Update on Research Associated With HBOT Utilization

Editor’s Note: This commentary piece is published in place of our regularly occurring From The Editor message.

The American College of Hyperbaric Medicine (ACHM) was formed in 1983 by a group of physicians who were practicing the developing specialty of hyperbaric medicine and recognized the need for a national professional organization dedicated to serving as a medical specialty society. Originally based in Houston, TX, the organization relocated to Milwaukee, WI, in 2006 and operated under the direction of the late Dr. Eric P. Kindwall, MD, the first official ACHM executive director. His legacy lives on through the organization’s work today, which focuses on promoting the importance of appropriate utilization, standard of care, education, training, certification, and recognition of hyperbaric oxygen therapy (HBOT) as a distinct medical specialty and a full-time practice. The organization has relocated to Lafayette, LA, as of 2018 and has contracted with M3M to manage the organization.

RESEARCH FOUNDATION & HISTORY OF THE ACHM

In 2003, the ACHM established the first pathway to clinical certification in hyperbaric medicine for physicians. This pathway provides a certificate of added qualification and has become a recognized certification alternative for physicians who are not eligible for formal board certification. Another historical clinical influence was the ACHM’s publication of the Preferred Practice Protocols for Hyperbaric Medicine in 1995. These protocols provided a basic description of how and when to use hyperbarics to aid patients living with specific ailments. These protocols stand as the first best-practice hyperbaric guidelines and standards to be published and include hundreds of references to key studies that at the time proved the effectiveness of hyperbarics in certain conditions. The ACHM is in process of updating these protocols in 2018.

As early as 2004, the ACHM began to receive numerous notifications from its membership stating that several national insurance carriers had determined that HBOT for the treatment of radiation necrosis would be categorized as experimental/investigational and subsequently resulted in denial of submitted claims. The results of these determinations, if left unchallenged, would have eliminated the use of HBOT for patients living with radiation injuries. In response to this situation, the ACHM initiated the
Radiation Research Registry in 2006 to address what was becoming a growing crisis. This monumental effort produced the largest hyperbaric registry ever, thanks in part to funding from the Kindwall Foundation, and demonstrated the significant efficacy and usefulness of HBOT in the management of radiation-injured patients.

Fast forward to present day, and we are at a similar crossroads in which insurance companies are more strictly looking at resource utilization and value-based care. It is imperative for professional organizations such as the ACHM to encourage members to research the value of HBOT for existing indications as well as to learn whether there is evidence to support its use in other widespread conditions. The ACHM’s board of directors is passionate about supporting research to develop more evidence on existing indications and to look at other potential new indications where there is a lot of global anecdotal evidence, but not enough data to support routine use — for example, use of HBOT for ulcerative colitis and Crohn’s disease. Recent literature shows that HBOT can be useful and is a cost-effective therapy for patients living with ulcerative colitis, but rightly concludes that further studies are needed. Traditional treatment for ulcerative colitis is biological therapy, which is an extremely costly treatment. That said, we at the ACHM want to know if patients could benefit from HBOT as an adjunct. We also want to know if we can start HBOT before starting biological therapy, which also needs more research. 

Many hyperbaric medicine physicians also report seeing the beneficial effect of HBOT for patients living with pyoderma gangrenosum, but a lack of evidence has resulted in most insurance carriers considering HBOT in these cases to be considered experimental and, therefore, non-reimbursable. Studies are ongoing for the use of HBOT to treat traumatic brain injury, and there are several studies already published on this subject that have garnered considerable interest. Stroke is another indication for which HBOT might be useful, but more work is needed to develop sound evidence, and that remains a mission of the ACHM. The organization established a research foundation in 2017 to support work that focuses completely on HBOT research, as this area of medicine is not funded by pharmaceutical companies.

FOCUS ON QUALITY, PRACTICE IMPROVEMENT 

Quality assurance and improvement in the practice of hyperbaric medicine remains an integral part of the mission of the ACHM, especially as it pertains to the treatment of chronic wounds. The ACHM and its officers are dedicated to establishing relationships with Medicare and other insurance carriers to advise on payment policies and practice issues. The ACHM recently published recommendations to guide hospitals in establishing physician credentialing standards and has continued to serve as a primary educational resource for clinicians practicing hyperbaric and wound medicine through the establishment of training criteria and certification pathways for clinicians. Today, the ACHM offers certification examinations for physicians, nurses, and technicians and has endorsed the pathways to certification administered by the American Board of Wound Healing. These standards have also been adopted by numerous hyperbaric facilities and third-party payers. The ongoing mission of the ACHM remains to improve the quality, practice, and expansion of scope for the utilization of hyperbaric medicine.

The ACHM approves and endorses hyperbaric educational courses/activities that satisfy prescribed requirements and comply with standards as established by Medicare for the training of physicians and providers credentialed to supervise HBOT. ACHM-approved curriculum must consist of a minimum of 40 hours of training dedicated to the practice of hyperbaric medicine. Significant focus must be devoted to the clinical aspects of HBOT as it applies to wound care. The educational experience must include didactic lectures (provided via classroom or online platforms) and practical sessions (typically accomplished at the facility where the clinician will practice). The intent of this practicum is to allow students to become familiar with the utilization and operation of hyperbaric chambers at their hospital of facility, as well as to learn the emergency procedures and operational protocols for other support equipment located onsite that would be used under the supervision of the provider. The ACHM recommends that the practical sessions be provided via preceptorship allowing for direct student interaction, discussion, clarification, and reinforcement of didactic concepts, as well as technical or clinical applications. 

Jayesh B. Shah is president of the ACHM and serves as medical director for two wound centers based in San Antonio, TX. He is also president of South Texas Wound Associates, San Antonio, and is past president of the American Association of Physicians of Indian Origin, Chicago, IL, and the Bexar County Medical Society, Shavano Park, TX.