Implications of Race Adjustment in Lung-Function Equations.

BACKGROUND: Adjustment for race is discouraged in lung-function testing, but the implications of adopting race-neutral equations have not been comprehensively quantified. METHODS: We obtained longitudinal data from 369,077 participants in the National Health and Nutrition Examination Survey, U.K. Biobank, the Multi-Ethnic Study of Atherosclerosis, and the Organ Procurement and Transplantation Network. Using these data, we compared the race-based 2012 Global Lung Function Initiative (GLI-2012) equations with race-neutral equations introduced in 2022 (GLI-Global). Evaluated outcomes included national projections of clinical, occupational, and financial reclassifications; individual lung-allocation scores for transplantation priority; and concordance statistics (C statistics) for clinical prediction tasks. RESULTS: Among the 249 million persons in the United States between 6 and 79 years of age who are able to produce high-quality spirometric results, the use of GLI-Global equations may reclassify ventilatory impairment for 12.5 million persons, medical impairment ratings for 8.16 million, occupational eligibility for 2.28 million, grading of chronic obstructive pulmonary disease for 2.05 million, and military disability compensation for 413,000. These potential changes differed according to race; for example, classifications of nonobstructive ventilatory impairment may change dramatically, increasing 141% (95% confidence interval [CI], 113 to 169) among Black persons and decreasing 69% (95% CI, 63 to 74) among White persons. Annual disability payments may increase by more than $1 billion among Black veterans and decrease by $0.5 billion among White veterans. GLI-2012 and GLI-Global equations had similar discriminative accuracy with regard to respiratory symptoms, health care utilization, new-onset disease, death from any cause, death related to respiratory disease, and death among persons on a transplant waiting list, with differences in C statistics ranging from -0.008 to 0.011. CONCLUSIONS: The use of race-based and race-neutral equations generated similarly accurate predictions of respiratory outcomes but assigned different disease classifications, occupational eligibility, and disability compensation for millions of persons, with effects diverging according to race. (Funded by the National Heart Lung and Blood Institute and the National Institute of Environmental Health Sciences.).

Novedades en la enfermedad pulmonar obstructiva crónica / Advances in chronic obstructive pulmonary disease

Aunque la enfermedad pulmonar obstructiva crónica (EPOC) se defi ne por la presencia de obstrucción crónicay poco reversible al fl ujo aéreo, desde un punto de vista clínico, debemos seguir avanzando en el diagnósticoy el tratamiento de estos pacientes, de modo que no queden relegados a un simple valor espirométrico.Entender que la EPOC es un proceso heterogéneo y que la complejidad del paciente suele aumentarpor la asociación de otras enfermedades, permitirá diseñar estrategias más individualizadas, que puedenmejorar nuestros resultados en el control del proceso.Los estudios TORCH y UPLIFT nos han mostrado que con el tratamiento actual podemos mejorar aspectosmuy importantes de la enfermedad, incluyendo la mortalidad. Sin embargo, la fi nalización de estos dosgrandes estudios ha generado una corriente de opinión que favorece un abordaje más individualizado delos pacientes, abordaje que deberá tener en cuenta todos los factores, pulmonares y no pulmonares, quepueden modifi car la forma de presentación del paciente en la clínica.Aunque ya estamos asistiendo a un cambio en el enfoque terapéutico de la EPOC, el futuro del tratamientodeberá basarse en estudios realizados en subgrupos específi cos de pacientes, así como en clarifi car la interrelaciónentre la EPOC y otras enfermedades que frecuentemente presentan estos pacientes. Aunque unmejor conocimiento de su patogenia puede desembocar en mejores tratamientos farmacológicos, no seprevén fármacos que por sí solos cambien, a corto y medio plazo, la situación de la EPOC; no obstante, unabordaje más dirigido al paciente puede ser la principal herramienta que actualmente tiene el médico paramejorar la calidad y, posiblemente, la cantidad de vida de estos pacientes(AU)

Although chronic obstructive pulmonary disease (COPD) is characterized by poorly reversible, chronic airfl owobstruction, from the clinical point of view we must continue to make progress in the diagnosis andmanagement of these patients so that spirometry is not the only technique used. Understanding that COPD isa heterogeneous process and that patient complexity usually increases due to the presence of comorbiditieswill allow more individualized strategies to be designed, which may improve control of the process.The TORCH and UPLIFT trials have shown that current treatment can improve important aspects of thedisease, including mortality. However, the fi nalizing of these two large trials has generated a current ofopinion favoring a more individually-tailored approach that should include all the factors –both pulmonaryand extrapulmonary– that can modify the patient’s form of presentation.Although we are witnessing a change in the therapeutic approach to COPD, future treatment will probablybe based on studies performed in specifi c patient subgroups and on clarifying the interrelation betweenCOPD and other diseases that are common in these patients. Greater knowledge of the pathogenesis of thedisease may improve pharmacological treatment but drugs that, by themselves, alter the short- and longtermcourse of COPD are not on the horizon. However, a more patient-focussed approach may be the maintool available to physicians to increase quality of life –and possibly survival– in these patients(AU)

The carbon monoxide diffusing capacity: clinical implications, coding, and documentation.

The test for the diffusing capacity of the lung for carbon monoxide (DLCO) has been available for nearly 100 years for research and clinical purposes. The single-breath method is used almost exclusively in the United States It has been available in clinical pulmonary function laboratories for > 50 years. DLCO has great value in evaluating patients with lung diseases. Guidelines to standardize DLCO have been published by the American Thoracic Society and European Respiratory Society to reduce the interlaboratory variability that has existed. One code, 94720, should be reported for the billing for DLCO. Another code, 94725, the membrane diffusing capacity, exists for the measurement of the membrane and blood components of the DLCO. Currently, no clinical indications exist for the use of the membrane diffusing capacity. The finding that the number of tests in the Medicare population coded with 94725 has increased by > 1,000% from 2000 to 2005 is quite surprising. This rate is 14-times higher than the rate of increase in the utilization of 94720 over the same period. The possible reasons for these increases are discussed, but the most likely explanation is the financial gain derived from coding 94725. It is proposed that coding and billing of 94725 be stopped until the clinical indications for membrane diffusing capacity have been established. Those who code and bill for 94725 must be prepared to justify the use of this code to Medicare and third-party payers.

[Cystic fibrosis: how to use pulmonary function tests]. / Mucoviscidose: du bon usage des explorations fonctionnelles respiratoires.

INTRODUCTION: Neonatal screening for cystic fibrosis (CF) leads to early dedicated specialist care for all patients. BACKGROUND: Pulmonary function tests (PFT) are mandatory for routine monitoring of CF patients. The aim of this article is to review the current guidelines for PFTs in CF, particularly the type of test, the age and the clinical status of the patient. VIEWPOINT: The regular use of spirometry is generally accepted. Many other tests are used but their clinical value in the routine follow-up of CF patients remains to be established. CONCLUSION: Further efforts should be made to evaluate the value of PFTs in CF, particularly in very young children.

Pulmonary function testing: coding and billing issues.

Clinicians who conduct pulmonary function tests should understand the principles and rules of the coding and billing system for pulmonary function testing. Certain billing codes will not be paid by most insurance payers. To ensure that your pulmonary function tests are appropriately coded, billed, and paid: (1) obtain a Current Procedural Terminology (CPT) coding book and an International Classification of Diseases 9th Revision (ICD-9) diagnosis book, and understand how they are used in setting coding and billing strategies, (2) know the people in your facility who do the billing and work with them to produce an appropriate coding and billing strategy, (3) make sure the physicians are involved in developing and implementing your coding and billing strategy, and (4) assure that your laboratory is set up properly to follows the Medicare rules for participation, that you have the appropriate testing supervision, that the appropriate administrative structure is in place to assure compliance with all regulations, and that you meet American Thoracic Society testing standards.

Pruebas de función pulmonar en el niño / Lung function tests in children

Las pruebas de función pulmonar contribuyen al diagnóstico de la patología respiratoria, determinando el tipo de disfunción fisiológica, como por ejemplo, la obstrucción, la restricción, la hiperreactividad bronquial y la variabilidad de la vía aérea. Las pruebas que más se utilizan en niños mayores de 5 años son la espirometría, la curva flujo volumen, la provocación bronquial con ejercicio y con metacolina, y la flujometría. Este trabajo fue realizado con el objetivo de unificar criterios en la realización e interpretación de estas pruebas, por un grupo de 18 médicos representantes de los distintos centros dondo se realizan pruebas de función pulmonar en el niño en Chile. Se describen, para cada una de ellas, sus indicaciones, contraindicaciones, técnicas de realización e interpretación de los resultados

[Classification of pulmonary-function tests by principal component analysis].

The structure of pulmonary-function data obtained from 468 randomly selected subjects was analyzed. The subjects included patients with chronic bronchitis, bronchial asthma, chronic pulmonary emphysema, diffuse panbronchiolitis, and idiopathic interstitial pneumonitis, and normal health adults. From among the many possible indices of pulmonary function, 19 were chosen and were used as variables in principal component analysis. Six significant principal components (PCs) were extracted. The first three PCs accounted for 70% of the total information and were termed "ventilation," "volume," and "diffusion." The second three PCs accounted for 17% of the information and were termed "small airway," "lower airway," and "shape." Indices of ventilatory unevenness were not separated from indices of airway obstruction, and were included in the first PC. No other, unknown PC was detected with these pulmonary-function indices. The relationship among indices is displayed in a factor loading matrix, and pulmonary-function tests are classified statistically.

Evaluation of pulmonary function in children.

Pulmonary function tests determine the type of impairment in many pulmonary, neuromuscular, metabolic, and cardiac disorders, and in this way they allow for rational treatment.