealth OR telehealth OR mhealth)) OR (videoconferencing OR videoconference)).

References

1. Kirsh S., Su G.L., Sales A., et al. Access to outpatient specialty care: solutions from an integrated health care system. Am J Med Qual. 2015;30:88-90.

2. Wilson L.S., Maeder A.J. recent directions in telemedicine: review of trends in research and practice. Healthc Inform Res. 2015;21:213-22.

3. Cross R.K., Kane, S. Integration of telemedicine into clinical gastroenterology and hepatology practice. Clin Gastroenterol Hepatol. 2017;15:175-81.

4. Darkins A., Ryan P., Kobb R., et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14:1118-26.

5. Tuerk P.W., Fortney J., Bosworth H.B., et al. Toward the development of national telehealth services: the role of Veterans Health Administration and future directions for research. Telemed J E Health. 2010;16:115-7.

6. VA Press Release. Available: https://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2789. Accessed: July 27, 2017.

7. Arora S., Kalishman S., Thornton K., et al. Expanding access to hepatitis C virus treatment-extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52:1124-33.

8. Mitruka K., Thornton K., Cusick S., et al. Expanding primary care capacity to treat hepatitis C virus infection through an evidence-based care model–Arizona and Utah, 2012-2014. MMWR Morb Mortal Wkly Rep. 2014;63:393-8.

9. Ahmed A., Slosberg E., Prasad P., et al. The successful use of telemedicine in acute variceal hemorrhage. J Clin Gastroenterol. 1999;29:212-3.

10. Croome K.P., Shum J., Al-Basheer M.A., et al. The benefit of smart phone usage in liver organ procurement. J Telemed Telecare. 2011;17:158-60.

11. Bhati C.S., Wigmore S.J., Reddy S., et al. Web-based image transmission: a novel approach to aid communication in split liver transplantation. Clin Transplant. 2010;24:98-103.

12. Mammas C.S., Geropoulos S., Saatsakis G., et al. Telepathology as a method to optimize quality in organ transplantation: a feasibility and reliability study of the virtual benching of liver graft. Stud Health Technol Inform. 2013;190:276-8.

13. Egert E.M., et al. A regional multidisciplinary liver tumor board improves access to hepatocellular carcinoma treatment for patients geographically distant from tertiary medical center. Hepatology. 2015;62:469A

14. Thomson M., Volk M., Kim H.M., et al. An automated telephone monitoring system to identify patients with cirrhosis at risk of re-hospitalization. Dig Dis Sci. 2015;60:3563-9.

15. Ertel A.E., Kaiser T.E., Abbott D.E., et al. Use of video-based education and tele-health home monitoring after liver transplantation: results of a novel pilot study. Surgery. 2016;160:869-76.

16. Thygesen G.B., Andersen H., Damsgaard B.S. et al. The effect of nurse performed telemedical video consultations for patients suffering from alcohol-related liver cirrhosis. J Hepatol. 2017;66:S349

17. Proctor E., Silmere H., Raghavan R. et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38:65-76.
 

Dr. Serper is in the division of gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, and the department of medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia; Dr. Volk is in the division of gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, Calif. The authors disclose no conflicts.

Telemedicine is defined broadly by the World Health Organization as the delivery of health care services at a distance using electronic means for “the diagnosis of treatment, and prevention of disease and injuries, research and evaluation, education of health care providers”¹ to improve health. Although no single accepted definition exists, telehealth often is used as the umbrella term to encompass telemedicine (health care delivery) in addition to other activities such as education, research, health surveillance, and public health promotion.² These various terms often are used interchangeably throughout the literature, leading to confusion.^1,3 For the purpose of this review, we will use the term telemedicine to describe any care delivery model whereby patient care is provided at a distance using information technology such as cellphones, computers, or other electronic devices.

Use of telemedicine in chronic liver disease: A literature review

We performed a systematic review of telemedicine in chronic liver disease. In consultation with a biomedical librarian, we searched for English-language articles for relevant studies with adult participants from July 1984 to May 2017 in PubMed, OVID Medline, American Association for the Study of Liver Disease, EMBASE, Web of Science, ClinicalTrials.gov, Elsevier/Science Direct, and the Cochrane Library (the search strategy is shown in the Supplementary Material at https://doi.org/10.1016/j.cgh.2017.10.004). The references of original publications and of review articles additionally were screened for potentially relevant studies. Abstracts that later resulted in no publications and studies in which telemedicine was used to deliver care, but was neither an exposure nor outcome, were excluded. Social media studies were not considered telemedicine if no patient care was involved. Studies of purely medical education interventions or those that evaluated the accuracy of technology to aid in diagnosis also were excluded.

Supplementary Table 1 (https://doi.org/10.1016/j.cgh.2017.10.004) shows the 20 published articles of telemedicine studies. Among these, there were 9 prospective trials, 3 retrospective studies, 2 case reports, and 6 small case series. One of the studies was randomized prospectively and 10 were uncontrolled.
 

Telemedicine in hepatitis C treatment

Telemedicine to aid in procedural/surgical management

A few reports have been published in the use of synchronous video and digital technology to aid in periprocedural management in liver disease. A case report highlighted a successful example of gastroenterologist-led teleproctoring using basic video technology to enable a surgeon to perform sclerotherapy for hemostasis in the setting of a variceal bleed.⁹ Another case report described the transmission of smart phone images from surgical trainees to an attending physician to make a real-time decision regarding a possibly questionable liver procurement, which took place 545 km away from the university hospital.¹⁰ A retrospective case series described the feasibility and successful use of high-resolution digital macroscopic photography and electronic transmission between liver transplant centers in the United Kingdom to increase the utilization of split liver transplantation, a setting in which detailed knowledge of vessel anatomy is needed for advanced surgical planning.¹¹ Similarly, an uncontrolled case series from Greece reported on the feasibility and reliability of macroscopic image transmission to aid in the evaluation of liver grafts for transplantation.¹²

Telemedicine to support evaluation and management of hepatocellular carcinoma

One recent abstract reported on the use of asynchronous store-and-forward telemedicine for screening and management of hepatocellular carcinoma and evaluated process outcomes of specialty care access for newly diagnosed patients.¹³ A multifaceted approach included live video teleconferencing and centralized radiology review, which was conducted by a multidisciplinary tumor board at an expert hub site, which provided expert opinion and subsequent care (e.g., locoregional therapy, liver transplant evaluation) to spoke sites. As a result of the initiative, the time to specialty evaluation and receipt of hepatocellular carcinoma therapy decreased by 23 and 25 days, respectively.

Remote monitoring interventions

Proposed framework for advancing telemedicine in liver disease: The case for more research and policy changes

Telemedicine can serve two main goals in liver disease: improve access to specialty care, and improve care between visits. For the first goal, the technology is straightforward and limited research is required; the main barriers are regulatory and reimbursement. As an example, one of the authors (M.L.V.) uses telemedicine to perform liver transplant evaluations in Las Vegas, N.V., a state without a liver transplant program. Patients are seen initially by a nurse practitioner who resides in Las Vegas, and those patients needing transplant evaluation are scheduled for a video visit with the attending physician who is physically in California. This works well and patients love it; however, the business model is dependent on the downstream financial incentive of transplantation. In addition, various regulatory requirements must be satisfied such as monthly in-person visits. For the second goal, a number of exciting possibilities exist such as remote monitoring and patient disease management, but more research is needed.

Research

According to the Pew Research Center, 95% of American adults own a cellphone and 77% own a smartphone. These devices passively gather an extraordinary amount of data that could be harnessed to identify early warning signs of complications (remote monitoring). Another potentially fruitful area of research is patient disease management. This includes using technology (e.g., reminder texts) to effect behavior change such as with medication adherence, lifestyle modification, education, or peer mentoring. As an example, the coauthor (M.S.) is leading a study to promote physical activity among liver transplant recipients by using an online web portal developed by researchers at the University of Pennsylvania (Way to Health), which interfaces with patient cell phones and digital accelerometer devices. Participants receive daily feedback through text messages with their step counts, and small financial incentives are provided for adequate levels of physical activity. Technology also can facilitate the development of disease management platforms, which could improve both access and in-between visit monitoring, especially in remote areas. One of the authors (M.L.V.) currently is leading the development of a remote disease management program with funding from the American Association for the Study of Liver Diseases.

Despite the tremendous promise, traditional research methods in telemedicine may be challenging given the rapid and increasing uptake of health technology among patients and health systems. As such, the classic paradigm of randomized controlled trials to evaluate the success of an intervention or change in care delivery often is not feasible. We believe there is a need to recalibrate the definition of what constitutes a high-quality telemedicine study. For example, pragmatic trials and those designed within an implementation science framework that evaluate feasibility, scalability, and cost, in parallel with traditional clinical outcomes, may be better suited and should be accepted more widely.¹⁷



Policy

Even when the technology is available and research shows efficacy, the implementation of telemedicine in clinical practice faces regulatory and reimbursement barriers. The first regulatory question is whether a patient–provider relationship is being established (with the exception of limited provider–provider curbside consultation, the answer usually is yes). If so, the practice then is subject to all the usual regulatory concerns. The provider needs to be licensed at the site of origin (where the patient is located) and hold malpractice coverage for that location, and the video and medical record transmission should be compliant with the Health Insurance Portability and Accountability Act. The next challenge is reimbursement. Medicare only pays for video consultation if the patient lives in a designated rural Health Professional Shortage Area (www.cms.gov), and reimbursement by private payers varies. Even this is dependent on ever-changing state laws. Reimbursement for remote patient monitoring is even more limited (the National Telehealth Policy Research Center publishes a useful handbook: http://www.cchpca.org/sites/default/files/resources/50%20State%20FINAL%20April%202016.pdf). Absent a bipartisan Congressional effort to remedy this situation, the best hope for removing reimbursement barriers lies with payment reform. The Medicare Access and CHIP Reauthorization Act of 2015 mandates that the Centers for Medicare and Medicaid Services shift from fee-for-service to alternative payment models in the coming years. In these alternate payment models, providers are responsible for the overall quality and total cost of care for a population of patients. In this scenario, there may be a financial incentive for telemedicine, especially remote monitoring, to keep patients out of the hospital. Until then, under current payment models, reimbursement is limited and the barriers to widespread implementation are high.
 

Conclusions

Telemedicine has continued to increase in uptake and shows tremendous promise in expanding access to health care, promoting patient disease management, and facilitating in-between health care visit monitoring. Although the future is bright, more research is needed to determine optimal ways to integrate telemedicine — especially remote monitoring — into routine clinical care. We call on our specialty societies to send a clear political advocacy message that policy changes are needed to overcome regulatory and reimbursement challenges.

Acknowledgments

The authors would like to thank Lauren Jones and Mackenzie McDougal for their assistance with the literature review.

Supplementary materials and methods

The telemedicine interventions PubMed literature search strategy was as follows: ((“liver diseases”[MeSH Terms] OR (“liver”[All Fields] AND “diseases”[All Fields]) OR “liver diseases”[All Fields] OR (“liver”[All Fields] AND “disease”[All Fields]) OR “liver disease”[All Fields] OR liver dysfunction OR liver dysfunctions)) OR “liver transplantation”[MeSH Terms] OR “liver transplantation” [All Fields] AND (((“telemedicine”[MeSH Terms] OR “telemedicine”[All Fields] OR mobile health OR mhealth OR telehealth OR mhealth)) OR (videoconferencing OR videoconference)).

References

1. Kirsh S., Su G.L., Sales A., et al. Access to outpatient specialty care: solutions from an integrated health care system. Am J Med Qual. 2015;30:88-90.

2. Wilson L.S., Maeder A.J. recent directions in telemedicine: review of trends in research and practice. Healthc Inform Res. 2015;21:213-22.

3. Cross R.K., Kane, S. Integration of telemedicine into clinical gastroenterology and hepatology practice. Clin Gastroenterol Hepatol. 2017;15:175-81.

4. Darkins A., Ryan P., Kobb R., et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14:1118-26.

5. Tuerk P.W., Fortney J., Bosworth H.B., et al. Toward the development of national telehealth services: the role of Veterans Health Administration and future directions for research. Telemed J E Health. 2010;16:115-7.

6. VA Press Release. Available: https://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2789. Accessed: July 27, 2017.

7. Arora S., Kalishman S., Thornton K., et al. Expanding access to hepatitis C virus treatment-extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52:1124-33.

8. Mitruka K., Thornton K., Cusick S., et al. Expanding primary care capacity to treat hepatitis C virus infection through an evidence-based care model–Arizona and Utah, 2012-2014. MMWR Morb Mortal Wkly Rep. 2014;63:393-8.

9. Ahmed A., Slosberg E., Prasad P., et al. The successful use of telemedicine in acute variceal hemorrhage. J Clin Gastroenterol. 1999;29:212-3.

10. Croome K.P., Shum J., Al-Basheer M.A., et al. The benefit of smart phone usage in liver organ procurement. J Telemed Telecare. 2011;17:158-60.

11. Bhati C.S., Wigmore S.J., Reddy S., et al. Web-based image transmission: a novel approach to aid communication in split liver transplantation. Clin Transplant. 2010;24:98-103.

12. Mammas C.S., Geropoulos S., Saatsakis G., et al. Telepathology as a method to optimize quality in organ transplantation: a feasibility and reliability study of the virtual benching of liver graft. Stud Health Technol Inform. 2013;190:276-8.

13. Egert E.M., et al. A regional multidisciplinary liver tumor board improves access to hepatocellular carcinoma treatment for patients geographically distant from tertiary medical center. Hepatology. 2015;62:469A

14. Thomson M., Volk M., Kim H.M., et al. An automated telephone monitoring system to identify patients with cirrhosis at risk of re-hospitalization. Dig Dis Sci. 2015;60:3563-9.

15. Ertel A.E., Kaiser T.E., Abbott D.E., et al. Use of video-based education and tele-health home monitoring after liver transplantation: results of a novel pilot study. Surgery. 2016;160:869-76.

16. Thygesen G.B., Andersen H., Damsgaard B.S. et al. The effect of nurse performed telemedical video consultations for patients suffering from alcohol-related liver cirrhosis. J Hepatol. 2017;66:S349

17. Proctor E., Silmere H., Raghavan R. et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38:65-76.
 

Dr. Serper is in the division of gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, and the department of medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia; Dr. Volk is in the division of gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, Calif. The authors disclose no conflicts.

Telemedicine is defined broadly by the World Health Organization as the delivery of health care services at a distance using electronic means for “the diagnosis of treatment, and prevention of disease and injuries, research and evaluation, education of health care providers”¹ to improve health. Although no single accepted definition exists, telehealth often is used as the umbrella term to encompass telemedicine (health care delivery) in addition to other activities such as education, research, health surveillance, and public health promotion.² These various terms often are used interchangeably throughout the literature, leading to confusion.^1,3 For the purpose of this review, we will use the term telemedicine to describe any care delivery model whereby patient care is provided at a distance using information technology such as cellphones, computers, or other electronic devices.

Use of telemedicine in chronic liver disease: A literature review

We performed a systematic review of telemedicine in chronic liver disease. In consultation with a biomedical librarian, we searched for English-language articles for relevant studies with adult participants from July 1984 to May 2017 in PubMed, OVID Medline, American Association for the Study of Liver Disease, EMBASE, Web of Science, ClinicalTrials.gov, Elsevier/Science Direct, and the Cochrane Library (the search strategy is shown in the Supplementary Material at https://doi.org/10.1016/j.cgh.2017.10.004). The references of original publications and of review articles additionally were screened for potentially relevant studies. Abstracts that later resulted in no publications and studies in which telemedicine was used to deliver care, but was neither an exposure nor outcome, were excluded. Social media studies were not considered telemedicine if no patient care was involved. Studies of purely medical education interventions or those that evaluated the accuracy of technology to aid in diagnosis also were excluded.

Supplementary Table 1 (https://doi.org/10.1016/j.cgh.2017.10.004) shows the 20 published articles of telemedicine studies. Among these, there were 9 prospective trials, 3 retrospective studies, 2 case reports, and 6 small case series. One of the studies was randomized prospectively and 10 were uncontrolled.
 

Telemedicine in hepatitis C treatment

Telemedicine to aid in procedural/surgical management

A few reports have been published in the use of synchronous video and digital technology to aid in periprocedural management in liver disease. A case report highlighted a successful example of gastroenterologist-led teleproctoring using basic video technology to enable a surgeon to perform sclerotherapy for hemostasis in the setting of a variceal bleed.⁹ Another case report described the transmission of smart phone images from surgical trainees to an attending physician to make a real-time decision regarding a possibly questionable liver procurement, which took place 545 km away from the university hospital.¹⁰ A retrospective case series described the feasibility and successful use of high-resolution digital macroscopic photography and electronic transmission between liver transplant centers in the United Kingdom to increase the utilization of split liver transplantation, a setting in which detailed knowledge of vessel anatomy is needed for advanced surgical planning.¹¹ Similarly, an uncontrolled case series from Greece reported on the feasibility and reliability of macroscopic image transmission to aid in the evaluation of liver grafts for transplantation.¹²

Telemedicine to support evaluation and management of hepatocellular carcinoma

One recent abstract reported on the use of asynchronous store-and-forward telemedicine for screening and management of hepatocellular carcinoma and evaluated process outcomes of specialty care access for newly diagnosed patients.¹³ A multifaceted approach included live video teleconferencing and centralized radiology review, which was conducted by a multidisciplinary tumor board at an expert hub site, which provided expert opinion and subsequent care (e.g., locoregional therapy, liver transplant evaluation) to spoke sites. As a result of the initiative, the time to specialty evaluation and receipt of hepatocellular carcinoma therapy decreased by 23 and 25 days, respectively.

Remote monitoring interventions

Proposed framework for advancing telemedicine in liver disease: The case for more research and policy changes

Telemedicine can serve two main goals in liver disease: improve access to specialty care, and improve care between visits. For the first goal, the technology is straightforward and limited research is required; the main barriers are regulatory and reimbursement. As an example, one of the authors (M.L.V.) uses telemedicine to perform liver transplant evaluations in Las Vegas, N.V., a state without a liver transplant program. Patients are seen initially by a nurse practitioner who resides in Las Vegas, and those patients needing transplant evaluation are scheduled for a video visit with the attending physician who is physically in California. This works well and patients love it; however, the business model is dependent on the downstream financial incentive of transplantation. In addition, various regulatory requirements must be satisfied such as monthly in-person visits. For the second goal, a number of exciting possibilities exist such as remote monitoring and patient disease management, but more research is needed.

Research

According to the Pew Research Center, 95% of American adults own a cellphone and 77% own a smartphone. These devices passively gather an extraordinary amount of data that could be harnessed to identify early warning signs of complications (remote monitoring). Another potentially fruitful area of research is patient disease management. This includes using technology (e.g., reminder texts) to effect behavior change such as with medication adherence, lifestyle modification, education, or peer mentoring. As an example, the coauthor (M.S.) is leading a study to promote physical activity among liver transplant recipients by using an online web portal developed by researchers at the University of Pennsylvania (Way to Health), which interfaces with patient cell phones and digital accelerometer devices. Participants receive daily feedback through text messages with their step counts, and small financial incentives are provided for adequate levels of physical activity. Technology also can facilitate the development of disease management platforms, which could improve both access and in-between visit monitoring, especially in remote areas. One of the authors (M.L.V.) currently is leading the development of a remote disease management program with funding from the American Association for the Study of Liver Diseases.

Despite the tremendous promise, traditional research methods in telemedicine may be challenging given the rapid and increasing uptake of health technology among patients and health systems. As such, the classic paradigm of randomized controlled trials to evaluate the success of an intervention or change in care delivery often is not feasible. We believe there is a need to recalibrate the definition of what constitutes a high-quality telemedicine study. For example, pragmatic trials and those designed within an implementation science framework that evaluate feasibility, scalability, and cost, in parallel with traditional clinical outcomes, may be better suited and should be accepted more widely.¹⁷



Policy

Even when the technology is available and research shows efficacy, the implementation of telemedicine in clinical practice faces regulatory and reimbursement barriers. The first regulatory question is whether a patient–provider relationship is being established (with the exception of limited provider–provider curbside consultation, the answer usually is yes). If so, the practice then is subject to all the usual regulatory concerns. The provider needs to be licensed at the site of origin (where the patient is located) and hold malpractice coverage for that location, and the video and medical record transmission should be compliant with the Health Insurance Portability and Accountability Act. The next challenge is reimbursement. Medicare only pays for video consultation if the patient lives in a designated rural Health Professional Shortage Area (www.cms.gov), and reimbursement by private payers varies. Even this is dependent on ever-changing state laws. Reimbursement for remote patient monitoring is even more limited (the National Telehealth Policy Research Center publishes a useful handbook: http://www.cchpca.org/sites/default/files/resources/50%20State%20FINAL%20April%202016.pdf). Absent a bipartisan Congressional effort to remedy this situation, the best hope for removing reimbursement barriers lies with payment reform. The Medicare Access and CHIP Reauthorization Act of 2015 mandates that the Centers for Medicare and Medicaid Services shift from fee-for-service to alternative payment models in the coming years. In these alternate payment models, providers are responsible for the overall quality and total cost of care for a population of patients. In this scenario, there may be a financial incentive for telemedicine, especially remote monitoring, to keep patients out of the hospital. Until then, under current payment models, reimbursement is limited and the barriers to widespread implementation are high.
 

Conclusions

Telemedicine has continued to increase in uptake and shows tremendous promise in expanding access to health care, promoting patient disease management, and facilitating in-between health care visit monitoring. Although the future is bright, more research is needed to determine optimal ways to integrate telemedicine — especially remote monitoring — into routine clinical care. We call on our specialty societies to send a clear political advocacy message that policy changes are needed to overcome regulatory and reimbursement challenges.

Acknowledgments

The authors would like to thank Lauren Jones and Mackenzie McDougal for their assistance with the literature review.

Supplementary materials and methods

The telemedicine interventions PubMed literature search strategy was as follows: ((“liver diseases”[MeSH Terms] OR (“liver”[All Fields] AND “diseases”[All Fields]) OR “liver diseases”[All Fields] OR (“liver”[All Fields] AND “disease”[All Fields]) OR “liver disease”[All Fields] OR liver dysfunction OR liver dysfunctions)) OR “liver transplantation”[MeSH Terms] OR “liver transplantation” [All Fields] AND (((“telemedicine”[MeSH Terms] OR “telemedicine”[All Fields] OR mobile health OR mhealth OR telehealth OR mhealth)) OR (videoconferencing OR videoconference)).

References

1. Kirsh S., Su G.L., Sales A., et al. Access to outpatient specialty care: solutions from an integrated health care system. Am J Med Qual. 2015;30:88-90.

2. Wilson L.S., Maeder A.J. recent directions in telemedicine: review of trends in research and practice. Healthc Inform Res. 2015;21:213-22.

3. Cross R.K., Kane, S. Integration of telemedicine into clinical gastroenterology and hepatology practice. Clin Gastroenterol Hepatol. 2017;15:175-81.

4. Darkins A., Ryan P., Kobb R., et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14:1118-26.

5. Tuerk P.W., Fortney J., Bosworth H.B., et al. Toward the development of national telehealth services: the role of Veterans Health Administration and future directions for research. Telemed J E Health. 2010;16:115-7.

6. VA Press Release. Available: https://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2789. Accessed: July 27, 2017.

7. Arora S., Kalishman S., Thornton K., et al. Expanding access to hepatitis C virus treatment-extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52:1124-33.

8. Mitruka K., Thornton K., Cusick S., et al. Expanding primary care capacity to treat hepatitis C virus infection through an evidence-based care model–Arizona and Utah, 2012-2014. MMWR Morb Mortal Wkly Rep. 2014;63:393-8.

9. Ahmed A., Slosberg E., Prasad P., et al. The successful use of telemedicine in acute variceal hemorrhage. J Clin Gastroenterol. 1999;29:212-3.

10. Croome K.P., Shum J., Al-Basheer M.A., et al. The benefit of smart phone usage in liver organ procurement. J Telemed Telecare. 2011;17:158-60.

11. Bhati C.S., Wigmore S.J., Reddy S., et al. Web-based image transmission: a novel approach to aid communication in split liver transplantation. Clin Transplant. 2010;24:98-103.

12. Mammas C.S., Geropoulos S., Saatsakis G., et al. Telepathology as a method to optimize quality in organ transplantation: a feasibility and reliability study of the virtual benching of liver graft. Stud Health Technol Inform. 2013;190:276-8.

13. Egert E.M., et al. A regional multidisciplinary liver tumor board improves access to hepatocellular carcinoma treatment for patients geographically distant from tertiary medical center. Hepatology. 2015;62:469A

14. Thomson M., Volk M., Kim H.M., et al. An automated telephone monitoring system to identify patients with cirrhosis at risk of re-hospitalization. Dig Dis Sci. 2015;60:3563-9.

15. Ertel A.E., Kaiser T.E., Abbott D.E., et al. Use of video-based education and tele-health home monitoring after liver transplantation: results of a novel pilot study. Surgery. 2016;160:869-76.

16. Thygesen G.B., Andersen H., Damsgaard B.S. et al. The effect of nurse performed telemedical video consultations for patients suffering from alcohol-related liver cirrhosis. J Hepatol. 2017;66:S349

17. Proctor E., Silmere H., Raghavan R. et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38:65-76.
 

Dr. Serper is in the division of gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, and the department of medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia; Dr. Volk is in the division of gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, Calif. The authors disclose no conflicts.