Role of the Community Physician in Management of PH

Dr. Channick:
Hello, welcome to our round table discussion. Today we're going to be talking about the role of community physicians, in some of the difficult to reach patients with PH that we've been discussing in other segments. My name is Richard Channick. I'm professor of medicine at UCLA Medical Center and co-director of the Pulmonary Vascular Disease program. And I'm delighted to be joined by some colleagues, Dr. Rajan Saggar, who's my partner at UCLA, and also co-director of the Pulmonary Vascular Disease Center and professor of medicine at UCLA. Dr. Oksana Shlobin, who's associate professor of medicine at University of Virginia, and medical director of the Pulmonary Hypertension program at Inova Fairfax Medical Center. And Dr. Jean Elwing, who's professor of medicine at University of Cincinnati, and director of the Pulmonary Hypertension program there. So welcome everybody. It's good to be talking.

 So what I want to talk about today, is really trying to bridge some of the gap, between some of these patients who are difficult to reach for a variety of reasons like geography, socioeconomic, cultural language issues. And how we can interface with maybe some of the community physicians. So we want to kind of touch on that. And maybe before we talk about sort of solutions, maybe we can start with actually Raj. Why don't you give me sort of an example? You've been doing this for quite a while, example of the, sort of the role of the community doctor in the PH patient and how that can maybe help with the problem we're discussing today?

Dr. Saggar:
Well, so I think traditionally the community physician, we've always had tried to have a relationship with the community physician in PAH. And so, as you know, most of our patients are referrals from one of these community physicians. And so we try to do this co-management strategy. And I think in Los Angeles, as you know, being a locally large area, it's important for them to have an access to a local provider, who understands their pulmonary vascular disease. So for me, dealing with the difficult to reach patients, and collaboration with the community physician, is even more important because it allows us particularly, so I have a communication, a line of communication, usually pretty, not just a pager, but actually cell phone to cell phone. And so we'll be pretty active in terms of communicating about our various patients with the community provider. And I think I personally get a lot out of that, as I think the community provider does too, because we were able to deal with things in real time, not through sort of all the paperwork, or the telephone network or anything. So it's pretty quick turnaround, and I think that's been helpful.

Dr. Channick:
And what is, I mean, I can ask you Jean, what do you think the role of that community physician is specifically to let's say, PH patient. So an example, maybe you've evaluated the patient, made the diagnosis, maybe started initial therapy. What is sort of for these some of these patients, let's say out in the more rural communities you deal with. How involved are these community physicians in the continuing the medication, and are you even adjusting things, diuretics, all that stuff.

Dr. Elwing:
So I think they play a huge role in making sure all of their comorbidities stay well controlled. So we can have benefit from our pulmonary hypertension therapies. So oftentimes they do the diuretic management, and if they get in trouble, they have questions, and they'll reach out. And I think that is really complimentary, because the patient knows that person, they have access to that person more quickly. And then if there is complicating factors, we can discuss, make this next steps in a plan of care. And they can really fill in the gaps when the patient is at home nearer to that facility.

Dr. Channick:
And so you found that that works pretty well?

Dr. Elwing:
Extremely well, and patients trust that person and we can talk. And then that really gives them a confidence in the plan of care.

Dr. Saggar
I was just going to add to that, that, you know just to pick up on what Jean's saying. So, one of the things that I think they're really helpful, the community physicians, with is given that a lot of the, in our area, geography is a big problem, getting the testing done, they can often help us get the testing done locally. And particularly if we're looking for, how the right ventricle is working, that individual, that community practitioner really helps us put in the proper order. So we actually get the information we're looking for, let's say, from an echo or a repeat pulmonary function test, or if we need a new VQ scan. It's a lot easier for that patient who's difficult to reach, to sort of do something locally, than to have to come all the way out to the center.

Dr. Channick:
Yeah, no, absolutely. And there's obviously different types of community physicians, different levels of interest or expertise. Oksana, you're very involved with the Pulmonary Hypertension Association accreditation program that I was involved in from, when we first started it many years ago, and you're on committee that oversees that. So maybe you can tell us a little bit about that program and how this may help with what we're talking about with the community.

Dr. Shlobin:
Yeah, sure. I think the PHA as you know, because you were there from the start originally, the goal of this undertaking was to create a network of centers across the United States that really houses the physicians, nursing coordinators, nurse practitioners that can provide appropriate level of care. So there are patients, really across the entire country that would have access to the same sophisticated level of care, medications, and support. There is a large network now of what we call comprehensive care centers. So usually there are large centers that are housed, either in the academic center, or a large community hospital, but there are also a large really, and growing network of what we call RCPs. So there are regional care centers. So they may be smaller programs. They may not be as involved in research, but again the goal is to provide the same care to patients no matter where they live.

Now, one good thing about this program, is that there is usually a connection between a comprehensive care center, and the regional care center which is maybe a couple of hours away. So for example, we are a comprehensive care center, and there is a medical center in Virginia, and we are partnering with them. So we serve as sort of as a second opinion for their center. They send their patients to our center for lung transplant evaluation. if this is what they need, we have conferences together. So it really has created this pathway to connect with a local center that is gaining expertise, but providing this invaluable care for patients, for whom it's difficult to drive three hours. So I think it's an excellent initiative. Again, the goal is for patients across the United States to the same cure, which is what we need, because this disease is progressive and deadly if untreated.

Dr. Channick:
Yeah, no, I think I remember very well when we designed this sort of hub and spoke concept of, like we said, a regional clinical program that has some degree of expertise, but doesn't have offer off all services, like intravenous process cycling, and that kind of thing for that they would send to the comprehensive center. And it sounds like it's working pretty well. Do you have a similar model Jean?

Dr. Elwing:
So we don't collaborate with a regional center. We are a comprehensive care center. And we really collaborate a lot with the cardiologist and the pulmonologist in the community. And then we have access of course by cell phone but also, they have a 24-hour doc to doc line that helps if they have a problem. Two patients today, I was called on, just to try to help navigate when should we transfer them in? What can we do at this time? What should we do in terms of follow-up? So, they can collaborate with us in a true fashion. And not only it helps the patient we're talking about, but through that discussion, I think we both learn a lot about what they can offer us, what they can offer patients, and we can teach them about what we do in our pulmonary hypertension specialty. So I think it's a win-win all across.

Dr. Channick:
Yeah, I think in some ways it's, we talk about difficult to reach patients, but in some ways the problem is that they don't know where to go either. And so I think this program has offered that. I'm sure you both have gotten several patients where they looked up on the web, where the centers of excellence are for pulmonary hypertension. And through the PHA website, they found your center in their area and they came. So I think obviously, and we'll talk about this in another snippet, but you know the use of technology in general, to help solve some of this problem and bridge this gap, I think goes both ways.

Dr. Elwing:
Yes definitely.

Dr. Channick:
So thank you very much all for a great discussion and thank you for your attention.