Portal de Periódicos da CAPES

Essential Components of an Interstitial Lung Disease Clinic

2020; Elsevier BV; Volume: 159; Issue: 4 Linguagem: Inglês

10.1016/j.chest.2020.09.256

1931-3543

Bridget A. Graney, Christophe He, Michael Marll, Scott M. Matson, Pauline Bianchi, Gregory P. Cosgrove, Joyce Lee, Rodeo Abrencillo, Rebecca Bascom, Mary Beth Scholand, Nitin Bhatt, Amy Hajari Case, Sachin Chaudhary, Daniel A. Culver, Sonye K. Danoff, Alpa Desai, Daniel F. Dilling, Craig S. Glazer, Mridu Gulati, Nishant Gupta, Michael R. Hamblin, Nabeel Hamzeh, Tristan J. Huie, Hyun Kim, Christopher King, Maryl Kreider, Peter LaCamera, Lisa Lancaster, Tracy Luckhardt, Yolanda Mageto, Robert Matthew Kottman, J. R. McCormick, Borna Mehrad, P. Suresh Menon, Sydney B. Montesi, Joshua J. Mooney, Doug Moore, Teng Moua, Anoop M. Nambiar, Justin M. Oldham, Divya Patel, Tessy Paul, Rafael L. Perez, Anna J. Podolanczuk, Murali Ramaswamy, David Roe, Mohamed Saad, Nathan Sandbo, Thomas Schaumberg, Shelley L. Schmidt, Barry S. Shea, Adrian Shifren, Mary E. Strek, Krishna Thavarajah, Nevins W. Todd, Srihari Veeraraghavan, Stephen Weight, Paul J. Wolters, Joseph D. Zibrak,

Tracheal and airway disorders

BackgroundManagement of patients with interstitial lung disease (ILD) requires subspecialized, comprehensive, multidisciplinary care. The Pulmonary Fibrosis Foundation established the Care Center Network (CCN) in 2013 with identified criteria to become a designated CCN site. Despite these criteria, the essential components of an ILD clinic remain unknown.Research QuestionsHow are ILD clinics within the CCN structured? What are the essential components of an ILD clinic according to ILD physician experts, patients, and caregivers?Study Design and MethodsThis study had three components. First, all 68 CCN sites were surveyed to determine the characteristics of their current ILD clinics. Second, an online, three-round modified Delphi survey was conducted between October and December 2019 with 48 ILD experts participating in total. Items for round 1 were generated using expert interviews. During rounds 1 and 2, experts rated the importance of each item on a 5-point Likert scale. The a priori threshold for consensus was more than 75% of experts rating an item as important or very important. In round 3, experts graded items that met consensus and ranked items deemed essential for an ILD clinic. Third, ILD patient and caregiver focus groups were conducted and analyzed for content to determine their perspectives of an ideal ILD clinic.ResultsForty items across four categories (members, infrastructure, resources, and multidisciplinary conference) achieved consensus as essential to an ILD clinic. Patient and caregiver focus groups identified three major themes: comprehensive, patient-centered medical care; expanded access to care; and comprehensive support for living and coping with ILD.InterpretationThe essential components of an ILD clinic are well-aligned between physician experts and patients. Future research can use these findings to evaluate the impact of these components on patient outcomes and to inform best practices for ILD clinics throughout the world. Management of patients with interstitial lung disease (ILD) requires subspecialized, comprehensive, multidisciplinary care. The Pulmonary Fibrosis Foundation established the Care Center Network (CCN) in 2013 with identified criteria to become a designated CCN site. Despite these criteria, the essential components of an ILD clinic remain unknown. How are ILD clinics within the CCN structured? What are the essential components of an ILD clinic according to ILD physician experts, patients, and caregivers? This study had three components. First, all 68 CCN sites were surveyed to determine the characteristics of their current ILD clinics. Second, an online, three-round modified Delphi survey was conducted between October and December 2019 with 48 ILD experts participating in total. Items for round 1 were generated using expert interviews. During rounds 1 and 2, experts rated the importance of each item on a 5-point Likert scale. The a priori threshold for consensus was more than 75% of experts rating an item as important or very important. In round 3, experts graded items that met consensus and ranked items deemed essential for an ILD clinic. Third, ILD patient and caregiver focus groups were conducted and analyzed for content to determine their perspectives of an ideal ILD clinic. Forty items across four categories (members, infrastructure, resources, and multidisciplinary conference) achieved consensus as essential to an ILD clinic. Patient and caregiver focus groups identified three major themes: comprehensive, patient-centered medical care; expanded access to care; and comprehensive support for living and coping with ILD. The essential components of an ILD clinic are well-aligned between physician experts and patients. Future research can use these findings to evaluate the impact of these components on patient outcomes and to inform best practices for ILD clinics throughout the world. Interstitial lung diseases (ILD) represent a rare and heterogeneous group of more than 100 diseases. Among them, idiopathic pulmonary fibrosis is the most common and carries significant morbidity and mortality, with a median survival of 41 months.1Nathan S.D. Shlobin O.A. Weir N. et al.Long-term course and prognosis of idiopathic pulmonary fibrosis in the new millennium.Chest. 2011; 140: 221-229Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar The scope of care for patients with ILD can be challenging and complex, ranging from obtaining accurate diagnoses, initiating disease-modifying treatments, providing supportive care, including oxygen therapy, and managing comorbidities to discussing lung transplantation and providing palliative and end-of-life care. The multidimensional, complex, and longitudinal needs of this patient population has led to the emergence of specialized, comprehensive ILD clinics in the last two decades. The Pulmonary Fibrosis Foundation (PFF) is a nonprofit organization dedicated to providing support to those living with pulmonary fibrosis. In 2013, the PFF started the Care Center Network (CCN), which now consists of 68 designated medical centers across the United States recognized for having expertise in the diagnosis and treatment of ILD through multidisciplinary care and patient engagement in education, support, and research. Although the PFF CCN delineates the criterion to qualify and maintain designated site status,2Pulmonary Fibrosis FoundationWorking together to improve patient outcomes: PFF Care Center Network. Updated March 1, 2019. Pulmonary Fibrosis Foundation website.https://www.pulmonaryfibrosis.org/docs/default-source/medical-community-documents/pff-care-center-criteria-2019-v-03-updated_03-01-2019.pdf?sfvrsn=a02d918d_2Google Scholar little is known about the composition, structure, and function of an ideal ILD clinic. Because of a lack of clinical practice guidelines to inform the structure of an ILD clinic, we identified three objectives for this study: first, to assess the current structure of ILD clinics within the PFF CCN; second, to determine the essential components of an ILD clinic using a three-round modified Delphi survey administered to a group of ILD experts, all of whom are directors of PFF CCNs; and third, to identify the essential components of an ILD clinic from the perspectives of ILD patients and caregivers using a series of focus groups. The Colorado Multiple Institutional Review Board approved the study (Identifier: COMIRB 19-0841, 19-1583). A 60-item, web-based survey using Research Electronic Data Capture (REDCap) was sent to all 68 PFF CCN directors via e-mail to determine baseline characteristics and composition of their ILD clinics. Items included in the first round of the modified Delphi survey were compiled based on content analysis of transcripts from individual, semistructured telephone interviews with PFF CCN directors (e-Appendix 1). Nine directors were selected based on their clinical expertise and background to ensure representation with respect to sex, geography, and size of ILD clinic. All interviews were conducted by C. H., digitally recorded, and transcribed verbatim. All PFF CCN directors, including those who had participated in the telephone interviews, were invited via e-mail to participate in the modified Delphi survey. We conducted a three-round Delphi survey using a secure, online REDCap database between October and December 2019. In rounds 1 and 2, the Delphi collaborators ranked items by degree of importance on a five-point Likert scale (very important, important, less important, not important, and not sure). In the third round, participants were instructed to rank items on a five-point Likert scale based on if items were thought to be essential to an ILD clinic (strongly agree, agree, disagree, strongly disagree, and not sure). Results were analyzed anonymously and reported according to the defined methodologic criteria for Delphi studies.3Diamond I.R. Grant R.C. Feldman B.M. et al.Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies.J Clin Epidemiol. 2014; 67: 401-409Abstract Full Text Full Text PDF PubMed Scopus (1586) Google Scholar The a priori threshold for an item to be considered important to an ILD clinic in Delphi rounds 1 and 2 was defined as more than 75% consensus among experts rating an item as "very important" or "important," and the a priori threshold for an item to be considered not important to an ILD clinic was defined as more than 75% consensus among experts rating an item as "not important" or "less important." The same thresholds were used for the third Delphi round, but in relationship to level of agreement with an item being "essential" for an ILD clinic. We conducted focus groups with patients with ILD and self-identified caregivers. We chose a qualitative study design using content analysis as our methodologic framework to gain a comprehensive understanding of the experiences, wants, and needs of patients and caregivers seeking medical care at ILD clinics. Eligible participants had to reside currently in the United States. Participants were not excluded if they were not currently or had not previously received care at a PFF CCN site. Participants were recruited at the PFF 2019 Summit at an informational table and through a recruitment flyer distributed electronically to the PF Warrior community e-mail distribution list. Informed consent was obtained from all participants at the time of the focus group. Participants were not compensated for their time. Real-time focus groups were conducted using a secure, web-based meeting interface and facilitated by authors (B. A. G., C. H., and M. M.) from November 2019 through January 2020. The focus groups followed a semistructured, open-ended approach to elicit participants' opinions and experiences of ILD clinics (e-Appendix 2). All focus groups were audio recorded and transcribed verbatim. Three focus groups initially were planned, but new themes emerged from the second and third groups. Therefore, two additional focus groups were conducted, after which thematic saturation was achieved based on debriefing after group meetings and note comparison by the moderator (B. A. G.) and comoderators (C. H. or M. M.). This number of groups is consistent with existing literature examining the relationship between number of focus groups conducted and thematic saturation.4Hennink M.M. Kaiser B.N. Weber M.B. What influences saturation? Estimating sample sizes in focus group research.Qual Health Res. 2019; 29: 1483-1496Crossref PubMed Scopus (429) Google Scholar,5Saunders B. Sim J. Kingstone T. et al.Saturation in qualitative research: exploring its conceptualization and operationalization.Qual Quant. 2018; 52: 1893-1907Crossref PubMed Scopus (5179) Google Scholar Transcripts were entered into Atlas.ti version 8.0 software (ATLAS.ti Scientific Software Development GmbH) and analyzed for content using a general inductive approach. Analysis was completed by organizing the data through open coding and repeated comparisons to identify key themes. The primary coders (B. A. G. and M. M.) met regularly to discuss coded data, to reconcile differences, and to achieve consensus. Both coders double-coded all focus groups. Coded data were analyzed within and across groups to identify the emergent themes. A total of 36 of 68 (53%) PFF CCN directors completed the survey (Table 1 and e-Table 1). The median number of new patient visits per year was 250 (interquartile range, 150-383), and the median number of total patient visits per year was 1000 (interquartile range, 500-1500). Sixty-seven percent of clinics were staffed with two to five physicians. Nearly all clinics (92%) had nursing support, with 56% of sites having dedicated ILD nurses. Available ancillary support staff varied across clinics. Every clinic participated in research and clinical trials. All clinics, except for one, held a multidisciplinary conference and conferences at least once per month.Table 1Baseline Characteristics of ILD Clinics in the PFF CCNItemResultMembers... No. of ILD-focused pulmonologists working in the ILD clinic...12 (6)2-524 (67)> 510 (27) Nursing support for the ILD clinic33 (92) Nurses who are dedicated solely to ILD clinic (in the clinics with nurses)18 (56) Advanced practice providers working in the ILD clinic18 (50)Infrastructure... New patient visits per y250 (150-383) Total patient visits per y1000 (500-1,500) No. of half days of ILD clinic per wk7 (4-8) Average wait time from referral to clinic visit...1 wk-1 mo15 (42)1-3 mo16 (44)3-12 mo4 (11)Unknown1 (3) Most patients traveling > 60 min to get to clinic19 (53) Use of telemedicine3 (8)Resources... Access to social worker11 (31) Access to respiratory therapists24 (67) Access to a palliative care program33 (92) Access to a dedicated ILD palliative care program3 (8) Access to a local pulmonary rehabilitation program36 (100) Access to a local support group36 (100) Participate in clinical trialsaOnly 35 respondents answered this question.35 (100) Participate in patient registries32 (89) Participate in biobanking of specimens31 (86)Multidisciplinary conference... Participation in a multidisciplinary conference35 (97) Frequency of multidisciplinary conference...> Once/wk1 (3)Once/wk17 (49)Once/2 wks9 (26)Once/mo8 (23)Data are presented as No. (%) or median (interquartile range). CCN = Care Center Network; ILD = interstitial lung disease; PFF = Pulmonary Fibrosis Foundation.a Only 35 respondents answered this question. Open table in a new tab Data are presented as No. (%) or median (interquartile range). CCN = Care Center Network; ILD = interstitial lung disease; PFF = Pulmonary Fibrosis Foundation. Eight of the 9 identified PFF CCN directors participated in the telephone interviews. Eighty-seven total items were generated for inclusion in the first round of the modified Delphi survey. Items were divided into four categories: members of an ILD team, infrastructure for an ILD clinic, resources for an ILD clinic, and multidisciplinary conference. Of the 67 PFF CCN directors invited to participate (J. S. L., as PFF CCN Director at the University of Colorado, was not invited to participate), the response rate for the three rounds of modified Delphi was 48 (72%) for the first round, 42 (63%) for the second round, and 40 (60%) for the third round (Fig 1). The number of items in each round is summarized in Figure 2, and detailed results of all three rounds can be found in the online Supplemental Materials (e-Tables 2-4). At completion of the third round, 40 unique items achieved consensus as essential for an ILD clinic (Table 2).Figure 2Flow diagram showing items through each round of the modified Delphi process. The Delphi collaborators were asked to rank items in degree of importance for interstitial lung disease (ILD) clinics on a five-point Likert scale during each of the three rounds. During round 1, participants were given the opportunity to add any additional items they found important for an ILD clinic that were not included already in the first-round items. In the second round, the amended list of items (including the items generated in round 1) and results of the first round that did not achieve consensus were presented. Participants were asked to rate this amended list on the same five-point Likert scale. In the final round, participants ranked consensus items on a five-point Likert scale on whether these items were not only important, but also essential, for an ILD clinic. ∗Threshold of importance: 75% of respondents selected "very important" or "important." †Item: If advanced practice providers are present in ILD clinic, their role mainly should be diagnosis of new ILD patients. ‡One item duplicated–total of 52 unique items in round 3.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 2Items That Achieved Consensus in the Modified Delphi Survey as Essential or Important for an ILD ClinicItems That Are Essential to Have for an ILD ClinicItems That Are Important to Have for an ILD ClinicMembers of the ILD team PhysiciansHaving expertise in ILD (a certain number of years working in ILD patient care)Having at least 2 or more pulmonologists working the ILD clinic NursesDedicated ILD nurse If a clinic has advanced practice providersClose supervision by physiciansTheir role should be mainly longitudinal care of ILD patients Research coordinatorsClinic coordinatorsFellows and traineesInfrastructure of ILD clinics GeneralILD clinic sees a minimum number of patients per yearILD clinic sees a minimum of 100 unique patients/yaIf threshold for agreement were increased to > 80%, these items would have been considered important, but not essential, for an ILD clinic.Minimum number of clinics per weekEase of access to clinicTriaging and rerouting referrals to ILD clinics from general pulmonary clinicsTriaging of ILD patients before new patient visit to avoid multiple visits (prescheduling tests before the visit, obtaining prior records and imaging, and so forth)The maximum time from referral to new appointment is less than 2 mo for a standard new patient visitbMaximum time to new patient visit < 1 mo or < 3 mo for a standard new patient visit were important, but not essential.Maximum time from referral to new appointment is less than 7-10 d for an urgent patient visit Patient management strategiesProviding a mix of primary management, collaborative/shared care, and consultative managementProviding primary management of ILD care Exposure historyObtain a structured occupational and environmental exposure history for all new ILD patientsResources for ILD clinics Pulmonary rehabilitationA pulmonary rehabilitation facility in close proximity (within a 30-60-min drive from the center) to the ILD clinicaIf threshold for agreement were increased to > 80%, these items would have been considered important, but not essential, for an ILD clinic. Ancillary services within the same institutionGeneral rheumatologyAccess to rheumatologists with expertise in ILDThoracic radiologyAccess to sleep clinicPulmonary pathologyaIf threshold for agreement were increased to > 80%, these items would have been considered important, but not essential, for an ILD clinic.Thoracic surgeonPulmonary hypertensionaIf threshold for agreement were increased to > 80%, these items would have been considered important, but not essential, for an ILD clinic.CardiologyPalliative careExperience in treating patients with advanced lung diseasesAvailability in outpatient, inpatient, and hospice care Pulmonary function testingSame-day appointments as the ILD clinic visit RadiologyDedicated ILD HRCT protocolHRCT available same day or next day of clinic visitaIf threshold for agreement were increased to > 80%, these items would have been considered important, but not essential, for an ILD clinic. ResearchParticipation in researchParticipation in clinical trialsParticipation in patient registriesaIf threshold for agreement were increased to > 80%, these items would have been considered important, but not essential, for an ILD clinic. Patient educationPatient education is delivered by physiciansaIf threshold for agreement were increased to > 80%, these items would have been considered important, but not essential, for an ILD clinic.Patient education is delivered by nursesILD clinic participates in local patient support groupsMultidisciplinary conference Having a multidisciplinary conferenceFrequency is at least once/2 wks Staff (routinely participates in ILD conference)PulmonologistsTraineesRadiologistsPathologists Discussing the following types of patients at multidisciplinary conferenceComplex cases with diagnostic or therapeutic dilemmasPatients who already have undergone surgical lung biopsyPatients in whom a surgical lung biopsy is being consideredILD = interstitial lung disease.a If threshold for agreement were increased to > 80%, these items would have been considered important, but not essential, for an ILD clinic.b Maximum time to new patient visit < 1 mo or < 3 mo for a standard new patient visit were important, but not essential. Open table in a new tab ILD = interstitial lung disease. In the third round, if we changed the threshold for essential to 70%, this would have added six items to the list of essential items for an ILD clinic, including inclusion of more specific personnel (clinic and research coordinators, access to rheumatologists with expertise in ILD) and a minimum frequency of multidisciplinary conference (e-Table 4). In contrast, if the threshold were more stringent, only allowing for those with more than 80% agreement, seven items would be excluded from the essential list, including a minimum number of unique patients seen yearly, specific ancillary services at the same institution, and proximity of a pulmonary rehabilitation center (Table 2). A total of 21 individuals participated: 16 patients and five family caregivers. We conducted five focus groups with a range of three to seven participants per group. Among the patient participants, 69% were men and 31% were women. Among the caregiver participants, 20% were men and 80% were women. Additional demographics were not obtained to maintain participant confidentiality; some participants provided details of their diagnoses voluntarily. We identified three major themes from the focus groups that encompass patients' and caregivers' perspectives of an ideal ILD clinic: comprehensive patient-centered medical care, expanded access to care, and support for living and coping with ILD. See Table 3 for the three major themes, with subthemes and representative quotations.Table 3Major Themes and Subthemes With Representative Quotations From the Patient and Caregiver Focus GroupsThemeSubthemesComprehensive, Patient-Centered Medical CareAll-InclusivePatient-CenteredTimely and EfficientAssistance With Prescriptions and Insurance CompaniesExcerpts"They have in one building just about everything necessary. All of the diagnostic equipment; they have a blood lab; they have all kinds of scanning equipment. Of course, they have the equipment to test your breathing. Of course, they have the physicians there to meet with you after your tests are completed, so they go over your diagnosis and discuss a treatment plan . . . everything is in one building for all of your pulmonary diagnoses and treatments.""To me, to be able to go somewhere that they have all of the necessary specialties to provide complete diagnostic and treatment-option discussions, that really should be done in a day because of the psychological impact . . . the more quickly that you can get a definitive diagnosis, to me would be very important.""Very, very integrated and focused on the patient.""Being a patient-centered facility rather than a doctor-centered facility.""The idea of doctors being cued in to compassion and not just talking about the data or the interest in data in their research . . . also to remember that these are patients.""I think if I had had a place to go, and no matter how long it took me . . . but just to be able to stay in one spot and be able to get it done and know, 'Okay. This is it. This is what's happening' to me is very important.""For us, because we fatigue so easily and get so short of breath, the least amount of travel and appointment times would be ideal.""Maybe somebody who would go through insurance or check your insurance for the different medications.""It would be great if there was somebody that can look into your insurance benefits.""I think that a good clinic would have a more competent staffing level to deal with prescriptions for medication, prescriptions for oxygen, and prescriptions for rehab."Expanded Access to CareCommunicationGeographic Considerations and TravelPulmonary RehabilitationClinical Trials ParticipationExcerpts"I would advise people to sign up for the . . . patient portal, to get familiar with that process, it makes things a lot easier in contacting doctors and/or their staff . . . its just an easy, easy way of communicating and not having to be on the phone for minutes at a time waiting for someone to answer or someone to call you back.""I just feel like I can always reach out to her and ask her any questions, and she always gets back to me.""Its gonna go always to me location, location, location, you know what I mean? Wherever they're located at makes it easier. If I can get there within an hour, that's nice, but if I have to drive 6 hours to get to the place, once again, its just a hard thing.""I had to go out of state to get any help whatsoever.""But that could be just because I'm so far and remote from any facility. I'm so far away to the facility.""I think that would be my biggest complaint about any clinic is where is your pulmonary rehab and how can we get people there easy. These people don't travel well in the first place, and then they have to go so far to get—what I consider is one of the treatments for pulmonary fibrosis, is pulmonary rehab.""It took me actually 9 months to find a pulmonary rehab that was not too far away from us . . . most of 'em are [1] hour and a half, 2 hours away, which is kinda far when you're going two to three times a week.""I would love to get into a trial . . . I mean, that's how we're gonna beat this thing, you know, and to slow down the progression and to make things better for other people. Trials are extremely important.""I believe that most patients would be very happy to participate in trials if they were offered that participation in a hope that we might be able to, you know, help make some discoveries that will, if not prevent other people from having the condition in the future, at least to come up with some better treatment options."Comprehensive Support for Living and Coping With Interstitial Lung DiseasePatient AdvocateDisease EducationCounseling and Support ServicesPatient Support GroupsSupplemental OxygenExcerpts"First of all, they come in and tell that patient that they're not alone.""It would be somebody that you would feel comfortable going to with multiple questions . . . that would have access and obviously enough knowledge about the disease to know the next step that you're looking for or in need of.""Having somebody who essentially knows you, that maybe periodically would touch base with us if we haven't been in clinic in a month or two. Even if it's a phone call saying, 'Whad'ya need?' Or, you know, just, 'Let me know if you need something. I'll try to find it and tell you where to go and get it.'""If there was some sort of patient ambassador that people can have where there are so many questions that a patient will have afterwards . . . that coordinate the questions and to be able to pass on information to the patients or the families to get them pointed in the right direction when they have these different questions.""You always know you can call up this person and whether its getting a doctor's appointment scheduled, or getting a referral or getting a new medication or medication refill, if it's questions about insurance . . . to have somebody as a primary point of contact to coordinate all of these different things, whether its them being able to answer the question or just getting you pointed in the right direction to find that answer is something that would be very valuable.""I think on that first visit, there needs to be more information given, like that fact sheet of—you can get an IPF fact sheet. That needs to be handed out.""Things like where you can buy an oximeter and what oximeter is good to get, things like that just right off the bat are good things to get, and books to read . . . that they can start learning and preparing themselves. If they can be prepared right off the bat with stuff, I think, to me, is an ideal clinic.""As soon as you get a diagnosis like IPF, I know that my first inclination is to Google the disease and there's a lot of bad information out there, inaccurate information, and scary information . . . it's up to the patient to seek these things out most of the time, as opposed to maybe one center having all these things and not only providing the services but also giving an explanation of why these things are important." "The most important things they could do would be to make the patient aware of the organizations that exist to help support patients who have ILD.""There would be counsellors, counselling services there because you're being given a death sentence. That is the biggest shock in the entire world to have that happen.""There's got to be some help there, emotional help, as much as the physical-medical aspect of it.""A psychologist or a therapist. Whatever you wanna call it because, I mean, really and truly, you are filled with emotions of all different kinds. Panic, fear, sadness. You know? Just totally in awe about everything. And your life's been turned upside down.""The coordination of mental health . . . as part of the staff too where they can coordinate with the patient to, I guess, understand, cope with, get adjusted to this new way of life and being given this diagnosis.""This is the opportunity to interact very closely with other people who are similarly situated. You know, it's a great source of support as well as information . . . You can get together on a regular basis with a group of folks, who are similarly situated, and you'll find it to be a very beneficial just to be able to spend time together and compare notes. That, to me, I think is a very important part of the support that would be provided by this center.""I think a support group is critical in your area in some way. It doesn't have to be at your center, but I think also, what I'm hearing more an