Delivering Bronchiectasis and NTM Care in Safety-Net Health Systems: A Practical Framework for Implementation.

Abstract

The prevalence of bronchiectasis and nontuberculous mycobacterial (NTM) pulmonary disease are rising and increasingly managed in United States community and safety-net health systems. However, patients cared for in these settings remain underrepresented in epidemiologic studies and clinical trials that inform clinical practice guidelines. Although existing recommendations provide important standards of care, they often assume reliable access to subspecialty evaluation, advanced diagnostics, and costly therapies. In under-resourced systems, structural constraints shape how and when patients obtain subspecialty evaluation and evidence-based therapies. Drawing on previous evidence and experience from centers within the Bronchiectasis and NTM Care Center Network, we propose a practical framework for adapting guideline-concordant care to under-resourced systems. This framework focuses on four domains: diagnostic pathways that support earlier recognition, co-management models that prioritize high-risk patients and leverage disease expertise, pragmatic approaches to evidence-based therapies aligned with available resources, and linguistic and culturally responsive education to support adherence and shared decision-making. Aligning evidence-based recommendations with structural realities is necessary to improve care delivery and reduce inequality in bronchiectasis and NTM care.