Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole, and we have a panel for you today with two Allegheny Health Network Physicians highlighting the AHN Autoimmune Interstitial Lung Disease Clinic.

Joining me is Dr. Joanna Marco, she's a rheumatologist, and Dr. Briana DiSilvio, she's a pulmonologist. Doctors, thank you so much for joining us today. And Dr. DiSilvio, I'd like to start with you. Would you please tell us a little bit about your program? How did this come about? Why did you see a need for this type of program, and how did the idea for this lung disease clinic emerge?

Briana DiSilvio, MD: Wow. Well, first of all, so you know, I'm a pulmonologist who trained at Allegheny General Hospital. I always had an interest particularly in interstitial lung disease. And even within that, there's actually a niche of that, which is autoimmune related lung disease. Actually not too long after or maybe it was right before I had graduated, my division chair, Dr. Cheema and, the Division of Rheumatology at that time was Dr. Wasko had gotten together and said-- you know, we have some ideas. We'd like to find a way to bring Rheumatology and Pulmonology together to better care for patients with autoimmune lung disease. And I was actually a new graduate of the fellowship and so was Dr. Marco.

And so. I remember one night we actually went out to dinner. Dr. Marco and Dr. Wasko and I, and started just talking, getting to know each other a little bit. And soon after, we both respectively joined the practices after our fellowship started working together. First, it was informally just collaborating on a couple of patients, and then we put our heads together and really thought through the idea of a combined clinic, which we launched in May of 2022. So, we're coming up on three years of that.

And I think what we both recognized was that there was a need for these patients to have their care really be consolidated. We often say that when patients have autoimmune lung disease, rheumatologists and pulmonologists should be working closer together, but often just by nature of the healthcare system, they're practicing in silos. And that can lead to delays in diagnosis, delays in initiation of treatment. You know when patients need escalation of therapy or deescalation of therapy, sometimes that occurs over many months when physicians are practicing separately, as opposed to when Dr. Marco and I are together in one room and we make decisions right there in front of patients and decide we're going to change therapies, and we get to do that in a really collaborative fashion.

Melanie Cole, MS: Well, thank you so much for that. And Dr. Marco, as you do represent two different specialties, as Dr. DiSilvio was just discussing, how is care home managed between Rheumatology and Pulmonology and what are you finding? Are really the biggest benefits, not only for you and the other team members, but for the patients? Tell us about the importance of the multidisciplinary approach for this.

Joanna Marco, MD: You're exactly right that there's big benefits to this multidisciplinary approach, not just for the patients, but for us as doctors and really for the patient's whole care team. So, we often find that with autoimmune diseases like rheumatoid arthritis, vasculitis, Sjogren's, and many other conditions, these patients actually face the highest mortality when their lungs are involved with their autoimmune disease.

So in those cases, really that becomes the focus of all their care and their treatment is preserving their lung function, improving their lung function. And that's really how we make huge strides in their overall morbidity and mortality when they have these diseases. So kind of in that respect, just having Rheumatology, me addressing the diseases from an autoimmune and immune suppression standpoint, and having Dr. DiSilvio address their diseases from the respiratory function and respiratory symptoms standpoint really come up with cohesive plans.

One thing that we do before every clinic is we put our heads together, we review all the patients for that day, and we talk about how they're doing. And sometimes Dr. DiSilvio says, "Oh, did you know so-and-so called in? They've been having worsening cough." We put our heads together even before going in to see the patient about what could be going on, what might need addressed. Sometimes we might be looking at their CT scan and we say, "Oh. Looks wonderful. We've had some great improvement," or we say, "I don't like what I'm seeing. Here's all the options." Then, we go in together and see the patient actually together in real time. We both sit in the room right there with the patient. We take a history together. We talk about their respiratory symptoms as well as all their other symptoms, all the other ways that their autoimmune disease affects them.

And then, we come up with a plan in real time if we need to adjust or change anything, if we need to monitor something or get more testing. And patients really love to see us collaborate right there in real time in front of them. I think that adds up to a lot of confidence to have two doctors saying, "Ah, I understand and I agree this is what we need to do moving forward."

I definitely streamlines things for patients as well. They just come to one appointment slot in one location as opposed to, say, having to make an appointment with me. And then, two weeks later, they might see Dr. DiSilvio and then they have to wait for me and Dr. DiSilvio to talk behind the scenes. That really delays care in the traditional model. So in this combined multidisciplinary model, it really streamlines things and gets decisions made as quickly and efficiently and completely as possible.

Melanie Cole, MS: What a comprehensive approach that is. So beneficial for the patient. And Dr. DiSilvio, what kinds of patients are candidates to be referred to the clinic?

Briana DiSilvio, MD: So, we have actually a variety of patients that get referred to clinic. So, I would say our most common referrals are patients who have at some point been diagnosed either with a lung disease and there's workup ongoing, and the pulmonologist isn't sure, or the primary care doctor, if that lung disease may have an autoimmune cause. That's one type of patient.

The other patient is patients who have known autoimmune disease and for some time did really well. You know, they're working on their joints and their joint symptoms and their muscle symptoms, and that all has been well-controlled. And then, they get a scan of their lungs, or they start developing respiratory symptoms, and it is unveiled that they actually have pulmonary manifestations of their autoimmune disease. And then, that's a person who is commonly then referred to our clinic as well.

We offer a couple of different types, or should say our model, for continuity of care. One is many providers choose to transfer longitudinal care to our clinic. So, they'll say, "This patient's really getting complicated. We think that they need more centralized care. So, we'd like to transfer the care, and for you and Dr. Marco to take over the care of that patient long term." But we also take and see consultations. So, someone who has a well-established relationship with their pulmonologist or their rheumatologist, and that provider just wants a second opinion to make sure they're not missing something. And so, they'll refer to us and say, "Hey, this patient has been doing really well. But I just want to make sure that we're not missing something as far as the management of this complicated disease state." Or maybe they were not doing so well in the setting and the pulmonologist or rheumatologist decides, "I'd like them to be evaluated to maybe escalate care and to consider if your clinic is a better fit for them considering their progressive disease." We take referrals from all over. They come from our own partners in Rheumatology and Pulmonology. We take referrals from PCPs. We have referrals from far away from actually as far as two hours away. And so, some of our patients will drive, and Dr. Marco elaborated on the convenience of actually coming down for one comprehensive visit. They get to see two subspecialists and so many patients are willing to make that drive if they're able to really come down for that visit have a lot of headway made with regard to their care and some decision-making regarding their treatment. And then, they travel back to wherever they're from.

Melanie Cole, MS: Thank you for that. And Dr. Marco, from your perspective, how is integrating rheumatology into the care model improved early diagnosis and outcomes in patients with interstitial lung disease?

Joanna Marco, MD: It's a great question. We know about 20% of patients with interstitial lung disease. It's caused by an autoimmune disease. And in many of those cases, their interstitial lung disease can actually be the first and sometimes the only manifestation of a greater autoimmune disease. So in those patients, it's so critical to have a rheumatologist involved with their care to help identify those patients and get them an accurate diagnosis, because it really does have such a huge impact on their treatment and monitoring moving forwards. Now, of course, not every single case of interstitial lung disease has an autoimmune nature, so not every single case I'll be involved with. But for all these patients with autoimmune lung disease, I personally think it's a great value add to have a rheumatologist on as well.

Melanie Cole, MS: Along those lines, then, Dr. DiSilvio, tell us about nurse navigators and some of the other members of your team, because when these patients come, it can be very confusing and scary when they're told that they have interstitial lung disease, and whether there's an autoimmune component to it. It can be a little bit dizzying trying to figure out who to see first and what to do next. Tell us a little bit about how that's all navigated and actual logistics of coming to the clinic.

Briana DiSilvio, MD: So actually, our care team is probably one of the strongest elements of our clinic. You know, Dr. Marco mentioned that we-- during the visits, it's her and I together in the room. And so, when a patient comes and they're seeing two subspecialists, they'll leave the office with kind of, we say, their homework list. It's a long task list.

And one of the things that we really pride ourselves on is that we are very clear with what the followup's going to be. We review all testing during the visit. We show CT scans. We show breathing tests. We do a full comprehensive exam. And then, at the time of discharge, we write out very clear instructions for our patients. And that's where our care team comes in, really. You know, towards the end of that is we leave the room and then our nurse comes in. They review all of the instructions. They help with scheduling followup appointments, scheduling followup CTs, PFTs. When we start patients on new medications, we will have our autoimmune pharmacists reach out and go over the side effects of medications to make sure they understand the medications they have been started on. If our patients have any side effects of medications or maybe they're not responding as well to a medication that we anticipate, we encourage them to call the clinic.

Everybody is provided with the number and those messages are triaged by our clinic nurse. And so, we always say our clinic nurse actually has a tough job because, when the comments come in, or I should say the emails or messages to our clinic, she has to decide, "Okay, is this patient having some problems that are related more to their autoimmune disease and maybe non-pulmonary symptoms." And if that's the case, then she sends a message out to Dr. Marco. And then, Dr. Marco will respond and certainly loop me in if she thinks that it's something that I need to be involved with, and vice versa, the patient may call in and say, "You know what? My joints are doing really well. I'm actually moving around better, but I've had this really nagging cough or a wheeze since I had a cold." And so then, our triage nurse says, "Okay, this is a question more for Dr. DiSilvio" and she forwards it along to me. And so, our nurse is really vital with making sure that our patients, when they have issues, get directed to either one of us, whichever one is appropriate, and certainly that any recommendations we make or medications we prescribe or followup testing gets addressed afterwards. So, we wouldn't function without our team.

Joanna Marco, MD: Yeah, I couldn't agree more. Our whole support team, they're incredible and they're the ones who really make this clinic run all behind the scenes. We have a fantastic nurse navigator, Kristin. Exactly like you mentioned, Dr. DiSilvia, she gets to know the patients during the visits and between all the visits. Our scheduler, Laura, keeps us organized, keeps our schedule full, makes sure people get in, and we never have gaps in our schedule. She always gets people in off the waiting list.

Our clinic is embedded within the Autoimmunity Institute at West Penn, so that gives us access to a lot of the Autoimmunity Institute's resources there including, like you mentioned, a clinical pharmacist, a nutritionist, a social worker, a behavioral health specialist. And so, all of those are resources that are really important to help supporting our patients.

Melanie Cole, MS: It's so thorough and, I thank you both for telling us all of this, and I'd love to give you each a chance for a final thought here. So, Dr. Marco, have you looked at outcomes from the clinic from a research perspective? What are you seeing as far as patient satisfaction, overall outcomes and quality of life, which is really what I feel like this collaboration is really all about?

Joanna Marco, MD: Yes. So actually, after the first year of our clinic, we looked at some outcomes and the impact of patients, even just after their first visit with us. We found that 39% of patients who came to us either had their diagnosis changed or refined. So, there are a lot of people who came to us who maybe had an unclear diagnosis, an uncertain diagnosis, or after the discovery of their interstitial lung disease, their diagnosis changed. We also found that 49% of people after they saw us, received a recommendation for either a change in their immunosuppression or change in their antifibrotic therapy. So, our clinic really has had a substantial impact on the care of all these patients who come to see us. And we're glad to be able to leverage our expertise to have such a big impact on them.

Briana DiSilvio, MD: Actually, and I'll add to that because one followup study that we did after that initial study looked at actually the number of our patients after a year being in our clinic that were on chronic prednisone. And we were actually able to make a significant difference in reduction in patients, our proportion of patients that are on chronic prednisone for treatment of their autoimmune disease or lung disease, which as Dr. Marco and I educate patients on over and over again really has long-term effects on bone health and infection risk.

And so, one of our priorities actually is to move patients away from a dependence on prednisone and Medrol and some of these other steroids that they've been dependent on for their care and to better immunosuppressive agents that have less side effects, less infection risk, and often actually do a better job at controlling their interstitial lung disease in the long term.

Melanie Cole, MS: Dr. DiSilvia, last word to you, does the clinic plan to expand? What's your vision for this program? How will this care model change the way patients receive care for related conditions and for their outcomes? I'd like you to summarize and give the key takeaways for other providers today.

Briana DiSilvio, MD: One I will say is our model is definitely unique, and I always say if I could duplicate Dr. Marco and I, and make there be four times as many physicians as we have, we would love to expand to all of the neighboring hospitals that we have. Unfortunately, there is only two of us and so we know we started with just individual expansion of our clinic, which is to go another day every month and see patients and open up more slots.

But just recently, we have two partners a rheumatologist, Dr. Dore, and my partner who's a pulmonologist, Dr. Holden, and they are actually going to be expanding this clinic model into the Jefferson Hills area down at Jefferson Hospital. We find that there's actually a big need for someone who supports autoimmune lung disease down in that area. And many of those patients don't want to drive up into the city or they don't have the means to be able to be transported up this way to have a visit with Dr. Marco and I up at the West Penn Hospital.

And certainly, I woulda say in the future, ideally, we would love to add more days, and certainly we hope that there can be more physicians who really want to join us in this endeavor and take our model to a hospital, St. Vincent's up in Erie, which is a couple of hours away. And that way, our patients don't have to travel as far to get the similar experience that they have in a combined clinic.

I do know that what we are doing is certainly unique and I think that it is going to have a long-lasting impact on the healthcare of the patients at Allegheny Health Network, and I can only hope that we continue to increase our patient numbers and certainly our impact and our footprint in this region.

Melanie Cole, MS: Thank you both so much for joining us today and sharing your incredible expertise for other providers and patients alike. To get more information or to refer your patient to Dr. DiSilvio or Dr. Marco, there are a few ways you can do it. You can call 412-578-3511, or you can call 844-MD-REFER. You can also visit the website at ahn.org for more information. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.