Physician and patient perceptions in COPD: The COPD Resource Network Needs Assessment Survey

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1 The American Journal of Medicine (2005) 118, 1415.e e17 CLINICAL RESEARCH STUDY Physician and patient perceptions in COPD: The COPD Resource Network Needs Assessment Survey R. Graham Barr, MD, DrPH, a Bartolome R. Celli, MD, b Fernando J. Martinez, MD, c Andrew L. Ries, MD, MPH, d Stephen I. Rennard, MD, e John J. Reilly, Jr., MD, f Frank C. Sciurba, MD, g Byron M. Thomashow, MD, h Robert A. Wise, MD, i for the COPD Resource Network a Division of General Medicine, Department of Medicine, College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; b Pulmonary and Critical Care Division, Caritas St. Elizabeth s Medical Center, Tufts University, Boston, Mass; c Division of Pulmonary and Critical Care Medicine, University of Michigan Health System; d Departments of Medicine and Family and Preventive Medicine, University of California, San Diego; e Pulmonary and Critical Care Medicine Section, Department of Internal Medicine, University of Nebraska Medical Center; f Division of Pulmonary and Critical Care Medicine, Brigham and Women s Hospital and Harvard Medical School, Boston, Mass; g Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pa; h Division of Pulmonary, Allergy and Critical Care, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY; and i Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md. KEYWORDS: Chronic obstructive pulmonary disease; Guideline adherence; Compliance ABSTRACT PURPOSE: Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States, has received disproportionately little attention from physicians and institutions. National data are lacking on patient and physician perceptions of and patterns of care for COPD. METHODS: Linked surveys were administered to national samples of patients with COPD, primary care physicians, and pulmonologists to evaluate perceptions of COPD severity and quality of life, attitudes about COPD, health insurance barriers to COPD care, sources of information, and knowledge about COPD diagnosis and treatment. RESULTS: Overall, 1023 patients with COPD and 1051 primary care physicians and pulmonologists responded to the surveys. Despite experiencing significant symptoms and high health care use, the majority of patients were satisfied with their care. Eighty-eight percent of physicians agreed with the statement that COPD is a selfinflicted disease, and more than one third were nihilistic about the treatment of patients who continued to smoke. Patients and physicians reported that insurance problems impeded access to therapies. Patients were generally uninformed about COPD; 54% of primary care physicians were aware of any COPD guidelines. Both patient and physician surveys demonstrated continued confusion about the diagnosis of COPD and treatment choices. There was frequent use of regular oral steroids despite demonstrated lack of efficacy and under-use of pulmonary rehabilitation despite proven efficacy. CONCLUSIONS: Patients with COPD have a high prevalence of activity limitations. Although most physicians believed that proper treatment can slow progression, inadequate knowledge and poor adherence to practice guidelines, together with insurance impediments, negatively impact COPD care Elsevier Inc. All rights reserved. Funded by the Chronic Obstructive Pulmonary Disease Resource Network-National Emphysema COPD Association (NECA). Requests for reprints should be addressed to R. Graham Barr, MD, DrPH, Columbia University Medical Center, 630 West 168th Street, New York, NY address: rgb9@columbia.edu /$ -see front matter 2005 Elsevier Inc. All rights reserved. doi: /j.amjmed

2 1415.e10 The American Journal of Medicine, Vol 118, No 12, December 2005 Chronic obstructive pulmonary disease (COPD) is currently the fourth leading cause of death in the United States. Morbidity and mortality from COPD continue to increase, in contrast with declines in mortality from cardiovascular disease, cancer, and stroke. 1 The number of persons with a physician diagnosis of COPD in the United States increased from approximately 7 million in 1980 to approximately 10 million in In addition, some 20 million more are undiagnosed. 3 A number of effective therapies for COPD improve symptoms and reduce hospitalizations, exacerbations, and death. Although several national and international societies have provided detailed guidelines regarding the diagnosis and treatment of COPD, 4,5 the degree of awareness and use of these guidelines in clinical practice are unclear. 6 Surprisingly few published reports have assessed patient needs or current treatment practices regarding COPD. Consequently the COPD Resource Network National Emphysema COPD Association (NECA), a patient organization, commissioned national surveys of patients with COPD, primary care physicians, and pulmonologists to evaluate patient and physician perceptions of severity and quality of life, attitudes about COPD and its causes, health insurance barriers to COPD-related care, sources of information and knowledge, and the current practice of diagnosis and treatment of COPD. Methods National surveys of patients with COPD and physicians who care for outpatients with COPD were conducted from October 2003 to January Patient survey Patients were drawn from a national sample of 4003 households in which one or more persons reported a diagnosis of a form of COPD. We did not exclude patients with a co-diagnosis of asthma because of its overlap with COPD in clinical practice. The sampling frame was derived from an ongoing series of national surveys identifying households with members afflicted by various disease conditions. The use of the compiled list increased the likelihood that each contacted household included a person with COPD. The list excluded households that had previously indicated that they were not willing to participate in surveys. Selected households were mailed a 4-page questionnaire, explanatory letter, and return envelope. A second package was mailed to nonrespondent households. Those who did not respond within 8 weeks were contacted by telephone to determine household eligibility and to complete interviews. The total number of completed surveys was 1084, yielding a response rate of 74.4% in households having a member with COPD. Physician survey National probability samples of primary care physicians and pulmonologists were drawn from the American Medical Association master list. The primary care physician sample included general practitioners, family practice physicians, and general internists proportionate to their representation in the overall physician population. Both samples were restricted to physicians engaged in direct outpatient care. The physician packet was mailed to 2000 primary care physicians and 2000 pulmonologists and included a cover letter, 4-page questionnaire, and return envelope. Physicians received a small monetary incentive for completing the questionnaire. A reminder postcard was sent to all nonresponding physicians 2 weeks after the initial mailing. A supplemental sample of 1000 primary care physicians was sent a questionnaire without additional follow-up. Completed questionnaires were received from 523 primary care physicians (17%) and 528 pulmonologists (26%). Questionnaire items A panel of COPD experts including physicians, patients, and representatives from COPD organizations helped draft the questionnaires. Dyspnea severity was measured by the modified Medical Research Council Dyspnea index. 7 Stages of COPD were defined according to the original Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria based on forced expiratory volume in 1 second (FEV 1 ) percent predicted: mild (stage I), 80%; moderate (stages IIA and IIB), 30% FEV 1 80%; severe (stage III), FEV 1 30% or FEV 1 50% plus chronic respiratory failure. 4 Statistical analysis Data are presented as proportions and means with standard deviations (SDs) or medians with interquartile ranges, as appropriate. The association between categoric factors was tested with the chi-square test. Multivariate analyses were performed using logistic regression models. All P values were 2-tailed, with P less than.05 considered statistically significant. Analyses were performed using SAS 9 (SAS Institute, Cary, NC). NECA had no involvement in the design and conduct of the study, the collection, management, analysis, and interpretation of the data, and preparation, review, or approval of the article. Results Patient survey The characteristics of the 1023 patients who responded to the COPD patient survey are shown in Table 1. The mean

3 Barr et al Needs assessment of COPD 1415.e11 Table 1 Characteristics of participants in a national sample of patients with chronic obstructive pulmonary disease All patients with COPD n 1023 Mean age (y SD) Gender, female (%) Ever smoker (%) Years smoked more than 1 pack per day (mean SD) Occupational or environmental exposure (%) Exposure type (% of those reporting exposure) Fumes Smoke Dust Chemicals Asbestos Other Do not known 2 4 Diagnosis (%) COPD Emphysema Chronic bronchitis antitrypsin deficiency 1 1 Concurrent diagnosis of asthma (%) 38 0 Family history of COPD (%) Parent Sibling No first-degree relative with COPD Age of onset of COPD symptoms (%) 45 y y y y y 2 2 Age of diagnosis of COPD (%) 45 y y y y y 1 1 Median MRC Dyspnea Score (IQR) 3 (2, 4) 3 (2, 4) Symptoms every/most days in past year (%) Coughed Brought up phlegm Shortness of breath Awaked at night by coughing, wheezing None of these 4 6 Current degree of dyspnea (%) None of these 2 2 I only get breathless after strenuous exercise 7 8 I get breathless when hurrying on level ground or walking up a slight incline I walk slower than people my own age I have to stop for breath when walking on level ground at my own pace I have to stop for breath after walking a few minutes on level ground I am too breathless to leave the house 6 6 Activity limitation from COPD (%) Keep you from working Limit amount or type of work you can do Limit activities other than working Not limit your activity Patients with COPD without asthma co-diagnosis n 635 COPD chronic obstructive pulmonary disease; SD standard deviation; MRC Medical Research Council; IQR interquartile range.

4 1415.e12 The American Journal of Medicine, Vol 118, No 12, December 2005 age ( SD) was years, and the majority were women. Ninety-four percent noted a history of current or past daily cigarette use, and 44% described a history of environmental or occupational exposure to fumes, dust, or chemicals that they believed had contributed to their COPD. A sizable minority described diagnosis of COPD before 45 years of age, and more than one third reported a concurrent diagnosis of asthma. The presence or absence of a codiagnosis of asthma, however, did not affect the main results of the survey (Table 1 and data not shown). Severity and health care use Nearly all patients reported breathlessness on most days (Table 1). Activity limitation was severe, with most patients reporting work limitation or inability to work because of COPD. One quarter of patients reported being hospitalized for COPD in the past year, and 54% described emergency visits for respiratory complaints. Patients reported a median of 6 physician visits during the last year (interquartile range 3-12). Patient perceptions Thirty-seven percent of patients rated their current health status as poor or very poor; 5% rated it as very good or excellent. Despite their symptoms, limitations, and poor self-reported health status, 85% of patients were somewhat or very satisfied with their doctor s care whereas 14% were somewhat or very dissatisfied. Among those describing their health as poor or very poor, 78% were somewhat or very satisfied with their care. Health insurance The US Government provided most health care insurance coverage (Medicare, 44%; Medicaid, 19%; Veterans Administration, 7%). Employer-based insurance was reported by 33%. Twelve percent of patients reported no health care coverage. Seventy percent believed that insurance coverage had not been a barrier to therapy. Insurance-related limits on access were reported for prescription drugs (38%), physicians (14%), respiratory therapy (13%), pulmonary rehabilitation (12%), and home oxygen (9%). Sources of information regarding COPD Twenty-five percent of patients considered themselves to be well informed about COPD and treatment, whereas 36% considered themselves to be less than adequately or poorly informed. Patients obtained information about COPD from physicians (77%), the Internet (47%), nurses (38%), respiratory therapists (22%), television (13%), and patient organizations (3%). Table 2 Characteristics of respondents in a national sample of primary care physicians and pulmonologists Primary care physicians Pulmonologists P value n 523 n 528 Year of medical.001 school graduation (%) Before to to or later 37 6 Gender, female (%) Self-reported primary.001 specialty (%) General practice 5 0 Family practice 47 0 Internal medicine 45 5 Pulmonary 0 93 medicine Other 3 2 Practice type (%).001 Solo practice Single specialty group Multispecialty group practice Other (clinic, HMO, hospitalist outpatient) HMO health maintenance organization. Disease management and treatment Most patients reported the physician primarily responsible for their COPD care was a primary care physician (general/ family practice, 50%; general internal medicine, 12%), whereas 30% reported a pulmonologist. Pulmonologists saw patients with more severe disease than primary care physicians: 44% of patients under the pulmonologists care rated their dyspnea as 4 or 5 on the Medical Research Council scale compared with 31% under a primary care physician s care (P.0001). Sixty-three percent of patients reported lung function testing at least once in the last year, 28% reported prior testing, and 8% never recalled being tested. Only 4% recalled being tested for 1 -antitrypsin deficiency, but almost half of those reported a positive test. Eighty percent of patients reported regular inhaler use, whereas 46% reported use of a nebulizer. Twelve percent reported no regular prescription medication for COPD. Two thirds of patients took antibiotics for acute infections. Selfreported immunization rates were low and more frequent among those under pulmonologists care: pneumococcal vaccine (39% vs 26%; P.0001) and influenza vaccine (71% vs 56%; P.0001). Thirty-one percent of patients reported regular oxygen use, of which 66% was continual, 19% night only, and 4% with exercise or as needed. Eleven

5 Barr et al Needs assessment of COPD 1415.e13 Table 3 Physician attitudes about chronic obstructive pulmonary disease in a national sample of primary care physicians and pulmonologists Primary care physicians Pulmonologists P value n 523 n 528 Strongly or somewhat agree (%) Smoking is the cause of most cases of COPD In most cases, COPD is a self-inflicted disease There is nothing that can be done for COPD patients who will not quit smoking With proper treatment, most people with COPD can lead a full and active life With proper treatment, progressive loss of airway function can be slowed There are no truly effective treatments for COPD The health care system could do a better job of helping people with COPD (%) How has the long-term outlook for patients with.02 COPD changed in the last 10 years (%) Gotten better Stayed the same Gotten worse 2 0 Reason for health outlook improvement (% of those.22 reporting improvement ) Better medications Pulmonary rehabilitation programs Long-term oxygen therapy Better lifestyle modifications Better compliance with treatment regimens Lung volume reduction surgery Other 3 5 COPD chronic obstructive pulmonary disease. percent reported participating in a pulmonary rehabilitation programs; 57% were not aware of pulmonary rehabilitation. Physician survey The characteristics of the 523 primary care physicians and 527 pulmonologists who responded to the physician survey are enumerated in Table 2. The average year of graduation from medical school among respondents was 1984 for primary care physicians and 1978 for pulmonologists, which was comparable to 1980 and 1976, respectively, among those invited to participate. Health care use Primary care physicians saw a mean of outpatients each week, of whom 12% had COPD. Pulmonologists saw a mean of outpatients each week, of whom 46% had COPD. Physician perceptions about COPD Eighty-two percent of both primary care physicians and pulmonologists believed that patients with mild or moderate COPD were satisfied with their disease management. Virtually all agreed with the statement that smoking is the cause of most cases of COPD (Table 3). Almost 9 of 10 physicians in both groups described COPD as a self-inflicted disease, and sizable minorities agreed with the statement There is nothing that can be done for COPD patients who will not quit smoking. On the other hand, most primary care physicians and pulmonologists thought that proper treatment improved outcomes in COPD (Table 3). Health insurance Only 33% of pulmonologists and 42% of primary care physicians believed that reimbursement standards for medical management of patients with COPD were adequate or very reasonable, whereas 67% and 58%, respectively, thought that they were inadequate or very unreasonable. Physicians reported that the cost of insurance and insurance coverage for pulmonary rehabilitation were major barriers to care. Professional guidelines and sources of information Fifty-four percent of primary care physicians were aware of any professional guidelines for the diagnosis

6 1415.e14 The American Journal of Medicine, Vol 118, No 12, December 2005 and management of COPD, compared with 94% of pulmonologists. Among physicians aware of published COPD guidelines, only 5% of generalist physicians and 23% of pulmonologists recognized the landmark international GOLD guidelines (P.0001). A Diagnosis and monitoring Seventy-seven percent of primary care physicians and 96% of pulmonologists used spirometry always or most of the time to diagnose COPD (P.0001). Fifty-one percent of primary care physicians and 65% of pulmonologists normally tested bronchodilator responsiveness before establishing a diagnosis of COPD (P.0001). A chest radiograph was obtained by 86% and a chest computed tomography scan was ordered by 4% of both physician groups before establishing the diagnosis. Spirometry was used to monitor patients with COPD by 43% of primary care physicians and 70% of pulmonologists (P.001). Primary care physicians monitored peak flows more frequently than pulmonologists (40% vs 10%; P.001). Physicians performed 1 -antitrypsin testing infrequently; 50% of generalist physicians and 37% of pulmonologists performed the test rarely. B Therapeutics pharmacologic The classes of medications that generalist physicians and pulmonologists reported that they would normally prescribe for stable patients with mild, moderate, and severe COPD are illustrated in Figure 1. Overall, prescribing patterns of primary care physicians and pulmonologists were similar. Clinically significant exceptions were that primary care physicians were less likely to prescribe anticholinergics and -agonists than pulmonologists for moderate and severe COPD and more likely to prescribe leukotriene modifiers and inhaled corticosteroids. These data corresponded with the 28% of primary care physicians who thought that anticholinergic agents are effective, compared with 36% of pulmonologists (P.009). Systemic corticosteroids were used for the treatment of stable moderate COPD by minorities of primary care physicians and pulmonologists (10% vs 11%, P.66). For patients with stable severe disease, systemic steroids were prescribed widely, particularly by primary care physicians (53% vs 41%, respectively; P.0002) Despite the availability of effective medical therapies, physicians reported that they do not treat all patients with COPD. Primary care physicians reported that they actively treat[ed] with prescription drug therapy 44% of patients with mild COPD, 72% with moderate COPD, and 81% with severe COPD. Pulmonologists reported prescription drug therapy for 35%, 81%, and 86% of patients with COPD, respectively. C Figure 1 Types of treatment normally prescribed for stable patients with mild (A), moderate (B), and severe (C) chronic obstructive pulmonary disease (COPD). *P.05. Therapeutics nonpharmacologic Primary care physicians estimated that 51% of their patients with COPD were active smokers compared with 28% for pulmonologists (P.001). Both physician groups reported discussion of the importance of smoking cessation at almost every visit and widespread prescription of nicotine products and antidepressants to aid smoking cessation. Almost all physicians agreed that indications for supplemental oxygen were primarily oxygen saturation levels and arterial blood gas measurements. However, 51% of primary

7 Barr et al Needs assessment of COPD 1415.e15 g m s Figure 2 Year of graduation from medical school and issues discussed with patient with newly diagnosed COPD. Questionnaire item was, Which of the following issues would be covered as a matter of course in your initial discussion with a patient with newly diagnosed COPD? *P.05. care physicians and 10% of pulmonologists (P.001) thought that symptoms were an additional indication for oxygen therapy. Thirty-one percent of primary care physicians reported that they performed oxygen titration studies for patients with moderate COPD, compared with 67% of pulmonologists (P.001). Forty-five percent of primary care physicians and 38% of pulmonologists found it somewhat or very difficult to convince patients with COPD to use oxygen. Twenty-five percent of physicians reported problems obtaining lightweight oxygen equipment. Although the majority of primary care physicians and pulmonologists reported that pulmonary rehabilitation would benefit patients with moderate (63% in both groups) or severe (76% of primary care physicians and 77% of pulmonologists) COPD, only 19% of primary care physicians and 54% of pulmonologists indicated that they regularly referred patients to pulmonary rehabilitation. Seventynine percent reported that cost and poor insurance coverage were major barriers to pulmonary rehabilitation, whereas 41% of pulmonologists and 60% of primary care physicians reported availability as a barrier. Twenty-three percent of primary care physicians and 8% of pulmonologists reported that no rehabilitation programs were available to them. Trend in physician knowledge by year of medical school graduation There were distinct trends in physicians knowledge by year of medical school graduation for many aspects of COPD care. Recent graduates performed worse than remote graduates for most measures, including exercise programs, diet, and sleep-disordered breathing (Figure 2). In multivariate analyses adjusting for specialty, patient care setting, and number of outpatients seen per week, recent graduates fared worse than remote graduates for exercise programs (P.001) and diet (P.001). Discussion The NECA surveys represented the first coordinated, national surveys of patients with COPD and the primary care physicians and pulmonologists who care for them. These surveys revealed high satisfaction with medical treatment despite significant symptom burden, a difference between patients and physicians opinions about the contributing causes of the COPD, problems with underinsurance, a lack of information and knowledge about COPD, and inconsistent treatment for COPD by both primary care physicians and pulmonologists. Self-reported indices of care for COPD were significantly worse among recent medical school graduates, which may suggest worsening physician knowledge of COPD in the face of increasing COPD prevalence. These findings are alarming for a disease that affects more than 20 million Americans and is soon to be the third-leading cause of death in the country. The only prior published national patient survey in the United States was the Confronting COPD International Survey, performed in Patients in both surveys were significantly limited by symptoms with a major impact on ability to work and perform activities of daily living. Both surveys reported frequent physician visits, although hospitalizations and emergency care visits were much more common in the current patient survey.

8 1415.e16 The American Journal of Medicine, Vol 118, No 12, December 2005 The current linked surveys revealed a divergence between patients and physicians attitudes about COPD. Patients frequently referenced nonsmoking-related causes of COPD, whereas physicians attributed the disease to smoking. The widespread belief by physicians that COPD is a self-inflicted condition has likely contributed to a nihilistic approach to its treatment. In fact, our survey documented a significant proportion of pulmonologists and general practitioners who believe that continuing smokers cannot be treated. Patients and physicians knowledge of COPD was limited. Patients considered themselves to be uninformed about COPD and obtained most of their information from physicians. Although a majority of primary care physicians and pulmonologists surveyed were aware of professional guidelines for COPD, only a very small percentage of primary care physicians and pulmonologists were able to identify the GOLD guidelines, 4 one of the most recent and comprehensive guidelines. This lack of knowledge of practice guidelines may in part account for the inappropriately frequent use of regular systemic steroids, antileukotriene medications, underuse of pulmonary rehabilitation, infrequent measurement of 1 -antitrypsin levels, infrequent vaccination, and incorrect perception that persistent smokers will not respond to treatment. Our findings agree with the limited, mainly European, literature that suggests that adherence to COPD guidelines is poor among pulmonologists 6,9,10 and generalists. 10,11 The majority of physicians reported use of spirometry to diagnose COPD, suggesting that efforts to increase use of spirometry in general practice 12,13 are producing beneficial results. A smaller majority of physicians used bronchodilator testing before establishing a diagnosis of COPD, which may reflect the continuing controversy regarding the value of such testing in defining the clinical phenotype of COPD. 14 After diagnosis, physicians underprescribed safe, effective therapies and overused ineffective therapies. Anticholinergic agents were still not routinely prescribed, particularly by primary care physicians, possibly because of the application of asthma treatment algorithms to COPD or inconsistencies in recommendations for COPD treatment by the international societies. 15 Primary care physicians prescribed more inhaled corticosteroids for all stages of COPD, similar to findings in surveys of generalists in France 9 and Belgium; 16 this may reflect either confusion with asthma therapy or a greater actual overlap between adult asthma and COPD in generalist compared with pulmonologist practices. Most concerning was the reported use of systemic steroids in stable patients with moderate and severe COPD, despite clear evidence that systemic steroids are indicated only for short courses during COPD exacerbations. 17 Although international societies support the use of longterm oxygen therapy only for impaired oxygenation, 4,5 primary care physicians, in particular, based management decisions on alternative indications and underused oxygen therapy. Both physician groups recognized a role for pulmonary rehabilitation in patients with moderate and severe disease, 5 yet primary care physicians, in particular, underused it. The survey suggests that limited access to pulmonary rehabilitation was perceived as a critical issue. The current study has limitations. The diagnosis of COPD was not validated in the patient surveys but was based on patient report, and the age of patients in this survey was younger than that of patients with COPD in the general population. 2 On the other hand, almost all patients had a substantial smoking history, and the prevalence of overlap with asthma reflected real-world clinical practice, particularly for primary care physicians. Restriction of the patient survey to those without asthma did not change results substantially. The response rate was adequate for the patient survey but low for the physician survey. Year of graduation of respondents was comparable to those invited to participate, as was the gender of primary care physician respondents compared with practicing primary care physicians. 18 We doubt that our findings were severely biased because of overrepresentation of physicians with a preferential interest in COPD because the proportion of patients with COPD seen by primary care physicians in our survey (12%) was very similar to the 11% with a respiratory illness visiting primary care physicians in the nationally representative 2001 National Ambulatory Health Survey. 19 If such preferential responses occurred, it should have biased our results toward an overestimate of physician knowledge of COPD. Patients with COPD have a high prevalence of activity impairment and disabling symptoms. Although advances in COPD mechanisms and clinical research will be needed to have a full impact on this disease, 20 our survey suggests that optimal care is impeded by suboptimal physician and patient knowledge and insurance coverage policies. Urgent attention to COPD research, patient access, treatments, guidelines, and patient and physician education is necessary to decrease the current and future health burden of COPD. Acknowledgments The authors thank John Walsh of Alpha-1 Foundation for assistance with the survey design Schulman, Ronca and Bucuvalas, Inc. for implementation of the survey; and Yuanjia Wang, PhD, for data review. In addition, NECA asked the authors to recognize organizations that endorsed the survey: the American Thoracic Society and its Public Advisory Roundtable, American Lung Association, American College of Chest Physicians, and American Association for Respiratory Care. References 1. Petty TL, Weinmann GG. 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