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

TOPIC: 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. IMPORTANCE: 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. OVERVIEW: 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.