Antifibrotic uptake for IPF and PPF rises faster at academic centers than community hospitals

For a decade, people with idiopathic pulmonary fibrosis have had only two approved drug options, nintedanib and pirfenidone, and nintedanib was later approved for progressive pulmonary fibrosis as well. Yet a new analysis of United States health records suggests that access to these antifibrotic medicines depends heavily on where a patient receives care. Using the TriNetX Collaborative Network, a large national database of electronic health records, researchers compared how often IPF and PPF were diagnosed and how often antifibrotic therapy was used at academic medical centers versus non-academic centers, tracking trends across the years following the pivotal INPULSIS and ASCEND trials for IPF and the INBUILD trial for PPF.

The analysis found that IPF prevalence increased more rapidly at non-academic centers in both the post-trial window of 2015 to 2017 and the full post-approval period of 2015 to 2024. Despite this growing patient population outside academia, antifibrotic use remained consistently higher at academic centers. By 2024, 33.5 percent of IPF patients at academic centers were on antifibrotic therapy compared with 20.1 percent at non-academic centers, a gap that was statistically significant with p less than 0.001.

The trajectory of treatment uptake also diverged by setting. During the full post-approval period from 2015 to 2024, antifibrotic initiation rose faster at academic centers by 0.26 percentage points per year relative to non-academic centers, with p equal to 0.002, and overall antifibrotic use rose faster by 1.25 percentage points per year, with p less than 0.001. In the immediate post-INPULSIS and post-ASCEND window of 2015 to 2017, overall use again climbed faster at academic centers, with a slope difference of 1.23 percentage points per year and p equal to 0.009, although initiation rates did not differ significantly between the two settings during that early period.

Progressive pulmonary fibrosis, a form of fibrosing lung disease that worsens despite initial treatment, showed a similar institutional pattern. Prevalence of PPF was comparable across center types, but antifibrotic use in 2024 was higher at academic centers, 17.1 percent versus 9.8 percent, with p less than 0.001. During the post-approval period from 2020 to 2024, both antifibrotic initiation and overall use increased faster at academic centers, with slope differences of 1.16 percentage points per year for initiation, p less than 0.001, and 1.94 percentage points per year for overall use, p equal to 0.009. In the post-INBUILD window of 2020 to 2022, initiation rose faster at academic centers by 1.42 percentage points per year, p equal to 0.002, while overall use slopes did not differ significantly.

Outcome patterns added a layer of complexity to the picture. Among IPF patients, academic centers recorded higher mortality and more lung transplants, but lower rates of respiratory failure and oxygen use. Among PPF patients, academic centers showed higher respiratory failure and mortality, with no significant differences in lung transplant or oxygen use. The authors note that these mixed findings suggest referral and severity bias may partially explain the institutional differences, since sicker patients and those needing transplant evaluation are often funneled to academic centers, but they argue such biases are unlikely to fully account for the treatment gaps.

The study carries an important limitation for the PPF findings: the non-academic PPF cohort included only 216 patients, a small sample that the authors say warrants caution in interpretation. Even so, the consistent pattern across both diseases, two time windows, and two approved therapies points to faster adoption of antifibrotic treatment at academic centers and potential barriers to uptake at non-academic sites, whether those barriers involve specialist access, diagnostic uncertainty, or resource constraints. The authors conclude that more research is needed to disentangle referral and severity bias from true differences in treatment delivery, and that the persistent academic versus non-academic divide in antifibrotic use deserves closer attention as these therapies remain the only approved options for fibrosing lung disease.

Subject of Research: Institutional patterns in diagnosis and antifibrotic-era treatment uptake for IPF and PPF across U.S. centers

Article Title: Institutional patterns in diagnosis and antifibrotic-era treatment uptake for IPF and PPF across U.S. centers

Article References: Sheffield, B. A., Cassel, B. J., Perelas, A., Sime, P., & Jackson, P. (2026). Institutional patterns in diagnosis and antifibrotic-era treatment uptake for IPF and PPF across U.S. centers. PLOS One, 21(10), e0360987. https://doi.org/10.1371/journal.pone.0360987

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0360987

Keywords: idiopathic pulmonary fibrosis, progressive pulmonary fibrosis, antifibrotic therapy, nintedanib, pirfenidone, academic medical centers, treatment uptake, TriNetX, health records analysis, INBUILD, INPULSIS, ASCEND