To the American Association of Respiratory Care and National Board of Respiratory Care,

As you know, the journal CHEST recently published an article authored by several members of the NBRC Board. The article, entitled “Evaluating a Potential National Board for Respiratory Care Credential for Pulmonary Disease Educators” (https://doi.org/10.1016/j.chest.2023.02.002) discussed the results of viability and personnel studies conducted regarding the development of a new potential new specialty credential during 2019 and 2020. The results of the interdisciplinary viability study encouraged the development of such a credential. Unfortunately, according to the article, the results of the personnel study were less favorable, leading NBRC to discontinue development of said credential. We, the undersigned respiratory therapists, care navigators, patient advocates, and other interested parties, believe the personnel study suffered from significant limitations and confounding factors, which led NBRC to an erroneous conclusion that will negatively affect patient care. We also therefore call upon NBRC to revisit their decision and resume development of a formal pulmonary disease credential. Per NBRC policy, we further call upon AARC to officially request this process to restart. 

As mentioned in the CHEST article, disease educator roles have an established track record of success in various disease states. Perhaps the greatest success story is that of the certified diabetes care and education specialist (CBDCE, originally the certified diabetic educator, or CDE). According to the Certification Board for Diabetes Care and Education (like NBRC, accredited by the National Commission for Certifying Agencies), the number of individuals holding this credential has risen from 1,248 to over 19,500 in 35 years. CBDCE credential holders have been able to improve the quality of life and overall health status of millions of people during that time, and they are the first specialists highlighted by the authors touting the benefits of a specialty credential.1 According to the Centers for Disease Control and Prevention (CDC), deaths from chronic lower respiratory diseases significantly exceed deaths from diabetes both in overall numbers and in age-adjusted mortality rates.2 However, disease prevalence rates indicate that the number of citizens that carry a diabetes diagnosis is similar to the number that have a current asthma or COPD diagnosis (12% of the population and 15%, respectively).3 This disparity would appear to indicate the need for additional respiratory disease education and speaks to the potential impact of a formally-recognized specialist on healthcare in the United States.

Indeed, research suggests that, across various healthcare professions, specialty credentials likely have a positive effect on patient outcomes. In 2009, Coleman et al. found that certification of oncology nurses resulted in enhanced knowledge of best practices as well as improved adherence to symptom management guidelines.4 Job satisfaction and patient satisfaction scores were also higher as compared to non-certified nurses. Certified wound care nurses scored significantly higher than their uncertified colleagues on a standardized knowledge test, suggesting that the additional (and continuing) education associated with their additional credential benefits patients by improving accuracy in staging and management.5 Surgical nurse certification has been associated with some reduction in complications and mortality, as well as a higher perceived level of professionalism. Improvements in disease detection and staging is essential at a time when COPD remains a leading cause of morbidity and mortality, when asthma remains a top cause of absenteeism at work and in school, and when long COVID poses unknown long-term risks for tens of millions across the country.

Additional specialty certification also provides for additional professional recognition and, as previously noted, personal job satisfaction. Significant majorities of certified nurses and administrators were found to agree that the certification process demonstrated professional commitment, increased credibility and competence, and even recognition from both employers and other health professionals.6 This is consistent with the potential benefits as perceived by administrators in the NBRC personnel study referenced in your article. We believe the increased commitment and increased recognition are both vitally important to the state of the profession, particularly as we aim to recruit new RTs (and retain existing ones) to overcome the current critical shortage.

We believe that the confounding factors surrounding this survey are significant enough to prevent an accurate conclusion from being drawn from these data. The authors note several identified limitations of the survey, notably concerns about potential population representation and nonresponse bias. The survey was also conducted in the midst of a pandemic, which likely affected motivation and capacity to respond. Respondents were primarily respiratory therapists, who are often established in inpatient settings and may not fully appreciate the need for education in the ambulatory care setting. The survey also quoted 78.6% of administrators reporting their patient populations having “access” to pulmonary rehabilitation programs where disease education may take place. However, it must also be noted there are no standardized criteria for pulmonary rehabilitation program certification and education standards vary wildly between programs. In addition, despite this level of supposed access, only 1.9% of people living with COPD actually utilize such a program within six months of a hospitalization.7 This speaks to a critical need to provide education in other venues, including primary care and other post-acute settings. Recently, the American Association of Respiratory Care highlighted the urgent need for additional pulmonary disease education with their call to improve respiratory staffing throughout the Department of Veterans Affairs. This increase is critically important in light of the many veterans impacted by exposures to burn pits and other toxic pollutants joining the 25% of all current veterans already impacted by COPD. In order to provide optimal care to our veterans and all others with chronic lung conditions, standardized pulmonary disease management education is essential. This becomes much easier in the framework of a credential exam.

We understand and respect the authors’ statement that “uncertainty is a threat that discourages a decision to move ahead” in the context of the SWOT analysis they conducted. However, the necessity for additional structured patient education regarding chronic respiratory conditions is certain. The desire from administrators for a credentialed professional to provide that education is also certain. Given the significant impact of respiratory disease with no decrease in prevalence in sight, it seems inevitable that this credential will be offered by some organization in the foreseeable future. We therefore feel that the development of a pulmonary disease educator specialty credential is in the best interests the respiratory care profession, in terms of recruitment, retention, and expansion, as well as the patients we serve. We submit that it is incumbent upon NBRC to assume a leadership role in developing said credential. Therefore, we call upon our professional bodies to facilitate this process. 

1.          Davies MJ, Aroda VR, Collins BS, et al. Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2022;45(11):2753-2786. doi:10.2337/DCI22-0034

2.          Xu J, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2021 Key findings Data from the National Vital Statistics System. Published online 2021. Accessed March 2, 2023. https://www.cdc.gov/nchs/products/index.htm

3.          CDC - BRFSS. Accessed March 2, 2023. https://www.cdc.gov/brfss/index.html

4.          Coleman EA, Coon SK, Lockhart K, et al. Effect of Certification in Oncology Nursing on Nursing-Sensitive Outcomes. Number 2 / April 2009. 1969;13(2):165-172. doi:10.1188/09.CJON.165-172

5.          Certification and Education: Do They Affect Pressure Ulcer K... : Advances in Skin & Wound Care. Accessed March 8, 2023. https://journals.lww.com/aswcjournal/Abstract/2007/01000/Certification_and_Education__Do_They_Affect.12.aspx

6.          The Value of Certification-A Research Journey - ProQuest. Accessed March 8, 2023. https://www.proquest.com/docview/200796817?parentSessionId=oq62qZUNKkU0FISHU63CK1w49iESXIBhhRxfunVJLL0%3D&pq-origsite=360link&accountid=160899

7.          Spitzer KA, Stefan MS, Priya A, et al. Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease among Medicare Beneficiaries. Ann Am Thorac Soc. 2019;16(1):99-106. doi:10.1513/ANNALSATS.201805-332OC