Cardiopulmonary Exercise Testing: Overcoming Institutional Barriers to Improve the Clinical Use of a Powerful Tool
Cardiopulmonary exercise testing has been used extensively in the research setting and has been shown to add diagnostic and prognostic value to the assessment of patients with cardiopulmonary disease. Despite this, its use in the clinic is limited. Barriers at all levels of the health care may explain this. This paper builds on earlier proposed solutions and goes further to suggest additional ones aimed at the clinician, the hospital/clinic and the health care industry.
Five Key Points:
• The use of cardiopulmonary exercise testing in the diagnostic and prognostic assessment of patients with cardiovascular or pulmonary disease is supported by nearly three decades of scientific research.
• Reporting of cardiopulmonary exercise test results needs to become more streamlined and easily interpretable. Excellent suggestions on how this could be accomplished have been offered by others and are supported by major medical associations.
• Efforts to increase the use of cardiopulmonary exercise testing in the clinical environment should focus also providing ongoing education to practicing clinicians, particularly those at the level of resident and fellow.
• Designating a “champion” who will is responsible for overseeing the use of cardiopulmonary exercise testing may increase the appropriate use of cardiopulmonary exercise testing in the clinical setting.
• In the last ten years significant efforts have been focused on improving the translation of basic science to clinical practice. The new federal health care reform law may provide additional incentives to improve the clinical application of research findings.
Cardiopulmonary exercise testing (CPX) combines the standard exercise test with ventilatory expired gas analysis, giving a clear clinical picture of the integrated function of a patient’s pulmonary and cardiovascular systems. Research investigating its use has been mounting for several decades and there is now an impressive body of literature supporting its incorporation into the clinical assessment of patients with heart failure, pulmonary hypertension, unexplained dyspnea and other cardiopulmonary disorders. Despite this, CPX seems to be used more as a research than a clinical tool in most institutions. In a previous issue of HCE, Arena and Guazzi suggested that the time has come for CPX to make the leap from the research laboratory to the exam room, aided by the use of a simplified ordering and reporting system.(Arena & Guazzi, 2012) This would allow clinicians to more readily identify and interpret those CPX variables with the highest clinical value.
These recommendations are particularly relevant to my practice which is at the intersection of the researcher and clinician. As a Physical Therapist, I use CPX in the evaluation and treatment of those with cardiovascular or pulmonary disease. As a Research Collaborator at a large medical center I collaborate with cardiologists, pulmonologists and exercise physiologists to carry out clinically relevant investigations using CPX. In this setting it is easy to see the myriad benefits – and the numerous challenges – to implementing the recommendations of Arena and Guazzi. It is also clear that additional barriers exist to more fully integrating CPX in the clinical setting. These barriers can be found at each level of the health care delivery system.
Translating research findings into clinical practice has been on the radar of the National Institutes of Health and major medical associations and foundations for many years. It has lately become particularly relevant with the new federal health care reform law. A recent commentary in the journal Health Affairs is especially instructive.(Jerry Avorn & Fischer, 2010) In the article, titled ‘Bench to Behavior’: Translating Comparative Effectiveness Research into Improved Clinical Practice, the authors described comparative effectiveness research as a cornerstone of the federal health care reform law. The intent of these investigations is to discover the most effective intervention (i.e. diagnostic test, drug, therapy, etc) for a given disease. Ideally, clinical practice patterns consistent with the findings would readily follow, as would reimbursement. Along with pay-for-performance initiatives, this has increased the urgency to finding effective solutions to remove barriers to the adoption of clinical research findings.
With this in mind, the objective of this paper is to build on the recommendations of Arena and Guazzi and place the specific case of CPX within the larger context of translational research.
CPX-specific Barriers: Arena and Guazzi describe, and pose solutions to, many of barriers specifically related to CPX itself. The overarching message is that to improve clinical use of CPX, the reporting must be simplified to allow clinicians to more readily and easily interpret the most relevant and evidence-based CPX findings. It is suggested that many physicians spend only seconds reviewing the results of tests they order. To date, the data that is reported by the most common software packages are not based on the results of the copious research conducted over the last 25 years. Instead, the reporting function has been decided upon by software developers and based on early descriptive work done by researchers in the field. However, custom reports can and should be created by those with more familiarity with the software to ensure only relevant data and interpretation is reported to ordering providers.
In terms of clinical acceptability, the color coding is an excellent step towards the type of easy-to-understand reporting of results necessary in a fast-paced interdisciplinary environment. In the current clinical environment nurse practitioners, physical therapists, respiratory therapists, and social workers are all involved in patient care and each has a stake in understanding test results. The use of color coding infuses the test result with additional meaning. It is no longer just a number, but also an indication of severity and allows for comparison to a prior study. This allows for improved communication between providers and recognition of the value added by CPX. This benefit is further extended to the patient who may find this method of reporting to be more meaningful.
Clinician Level Barriers and Solutions – In Clinical Research to Clinical Practice: Lost in Translation, Dr. Claude Lenfant, the longest serving Director of the National Heart, Lung and Blood Institute, suggested that we would enjoy greater improvements in life expectancy if we did a better job of incorporating what we know into clinical practice.(Lenfant, 2003) He argues that the problem is not simply in translating basic, or bench, scientific findings into clinical research, but also in getting those findings applied at the local level by hospitals and clinicians. There are many sources of physician resistance to adopting new tools and therapies. The first may simply come from a comfort with certain drugs, techniques, and therapies encountered in their formal training. CPX is not thoroughly covered, or may even go uncovered, in medical education. Exposure to CPX may happen during more advanced training but is likely to be sporadic and dependent on the use of CPX in a particular institution or by certain clinicians.
In order for CPX to be more fully implemented into clinical practice, improvements in practitioner education must be made. Medical trainees at the level of resident and fellow represent an excellent target audience. This can be informal, through small group discussions, or more formal through seminars and lecture series. Targeting practicing clinicians is also important, and not just those in the sub-specialties. All those clinicians who treat patients with known or suspected cardiovascular or pulmonary disease are the target audience. Reaching out to these clinicians may happen not only in the local hospital or clinic where they work, but also at regional, national and international conferences and scientific meetings.
The use of technology and the electronic medical record (EMR) may improve adoption of CPX. Automated alerts have been used to help with adherence to clinical practice guidelines and can be similarly implemented to inform a clinician when CPX is indicated. If well-conceived, this alert can not only serve as a tool to improve clinical practice but also as one that serves an educational purpose.
Institutional Barriers (Hospital or Clinic): Clinicians want to be informed of only those results that are important for the specific indication for which they are ordering the test. The standardized reporting form suggested by Arena and Guazzi is an excellent start and can be implemented with the help of the EMR and managed at the hospital or clinic level. The EMR has made it possible for health care providers to ensure all aspects of best clinical practice are ordered for patients undergoing work up for any problem. CPX could be included as an option in the standard order set for a patient with a cardiovascular or pulmonary diagnosis. For example, in addition to an echocardiogram, the patient with hypertrophic cardiomyopathy would automatically be scheduled for a CPX. Once the order is received, a technician overseeing testing logistics is cued to determine clinical appropriateness and utilize a unique reporting system to ensure only those variables most relevant to the patient’s condition are reported back to the provider.
Implementation of many of these recommendations may take inter-departmental and interdisciplinary coordination. There are real and perceived barriers created by organization structure. For example, although standard exercise testing may be in based in Cardiology, CPX may be housed in Pulmonary as a result of its close connection with pulmonary function testing. Further complicating matters, CPX may be found only in an outpatient division, limiting access (real or imagined) to it by those practicing in the inpatient environment.
Many of these solutions aimed at both the clinician and the local institution may require someone who is dedicated to improving patient care through the use of CPX, a so-called “CPX Champion”. This person, ideally a physician with a particular clinical and research interest in CPX, as well as practical experience, would have the responsibility of improving the utilization of CPX where clinically indicated. Specific tasks might include planning CME or educational opportunities, holding regular CPX conferences to discuss specific cases, disseminating research findings, following up with ordering providers, and interfacing with hospital/clinic administrators to discuss barriers and solutions to improve adoption. The overall goal would be to help providers see how CPX affects their clinical decision making and improves patient care.
Health Care-wide Barriers
There is a well-recognized gap between those who practice medicine and those who practice science. This is further complicated by the marketplace which is highly competitive and largely driven by profits. CPX does not compete well in this environment at the present time. CPX has no well-funded backer, such as the pharmaceutical or device manufacturer industry, and the research itself is either unfunded or funded at low levels. This makes traditional dissemination of research findings, such as advertising or sponsoring CME events, challenging. A possible solution to this might be academic detailing. Academic detailing involves the use of well-trained clinicians visiting providers in their offices to provide evidence-based non-commercial information about an intervention to guide optimal management of a clinical problem.(J Avorn, n.d.) Although this has been primarily used to inform physicians about drug therapy there are examples of it being successfully used for other purposes.(O’Brien et al., 2007)
Finally, an issue that is specific to CPX that may need to be addressed at higher organizational level is the problem of low reimbursement. Despite decades of research supporting its use, CPX is currently a Class I indication only for those with heart failure and unexplained dyspnea.(Balady et al., 2010) These indications drive reimbursement by third party payers. Low reimbursement provides a disincentive for the more widespread use of CPX. As noted earlier, the new federal health care law seeks to create a Patient Centered Outcomes Research Institute to fund comparative effectiveness research. The work of this group may have an impact on reimbursement for CPX. Until then, relevant medical associations and foundations will need to continue to work with third party payers on the on the state and national levels to better align reimbursement with the value it adds to patient care.
Has the time come for CPX to more definitely move from the research lab to the examination room? The answer is unequivocally yes. The recommendations of Arena and Guazzi provide strategies for translating the 20+ years of findings into a readily accessible and easily interpretable assessment of a patient’s disease status. However barriers other than those related to the test itself exist and must be overcome. Addressing these will require efforts on the hospital/clinic level, possibly with the help of a clinician who can be the “CPX champion”. This issue also aligns with national efforts to improve the adoption of research findings and the promotion of comparative effectiveness research and is therefore well-positioned to take advantage of opportunities that arise.
Barriers and proposed solutions to support increased clinical use of CPX
Level of Barrier Solution
• Simplified reporting, including reporting evidence-based data per clinical indication*
• Color coding results to indicate severity/progression of disease*
• Creation of evidence-based custom reports
Clinician • Use EMR to alert physicians when CPX is indicated or for those indications with strong CPX evidence
• Target CPX training to residents and fellows
Institution (local) • Designation of “CPX Champion”
• Creation of care sets within the EMR or standardized ordering protocols for different clinical indications
• Use of standard CPX report forms*
Institution (national) • Pursue continuing medical education opportunities to educate clinicians on the incorporation of CPX into their clinical practice
• Increased presence at major scientific meetings
• Academic detailing
• Continue to work with 3rd party payers for improved reimbursement
*Recommendations of Arena and Guazzi
Recommended tasks for clinician designated at “CPX Champion”
“CPX Champion” Tasks
• Identify institutional barriers and implement solutions
• Create formal and informal educational opportunities for medical trainees and others
• Regularly communicate with providers within and between departments
• Disseminate current research findings
• Be a readily available resource to providers
• Seek research opportunities within the institution to add to the CPX literature
Sherry O. Pinkstaff, PhD, PT, Brooks College of Health, Physical Therapy Program;
Marco Guazzi, MD PhD FACC, Heart Failure Unit Cardiology University of Milano;
Brian Shapiro, MD, Assistant Professor of Medicine and Radiology, Mayo Clinic – Jacksonville
Ross Arena, PhD, PT, FAHA, Professor and Department Head, Department of Physical Therapy, University of Illinois Chicago
Arena, R., & Guazzi, M. (2012). Cardiopulmonary Exercise Testing; The Time Has Come. Hospital Cardiology Europe, Winter, 13–16.
Avorn, J. (n.d.). National Resource Center for Academic Detailing. Retrieved from http://www.narcad.org/wp-content/uploads/2011/01/Avorn-AD-talk-for-web-1-15-2011.pdf
Avorn, Jerry, & Fischer, M. (2010). “Bench to Behavior”; Translating Comparative Effectiveness Research Into Improved Clinical Practice. Health Affairs, 29(10), 1891–1900.
Balady, G., Arena, R., Sietsema, K., Myers, J., Coke, L., Fletcher, G. F., … Milani, R. (2010). Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults: A Scientific Statement from the American Heart Association. Circulation, 122, 191–225.
Lenfant, C. (2003). Clinical Research to Clinical Practice – Lost in Translation? New England Journal of Medicine, 349, 868–74.
O’Brien, M., Rogers, S., Jamtvedt, G., Oxman, A., Odgaard-Jensen, J., Kristoffersen, D., … Harvey, E. (2007). Educational Outreach Visits: Effects on Professional Practice and Health Care Outcomes. The Cochrane Database of Systematic Reviews, 17(4).