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CME / CE

Multidisciplinary Collaboration in Pulmonary Arterial Hypertension: What, Who, and Why It Matters?

  • Authors: Charles P. Vega, MD; Richard N. Channick, MD
  • CME / CE Released: 9/29/2022
  • Valid for credit through: 9/29/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    You Are Eligible For

    • Letter of Completion

Target Audience and Goal Statement

This activity is intended for cardiologists, pulmonologists, primary care physicians, nurses/nurse practitioners, and pharmacists.

The goal of this activity is for learners to be better able to understand the role of an interprofessional care team for managing patients with pulmonary arterial hypertension (PAH). 

Upon completion of this activity, participants will:

  • Have increased knowledge regarding
    • Effective interprofessional strategies to diagnose and appropriately manage PAH


Disclosures

As organizations accredited by the ACCME, Albert Einstein College of Medicine-Montefiore Medical Center (EINSTEIN) and Medscape, LLC, require everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any ineligible entity (industry). The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 24 months prior to the activity that could create a conflict of interest. 
 

EINSTEIN and Medscape, LLC, encourage Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content. 


Host

  • Charles P. Vega, MD

    Clinical Professor, Family Medicine
    Director, UC Irvine Program in Medical Education
    for the Latino Community (PRIME-LC)
    Associate Dean for Diversity and Inclusion
    University of California, Irvine
    Irvine, California

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson

Faculty

  • Richard N. Channick, MD

    Professor of Medicine
    David Geffen School of Medicine
    Director, Pulmonary Vascular Disease Program
    UCLA Medical Center
    Los Angeles, California

    Disclosures

    Richard N. Channick, MD, has the following relevant financial relationships:
    Consultant or advisor for: Acceleron; Altavant; Aria CV; Bayer; Gossamer; Janssen; Third Pole; United Therapeutics
    Speaker or member of speakers bureau for: Bayer; Janssen
    Research funding from: Acceleron; Aria CV; Bayer; Janssen; Third Pole

Editor

  • George Boutsalis, PhD

    Senior Director, Content Development, Medscape, LLC

    Disclosures

    George Boutsalis, PhD, has no relevant financial relationships.

Compliance Reviewer/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Peer Reviewers

This activity has been peer reviewed in its entirety, for bias and objectivity, by reviewers that have no relevant financial relationships in the last 24 months prior to the activity. The authors of this activity provided educational content and resources in advance, as we requested. All their recommendations for patient care were made based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of unbiased diagnostic and therapeutic options.

Sandhya Murthy, MD
CME Reviewer, Montefiore Medical Center
Sandhya Murthy, MD, has disclosed no relevant financial relationships with ineligible companies in the last 24 months.

Kathleen O’Connor, BSN
CNE Reviewer, Montefiore Medical Center
Kathleen O’Connor, BSN, has disclosed no relevant financial relationships with ineligible companies in the last 24 months.

Katherine E. Di Palo, PharmD, FAHA, FHFSA, BCACP, BCGP 
CPE Reviewer, Montefiore Medical Center
Katherine E. Di Palo, PharmD, FAHA, FHFSA, BCACP, BCGP, has disclosed no relevant financial relationships with ineligible companies in the last 24 months.

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


Accreditation Statements

Developed through a partnership between Medscape and Montefiore Medical Center.


In support of improving patient care, Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

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    For Nurses

  • This activity is awarded 0.25 contact hours. (based on 60 minutes per contact hour)

    Contact This Provider

    For Pharmacists

  • This knowledge-based activity UAN # JA4008224-0000-22-047-H01-P qualifies for 0.25 contact hours (0.0025 CEUs) of continuing pharmacy education credit.

    PLEASE NOTE
    For submission of Pharmacist CE credit to CPE Monitor, please ensure your Medscape registration is PROVIDED with your birthdate (MM/DD) and NABP ID number.

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For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read about the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or print it out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate, but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period, you can print out the tally as well as the certificates from the CME/CE Tracker.

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CME / CE

Multidisciplinary Collaboration in Pulmonary Arterial Hypertension: What, Who, and Why It Matters?

Authors: Charles P. Vega, MD; Richard N. Channick, MDFaculty and Disclosures

CME / CE Released: 9/29/2022

Valid for credit through: 9/29/2023

processing....

Activity Transcript

Chuck P. Vega, MD: Hello and welcome to "Multidisciplinary Collaboration in PAH: What, Who, and Why It Matters?" I’m Chuck Vega. In this episode, we take a more in-depth look at these multidisciplinary health care professionals and how their collaboration helps to optimize the diagnosis, treatment, and management of PAH patients in expert care centers as well as community, regional, and academic hospitals.

To get a real-world perspective on how multidisciplinary health care professionals collaborate in the care of PAH patients, I invited Dr Richard Channick to join our presentation. Dr Channick is professor of medicine at the David Geffen School of Medicine at UCLA in Los Angeles, California, and director of the Pulmonary Vascular Disease Program at the UCLA Medical Center.

Richard, thank you for joining us.

Richard N. Channick, MD: Happy to be a part of it, Chuck.

Dr Vega: Our focus in this episode is the multidisciplinary health care team responsible for the care of patients with PAH and the importance of their collaboration in optimizing clinical outcome. Why do so many different types of healthcare professionals need to be involved in the management of PAH?

Dr Channick: PAH is an extremely complex disorder in several different ways. Its disease progression is complex, involving multiple pathophysiological pathways that damage the pulmonary vasculature and, consequently, impair right heart function. Its differential diagnosis is complex, entailing a series of tests and evaluations to rule out more common disorders before an eventual right heart catheterization leads to a diagnosis. And its management is complex, involving multiparameter-based mortality risk assessments, multidrug treatment protocols, and a lifetime of follow-up evaluations and therapeutic adjustments. In addition, although PAH is often idiopathic, it is also commonly associated with several underlying chronic comorbidities that, in themselves, require lifelong health care, adding another layer of complexity to patient management.

Dr Vega: Let’s start with the specialists and other healthcare professionals associated with your expert care center. Who’s involved in the care of a PAH patient after diagnosis?

Dr Channick: Well, a pulmonologist or cardiologist with expertise in treating PAH will typically manage the overall care of the patient, including mortality risk assessments and treatment strategies. As far as everyday care goes, the contributions of nurses and nurse practitioners are invaluable. They are often the patient’s primary point of contact with the health care team and are responsible for managing day-to-day challenges, including symptoms of PAH and issues relating to drug dosing, administration, and side effects.

Dr Vega: Are pharmacists also involved in helping patients to manage their multidrug regimens?

Dr Channick: Yes, very much so. Most patients with PAH are, at the very least, on dual combination therapy with PAH-specific drugs, and many are on triple therapy. And for those patients requiring inhaled or infused prostacyclin pathway drugs, safe and effective drug administration takes on another level of complexity.

Adding further to the challenge faced by pharmacists is managing drug interactions and side effects in patients who are also taking medications for underlying comorbidities associated with PAH, such as connective tissue disorders, left-heart disease, and HIV infection. Consequently, pharmacists with expertise on PAH-specific drug therapy need to collaborate with other health care professionals and with patients to ensure that dosing regimens are being followed and that side effects and drug interactions are not interfering with compliance. Unfortunately, despite our best efforts, medications are not always sufficient to slow PAH disease progression, and the expertise and collaboration of experienced surgeons may be required for lung transplantation and other procedures.

Dr Vega: What about the role of imaging professionals in the management of PAH?

Dr Channick: Imaging modalities, such as trans-thoracic echocardiography and, in some institutions, cardiac MRI, are playing an increasingly larger role not only in the diagnosis of PAH but also in evaluating right ventricular structure and function in response to therapy. So, yes, radiologists...radiologic technologists....and sonographers are also important contributors to the management of PAH patients.

Dr Vega: Earlier you mentioned that PAH is often associated with underlying comorbidities that require specialized care. Can you identify these comorbidities and the health care specialists involved in their treatment?

Dr Channick: The most common underlying chronic condition associated with the development of PAH is connective tissue disorders, such as scleroderma, systemic lupus, mixed connective tissue disease, and other connective tissue diseases. Patients with connective tissue disorders are often under the care of a rheumatologist.

Another comorbidity associated with PAH is congenital heart disease. So, yes, not only are cardiologists involved in the management of right-heart failure caused by PAH but also left-heart disease that can cause PAH.

Liver disease and portal hypertension also increase the risk of developing PAH, and these patients are likely to be under the care of a gastroenterologist or hepatologist.

And, finally, patients with HIV infection are also at an increased risk of developing PAH, and these patients are typically under the care of an infectious disease specialist.

Dr Vega: Can you talk a bit about the role of mental health professionals and social workers in the management of PAH?

Dr Channick: Like other serious chronic diseases, PAH impacts almost every aspect of a patient’s life. Although some patients can maintain relatively normal physical function and continue with their job, family obligations, daily routine, and so forth, others must make profound changes to adjust their lives to meet the demands of the disease and its treatment. Consequently, many patients with PAH suffer from depression, low self-esteem, anxiety, and a sense of social isolation. Ensuring that these patients get appropriate mental health counseling is not only important for their improved sense of well-being but also better enables them to participate fully in their own care, which is essential for an optimal clinical outcome.

Dr Vega: What about the role of social workers?

Dr Channick: PAH care, especially in its later stages, requires a tremendous support system for its everyday management. Patients may be dealing with debilitating symptoms and complex multi-drug treatment regimens, often involving pumps and nebulizers. For patients without a solid support system or for low-income patients, many basic needs, such as electricity, access to healthy food, transportation to health care appointments, and supplemental oxygen, can be a challenge.

Also, not surprisingly, management of PAH over the course of a lifetime can put a huge financial strain on patients and their families. In addition to the costs of health care, many patients are no longer able to work, or at least not at a full-time capacity. So, social workers can play a very important role in assisting patients and their families with psychosocial and practical life challenges and providing resources to cope with the stresses of living with PAH.

Dr Vega: Can you think of any examples from your practice that would illustrate the types of challenges these patients can face?

Dr Channick: Well, I had a patient not long ago who was living out of her truck, which is a major challenge even for those without a chronic debilitating condition requiring a complex dosing regimen. She was on triple therapy involving an inhalable formulation of prostacyclin that required a nebulizer, which needed to be periodically charged -- not a problem in a home with electricity, but certainly a problem when you’re living out of a truck. We connected her with a social worker to try to find her more stable housing, but in the meantime we found a solution to the charging problem by using a nebulizer that could be plugged into the cigarette lighter socket in her truck.

Dr Vega: Richard, how does multidisciplinary collaboration at PAH expert care centers compare with that in community, regional, and academic hospitals.

Dr Channick: The advantage of expert care centers is that they embody an organized and structured approach to the management of PAH, with defined goals, validated guidelines, and a comprehensive healthcare infrastructure. Included within this infrastructure is a multidisciplinary team of healthcare professionals, either based at the expert care facility or part of an established outside network and referral system, all experienced in managing the clinical needs of PAH patients in an inpatient and outpatient setting. In contrast, care at community, regional, or academic hospitals is obviously not totally focused on PAH, and therefore their level of expertise and health care infrastructure is not always consistent and can vary from excellent to inadequate.

In other words, some hospitals have physicians on staff who have expertise in PAH as well as the infrastructure to support a specialized pulmonary hypertension center within the hospital. Others do not.

Dr Vega: How do PAH expert care centers collaborate with community, regional, or academic hospitals in terms of patient care?

Dr Channick: Our job at expert care centers is to work with these other institutions, whatever their setup, and establish a relationship that enables them to feel comfortable picking up the phone and calling us for a consultation.

Dr Vega: So, you wouldn’t necessarily want the hospitals to transfer their PAH patients to an expert care center?

Dr Channick: Well, it depends. Of course, if we felt that there was a treatment or risk assessment procedure that we were uniquely qualified to perform, we would certainly suggest that. But we’re also open to reviewing the case on the phone or in a video chat and offering advice, which may or may not involve sending us the patient. One advantage of handling consultations on the phone is that there’s no delay or complication in terms of scheduling the patient for an appointment and getting them to the expert care center.

Dr Vega: Has the expansion in video conferencing capabilities over the past couple of years helped with the collaborative process with other institutions?

Dr Channick: Yes, it has. Not only does it allow for virtual face to face communication, but it also provides a means of virtually sharing patient data, such as scan results or patient history.

Dr Vega: Do you ever run into a situation in which community-based hospital doctors are concerned that if they refer patients to an expert care center, they’ll never see them again?

Dr Channick: This does occasionally happen, not only with expert care centers but also academic hospitals. This perceived “stealing of patients” obviously creates ill will in the community hospital and can interfere with optimized patient care. I’ve always fostered a very collegial relationship with physicians from community hospitals and assure them that we are simply collaborating on a patient case. If we end up seeing the patient in person, I get back to the referring physician and tell them “this is what we did...this is what we think...this is what we would like to do moving forward.” I then ask them how they want to proceed.

Some referring physicians will want to maintain oversight of the care of the patient and contact us for advice if they run into a problem. Others will say something along the lines of “You’re the experts, you can take over from here. Just send me a copy of your notes.”

As long as the interactions are handled respectfully, most physicians appreciate the advice -- PAH is such a complex disorder, both in its diagnosis and management, that even cardiologists and pulmonologists are not always aware of the latest guidelines and clinical study data.

Dr Vega: So, part of your collaboration with other hospitals is serving as an educational resource?

Dr Channick: Yes. We need to educate all health care professionals who may be involved in the care of PAH patients about the latest advancements and guidelines for mortality risk assessment, treatment, and long-term management.

Dr Vega: This collaboration and education would apply to differential diagnosis as well, I would think.

Dr Channick: Yes, absolutely. Although PAH patients these days are more likely to be diagnosed with functional class II or III symptoms rather than full-blown heart failure, the time span from the initial symptoms to diagnosis has only been reduced slightly over the past 20 years. As you know, Chuck, the earlier in the disease course a patient with PAH is diagnosed and started on PAH-specific therapy, the better the prognosis. So, we want pulmonologists and cardiologists to be thinking about the possibility of PAH earlier in patients with certain persistent symptoms and echo readings, especially patients with scleroderma, HIV infection, left heart disease, liver disease, and other comorbidities associated with an increased risk of PAH. And we want to encourage them to give us a call for a consult if they’re uncertain.

Dr Vega: As we come near the end of this episode, can you speak briefly about the importance of collaboration between patients and health care providers in the management of PAH?

Dr Channick: In chronic diseases such as PAH, patient self-care is a huge component of successful management. No matter the setting, patient education should begin at initial diagnosis and be reinforced at each follow-up visit. Topics should include symptoms of disease progression; the meaning of mortality risk; WHO functional classification; prognosis; and the benefits, drawbacks, and side effects of different therapeutic options.

The goal is to enable patients to make informed decisions about their treatment that are in sync with their goals and lifestyle needs. Having a patient’s buy-in to a treatment strategy encourages adherence and greatly improves the chances of a successful clinical outcome.

Dr Vega: I would think that the increased incorporation of telemedicine into health care has improved collaboration between patients and health care professionals.

Dr Channick: Very much so -- about half our patient visits are now telemedicine. Because of the complexity of managing PAH and the consequences of disease progression, we like to keep tabs on everything that’s going on with the patient -- worsening of symptoms, changes in risk parameters, treatment adherence issues or side effects, and so forth.

However, frequent in-person visits are not always practical. Many patients can’t easily get to an expert care center, or any hospital for that matter, because they’re busy or live too far away or don’t want to deal with traffic or public transportation. Of course, we need to see patients in person from time to time to do scans or bloodwork or other tests, but telemedicine allows us to reduce the number of required visits significantly. And most of my patients love it.

Dr Vega: Before we wrap up the episode, do you have any take-home messages you would like to share with our audience?

Dr Channick: As I mentioned earlier, PAH is an extremely complex disorder to manage. We now have a good understanding of how to optimize PAH-specific therapy through the use of mortality risk-assessments, upfront combination therapy, and proactive escalation of therapy before significant disease progression occurs.

However, putting this knowledge into practice so that it benefits patients does not occur on its own. It requires collaboration among a multidisciplinary team of skilled health care professionals who can address the many demands associated with the diagnosis, treatment, and management of PAH, in both an inpatient and outpatient setting.

The more seamless this multidisciplinary collaboration, the better the prognosis and care of the patient. And this is always our ultimate objective.

Dr Vega: Thank you for participating in the program, Richard. We appreciate it.

Dr Channick: You’re welcome. I enjoyed it.

Dr Vega: This brings us to the conclusion. We hope you found it informative and helpful to your practice. To proceed to the online CME test, click on the earn CME credit link on this page, and thank you for watching this program.

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