• Introduction
  • How Much Do HCPs Know About NTM Lung Disease?
  • Why Some Specialists May Be Frustrated by NTM
  • Goals of NTM Treatment
  • Regional Dynamics of NTM Management
  • Two NTM Treatment Mindsets Emerge
  • Progress Check Questions
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INTRODUCTION

Welcome to this installment of inspireWIRE, which explores HCP perspectives on nontuberculous mycobacterial (NTM) lung disease and approaches to management based on market research. After reviewing the contents of this eMagazine, you should be able to:

  • Explain the different types of HCPs involved with NTM and their level of knowledge of the disease
  • Describe the challenges HCPs may face when diagnosing and treating NTM
  • Understand the varying patient-centric/personalized approaches to NTM treatment and treatment goals
  • Understand the variability in treatment approaches to NTM across the US
  • Compare and contrast different NTM treatment mindsets

Instructions on eMagazine Icons

Throughout this eMagazine, you will encounter icons which when selected, offer more information around the topic being discussed.

Note that you may download and take notes on a PDF version of this installment of inspireWIRE by selecting the Resources download icon.

At the end of this eMagazine, you will be required to take the progress check and you should select the “Get Course Credit” button when you are done to receive credit.


HOW MUCH DO HCPs KNOW ABOUT NTM LUNG DISEASE?

Familiarity with NTM varies widely among healthcare providers, and, as you will learn, this can be due in part to the uneven regional distribution of NTM patients. As expected, primary care physicians and internists, particularly in areas with lower incidence of NTM, are unfamiliar with NTM and guidelines for its treatment. However, as you look closer at physicians in the therapeutic areas specific to NTM, pulmonary disease and infectious disease, knowledge about NTM and familiarity with treatment increases.

The graph below describes HCP market research on attitudes toward NTM lung disease. The data compare PCPs/IMs with pulmonologists and ID specialists. Keep in mind that the data shown below were gathered from HCPs who are actively managing NTM patients. In general, specialists consider themselves much more knowledgeable and comfortable with NTM than PCPs.

Select the buttons to see data for each subset of healthcare providers to learn more about each group's familiarity with NTM.

PCP/IM

Primary care physicians are typically the first healthcare providers to see patients with NTM, although they may not know it, because patients often remain undiagnosed until they are referred to a specialist.

Roughly a third of PCPs and IMs consider themselves knowledgeable about NTM and treatment guidelines and feel comfortable enough to prescribe first-line treatment.

PUD/ID

Pulmonologists (PUDs) and infectious disease specialists (IDs) studied in market research generally felt very familiar with NTM. Over 90% considered themselves knowledgeable about NTM and treatment guidelines and also felt comfortable prescribing first-line treatment to NTM patients. Only a small percentage of PUDs and IDs did not feel comfortable or knowledgeable in this disease state.

Considering their level of familiarity with treatment guidelines, it makes sense that 74% of HCPs report that they treat NTM with guidelines-based therapy (GBT) in the first line.

Select the icon to learn more about NTM patient distribution in the United States.

Did You Know?

According to the NTM Patient Journey Analysis from Symphony, half of all NTM patients reside in 7 states (Florida, New York, Texas, California, Pennsylvania, New Jersey, and Ohio), and 1 in 7 NTM patients resides in Florida.



WHY SOME SPECIALISTS MAY BE FRUSTRATED BY NTM

Although most pulmonologists and infectious disease specialists may feel knowledgeable about NTM and comfortable treating it first line, it can still be a frustrating disease to manage for a number of reasons. First, NTM can be very difficult to diagnose, with the diagnosis process often taking up to 2 years. Once the disease is diagnosed, treatment is burdensome for both patients and HCPs. Finally, many specialists perceive the chance of eradicating NTM in a given patient to be rather low. Recognizing the challenges of managing NTM will help you understand why HCPs choose different treatment approaches for their NTM patients.

Challenging Diagnosis

NTM can be a challenging disease to diagnose for a handful of reasons. The graph below lists the most commonly cited challenges specialists face when diagnosing NTM.

Select each issue listed below to see the percentage of HCPs who cited that issue as a challenge in diagnosing NTM:

In diagnosing NTM, 82% of HCPs perform a sputum culture as soon as NTM is suspected. However, a sputum culture does not provide a definitive diagnosis: a positive Mycobacterium avium complex (MAC) culture may be due to colonization rather than infection. Remember that a colonization refers to the harmless growth of bacteria at a particular body site, whereas an infection is a growth of bacteria that causes the body harm. HCPs must also rely on clinical, microbiologic, and radiographic findings to make a diagnosis, and these can be non-specific to NTM as well. 

Symptoms of NTM are not necessarily specific to NTM, which makes for a difficult diagnosis for HCPs. In addition, PCPs, who may be less knowledgeable about the disease, may not recognize the symptoms and risk factors for NTM and may not refer patients to a PUD or ID specialist for diagnosis. Complaints of coughing, wheezing, and chest pain may indicate any number of lung diseases. Similarly, radiographic findings may not be specific enough to suspect NTM, which can add to the confusion. 

See what specialists have to say about the difficulty of diagnosing NTM:

Select the arrows to see quotes from physicians about NTM diagnosis.

doctor1_1

“When it comes to symptoms, the lungs are pretty stupid. There are only so many symptoms – shortness of breath, you can cough with or without sputum, maybe have some chest pain/fluid collection, cough up blood, and wheezing. What else can you really complain of? In terms of comparing the symptoms that patients can complain of, it’s the same as everything else. What questions do you ask? What imaging do you ask for?” – PUD, Southern California

doctor2_1

“A lot of times these NTM cases end up being referred to me by PCPs. Most patients are limited by who they can see. They’re not just waking up and deciding, ‘Oh, I think I need to see a pulmonologist or an ID doc.’ Very seldom do you see someone just show up by themselves. Once a PCP sees something in the lungs from the x-ray, that’s when they’ll refer over to the experts.” – ID, Northern California 

doctor3_1

“It’s not on [PCPs’] radar. They don’t know when or how to treat or whether someone has the disease. But they understand MAC is a potential pathogen.”  – ID, New York  

doctor4_1

“Sometimes [patients] get referred to me, and sometimes they’ll seek out a specialist on their own, because people have been saying it’s asthma, but nothing’s working, so they seek out a specialist. It’s very possible that patients have had [NTM] a long time before they come to me.” – PUD, Pennsylvania 

doctor5_1

“PUDs do procedures to rule out other diseases. So with NTM, most of the time patients will come to me with a chronic cough or maybe an abnormal CT finding, so going down the diagnostic algorithm of pulmonary nodules and bronchiectasis and ruling out other potential diseases or other connective tissue diseases, like rheumatoid arthritis for instance, that might be putting the patient at risk or causes the problem in the first place.” – PUD, Southern California 

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Burdensome Treatment

NTM treatment can be burdensome for both patients and HCPs; learning why NTM treatment can be so difficult will help you understand the rationale of some HCPs who have chosen not to treat some of their NTM patients and instead “wait and watch.” 

First, the side effects of guidelines-based therapy (GBT) for NTM patients can be challenging. Below is a list of common side effects of GBT and the impact they have on patients’ quality of life. 

Select each button to reveal common side effects of GBT and the impact they have on patients’ quality of life.

In addition to being difficult to tolerate, NTM therapy is lengthy. It can take up to 18 months, including achievement of culture conversion, which may take up to 6 months, and an additional 12 months of continuing therapy after culture conversion. NTM therapy may also require multiple treatment courses if disease recurs. ATS/IDSA-recommended treatment consists of at least 3 recommended medications, and patients need to visit the doctor’s office frequently for ongoing monitoring and treatment follow-up. As a result, the decision about when to initiate therapy and the choice of treatment regimen depend largely on the goals for each specific patient, disease severity, and patient comorbidities.

Perceived Low Chance of Permanent Eradication

In some specialists’ experience, NTM has a high probability of relapse and/or reinfection. This may explain why HCP satisfaction with current treatment options is not particularly high, with only 27% of HCPs saying they are very satisfied with GBT. 

Consider the following example to understand why many HCPs may feel that NTM is difficult to treat and that GBT is a challenging treatment option for their NTM patients. Keep in mind that the HCPs included in the research below were selected because they are actively managing NTM patients.

The average PUD/ID sees approximately 20 NTM patients in 3 years. Select the buttons below to learn more about these NTM patients.

Approximately 63% of NTM patients have successful treatment, leaving another 37%, or about 8 patients for each specialist, still struggling with NTM

On average, another 28%, or about 3 of each specialist's patients, who had successful treatment will either relapse or be reinfected with NTM.

This means every PUD/ID will have, on average, 11 NTM patients over the course of 3 years who need better treatment options than what is currently available for NTM.


GOALS OF NTM TREATMENT

Because of the specific challenges NTM presents, HCPs may choose a treatment approach and define success based on several different goals. Treatment is personalized, and there is high variability in treatment approaches based on patient presentation and disease severity. Nevertheless, the following goals inform treatment decisions for most HCPs who treat NTM.

Select the arrows on the slider below to explore the most common NTM treatment goals.

INW_507-a.jpg

For 75% of HCPs managing NTM lung disease, symptomatic relief is the primary treatment goal in managing NTM.

INW_507-b.jpg

For just over half of HCPs, sputum culture conversion is a secondary treatment goal. That said, 20% of HCPs consider culture conversion their primary treatment goal, while another 26% consider it their tertiary goal.

INW_507-c.jpg

Radiographic improvement is most often an HCP’s third treatment goal, behind symptomatic relief and sputum culture conversion, although 31% of HCPs do consider it a secondary goal.

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Select the icon to learn more.

Understanding Goals for Treatment

The ATS/IDSA statement defines treatment response for NTM as clinical improvement in 3 to 6 months and sputum culture conversion to negative within 12 months on macrolide-containing regimens. 

Some physicians also believe that microbiological cure may be difficult to achieve in a large portion of patients. This expectation, ATS/IDSA guidelines, variability in patient presentation, and level of disease severity all lead HCPs to take several different treatment goals into account when treating NTM. 


As you've seen, treatment goals vary across all HCPs who manage NTM, but some of those differences may be due to their area of specialty. The chart below outlines some differing perspectives you may observe between pulmonologists and infectious disease specialists.

Differing Treatment Perspectives

PUDs IDs
General Characteristic Take pride in being able to improve quality of life in a tangible way Highly intellectual; take pride in identifying mystery disease
Approach Patient-focused; tend to be dealing with other lung conditions and focused on quality of life Condition-focused; tend to find satisfaction in completely eradicating disease, one patient at a time
Definition of Treatment Success Define success as symptom improvement and slowing progression of disease Define success as culture conversion

REGIONAL DYNAMICS OF NTM MANAGEMENT

NTM patients are not evenly distributed throughout the US. In fact, a handful of states (Florida, New York, Texas, California, Pennsylvania, New Jersey, and Ohio) are hotspots where half of all NTM patients reside. In these same areas, there are marked regional differences in HCP perspectives. Explore the map below to see how NTM is distributed across the US and learn more about HCP perspectives in the top 6 regions for NTM incidence. Note: The following infographic includes broad characterizations learned through market research, and you will certainly find that individual HCP perspectives will vary widely even within regions.

Select each of the callouts next to the 6 hotspot regions below to learn more about perceptions of NTM, diagnosis, treatment, and definitions of success among HCPs who treat NTM in that state.

Northern California

Perceptions of NTM
California physicians find NTM to be a frustrating, onerous disease.

Diagnosis
Physicians in Northern and Southern California generally follow the same diagnostic process, but Northern California PCPs tend to refer patients to specialists sooner.

Treatment
Northern California physicians focus on long-term effects of NTM on lung health and are therefore more comfortable and flexible with treatment.

Definitions of Success
Northern California physicians tend to enthusiastically attempt a cure for NTM.

New York

Perceptions of NTM
Because of its slow progression, New York physicians perceive NTM as an annoyance with no real risk. 

Diagnosis
Lack of urgency combined with conflated symptoms makes for a delayed diagnosis. 

Treatment
New York physicians may decide to treat NTM or not, and if they do treat, they focus on symptomatic relief and improved quality of life for patients. 

Definitions of Success
Quality of life is the biggest barometer of treatment success, as opposed to clinical results. 

Pennsylvania

Perceptions of NTM
Pennsylvania physicians see little urgency to treat NTM and prioritize more pressing conditions. 

Diagnosis
PUDs own the process of diagnosing NTM. 

Treatment
IDs take the lead for treatment, often seeing patients who have already been on multiple rounds of antibiotics.

Definitions of Success
Pennsylvania physicians may feel that it’s not always worthwhile to treat aggressively and focus instead on symptomatic relief. 

Southern California

Perceptions of NTM
California physicians find NTM to be a frustrating, onerous disease.

Diagnosis
Physicians in Northern and Southern California generally follow the same diagnostic process, but Southern California PCPs tend to refer patients to specialists later.

Treatment
Southern California physicians tend to be more apprehensive about treatment and feel that patients in their region may be more reluctant to get treatment for NTM due to fear of taking antibiotics.

Definitions of Success
Frequent failures in attempts to treat or manage NTM make long-term eradication feel unlikely for Southern California physicians, leading them to focus more on symptomatic relief.

Florida

Perceptions of NTM
Florida physicians have a more nuanced understanding of all of the different strains of NTM. 

Diagnosis
Understanding of different species and subspecies of NTM leads to more individualized treatment regimens. 

Treatment
Florida physicians generally see an immediate need to treat NTM. Florida PUDs don’t feel as confident treating NTM and will often refer NTM patients to IDs. 

Definitions of Success
Florida physicians strive for eradication but know it’s a challenge to achieve.

Texas

Perceptions of NTM
Texas PUDs tend to see NTM as a chronic condition, while IDs see NTM as a more incidental infection, like the flu.

Diagnosis
Texas radiologists may take on a bigger role in NTM diagnosis.

Treatment
Texas physicians feel that NTM requires constant, consistent monitoring. 

Definitions of Success
Given the challenge in achieving eradication, Texas physicians set realistic expectations for themselves and their patients for NTM treatment.


TWO NTM TREATMENT MINDSETS EMERGE

During market research, two general NTM treatment mindsets have emerged among the physicians studied: those physicians who ‘Wait and See’ how NTM progresses and affects patients’ quality of life, and ‘Treatment Trailblazers,’ who feel a strong urgency to treat NTM right away.

The typical characteristics of each of these treatment mindsets are shown in the chart below.

Select each row to reveal the aspects of treatment approach that define each of these mindsets.

The differences in treatment approach between these two mindsets may be explained by psychology. People tend to trivialize obstacles or issues they don’t feel capable of addressing. Likewise, physicians who don’t feel confident in their ability to improve NTM or feel unsure that treatment will result in the desired outcome may tell themselves the issue is lower priority and doesn’t require their time or resources. This attitude could result in the ‘Wait and See’ mindset. 

Conversely, positive outcomes activate reward circuits in the brain, helping us form habits that lead to more positive outcomes. ‘Treatment Trailblazers’ are motivated by positive outcomes in previous patients to continue treating NTM. 

As you can see, understanding the psychology and resulting treatment profile of each of the HCPs in your local market is critical to managing your territory and planning your approach to conversations with each HCP.

Now that you’ve learned a little bit about what makes these two treatment mindsets different, review some quotes from market research from physicians with each mindset.

Select each thought bubble to read a quote from market research reflective of the Wait and See mindset.

Wait and See Mindset

Select each thought bubble to read a quote from market research reflective of the Treatment Trailblazer mindset.

Treatment Trailblazer Mindset

Progress Check Questions

Let's assess your understanding of the HCP Perspectives on NTM. Answer the following Progress Check Questions. When you are finished, be sure to select the “Get Course Credit” button to get credit.

  1. Q1
  2. Q2
  3. Q3
  4. Q4
  5. Q5
  6. Q6

Of the HCPs surveyed in market research who are actively managing NTM patients, what percentage of PUDs/IDs consider themselves knowledgeable about NTM?





Which of the following are the top 3 challenges in NTM diagnosis? (Select all that apply.)





Based on market research, in what percentage of NTM patients is treatment unsuccessful?





Based on market research, which answer option correctly ranks NTM treatment goals in order of importance for most HCPs?





According to market research, which option is more often the primary treatment goal for IDs vs PUDs?





Which of the following aspects of treatment approach are part of the Treatment Trailblazer mindset? (Select all that apply.)





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