Treat or Refer? Pulmonologists Share Best Practices

Acute and chronic lower respiratory tract conditions — such as asthma, chronic obstructive pulmonary disease (COPD), and bronchitis — are among the most common respiratory diseases seen by general practitioners. Though most can be managed effectively and efficiently within the primary care setting, others carry a risk for sustained, worsening, or overlapping symptoms. Diagnostic uncertainty could also arise, or the patient may require more complex care.

Given these various challenges, what are best practices before writing that referral order?

“An important thing to highlight upfront is that primary care providers (PCPs) face complex, multifaceted issues that they have to deal with in any given patient’s care and typically within a limited timeframe,” said Carolyn L. Rochester, MD, professor of medicine in the Section of Pulmonary, Critical Care & Sleep Medicine at Yale School of Medicine, Yale University, in New Haven, Connecticut.

“They have to take a thoughtful and thorough overarching umbrella look at what may be going on with that patient but may not have the time to delve into all of the details on any given individual visit,” she said. “That’s one aspect that drives referrals.”

Referral Roadmap

There are a few general rules of the referral thumb:

• Lack of clarity

“If a PCP is uncomfortable with management or unclear about what’s happening, they should absolutely refer out to a pulmonologist,” said Khalilah L. Gates, MD, assistant dean of medical education and assistant professor of medicine in the Division of Pulmonary and Critical Care at Northwestern Medicine in Chicago.

This is especially true when patients return time and again complaining of the same or worsening symptoms.

“If the patient you’re treating isn’t improving, that’s a sign that perhaps there needs to be different people involved in the cases, even if it’s only to gain a different perspective on how that patient is presenting,” she said.

• Differential diagnosis

Diagnosis can sometimes be challenging, which is where a specialist can step in to take a deeper dive, added David A. Beuther, MD, a pulmonologist at National Jewish Health in Denver.

“We have a huge problem with underdiagnosis and overdiagnosis, especially in conditions like asthma and COPD,” said Beuther. The same rings true for sleep-disordered breathing, which is also often under- or misdiagnosed.

“Problems arise when the patient has very severe lung disease of one form of another, and especially, if they have multiple comorbidities that are difficult to distinguish from one another, such as cardiac disease,” said Rochester.

• Treatment

Treatment is another gray area, especially when patients are nonresponsive, have frequent exacerbations, or return with worsening, progressive symptoms. Common conditions, such as severe asthma or COPD, often require specialized, more complex treatments, like injectable biologics, Beuther explained.

“It’s hard to keep up with the literature on who’s a good candidate or how to use these drugs,” he said, also referring to the insurance maze. Although many PCPs are aware of the clinical pathways that may or may not require these drugs, “prior insurance authorization for most of these advanced therapies requires a very complex pathway and nuanced navigation to get a patient the best therapy at the best cost,” said Beuther.

Testing Considerations

From in-office spirometry to lung function assessments, pulmonary testing can be effectively conducted in the primary care setting. But Rochester contends that despite their ability to scope out all types of problems prior to sending the patient on to a specialist, tests are underutilized.

Testing quality can also be an issue.

“A lot of primary care colleagues know the pathway of what needs to be done but don’t have access to the type of testing they know they need or don’t have good quality testing,” said Beuther, who also expressed concern about chest CT scans not being read by thoracic fellowship-trained radiologists, but by general radiologists.

“We have data that 50%-60% of the time, there’s at least one major flaw in the technical performance of the study — like they’re missing part of the lung,” he said. “But they never go back to look. Lung function tests are similar.”

Rochester takes a broader view.

“I think about chest x-rays a little bit more; they are ‘blunt instruments’ for looking at the chest as a whole and can provide a lot of clues to a lot of things: For example, a very big heart, very abnormal appearing lungs with diffuse haziness, or a big tumor,” she said.

On the other hand, CT scans, even if flawed, can often help capture certain comorbidities not previously recognized, such as comorbid emphysema and COPD or inflammatory airway disease and bronchiectasis.

Both tests should be accompanied by an echocardiography, said Rochester.

“Respiratory symptoms are often commonly mimicked by a variety of cardiac conditions, which is why, as specialists, we are commonly interested in having echocardiogram data to help characterize things more precisely than lung imaging alone,” she said.

Immediate Referrals

A majority of PCPs know when to “hold em and when to fold em,” and interstitial lung disease (ILD) is one condition that benefits from immediate referral. Depending on the type and severity of disease, symptoms can range from shortness of breath during exertion and a dry, hacking cough, to chest discomfort, shallow, labored breathing, and bleeding in the lungs.

“ILD is an intuitive diagnosis that involves radiology, pathology, and a lung function history; it’s a difficult one,” said Beuther. “The reason to refer is to learn if it is a true, idiopathic inflammatory progressive disease or just scarring from an old pneumonia,” he explained. Although PCPs are able to manage ILD, it does require a deeper dive before it becomes an emergent situation, especially in case of recurring pulmonary embolism.

The same rings true for lung nodules, which (depending on size or density) are effectively managed in the primary care setting. But Beuther added a word of caution: “If they’re growing or larger, it’s a fairly urgent referral,” he said. “I’ve seen pulmonologists, as well as primary care, sit on a nodule that has high risk features; sometimes, it’s a whole lot of nothing, but if [it is a point of concern] these are chances to cure somebody that we don’t want to miss,” he said.

Working Together

Regardless of whether a practice setting is urban or rural, or a large or private network, decisions about sending complex respiratory cases to the next level of care remain firmly in the hands of the PCP.

From the point of view of specialists such as Gates, Beuther, and Rochester, it all comes down to a team effort.

“We want primary care physicians to know that we have their backs; we’re here, and we want to help,” emphasized Gates.

Gates reported having no relevant financial relationships. Beuther sits on an advisory board for AstraZeneca. Rochester reported receiving consulting fees from Boehringer Ingelheim and GlaxoSmithKline.

Liz Scherer is an independent health and medical journalist.