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REVIEW OF MANAGEMENT INFORMATION SYSTEMS RESEARCH: A MANAGEMENT SUPPORT EMPHASIS

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Journal of Information Engineering and Applications

PIUS VINCENT OKOYE

Saiful Islam

Alexander Decker

Dinasti International Journal of Education Management And Social Science

Ali M Zebua

Management Information System (MIS) is one of the most important achievements in the field of work administration, which aims to provide reliable, accurate, relevant and complete information to managers to improve organizational performance in organizations. This research reviews other research in the field of MIS adoption in organizations. Synthesizing from the previous literature with several books, articles and related studies, this paper proposes a theoretical framework. Previous research or relevant research is very important in a research or scientific article. Previous research or relevant research serves to strengthen the theory and phenomena of the relationship or influence between variables. This article reviews the factors that influence Information Systems in the academic field, namely: Software, Databases and Information Technology, a literature study on Information Systems Management. The purpose of writing this article is to build a hypothesis of the influence between...

Information Systems Journal

Tor Magnus T M L Larsen

Renée Pratt , Christopher Furner

The purpose of this paper is to classify the most cited papers in Management Information Systems (MIS) by theoretical perspective and subject area. The determination of the underlying theoretical perspective of these papers facilitates and verifies the dominance of positivist perspectives. Our analysis indicates that 74% of the most cited articles are positivist and 26% are interpretivist. The presence of a significant percentage of interpretive work suggests that differing theoretical perspectives are being considered relevant to solving the problems identified in the current research streams. Our results also indicated User Satisfaction and Instrument Development and Group Support Systems as the most cited articles subject areas, 16% and 14% respectively. The significance of these subject areas promotes and supports that systems is the foundation of MIS.

Relatively speaking, the field of information systems is still young, developing into a coherent field. This introduction to the minitrack is organized into the following four sections. The first section discusses three prerequisite conditions for MIS to become a coherent field of a study, as suggested by Keen (1980). 1.1 Clarifying reference disciplines 1.2 Building a cumulative research tradition 1.3 Defining the dependent variables The second section is concerned with the process by which an academic discipline becomes establishment. Once the prerequisite conditions for becoming a classic field of study have been met, a review of the major works of Kuhn (1970), Kaplan (1964), and Cushing (1990) describes the process by which an academic discipline becomes establishment in terms of the following steps: 2.1 Consensus building 2.2 Empirical studies 2.3 Articulation of Theories 2.4 Paradigm Building The third section overviews the current state of MIS research in terms of the prerequ...

JUSTIN GABRIEL

Abstract : Information has become an essential resource for managing modern organizations. This is so because today’s business environment is volatile, dynamic, turbulent and necessitates the burgeoning demand for accurate, relevant, complete, timely and economical i nformation needed to drive the decision - making process in order to accentuate organizational abilities to manage opportunities and threats . This paper is a reflection of amassed discourse available in literature concerning the nexus between management inf ormation systems – MIS and corporate decision - making. The paper suggests that a painstaking development and management of MIS in organizations is capable of triggering decisions that would not only be fast and accurate but would be in line with industry best practices and ultimately result in organizational efficiency and effectiveness.

Mahmoud Moussa, PhD

Employers at all levels, in all settings, are continually in search of information to develop decisions that can be supportive when facing complex, and unpredictable scenarios in the global market. Hence, information and information systems have become strategic tools in the hands of decision makers in today " s businesses. This paper is a presentation of the contemporary reality of information systems, and their influence in enhancing organizational performance. Further, the author identifies the types and levels of information systems available, and their fundamental purposes and roles, alongside the challenges and risks involved. Ultimately, practical implications for business leaders, and recommendations for further studies are provided.

A Growth Strategy that Creates and Protects Value

David A. Hofmann
John J. Sumanth

Four steps to build a continuous value creation cycle.

For organizations to truly innovate and grow, leaders in every role and at every organizational level must be attuned to how they are creating new value while simultaneously protecting existing value. Just as a soccer coach must simultaneously pursue both scoring and defending, leaders must constantly focus their attention on opportunities to create value — through innovation, risk-taking, and experimentation — and to protect value — by preserving and defending key aspects of their responsibilities. Because both approaches are essential to success, organizational leaders must proactively and continually encourage their teams to adopt both a creating value and protecting value mindset when tackling their day-to-day responsibilities. But how can leaders do this? More specifically: Where and how do leaders deploy these two approaches, and how do these approaches change over time? In this article, the authors offer four steps leaders can take to ensure that they’re on the right path for growth.

Ask any leader what comes to mind when they hear the word “innovation” and you’ll quickly hear examples of a new, user-centric product design, or an R&D team pursuing a new mission, or their company’s exploration of a new market opportunity to drive additional revenue. But what if this relatively narrow view captures only a slice of the potential innovation that resides within your organization? What if your organization could unlock non-traditional avenues and areas for innovation, experimentation, and value creation?

David A. Hofmann is the Hugh L. McColl, Jr. Distinguished Professor of Leadership and Organizational Behavior and Senior Associate Dean of UNC Executive Development at the Kenan-Flagler Business School at the University of North Carolina at Chapel Hill.
John J. Sumanth is the James Farr Fellow & Associate Professor of Management at the Wake Forest University School of Business.

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Progress in Pharmacologic Management of Neuropsychiatric Syndromes in Neurodegenerative Disorders : A Review

1 Chambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, School of Integrated Health Sciences, University of Nevada, Las Vegas
2 Departments of Psychiatry and Pharmacology, University of Toronto, Sunnybrook Research Institute, Toronto, Ontario, Canada
3 Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, St Louis, Missouri
4 Exeter University Medical School, University of Exeter, Exeter, United Kingdom

Importance Neuropsychiatric syndromes (NPSs) are common in neurodegenerative disorders (NDDs); compromise the quality of life of patients and their care partners; and are associated with faster disease progression, earlier need for nursing home care, and poorer quality of life. Advances in translational pharmacology, clinical trial design and conduct, and understanding of the pathobiology of NDDs are bringing new therapies to clinical care.

Observations Consensus definitions have evolved for psychosis, agitation, apathy, depression, and disinhibition in NDDs. Psychosocial interventions may reduce mild behavioral symptoms in patients with NDD, and pharmacotherapy is available for NPSs in NDDs. Brexpiprazole is approved for treatment of agitation associated with Alzheimer disease dementia, and pimavanserin is approved for treatment of delusions and hallucinations associated with psychosis of Parkinson disease. Trials are being conducted across several of the NDDs, and a variety of mechanisms of action are being assessed for their effect on NPSs.

Conclusions and Relevance Detection and characterization of NPSs in patients with NDDs is the foundation for excellent care. New definitions for NPSs in NDDs may inform choices regarding clinical trial populations and translate into clinical practice. Psychosocial and pharmacologic therapies may reduce behavioral symptoms and improve quality of life for patients and caregivers. Approved agents may establish regulatory precedents, demonstrate successful trial strategies, and provide the foundation for further advances in treatment development.

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Non-acute heart...

Non-acute heart failure management in primary care

Related content
Peer review
Rachel Roskvist , senior lecturer 1 ,
Kyle Eggleton , senior lecturer 1 ,
Bruce Arroll , professor 1 ,
Ralph Stewart , adjunct clinical professor 2
1 Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand
2 Department of Medicine, School of Medicine, University of Auckland, New Zealand
Correspondence to: B Arroll bruce.arroll{at}auckland.ac.nz

What you need to know

Heart failure should be considered in any patient presenting with breathlessness in primary care

B-type natriuretic peptide (BNP) is an important initial test for heart failure, with a negative result usefully ruling out the condition

Heart failure encompasses various causes, many of which have specific treatment options

Heart failure is prevalent worldwide, impacts quality of life, and is associated with high morbidity and mortality. Global prevalence estimates indicate that 1-2% of adults in the developed world have known heart failure. 1 2 In the UK alone, almost one million people have diagnosed heart failure, placing a substantial demand on specialist cardiology services. 3 Heart failure often presents in primary care, where many patients have risk factors and long term treatments are usually indicated even after symptoms have improved. This update focuses on recent evidence and changes to heart failure clinical practice guidelines, emphasising aspects most relevant to primary care.

Stages and classes of heart failure

A universal definition and novel classification system for heart failure was proposed in 2021 by the Heart Failure Society of America (HFSA), Heart Failure Association of the European Society of Cardiology (HFA-ESC), and Japanese Heart Failure Society (JHFS), and the system has been included in the recent American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) guidelines. 4 5 This four-stage classification system recognises two pre-heart failure stages without symptoms (stages A “at risk” and B “pre-heart failure”) and two symptomatic stages encompassing the clinical syndrome of heart failure (stages C “symptomatic” and D “advanced”) ( box 1 ). 4 5 Most guideline-directed pharmacological treatments target stages C and D, but they may also be indicated in asymptomatic patients to reduce the risk of progression to symptomatic heart failure. The New York Heart Association (NYHA) functional classification system complements this staging system and is applied to stages C and D, where the severity of symptoms can be assessed using this functional classification.

Definition and classification of heart failure

Definition*.

Heart failure is

A clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and

Corroborated by elevated B-type natriuretic peptide (BNP) levels and/or objective evidence of pulmonary or systemic congestion

Stage A: At risk —Risk factors such as coronary artery disease, diabetes, hypertension, atrial fibrillation, valvular heart disease

Stage B: Pre-heart failure —Raised BNP levels, reduced ejection fraction

Stage C: Symptomatic —Symptoms such as dyspnoea, ankle swelling, fatigue

Stage D: Advanced

New York Heart Association (NYHA) functional classification system (applied to stages C and D)

Class 1: No limitation

Class 2: Slight limitation

Class 3: Marked limitation

Class 4: Symptoms at rest

Classes by left ventricular ejection fraction

HFrEF —Heart failure with reduced ejection fraction (≤40%)

HFmrEF —Heart failure with mildly reduced ejection fraction (41-49%)

HFpEF —Heart failure with preserved ejection fraction (≥50%)

HFimpEF —Heart failure with improved ejection fraction (≤40% before treatment, >40% at follow-up)

* Universal definition proposed by the Heart Failure Society of America (HFSA), Heart Failure Association of the European Society of Cardiology (HFA-ESC), and Japanese Heart Failure Society (JHFS) 4

† Stages included in guidelines from American Heart Association (AHA), American College of Cardiology (ACC), and Heart Failure Society of America (HFSA) 5

In addition, the ESC (European Society of Cardiology) and AHA/ACC/HFSA guidelines for heart failure 5 6 and the universal definition proposed by the HFSA/HFA-ESC/JHFS 4 distinguish between patients with reduced left ventricular ejection fraction (HFrEF), those with mildly reduced (previously called mid-range) ejection fraction (HFmrEF), and those with preserved ejection fraction (HFpEF) ( box 1 ). Many of the treatments discussed improve cardiac function and outcomes for heart failure with reduced left ventricular ejection fraction but have less benefit and evidence for patients with preserved ejection fraction.

Patients with heart failure, whether with preserved or reduced left ventricular ejection fraction, face high mortality and morbidity. 2 The differences in prognosis between patients with preserved ejection fraction and those with reduced ejection fraction are uncertain, with conflicting evidence suggesting that preserved ejection fraction confers a lower mortality risk. 2 6 The prognosis for patients with mildly reduced ejection fraction is better than for those with reduced ejection fraction, provided ejection fraction does not deteriorate. 6 In patients with reduced ejection fraction, this may improve with medications or by treating underlying causes, and this subgroup is referred to as heart failure with improved ejection fraction (HFimpEF) ( box 1 ). Disease modifying medications typically need to be continued for these patients, even with improved ejection fraction. 4 5 7

What helps to diagnose heart failure?

Heart failure should be considered in any patient with breathlessness, which can be acute or develop slowly. Other symptoms include lower limb swelling, fatigue, abdominal discomfort, and loss of appetite. Clinical signs include an elevated jugular venous pressure, pulmonary crackles or wheeze, peripheral oedema, and a displaced cardiac apex. Cardiac auscultation may reveal a gallop rhythm or heart murmur. Signs may not manifest in patients with early stage heart failure or those undergoing treatment. 6 Missed diagnoses are common, particularly in those with pre-existing respiratory diseases.

Initial key investigations in primary care include an electrocardiogram, a chest radiograph, and measurement of B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide ( box 2 ). 5 6 Other investigations to assess potential causes or comorbid diseases that may affect management include a full blood count, creatinine, urea and electrolytes, thyroid function tests, liver function tests, haemoglobin A1c, ferritin, and iron studies. 6 8 9

Key initial investigations in primary care

B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) —A low or normal plasma BNP or NT-proBNP concentration makes heart failure unlikely. 6 However, BNP can be normal in some patients with heart failure with preserved ejection fraction, 4 10 11 and those who are obese. 4 11 The cut-off value for natriuretic peptide levels varies between guidelines: the National Institute for Health and Care Excellence (NICE) 2018 guidelines require higher levels than those in the ESC 2021 guidelines and may potentially miss one in five cases. 12

Electrocardiogram —This is often abnormal in patients with heart failure. 13 It is important for determining the underlying cardiac rhythm and may provide clues to the underlying pathology. 6 14

Chest x ray —This may confirm pulmonary congestion or identify other reasons for dyspnoea. However, a normal chest x ray does not rule out heart failure. 13 14 15

The key diagnostic investigation is an echocardiograph to determine left ventricular ejection fraction (LVEF), which represents the proportion of left ventricular volume ejected per heartbeat and guides pharmacological treatment and indications for cardiac devices. 5 6 14 Echocardiography, or other cardiac imaging modalities, can also evaluate cardiac structure and function and identify potential causes of heart failure. Diagnosis of heart failure with reduced or improved ejection fraction in symptomatic patients rests on the echocardiographic determination of LVEF.

The diagnosis of heart failure with preserved ejection fraction is made when there is clinical evidence (symptoms, signs) of heart failure and the LVEF is >50%. Diagnosis is supported by increased left ventricular filling pressures at rest or during exercise, structural abnormalities such as left atrial enlargement, decreased longitudinal strain, or left ventricular hypertrophy on echocardiography or other cardiac imaging. No one feature is diagnostic, and the probability increases as the number of objective non-invasive markers (including cardiac imaging and natriuretic peptide levels) of raised left ventricular filling pressures increases. 6 Invasive testing provides certainty, but this has risks and is not commonly done.

Should delays in access to investigations such as echocardiography occur, a clinical diagnosis of heart failure can be made and treatment initiated (such as diuretics and potentially, as some advocate, sodium-glucose cotransporter 2 inhibitors, given their benefit across the spectrum of heart failure) before a definitive diagnosis. 13 Point-of-care testing of troponins and natriuretic peptides, 16 as well as point-of-care ultrasound scanning of the lungs 8 and heart 17 may be helpful in rural and remote prehospital settings. However, confirming the diagnosis and ascertaining LVEF are critically important to ensure longer term treatment is appropriate. 5

How is heart failure managed in primary care?

Treatment of congestion.

Loop diuretics are used across all subtypes of heart failure to decrease pulmonary and peripheral congestion, in both acute and chronic settings, as well as for prevention of congestion in high risk patients. 8 These drugs effectively alleviate congestion related symptoms, with dosing targeted to achieve euvolaemia. 5 However, additional management is needed to treat the cause of heart failure (where possible) or to improve cardiac function over time. 5 For this reason, long term heart failure management should not rely on diuretics alone.

Use of diuretics may result in electrolyte disturbances, particularly hypokalaemia. Without careful monitoring and patient education, there is a risk of over-diuresis, which might precipitate symptomatic hypotension or pre-renal acute kidney injury. Polyuria is a common and expected effect and can reduce patients’ quality of life, leading to non-adherence to therapy. Lowering the dose may be helpful, but if dose reduction is not possible the timing of administration can be adjusted, in discussion with patients, to best fit their schedule. 5 14 With effective, guideline-directed management, diuretic requirements may decrease, necessitating adjustments to avoid hypovolaemia. Regular review of diuretic needs and self management strategies can further optimise therapy.

What medications to consider for heart failure with reduced LVEF?

Current clinical practice guidelines agree in recommending that foundational pharmacological therapy for heart failure with reduced ejection fraction should, when possible, include a combination of drugs from four distinct classes: renin-angiotensin-aldosterone system inhibitors (RAASi), β blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose co-transporter 2 inhibitors (SGLT2i). 5 6 18 19 20 Each of these drug classes has been shown to reduce mortality and hospitalisations for heart failure, 5 6 and combination therapy provides additive benefits in improving outcomes. 21 Titration to target or the maximal tolerated dose is recommended. However, benefits are seen even if maximal (target) doses are not reached. 22

In a network meta-analysis the most favourable combination of SGLT2i, β blockers, angiotensin receptor-neprilysin inhibitors (ARNi), and MRA greatly decreased all-cause mortality (hazard ratio 0.39 (95% confidence interval (CI) 0.31 to 0.49)) and the composite measure of cardiovascular death or first hospitalisation for heart failure (hazard ratio 0.36 (95% CI 0.29 to 0.46)). 21 Typically, these medications need to be continued long term, even if symptoms resolve and left ventricular function improves. 4 5 7

Polypharmacy is often a concern in primary care, and the suggestion of combination therapy may raise alarm. However, this concern needs to be balanced against the evidence for the additive benefits described. Emerging evidence suggests that more novel agents (SGLT2i and ARNi) “work together” to improve tolerance and persistence of other medication classes, such as MRA. 22 23 24 25 26

Renin angiotensin system inhibitors

Patients should be offered one of the following: an angiotensin-converting enzyme inhibitor (ACEi), an angiotensin receptor blocker (ARB), or an ARNi (a combination medication containing valsartan, an angiotensin receptor blocker, and sacubitril, a neprilysin inhibitor). These medications improve symptoms (over a few weeks to months) and exercise capacity, reduce the risk of hospitalisation for heart failure, and increase survival. 27 Guidelines offer mixed recommendations on which RAASi to start treatment with. The AHA/ACC/HFSA guidelines recommend ARNi as first line therapy, as do the Canadian Cardiovascular Society (CCS) guidelines. 5 20 The ESC guidelines recommend ARNi when symptoms persist despite optimal ACEi or ARB treatment, but suggest it can also be considered as first line therapy. 6 Pre-existing ACEi or ARB treatment must be stopped (with a washout period of 36 hours for ACEi) before initiating ARNi. Once commenced, withdrawal of ARNi can lead to clinical deterioration. 27

Common issues include symptomatic postural hypotension, which should prompt dose reduction, 22 27 but this may improve with time. 27 Diuretic dose adjustment may be necessary as ARNi may reduce diuretic requirements. 20 ACEi can cause a troublesome cough, necessitating a medication change, typically to an ARB. Other causes for cough should also be considered, particularly ongoing congestion, if the cough is nocturnal. Angioedema, a rare but serious side effect of ACEi, poses an increased risk when ACEi are used in combination with an ARNi, so their co-prescription is contraindicated.

Mineralocorticoid receptor antagonists

Mineralocorticoid receptor antagonists (MRAs) improve symptoms over several weeks to months, reduce the risk of heart failure hospitalisation, and increase survival. 27 These favourable effects are probably mediated predominantly by the non-diuretic effects of aldosterone receptor blockade, which include decreasing adverse myocardial remodelling and fibrosis. 28 Common issues with MRAs include painful gynaecomastia with spironolactone (patients should be warned about this), often necessitating a change to eplerenone, which has a greatly reduced incidence. Hyperkalaemia is also a concern, necessitating careful monitoring of renal function and potassium levels. 27 29 Recommendations for monitoring suggest checking renal function and electrolytes one week after initiating or increasing the dose, then monthly for the first three months, quarterly for a year, and then every six months. 30 Use of MRAs should be avoided in patients with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m 2 . 20 30 During an intercurrent, volume-depleting illness (such as gastroenteritis), MRAs should be withheld to prevent hyperkalaemia.

The β blockers metoprolol succinate, bisoprolol (β1-selective, cardioselective), or carvedilol (a non-selective β blocker with additional selective α1 receptor blockade) should be considered in all patients with reduced LVEF without contraindications. 5 Importantly, the β1-selective β blockers can be safely used in most patients with chronic obstructive pulmonary disease. 31 These medications improve symptoms, but this may take several months. 20 27 They also reduce the risk of heart failure hospitalisation and increase survival. 27 Initiation usually requires low doses and slow up-titration, particularly after recent decompensation or with severe cardiac impairment. 20 A deterioration in symptoms can occur with initiation and up-titration despite long term positive benefits. Hypotension and bradycardia are potential adverse events, and the dose should be reduced with symptomatic postural hypotension or a heart rate of less than 50 beats per minute. 22

Sodium-glucose co-transporter 2 inhibitors

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) improve quality of life (within weeks to a few months), reduce the risk of heart failure hospitalisation, and increase survival. 27 They should be considered for all patients with reduced LVEF who do not have contraindications. This recommendation is a recent addition to ACC/AHA/HFSA (2022), ESC (2021), CCS (2021), and Australian (2022) guidance. 5 6 19 20 Adverse effects include urinary infections, fungal and yeast infections, and a mild lowering of blood pressure. In people with type 2 diabetes, other glucose lowering medications may need adjustment, and SGLT2i are presently not routinely recommended for patients with type 1 diabetes. Adjustment and down-titration of diuretics may be required as diuresis can be intensified. 5 6 29 Even though SGLT2i may worsen measured renal function in the short term, they slow the decline in renal function in the long term as well as improve other clinical outcomes. 20 29 Titration is unnecessary as a single dose is recommended.

When and how are medications started for heart failure with reduced LVEF?

Initiation and titration.

ACEi, ARB, ARNI and MRA act within the renin-angiotensin-aldosterone system. Disturbances to renal function and electrolytes are possible, and monitoring of these when commencing or up-titrating medications is important. A baseline minimum eGFR of >30 mL/min/1.73 m 2 and blood potassium level <5.4 mmol/L are recommended as necessary for initiation. 22 Some disturbances may be tolerable; for instance, the ESC guidelines suggest a creatinine rise of up to 50% above baseline, or 266 µmol/L (3 mg/dL) or an eGFR <25 mL/min/1.73 m 2 , whichever is the smaller, and an increased potassium level to 5.5 mmol/L are tolerable when initiating ACEi. 27 Elsewhere it is proposed that a 30% rise in creatinine above baseline may be tolerated, after which the drug dose must be reduced, or stopped if the rise is greater than 50%. 22 30 32 Strategies such as temporary discontinuation of medication can be used, but re-initiation trials when renal function improves are important. 32 33

A systolic blood pressure of >100 mm Hg is recommended before starting drugs that may lower blood pressure. If such a drug is tolerated, lower blood pressure or mild symptomatic hypotension should not automatically lead to medication cessation but may warrant dose reduction. Symptomatic postural hypotension should prompt dose reduction. 22 In discussion with patients, strategies such as staggering medication administration or reducing other drugs without cardiovascular benefit (such as calcium channel blockers) and reviewing diuretic dose may allow continuation of these medications, which are critically important for optimal management and for the benefits of combination therapy. 22 33

Sequencing of drug initiation

Traditional guidance for initiation of these disease modifying medicines followed a sequential approach in which a drug from each class is introduced singly at low dose, with achievement of its target or maximal tolerated dose before the next drug is added ( fig 1 ). 22 However, more rapid initiation of a low dose of each of the four classes of disease modifying medications is currently recommended to more rapidly achieve additive benefits with combination therapy. 22 Simultaneous commencement of all classes at low dose has been suggested, 34 35 and other protocols have been proposed though evidence based randomised trial data is not yet available to support these (see fig 1 for examples). 18 35 36 37 The ACC/AHA/HFSA guidelines suggest the introduction and increase in dose of medications should be individualised to the patient and does not necessarily need to follow that of trial publications (the traditional sequential approach). 5 There is presently a gap in evidence for sequencing strategies in primary care, but both the ESC and ACC/AHA/HFSA guidelines suggest initiation and up-titration of these drugs are possible in the community in stable patients. 5 6

Proposed protocols for initiation and sequencing of pharmacological therapy for heart failure with reduced ejection fraction. In the traditional approach based on the major clinical trial sequences, 22 each drug is initiated (1) and then up-titrated to its to maximal dose or maximal tolerated dose (2) before the next drug is introduced (3), etc. In a rapid sequential approach (such as that proposed by Kittleson 37 ) each drug is initiated at low dose stepwise every 1-2 weeks (steps 1 to 4) before the ARNi and β blocker are up-titrated (5, 6). In a rapid initiation approach (proposed Straw et al 18 ; see also McMurray and Packer 36 ) low dose SGLT2i and ARNi are introduced simultaneously (1) and then, a few days later, the β blocker and MRA are added (2), and the four drugs are up-titrated together (3)

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Cost considerations

Β blockers, ACEi, ARB, and MRA are widely available with generic options, and provide high economic value. 5 ARNi and SGLT2i may be less widely available in resource-constrained health systems, and the economic value of these medications may be lower. 5 However, some analyses have suggested there are cost savings to healthcare systems with ARNi, 38 particularly in early initiation. 39

What treatments to consider for heart failure with mildly reduced LVEF?

The medications described above for heart failure with reduced LVEF should also be considered cases with mildly reduced LVEF, but the evidence base is less robust. 6 An exception to this is the SGLT2i. Recent trial evidence and a meta-analysis have resulted in an endorsement for this medication for management of mildly reduced LVEF in the 2023 focused update of the ESC guidelines, to reduce the risk of hospitalisation for heart failure or cardiovascular death. 40

What drug management is recommended for heart failure with preserved LVEF?

Management of heart failure with preserved LVEF has until recently focused on symptom management with diuretics and managing comorbid disease, particularly hypertension (aiming for blood pressure <130/80 mm Hg, with medication choice guided by other comorbidities 5 ), atrial fibrillation, and obesity, as well as other risk factors. 5 33 41

There is now an established role for SGLT2i in the treatment of heart failure with preserved LVEF. Two recent randomised controlled trials of SGLT2i have established a benefit with reductions in a composite outcome of hospitalisations or cardiovascular mortality, 42 43 and a recent meta-analysis has reinforced these findings (hazard ratio 0.80 (95% CI 0.73 to 0.87)). 44

The 2022 ACC/AHA/HFSA guidelines and an Australian consensus statement give a moderate strength recommendation to the use of SGLT2i in patients with heart failure with preserved LVEF, and the 2023 focused update of the ESC guidelines also endorses their use. 5 19 40

ACEi, ARB, ARNi, MRA, and β blockers have less benefit heart failure with preserved LVEF. MRA and ARB or ARNi may have a role in reducing hospitalisations, but the evidence base is limited and weak. 5 45 46 47 48 Reflecting this, the strength of recommendation in the ACC/AHA/HFSA guidelines for these interventions is “weak” for patients with preserved LVEF. 5

Non-pharmacological management of heart failure

Psychosocial support and education for patients and family are important to improve understanding of heart failure. This includes recognising the importance of medication adherence, learning when to take action for symptoms or signs of decompensation, and addressing barriers to care. 6

Many patients with heart failure reduce physical activity, which adds to deconditioning and loss of fitness. Regular exercise improves quality of life and exercise capacity. 14 49 50 Supervised exercise programmes or formal cardiac rehabilitation have evidence of benefit, and, ideally, all patients should be referred for this where available. 51 52

Loss of lean body mass is common in heart failure. Appetite may be poor because of gut congestion or reduced cardiac output, but it often improves with effective heart failure therapy. Patients are encouraged to consume tolerated foods to maintain body weight. 6

Strict fluid restriction is no longer generally recommended for patients with stable heart failure, though avoidance of excessive fluid intake is suggested. 53 This recommendation is based on limited evidence showing no significant difference in outcomes with and without fluid restriction. 53 The exceptions are for acute exacerbations of heart failure, patients with hyponatraemia, or advanced heart failure; in these settings, fluid restriction should be guided by heart failure specialists. 6 53

Similarly, sodium restriction is falling out of favour. A recent meta-analysis found that sodium restriction did not reduce the risk of all-cause death, hospitalisation, or a composite measure of death and hospitalisation in patients with heart failure. 54 Low sodium table salt alternatives should be avoided because of the potential for clinically important hyperkalaemia. Alcohol intake should not exceed general guideline recommendations and should be avoided when heart failure or comorbid diseases related to alcohol are present. 6 55 56

Evidence for vitamin or other supplements (without indication) is weak and not presently recommended. 56

Immunisation

Influenza vaccine is recommended, with evidence from a meta-analysis suggesting that it leads to reduced all-cause mortality in patients with heart failure (though the evidence quality is noted to be low). 57 Vaccination against pneumococcal disease 6 and covid-19 58 are also recommended.

Addressing causes and contributors

Heart failure stems from diverse pathways and causes ( table 1 ), most requiring specific treatments. 5

Common causes of heart failure and specific treatments

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Specialist cardiology assessment is usually indicated in patients with arrhythmias such as atrial fibrillation or flutter, left bundle branch block causing left ventricular dyssynchrony, or valve disease contributing to heart failure. In these patients, arrhythmia ablation, resynchronisation by pacing, or heart valve replacement or repair respectively may be indicated. Deterioration should also prompt a review to identify new conditions or causes. Additionally, some causes have implications regarding the screening of family members (such as cardiomyopathy).

Comorbidities such as hypertension, diabetes, atrial fibrillation, coronary artery disease, and chronic obstructive pulmonary disease may contribute to heart failure, be a part of the underlying cause, and/or make the diagnosis more difficult. 2 4 59 60 Optimal treatment of these is an important part of heart failure management. 5 14 For patients with heart failure and atrial fibrillation, oral anticoagulation is usually indicated to decrease stroke risk. Direct oral anticoagulants are usually preferred, with dose reduction if renal function is impaired. 6

Medications commonly prescribed in primary care can worsen heart failure, including non-steroidal anti-inflammatory medications, corticosteroids, tricyclic antidepressants, and α blockers. These should be avoided. 5 41 Medications known to decrease cardiovascular mortality or heart failure hospitalisation should be used in preference to non-dihydropyridine calcium antagonists unless there is another specific indication.

Iron deficiency is common in chronic heart failure 29 and can be treated with intravenous ferric carboxymaltose. Treatment improves quality of life 61 and reduced a composite measure of cardiovascular mortality and hospitalisation (relative risk 0.85 (95% CI 0.77 to 0.95)) in patients with heart failure with reduced LVEF. 62 The benefits for patients with preserved LVEF are not yet established but are under investigation. 62 Notably, the definition of iron deficiency commonly used in clinical trials (serum ferritin <100 μg/L) likely differs from commonly reported cut-off values used in primary care. Oral iron therapy benefits are limited due to variable absorption and intolerance. 29

Monitoring is important to guide treatment and detect deterioration. Stable patients on optimal therapy should be reviewed regularly, 14 including clinical evaluation of jugular venous pressure, chest and cardiac auscultation, heart rate and rhythm, and blood pressure.

Little evidence exists for the frequency of review, but some guidelines recommend a review every six months, 6 and this review can be undertaken in primary care. 63 Regular laboratory investigations include full blood count, electrolytes, and renal function. 6 B-type natriuretic peptide is not recommended for routine monitoring of stable patients. 6 An annual electrocardiograph is recommended. 5 A new finding of a QRS duration over 140 milliseconds in a patient with reduced ejection fraction should prompt a referral for consideration of cardiac resynchronisation therapy. 64 65

Patients can self monitor symptoms such as dyspnoea, fatigue, and pedal oedema, as well as changes in daily weight, which may reflect fluid accumulation or dehydration from excessive diuresis. Patients can be taught how to self adjust their diuretic doses and when to contact their care team. 6 For instance, increasing their diuretic dose if their weight increases persistently (for >48 hours) by more than 1.5-2.0 kg/day.

Covid-19 has highlighted the value of telemedicine, particularly as it provides opportunities to increase access to care without the risk of exposure to other illnesses. 6 Telemedicine can be useful particularly when optimising treatment, allowing for more frequent review and adjustment of medications. 6 A systematic review and meta-analysis of mobile health technology found interventions incorporating remote monitoring and clinical support reduced mortality and heart failure hospitalisations. 66

We think that simple devices which allow patients to measure heart rate, rhythm, and blood pressure are, combined with telemedicine, useful. Healthcare systems will need to adapt to use these technologies to fulfil their potential and manage any associated burden, particularly for primary care.

End of life considerations

The disease trajectory of heart failure patients can be difficult to predict. Death may be from progressive heart failure or occur suddenly and unexpectedly.

Many of the elements that contribute to effective care of patients with heart failure at the end of life can be initiated early on in primary care alongside other heart failure management. 14 67 This is particularly crucial when deterioration becomes apparent, such as following progression to advanced kidney disease, worsening hypotension requiring withdrawal or down-titration of the four pillars of medical therapy, frequent hospital admissions in the absence of clear precipitants, or diuretic resistance.

Timely conversations regarding expectations of treatment, advance care planning, assessing and relieving emotional distress and burden to patient and family, and consideration of involvement of specialist palliative care services are important roles for primary care practitioners. 68 69

Sources and selection criteria

We conducted a literature search of Medline and EMBASE databases using the terms “heart failure,” “preserved ejection fraction,” “reduced ejection fraction,” and “epidemiology.” We sought further items from the reference lists of relevant articles. We also consulted the latest National Institute for Health Care Excellence (NICE) guidelines and, particularly, the recently released European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Failure Society America guidelines. Further references as suggested by reviewers were also included where relevant.

Additional educational resources

European Society of Cardiology ( https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure ). 2021 guidelines and associated resources. The supplementary tables are particularly helpful for troubleshooting medication issues.

BMJ best practice ( https://www.bmj.com/company/bmj-resources/bmj-best-practice/ )

Patient Info. Articles for professionals on heart failure management and diagnosis and investigation. ( https://patient.info/doctor/heart-failure-management , https://patient.info/doctor/heart-failure-diagnosis-and-investigation )

Heart Foundation of Australia. Articles for professionals on heart failure clinical guidelines ( https://www.heartfoundation.org.au/for-professionals/clinical-guidelines-position-statements , https://www.heartfoundation.org.au/for-professionals/heart-failure-tools-and-resources )

Information resources for patients

Patient Info. Congestive heart failure. ( https://patient.info/heart-health/heart-failure-leaflet )

American Heart Association. Heart failure tools and resources. ( https://www.heart.org/en/health-topics/heart-failure/heart-failure-tools-resources )

Health Navigator. Heart failure. ( https://healthify.nz/health-a-z/h/heart-failure )

British Heart Foundation. Heart failure. ( https://www.bhf.org.uk/informationsupport/conditions/heart-failure )

Heart Failure Matters. ( https://www.heartfailurematters.org/ )

Education into practice

Consider an audit of your current patients with heart failure with reduced ejection fraction. Are these patients receiving all four disease-modifying treatments with dosing to target or tolerance?

How were patients involved in the creation of this article?

One of our team asked a primary care patient with heart failure (preserved ejection fraction) to review a draft of the paper. He commented that clinicians should be aware that, as a patient, he had questions about management, particularly medication, and wanted information that was meaningful to him in terms of impact on his day-to-day life such as: “What symptoms (in patient friendly terminology) will it affect?” “What are the likely effects and expected onset of these (such as furosemide and its associated inconvenience of diuresis)?” This led us to revise sections related to pharmacological management and psychosocial support. In addition, one of the first reviewers was a carer of a patient with heart failure, and we incorporated their suggestions into the final version.

Contributors: BA conceived the original idea. All authors were involved in the development and planning of the manuscript. BA and RR conducted the literature search. RR oversaw the creation of the article. All authors contributed to writing the manuscript and will act as guarantors.

Competing interests: The BMJ has judged that there were no disqualifying financial ties to commercial companies at the time of commissioning and writing the article ( https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf ). The authors declare the following other interests two years after commissioning and submission of the first draft: RS is a co-investigator for phase 3 randomised clinical trials on treatment of atrial fibrillation, acute coronary syndromes, and LDL cholesterol lowering (Librexis-ACS, Librexia-AF, and Victorion trials).

Provenance and peer review: Commissioned; externally peer reviewed.

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Genetic testing, communication and psychosocial issues, no consensus, limitations and areas for future research, cystic fibrosis foundation evidence-based guideline for the management of crms/cfspid.

Contributed equally as co-senior authors.

FUNDING: This guideline was supported by the Cystic Fibrosis Foundation. The sponsor assisted with the application of the committee members and resources for weekly and monthly virtual meetings of the committee members.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

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Deanna M. Green , Thomas Lahiri , Karen S. Raraigh , Fadel Ruiz , Jacquelyn Spano , Nicholas Antos , Lynn Bonitz , Lillian Christon , Myrtha Gregoire-Bottex , Jaime E. Hale , Elinor Langfelder-Schwind , Álvaro La Parra Perez , Karen Maguiness , John Massie , Erin McElroy-Barker , Meghan E. McGarry , Angelique Mercier , Anne Munck , Kathryn E. Oliver , Staci Self , Kathryn Singh , Michael Smiley , Steven Snodgrass , Audrey Tluczek , Pamela Tuley , Paula Lomas , Elise Wong , Sarah E. Hempstead , Albert Faro , Clement L. Ren; Cystic Fibrosis Foundation Evidence-Based Guideline for the Management of CRMS/CFSPID. Pediatrics 2024; e2023064657. 10.1542/peds.2023-064657

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Video Abstract

A multidisciplinary committee developed evidence-based guidelines for the management of cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen-positive, inconclusive diagnosis (CRMS/CFSPID). A total of 24 patient, intervention, comparison, and outcome questions were generated based on surveys sent to people with CRMS/CFSPID and clinicians caring for these individuals, previous recommendations, and expert committee input. Four a priori working groups (genetic testing, monitoring, treatment, and psychosocial/communication issues) were used to provide structure to the committee. A systematic review of the evidence was conducted, and found numerous case series and cohort studies, but no randomized clinical trials. A total of 30 recommendations were graded using the US Preventive Services Task Force methodology. Recommendations that received ≥80% consensus among the entire committee were approved. The resulting recommendations were of moderate to low certainty for the majority of the statements because of the low quality of the evidence. Highlights of the recommendations include thorough evaluation with genetic sequencing, deletion/duplication analysis if <2 disease-causing variants were noted in newborn screening; repeat sweat testing until at least age 8 but limiting further laboratory testing, including microbiology, radiology, and pulmonary function testing; minimal use of medications, which when suggested, should lead to shared decision-making with families; and providing communication with emphasis on social determinants of health and shared decision-making to minimize barriers which may affect processing and understanding of this complex designation. Future research will be needed regarding medication use, antibiotic therapy, and the use of chest imaging for monitoring the development of lung disease.

Cystic fibrosis (CF) newborn screening (NBS) has been offered in many countries around the world and in every US state since 2010. 1 An unintended consequence of CF NBS is the detection of infants with an abnormal CF NBS result but inconclusive diagnostic testing, which has been termed CF transmembrane conductance regulator ( CFTR )-related metabolic syndrome (CRMS) in the United States and CF screen-positive, inconclusive diagnosis (CFSPID) in other parts of the world. 2 Many people with CRMS/CFSPID are healthy, but a small proportion (<10%) will be reclassified as CF because of an updated annotation of their CFTR variants as CF-causing or an increase in sweat chloride concentration (sweat [Cl - ]) to ≥60 mmol/L(2). Approximately 10% will also develop clinical features that are concerning for CF (eg, pulmonary disease, Pseudomonas aeruginosa [ Pa ] in a respiratory culture). 2

In 2009, the Cystic Fibrosis Foundation (CFF) convened an expert panel to develop consensus recommendations for the management of infants with CRMS. 3 There have been multiple studies of CRMS/CFSPID outcomes and genetics 2 , 4 since then; thus, a diverse committee of CF providers and parents of people with CRMS/CFSPID was assembled in 2021 to develop an up-to-date, evidence-based guideline for the management and care of people with CRMS/CFSPID.

This guideline is intended to be used by both CF specialists and primary care providers (PCPs) who care for people with CRMS/CFSPID and their families. It should supplement the standard care provided in primary care. The guideline will not address how CRMS/CFSPID is diagnosed, nor the criteria for reclassifying people with CRMS/CFSPID as people with CF (pwCF) because these recommendations already exist; 2 , 5 however, it will address genetic testing to better refine the diagnosis. The European Cystic Fibrosis Society (ECFS) recently published a consensus guidance document concerning the management of children with CRMS/CFSPID. 6 The current guideline is evidence-based and is intended to complement the ECFS paper.

CFF intends for this guideline to summarize data and provide reasonable clinical recommendations to clinicians, patients, and other stakeholders. The application of these recommendations should not be mandated. Care decisions regarding individual patients should be made by using a combination of these recommendations, an associated benefit–risk assessment of the treatment options, the patient’s individual and unique circumstances, and the goals and preferences of the patients and families that the team serves as a part of shared decision-making (SDM) between the patient and clinician.

CFF sponsored the creation of the committee. The committee defined people with CRMS/CFSPID as people with an abnormal CF NBS result and (1) a sweat [Cl - ] of <30 mmol/l (normal) and 2 CFTR variants, at least 1 of which with unclear phenotypic consequences, or (2) sweat [Cl - ] of ≥30 to 59 mmol/L (intermediate value) and 1 or no CF-causing variants. 2 An online survey was sent to CF care centers (CFCC) and the families of people with CRMS/CFSPID to identify high-priority issues for both groups. Based on survey results, input from the committee, and areas of further research identified in previous guidelines, 24 questions were written in patient, intervention, comparison, outcome (PICO) format. 7 A systematic review was performed by using PubMed and the Cumulative Index to Nursing and Allied Health Literature databases. Literature review and evidence grading were performed by 4 working groups: genetic testing, monitoring, treatment, and psychosocial and communication issues. The groups generated recommendations that were graded by using the US Preventive Services Task Force (USPSTF) definitions ( Table 1 ). 8 The committee adhered to the USPSTF Procedure Manual 9 in generating and reviewing 31 specific recommendations. Statements that received ≥80% consensus among the committee were approved, resulting in 30 final recommendations ( Table 2 ) and 1 non-consensus statement ( Table 3 ). Details of the committee selection, PICO framework, search terms, and recommendation statements are available in the Supplemental Information and Supplementary Table 5 .

USPSTF Guideline Recommendations 8

Consensus Recommendation Statements: 30 Statements That Made Consensus

Non-Consensus Recommendation Statement: 1 Statement That Did Not Make Consensus

Additional CFTR Genetic Testing

The CFF recommends that people with CRMS/CFSPID who have <2 disease-causing variants identified by NBS should undergo sequencing of the coding and flanking regions and deletion/duplication (del/dup) analysis of the coding and exon flanking regions of CFTR (Grade B).

Establishing the CFTR genotype of people with CRMS/CFSPID is important for diagnosis, monitoring, and genetic counseling and, should reclassification to CF occur, may also be useful for the approval of CFTR modulators. Genotyping requires a stepwise approach that is dependent on the state’s NBS algorithm. A glossary of genetic terms is available in Supplemental Table 6 . Further genetic analysis is not necessary when 2 CFTR variants identified by NBS are confirmed to be in trans (1 inherited from each parent). However, sequencing of the coding and flanking intronic regions of CFTR, with del/dup analysis to evaluate for large structural variants, such as exon deletions, is useful in the diagnostic workup. 10 It should be performed when people with CRMS/CFSPID have only 1 or no identified disease-causing CFTR variants from NBS.

2. The CFF recommends, for people with CRMS/CFSPID, selectively offering full-gene CFTR sequencing including intronic regions when the CFTR genotype remains incomplete after coding and flanking region sequencing and del/dup (Grade C).

CFTR sequencing that includes all intronic regions has identified putatively causal variants among individuals with CF, CFTR -related disorders, and positive CF NBS results. 18 , – 23 Tests that include many flanking nucleotides and several deep intronic variants are fairly comprehensive; additional testing of all other intronic regions may offer little additional value or sensitivity. Full intronic sequencing should be selectively performed in people with CRMS/CFSPID who demonstrate evidence of potential CFTR dysfunction (eg, sweat [Cl-] of 30–59 mmol/L), or individuals for whom the clinical suspicion of CF development is high and who possess only 1 previously identified causal variant after full sequence and del/dup is provided (see Supplemental Information for further discussion). Availability of full CFTR sequencing is currently limited; this service may become more widely available in the future.

CFTR Testing in Family Members

3. The CFF recommends CFTR genetic evaluation for parents of people with CRMS/CFSPID when phasing the CFTR variants (ie, in cis or trans ) would inform the diagnostic status of the individual by confirming the inheritance pattern (Grade A).

4. The CFF recommends offering CFTR genetic evaluation for siblings of people with CRMS/CFSPID (Grade B).

For people with CRMS/CFSPID who have 2 identified CFTR variants, determining if the variants reside within the same copy (in cis ) or different copies (in trans ) of CFTR is achieved through the genetic testing of at least 1 first-degree relative, which is referred to as “phasing.” CFTR variants in cis can lead to diagnosis of CF carrier instead of CRMS/CFSPID, 21 , 24 which bears health and reproductive implications for the individual and family members.

Evaluating the siblings of people with CRMS/CFSPID can identify at-risk individuals who may also benefit from clinical monitoring and follow-up. 25 , 26 This assessment should be offered to families and promotes SDM with emphasis on the risks and benefits to the individual sibling. 6 In many instances, this may be delayed until childbearing age and at a time the sibling may also share in the decision-making regarding the value of this genetic information.

Genetic Counseling

5. The CFF recommends, for families of people with CRMS/CFSPID, that health care professionals (HCPs) providing genetic counseling should have training or clinical expertise in CF and genetics. A licensed or certified genetic counselor (GC) should be accessible to families of people with CRMS/CFSPID for further support, including discussions regarding future reproductive decision-making (Grade B).

Published recommendations affirm that genetic counseling should be offered to the families of people with CRMS/CFSPID. 6 , 27 , 28 The genetic counseling provider, whether they are a licensed or certified GC or a CF clinician, should have a high level of expertise in both CF genetics and CRMS/CFSPID. 27 Some families feel more comfortable discussing these topics with providers outside the CFCC. 29 , 30 Having access to a trained GC to discuss genetic findings and complement team members in providing psychosocial support promotes understanding 3 , 6 and strengthens long-term retention of genetic knowledge. 31 Genetic counseling at regular intervals throughout the lifespan allows for timely, accurate, supportive, and nondirective information on recurrence risk and reproductive options. 29

Frequency of Follow-Up

6. The CFF recommends, for people with CRMS/CFSPID, at least annual follow-up by a CF clinician and nurse, with an initial assessment to include a social worker, a mental health coordinator (MHC), and/or a genetic counseling provider. Continued follow-up by a social worker, MHC, and/or genetic counselor should be part of the care of CRMS/CFSPID, depending on the needs of that individual and family (Grade B).

The primary goal of monitoring people with CRMS/CFSPID is to detect those individuals who may be reclassified as CF and would benefit from care at a CFCC. Equally important is avoiding the overmedicalization of otherwise healthy individuals, which involves its own set of adverse consequences. Families should be informed about possible outcomes for people with CRMS/CFSPID and plans for future monitoring visits. Communication with PCPs is essential and should highlight reasons for more frequent reassessment by CFCC (eg, persistent cough, constipation, or inadequate weight gain). Routine follow-up should be provided by clinicians with expertise in CF and CFTR genetics to reexamine CFTR variants (eg, periodic assessment of the CFTR2 database) and changes in clinical status. Because most people with CRMS/CFSPID are healthy, evaluation by an entire multidisciplinary team is often unnecessary.

Sweat Chloride Testing (SCT)

7. The CFF recommends for people with CRMS/CFSPID to repeat SCT at 6 months of life and annually, at least until age 8 years (Grade B).

SCT is the mainstay for diagnosing CF and part of the diagnostic criteria for CRMS/CFSPID. One reason for reclassification of CRMS/CFSPID to CF is a sweat [Cl - ] of >60 mmol/L. The authors of multiple studies have reported sweat [Cl - ] elevation above this level after an initial sweat [Cl - ] of <60 mmol/L during the newborn period. 16 , 30 , 32 , – 39 However, evidence is lacking regarding changes in sweat [Cl - ] after 8 years of age, and SDM with parents should be used to determine if SCT should continue past this age. Careful consideration for continued SCT may be given to certain populations, including (1) individuals with initial sweat [Cl - ] of 40 to 59 mmol/L because they are up to 10 times more likely to have a sweat [Cl-] elevation of >59 mmol/L in later childhood 33 , 40 and (2) individuals with sweat [Cl - ] increasing at a high rate over time (>5 mmol/L per year). 16

Respiratory Cultures

8. The CFF recommends, for people with CRMS/CFSPID, selectively offering CF respiratory cultures at each visit (at least until age 8 years) and as clinically indicated for respiratory symptoms (Grade C).

Airway infection with CF-associated microorganisms, specifically Pa , is considered a phenotypic feature supporting a CF diagnosis. Compared with the general population, people with CRMS/CFSPID exhibit a higher prevalence of Pa (10.7% to 78.6%), Stenotrophomonas maltophilia (4.9% to 10%), and Staphylococcus aureus (40% to 85%) in respiratory cultures. 30 , 41 , 42 Some studies have revealed that people with CRMS/CFSPID who reclassify to CF more likely have a positive culture result for Pa than those who do not reclassify (33% vs 10%), whereas other reports have revealed no difference. 30 , 35 However, a positive culture result alone does not warrant reclassification. Some families and physicians may not want to expose the individual to trauma associated with cultures. Respiratory culture data from people with CRMS/CFSPID >8 years of age are currently lacking. If persistent respiratory symptoms are present, obtaining respiratory cultures in people with CRMS/CFSPID may be warranted. Thus, the evidence supports that cultures obtained via throat swab or sputum should be selectively offered after SDM with the family.

Laboratory Testing

9. The CFF recommends, for people with CRMS/CFSPID, that measurement of fecal elastase (FE) should be performed at the initial assessment. Further testing of FE can be provided when clinically appropriate (Grade B).

10. The CFF recommends against routine laboratory evaluations, including fat-soluble vitamin testing, liver function testing, glucose monitoring, and blood counts for people with CRMS/CFSPID (Grade D).

Measuring FE at the initial assessment is important to evaluate for exocrine pancreatic function because pancreatic insufficiency is a clinical feature of CF. FE levels can fluctuate in the first year of life; therefore, a single abnormal FE level should be interpreted cautiously, and repeat testing may be warranted 43 if symptoms of steatorrhea or failure to thrive develop. Most people with CRMS/CFSPID exhibit normal growth and nutrition and are pancreatic sufficient; thus, the presence of pancreatic insufficiency would strongly support reclassification to CF. 35 , 44 , 45

There is no evidence that laboratory results, such as electrolyte concentrations or liver function tests, are abnormal in people with CRMS/CFSPID. 35 Excessive testing leads to overmedicalization and increased cost of care. Therefore, laboratory tests should only be considered when clinically indicated.

Pulmonary Function Testing

11. The CFF recommends against routine pulmonary function testing (PFT; ie, spirometry, multiple-breath washout) for people with CRMS/CFSPID (Grade D).

Spirometry and multiple-breath washout are normal in people with CRMS/CFSPID 4 , 33 , 35 and do not affect reclassification to CF. PFTs should be considered if clinical concern for respiratory disease arises, and if abnormal, may support reclassification to CF.

Radiographic Imaging

12. The CFF recommends against routine chest radiographs for people with CRMS/CFSPID (Grade D).

Chest imaging is normal in people with CRMS/CFSPID within the first years of life 35 and does not inform reclassification to CF. Chest radiographs should be considered if clinical concerns arise.

Infection Prevention and Control

13. The CFF recommends, for people with CRMS/CFSPID, the implementation of standard CF infection prevention and control (IPC) guidelines in health care settings and situations in which there is a high likelihood of being in close contact with multiple pwCF or people with CRMS/CFSPID (Grade B).

The acquisition of Pa may guide reclassification to CF, and there is a risk that exposure to pathogens commonly associated with CF may negatively impact the individual. 46 This risk is most substantial in the health care setting in which close contact could occur among multiple pwCF or people with CRMS/CFSPID. IPC guidelines have been adopted by CF programs with minimal negative impact. 47 The implementation of IPC guidelines in non-health care settings, such as schools, may have significant negative psychological effects that outweigh potential benefits and are not recommended.

Infectious Disease Interventions

14. The CFF recommends, for people with CRMS/CFSPID, selectively offering inhaled antibiotics for the treatment of Pa based on a positive respiratory culture (Grade C).

15. The CFF recommends, for people with CRMS/CFSPID and an unexplained prolonged cough (>2 weeks), selectively offering the use of oral antibiotics (Grade C).

A higher prevalence of Pa is reported in respiratory cultures from people with CRMS/CFSPID compared with those collected from children without CF, 2 , 4 , 41 , 42 and treatment to eradicate incident Pa infection is recommended for pwCF. 48 However, the clinical impact of Pa in respiratory cultures from people with CRMS/CFSPID is unclear. Pa may clear spontaneously, (ie, independent of whether treatment is provided), 49 calling into question the value of Pa eradication therapy. The committee recommends selectively offering this treatment after a SDM process incorporating the potential benefits, risks, and treatment burden of inhaled antibiotic therapy in people with CRMS/CFSPID with positive respiratory culture for Pa . If the decision is to treat, then follow-up cultures are warranted to ensure Pa clearance.

Precedent is established regarding use of oral antibiotics for prolonged cough for individuals with respiratory conditions other than CF, including tracheobronchomalacia, protracted bacterial bronchitis, non-CF bronchiectasis and neuromuscular disease. 50 , – 54 The committee discussed this consideration while weighing the potential benefits and harms of antibiotic therapy. The use of any antibiotic for eradication or treatment may depend on clinical status of the individual, and the risks and benefits of treatment burden should be assessed for each family. For people with CRMS/CFSPID with a cough lasting >2 weeks, other etiologies of persistent cough, such as asthma, should be considered.

Nutritional Interventions

16. The CFF recommends, for people with CRMS/CFSPID with adequate growth, that nutritional management be provided under the direction of the PCP (Grade B).

17. The CFF recommends, for people with CRMS/CFSPID with a downward trajectory of weight-for-age percentile or z-score (eg, crossing percentiles), that screening and evaluation be provided by a dietitian with experience in the management of CRMS/CFSPID and CF (Grade B).

18. The CFF recommends against salt supplementation for people with CRMS/CFSPID (Grade D).

19. The CFF recommends against the use of fat-soluble vitamins for people with CRMS/CFSPID (Grade D).

No evidence exists to support the use of supplemental nutrition, caloric modifications, or CF-specific diets for people with CRMS/CFSPID who are exhibiting normal growth. 55 A downward growth trajectory, as measured by weight-for-age percentile or weight z-score, may be a sign of reclassification to CF. Children who demonstrate this pattern should undergo nutritional screening and appropriate intervention by dietitians with experience in CRMS/CFSPID and CF. Given that people with CRMS/CFSPID have intermediate or normal sweat [Cl - ], excessive salt loss is not expected, and potentially harmful consequences could be conferred by a high-salt diet. 56 , 57 No evidence suggests the need for supplementing fat-soluble vitamins to people with CRMS/CFSPID 35 because deficits in these vitamins have not been observed, and routine laboratory tests are not being monitored.

Pulmonary Interventions

20. The CFF recommends against the routine use of airway clearance therapy (ACT) for people with CRMS/CFSPID (Grade D).

21. The CFF recommends for people with CRMS/CFSPID experiencing new respiratory symptoms selectively offering the use of ACT (Grade C).

22. The CRMS/CFSPID guideline committee recommends against the use of CFTR modulators for people with CRMS/CFSPID (Grade D).

23. The CFF has determined that there is insufficient evidence to recommend for or against the use of medications usually used to treat CF respiratory symptoms for people with CRMS/CFSPID (Grade I).

Routine ACT and its effects on outcomes, such as bronchiectasis, are unclear for people with CRMS/CFSPID; hence, daily use is not recommended. ACT has been recommended for the management of acute respiratory symptoms for pediatric patients with other pulmonary conditions 58 , 59 ; thus, for people with CRMS/CFSPID and new respiratory symptoms, ACT may be considered. Initiation should be discussed with the family because ACT may add a significant burden. The use of cost-effective methods (such as manual percussion) should be attempted.

No studies have been reported in which the authors investigated the outcomes of CFTR modulator therapies among people with CRMS/CFSPID, and potential adverse effects are associated with these medications. 60 , – 62 If people with CRMS/CFSPID develop signs and symptoms warranting the use of CFTR modulators, reclassification to CF may be justified.

Medications that are commonly used for CF lung disease, 63 , 64 (ie, dornase alfa, hypertonic saline, and low-dose azithromycin) have not been evaluated in people with CRMS/CFSPID. The potential benefits of these medications for people with CRMS/CFSPID are unclear because the degree of CFTR dysfunction in CRMS/CFSPID may not necessarily result in significant changes in airway surface liquid. Weighed against the risks of medical complexity, treatment burden, and cost, there is insufficient evidence to either recommend for or against use of these medications. For people with CRMS/CFSPID with chronic respiratory symptoms that would require consideration of therapy, the reassessment of CF is warranted.

Communication With Families

24. The CFF recommends, for people with CRMS/CFSPID, that HCPs assess and consider social determinants of health (SDOH) that can influence the understanding and psychological impact of a CRMS/CFSPID diagnosis and tailor communications appropriately (Grade B).

25. The CFF recommends, for people with CRMS/CFSPID, that HCP tailor communication about CFTR variants based on SDM to minimize psychological, cognitive, and other barriers to processing and understanding genetic information (Grade B).

26. The CFF recommends, for people with CRMS/CFSPID, that clear, concise, consistent, and timely information about the uncertainty related to the CRMS/CFSPID diagnosis is provided using family-centered communication strategies (Grade B).

27. The CFF recommends, for people with CRMS/CFSPID and their families, that gradual, clear, and consistent, verbal and written, developmentally appropriate education about CRMS/CFSPID is provided at diagnosis, at follow-up visits, and at the time of reproductive decision-making (Grade B).

The psychological impact of the uncertainty associated with CRMS/CFSPD is challenging for parents and highlights the need for consistent and clear communication between families, patients, and HCP. 65 , 66 SDOH can influence a persons’ understanding of a diagnosis based on previous knowledge, emotional state, genetic and health literacy, and perceptions of test results. 66 , – 69 Screening for SDOH will identify social needs for which CFCC can provide links to further services. Parental learning preferences should be considered. Qualified medical language interpreters should be involved unless the provider is certified as a proficient interpreter in the primary language of the people with CRMS/CFSPID and their caregivers.

Perceived lack of knowledge of the person communicating NBS results has been linked to parental distress. 70 Clear, concise, and consistent information with plans for future follow-up is necessary for parents managing the uncertainty associated with the diagnosis of CRMS/CFSPID. 2 , 65 Accurate information, with reassurance and without conjecture, is critical for moderating parental response to this diagnosis. 66 , 71 Educational tools have been developed to assist HCP when communicating information to families the uncertainty of other diagnoses. 70 Additional information on this topic is available in the Supplemental Information .

Communication With Primary Care

28. The CFF recommends, for people with CRMS/CFSPID, that the PCPs and other HCPs involved in the care of individuals with CRMS/CFSPID receive accurate and up-to-date education about CRMS/CFSPID, its management, and the state’s NBS program (Grade B).

When communicating with parents and HCPs, it is important to provide information regarding further symptoms that may arise and when to refer to a CFCC. Because NBS algorithms vary by state, 1 CFCCs should serve as a resource with current information for PCPs to help educate and clarify any CFTR results, SCT, or other evaluations that pertain to CRMS/CFSPID. 3 , 6

Screening for Depression and Anxiety

29. The CFF recommends that at least 1 primary caregiver of people with CRMS/CFSPID be offered screening for depression and anxiety annually (Grade B).

30. The CFF recommends, for people with CRMS/CFSPID aged 12 years and older still being followed by CFCC, that screening for depression and anxiety be provided annually (Grade B).

The International Committee on Mental Health in Cystic Fibrosis 72 and the USPSTF screening guidelines 73 , 74 recommend annual screening for depression and anxiety in people aged 12 years and older. To be consistent with guidelines, the committee recommends utilizing the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 forms. A team member with expertise and training in mental health should be identified to implement screening, follow-up, and referral. 72 Although there is insufficient evidence to recommend routine screening for anxiety and depression in people with CRMS/CFSPID aged 7 to 11 years, this population should be clinically evaluated for these problems when significant symptoms or behavioral concerns are reported or if caregiver depression or anxiety scores are elevated.

Mothers of people with CRMS/CFSPID exhibit increased rates of anxiety, depression, and postpartum depression that are comparable to rates detected among mothers of pwCF. 75 News of the CRMS/CFSPID designation may create a state of cognitive uncertainty regarding the nature of the diagnosis and prognosis. This mental state contributes to clinically significant distress for parents and caregivers 76 , – 78 like that experienced by parents of pwCF. 66 Discussions should be family-centered and may include asking about the caregiver’s emotional and mental health concerns and SDOH, racism, poverty, and relational health. 73 , 79 , 80

The committee was unable to reach a consensus of 80%, with 20 voting for recommendation (74%) and 7 voting against a recommendation for selectively offering chest computed tomography (CT) scans. There are few reports of chest CT imaging in people with CRMS/CFSPID, 35 , 49 , 81 , 82 and abnormal findings are rare. Many members of the committee felt that chest CTs are not routinely recommended for pwCF and should not be recommended for people with CRMS/CFSPID.

Although numerous studies of CRMS/CFSPID have been published since 2009, most encompass single-center analyses with relatively small cohorts. The CFF Patient Registry (CFFPR) contains many people with CRMS/CFSPID and has been used to study CRMS outcomes. However, there is no requirement for inclusion in the CFFPR, and many people with CRMS/CFSPID are not represented in this database. No randomized clinical trials of people with CRMS/CFSPID have been reported, and it is unlikely that such future studies will be performed, all of which affect the strength of the present recommendations. Enrolling more people with CRMS/CFSPID into CFFPR will be a primary way to develop larger multicenter cohort studies and better guide management.

Genetic testing technology is continually advancing. Tests with limited availability now (eg, compete sequencing of the intronic regions of CFTR ) may become more widely available in the future. Establishing the disease liability of VVCCs and variants of uncertain significance represents an unmet need that may help assess the risk of reclassifying CRMS/CFSPID to CF, as well as guide the selection of CFTR variants in NBS algorithms. Knowledge of state NBS algorithms and access to further genetic testing will be essential because these platforms continue to vary across the United States. 1 People with CFTR -related disorder have CFTR and SCT results similar to people with CRMS/CFSPID, 83 but the likelihood of people with CRMS/CFSPID developing into CFTR -related disorder is currently unknown. Pursuing this area of research is also an important area for future research.

Working closely with PCPs is a mainstay of care for people with CRMS/CFSPID. Table 4 is a suggestion for the continued monitoring and care of people with CRMS/CFSPID and can be employed at both specialty care and primary care. Determining an appropriate time to discharge from care at a specialized center will require SDM with the people with CRMS/CFSPID, family, specialty providers and PCPs. Guidance regarding when to refer back to specialty clinics (eg, change in respiratory symptoms) needs to be developed.

Monitoring and Care for the Person With CRMS/CFSPID

A, annually perform; C, consider; P, perform. —, not needed at this age.

a If still being followed at CFCC.

We present this evidence-based guideline for the management of CRMS. Most of the recommendations were grade C because of the limited data that are currently available. As more people with CRMS/CFSPID are followed for longer periods of time, reassessment of these recommendations will be required. Additionally, research is needed to assess clinical benefits of treating pulmonary symptoms with medications commonly used for CF lung disease, antibiotic therapy for Pa in respiratory cultures, and the use of PFTs or chest imaging for monitoring development of lung disease in people with CRMS/CFSPID.

Drs Green and Ren were co-chairs of the guideline committee, conceptualized the initial survey questions, outlined community concerns and topics to address, authorized and had final selection of committee members, participated in working group meeting and leadership meetings, drafted the initial manuscript, and critically reviewed and revised the manuscript; Drs Lahiri, Ruiz, and Spano and Ms Raraigh were the working group leads, reviewed data, conducted monthly meetings to revise statements, drafted initial sections of the manuscript, and critically reviewed and revised the manuscript; Drs Antos, Christon, Gregoire-Bottex, La Parra Perez, Massie, McGarry, Munck, Oliver, Smiley, and Snodgrass and Ms Bonitz, Ms Hale, Ms Langfelder-Schwind, Ms Maguiness, Ms McElroy-Barker, Ms Mercier, Ms Self, Ms Singh, Ms Tluczek, and Ms Tuley were assigned specific PICO questions to review and abstract data, participated in the final voting meeting for statement inclusion and grading, and critically reviewed and revised the manuscript; Ms Lomas, Ms Wong, Ms Hempstead, and Dr Faro critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

The guidelines and recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement.

airway clearance therapy

cystic fibrosis

cystic fibrosis care centers

Cystic Fibrosis Foundation

CFF Patient Registry

cystic fibrosis screen-positive, inconclusive diagnosis

cystic fibrosis transmembrane conductance regulator

CFTR-related metabolic syndrome

computed tomography

deletion/duplication

European Cystic Fibrosis Society

fecal elastase

genetic counselor

health care professional

infection prevention and control

mental health coordinator

newborn screening

Pseudomonas aeruginosa

primary care provider

pulmonary function testing

patient, intervention, comparison, outcome

people with cystic fibrosis

shared decision-making

social determinants of health

sweat chloride concentration

US Preventive Services Task Force

variants of varying clinical consequence

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Exorbitant fees and undisclosed kickbacks: Inside the poorly regulated strata management industry

Analysis Exorbitant fees and undisclosed kickbacks: Inside the poorly regulated strata management industry

From the ground up, a large brown brick apartment complex stands, with a cloudy blue sky backdrop.

Just after lunch on March 16, a pleasant Saturday afternoon, Stephen Brell took to the stage at a hotel in Lorne, on Victoria's Great Ocean Road.

The NSW President of the Strata Community Association was at an industry getaway which promised three days of “blending networking with relaxation”, interspersing canapés, barefoot bowls and golfing with talks by the leading lights of the strata industry that manages apartment buildings on behalf of owners.

Brell, a two-decade veteran of the strata game, was one of them.

He had risen to managing director of Netstrata, a naming rights sponsor of the Jubilee Stadium in Sydney and winner of multiple industry awards. The company last year turned over $66 million and Brell earned as much as $1.2 million in salary and dividends.

At 1.45pm he took the microphone to speak on his chosen topic, "Profitability and ethics in business management". Attendees were promised an exploration of the "intersection" of these concepts, including a focus on the industry's long habit of taking kickbacks from contractors and insurers. Brell spoke, and answered questions, on "the ethical considerations around commissions and how to balance profitability with ethical practices".

Just days later, it was these very issues which would turn Brell's world upside down. Confronted by evidence his firm had charged exorbitant and sometimes hidden fees and been the recipient of undisclosed kickbacks, he would be forced to step down from his leadership position with the organisation, then resign from the SCA board altogether .

Less than a week after his talk on ethics, the organisation he had previously led announced an "independent review" into Brell's company, and the commencement of a "formal complaints management process" against the firm. The government regulator, NSW Fair Trading, would later confirm it too had "commenced an investigation".

Profitability and ethics

The turn of fortune came just days after returning from Lorne, when Brell was interviewed by ABC's 7.30 and made several admissions.

Key among them: that Netstrata had been accepting "referral fees" from a suite of contractors, including debt collectors — all hired with owners corporation's funds — without disclosing the quantum of those kickbacks to its clients. This, despite explicit promises in its annual reports to owners that it would do so.

Opaque arrangements

To get some idea of how extensive these side-deals are, and how opaque the arrangements, consider but one example.

A company routinely hired by Netstrata to perform data entry and trades compliance work is an outfit called Prime Strata Support Services Pty Ltd. It’s a company registered in Australia, but staffed and operated out of the Philippines.

Netstrata's mandatory disclosures have misidentified this company for many years. It is described in its report to owners by a name that does not exist on the Australian corporate registry.

When asked whether Netstrata's dealings with the company created any further conflicts of interest the company had yet to disclose, Brell confirmed it is owned and run by relatives of one of Netstrata's most senior executives, Jeremy Stone.

In Brell's words: "I certainly appreciate that one of our directors, his father-in-law owns that company. Prior to this interview, I did review that and I said we should be disclosing that as a personal relationship."

In just the past three years, Netstrata has reported the receipt of almost $1 million as a result of this side deal with Prime Strata.

Brell told the ABC that its referral fees from such arrangements can be "as high as 15 per cent". "Some go higher," he said.

The non-disclosure of such kickbacks in reports to owners — the ABC checked annual reports as far back as 2015 and found not a single referral fee mentioned — were among the matters that Brell pledged he would "tidy up" once he returned to the office.

A deluge of complaints

It was because of the extent of the problems identified at Netstrata that the ABC’s investigative unit decided to undertake a nation-wide investigation into the strata management industry.

We are asking for owners, regulators, contractors and industry insiders to come forward with information in the public interest and have established a website for them to do so.

The ABC's reports plunged the industry into damage control. In addition to sidelining Brell, the SCA National Council, which includes a representative from every state and territory body, released a public statement assuring consumers it had "listened to the concerns that have been raised … from within the sector and externally".

Among early reforms it has promised was the fast-tracking of a requirement for members to disclose insurance brokerage fees that was not previously mandatory.

New guidelines for the industry "that clearly addresses conflicts of interest … outside of insurance" have also been promised and these rules would be enforced by a new "independent chair" of a "complaints and conduct panel".

Alisha Fisher, CEO of SCA Australasia, said the industry was "committed to raising standards and improving practices among its members".

Her pledges are symptomatic of an industry in crisis, desperate to head off any serious push for new legislation. Many strata managers know that in the long absence of proper regulation by government, the industry has become addicted to the routine exploitation of apartment owners, and the easy profits which flow as a result.

Evidence of the trouble is in the deluge of responses received by the ABC thus far.

In the less than two weeks since we published our findings about Netstrata, we have received more than 1,000 separate reports about suspect activities by a wide sweep of strata management companies. Practically all of the complaints appear to be credible and well-documented. Several have been lodged by people with intimate knowledge of how the industry operates.

Some of the experiences being described are simply dreadful. Extraordinary self-dealing by strata management companies, using subsidiary and associate outfits in defiance of the wishes of their owners corporations. Refusals of strata managers to abide by a termination of their contract and their ongoing extraction of management fees. The failure to return the assets and records of buildings, and the disappearance of trust funds. Police having to be called to AGM meetings.

Most concerning, perhaps, are the persistent reports that some strata managers have protected property developers from building defect warranty claims. What is being alleged is an arrangement by which a strata management firm is appointed to oversee a new building while the developer still owns a sufficient number of units in the complex to control the owners' corporation — the strata manager gains a lucrative new building management contract, and, in return, it dissuades owners from lodging claims against the builder.

Many people are also deeply upset by the ABC’s revelations concerning strata insurance.

We discovered Netstrata had been using a wholly-owned subsidiary to charge insurance broking fees at inflated rates. These fees had not been routinely disclosed to owners but had reached as high as 64 per cent of the base premium, when brokers would commonly charge between 5 and 15 per cent, and sometimes 20 per cent.

Worse than we initially knew

We are now learning it is so much worse than what we had understood.

One of many buildings managed by Netstrata, and now demanding answers from the company, has since received copies of its insurance invoices dating back several years. The owners are aghast. In one year they realised they had been charged more for the broking fee than the insurance policy itself. The fee they had been charged was 115 per cent of the base premium.

Netstrata's only public statement since the ABC story was broadcast was an apology to customers "affected by any lack of transparency to date" and a pledge to do better. In addition to undertaking "an immediate audit" itself, it has also invited the regulator, NSW Fair Trading, to "conduct a review of our practices".

What might we expect of the NSW government? So far, we've seen a single-sentence statement announcing an investigation, and we've heard nothing at all from the state's new strata commissioner, John Minns. Read into that what you will.

Netstrata has invited the government regulator inside the hen-house perhaps believing it isn’t much of a fox to begin with. Indeed, the company might be hoping for a lacklustre investigation that turns into a public relations coup.

Some at Netstrata certainly haven't been afraid of the Department of Fair Trading for a very long time. Two former managers at the company told me the regulator's nickname about the office was the "Department of Fairy Tales".

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Netstrata chief stands aside from peak body, company apologises after ABC report reveals excessive fees

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MSU Extension Fruit & Nuts

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At 1.45pm he took the microphone to speak on his chosen topic, "Profitability and ethics in business management". Attendees were promised an exploration of the "intersection" of these concepts ...
Lloyds Restructures Risk Management Unit After Internal Review
1:24. Lloyds Banking Group Plc is restructuring its risk management division, the latest change in Chief Executive Officer Charlie Nunn 's yearslong push to simplify the lender. The ...
Federal Register :: Agency Information Collection Activities
The Food and Drug Administration (FDA, Agency, or we) is announcing that a proposed collection of information has been submitted to the Office of Management and Budget (OMB) for review and clearance under the Paperwork Reduction Act of 1995. DATES: Submit written comments (including recommendations) on the collection of information by May 13, 2024.
2024 Michigan Fruit Management Guide available in print or downloadable PDF
The Michigan Fruit Management Guide (E0154) from Michigan State University Extension has long served to assist fruit growers with selecting pesticides and other pest management tools as they plan for the growing season. In addition to a printed spiral bound edition, you can also purchase a downloadable PDF of this resource for a reduced fee.