Yet another challenge to optimizing referral for lung transplantation is that survival prediction modules based on spirometry alone are inadequate. Indeed, fuller prediction requires more comprehensive modules that include a variety of parameters including subjective breathlessness, weight loss, exercise tolerance, hospitalizations, and lung morphology in reviewing diseases such as COPD and idiopathic pulmonary fibrosis. The role of newer therapies such as lung volume reduction in COPD and the use of prostanoids and endothelin antagonists in pulmonary arterial hypertension should be included in such a model. There is a clear need for more studies to develop accurate, disease-specific predictors of progression. For example, measures such as the 6-min walk test and the brain natriuretic peptide in assessing pulmonary arterial hypertension severity could be used in combination with other prognostic parameters to determine response to therapy and timing for referral.89 Articles such as this one by Nathan will encourage studies that shed new light on the rates of progression and expected survival for various advanced respiratory diseases and find better surrogate markers of disease progression. Another benefit may be increased dialogue in the lung transplant community to better define guidelines for referring physicians in the context of emerging developments, eg, new data regarding the natural history of advanced diseases such as idiopathic pulmonary fibrosis, new disease-specific survival analysis,9 and possible alternative therapies that may delay the option for transplantation in certain disease states such as COPD and pulmonary arterial hypertension. The new lung allocation strategy may, over the years, help improve our understanding of this and other related issues. Successful lung transplant centers usually have a close working relationship and partnership with their referring physicians to promote better care for their patients and appropriate, timely referrals. Education of physicians and other health-care providers caring for these patients is integral to this process.