Diagnostic assessments of spirometry and medical history data by respiratory specialists supporting primary care: are they reliable?

Abstract

To determine the intra- and inter-observer reliability of respiratory specialists' diagnostic assessments of spirometry and written medical history data obtained from primary care.
Five respiratory specialists assessed spirometry data and the history of 156 patients randomly selected from referrals to an asthma/COPD-service. The inter-observer reliability was evaluated. After six months, all specialists repeated the assessments and the intraobserver reliability was evaluated.
The diagnostic assessments for all patients had reasonable intra- and inter-observer reliability, resulting in a Cohen's kappa (kappa) of 0.67 and 0.66 respectively. The intra-observer reliability for assessing the need for additional diagnostic examinations had an average kappa 0.56 for new patients and an average kappa 0.39 for follow-up examinations. The assessments of clinical stability in follow-up patients--on which therapeutic advice was based--were inconsistent.
GPs who are reluctant to perform or interpret spirometry themselves may be supported diagnostically by respiratory specialists in an asthma/COPD-service. The reliability of this advice varies. More appropriate criteria for assessing clinical stability in patients with asthma and COPD are necessary to improve the reliability of the therapeutic advice.

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Primary Care Respiratory Journal (2009); 18(3): 177-184
ORIGINAL RESEARCH
Diagnostic assessments of spirometry and medical history
data by respiratory specialists supporting primary care:
are they reliable?
*Annelies EM Lucasa, Frank JWM Smeenkb, Ben EEM van den Borneb, Ivo JM Smeelec,
Onno CP van Schaycka
aResearch Institute Caphri, Department of General Practice, Maastricht University, Maastricht, The Netherlands
bDepartment of Pulmonology, Catharina Hospital, Eindhoven, The Netherlands
cCOPD & Asthma Primary Care Group (CAHAG), Utrecht, The Netherlands
Copyright General Practice Airways Group
Received 8th January 2008; resubmitted 9th March 2008; revised 18th July 2008; accepted 25th September 2008; online 12th January 2009
Abstract
Aim: To determine the intra- and inter-observer reliability of respiratory specialists’ diagnostic assessments of spirometry and written
medical history data obtained from primary care.
Reproduction prohibited
Method: Five respiratory specialists assessed spirometry data and the history of 156 patients randomly selected from referrals to an
asthma/COPD-service. The inter-observer reliability was evaluated. After six months, all specialists repeated the assessments and the intra-
observer reliability was evaluated.
Results: The diagnostic assessments for all patients had reasonable intra- and inter-observer reliability, resulting in a Cohen’s kappa (κ) of
0.67 and 0.66 respectively. The intra-observer reliability for assessing the need for additional diagnostic examinations had an average
κ 0.56 for new patients and an average κ 0.39 for follow-up examinations. The assessments of clinical stability in follow-up patients – on
which therapeutic advice was based – were inconsistent.
Conclusion: GPs who are reluctant to perform or interpret spirometry themselves may be supported diagnostically by respiratory
specialists in an asthma/COPD-service. The reliability of this advice varies. More appropriate criteria for assessing clinical stability in
patients with asthma and COPD are necessary to improve the reliability of the therapeutic advice.
© 2009 General Practice Airways Group. All rights reserved.
AEM Lucas, et al. Prim Care Resp J 2009; 18(3): 177-184.
doi:10.3132/pcrj.2009.00002
Keywords spirometry, primary care, asthma, COPD, diagnosis
*Corresponding author: Mrs Annelies EM Lucas, Research Institute Caphri, Department of General Practice (HAG), University of Maastricht,
PO Box 616, 6200 MD Maastricht, The Netherlands. Tel: +31 (0)43 3882149 Fax: +31 (0)43 3619344 E-mail: Annelies.Lucas@Hag.unimaas.nl
177
Introduction
In primary
implementation of spirometry,1,2
practitioners (GPs) encounter problems in interpreting
spirometry data.3Therefore, in several countries facilities have
been developed to support GPs in assessing the diagnosis of
asthma or COPD in patients with respiratory complaints. These
facilities provide spirometry testing assessed by specially-
trained GPs4or respiratory specialists.5Some services only
interpret the spirometry results,6whereas others include x-ray
care, practical thresholds
and many general
hinder the
and O2-saturation7assessments or use medical history data;8
furthermore, the respiratory specialists can collect data by
actually seeing the patient9or by assessing paper-based
information only.10In addition, computerised data assessment
is used on a wide scale.11
The reliability and validity of these assessment procedures
may be questioned, especially when a patient is not actually
seen by the assessor. Therefore, we examined the validity and
reliability of diagnostic assessments based on spirometry
results and written medical histories. In a previous study we
found that these assessments had good validity: there were
high similarities between the assessments of a pulmonologist
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AEM Lucas et al.
178
based on written information and the assessments of the
same pulmonologist based on “live” contact with the
patient.12In this paper, we examine the reliability of diagnostic
assessments by different respiratory specialists who used
spirometry data and written patient information. Our specific
questions were:
What are the intra- and inter-observer reliability of
1. the actual diagnoses given to the patient?
2. the advice for additional diagnostic examinations in case
of an unclear initial diagnosis ?
3. the assessment of the clinical stability of the patient and the
subsequent advice for adjustments in the treatment regime?
Method
Asthma/COPD-service
The study was performed at a Primary Care Diagnostic Centre
in Eindhoven in the Netherlands. This centre has developed an
asthma/COPD-service (AC-service). About 200 GPs refer their
patients with respiratory problems to the centre for diagnosis
and monitoring, and in 2007 approximately 6000 referrals
were made. When referred, a patient fills in a structured form
with questions about their medical history, smoking
behaviour, fitness, complaints (symptoms), medical treatment
and compliance. This medical history form is taken to the AC-
service where well trained lung function assistants perform
spirometry including reversibility testing.
The medical history form and the results of spirometry are
kept together and sent to co-operating respiratory specialists
from local hospitals. They perform diagnostic assessments
according to an assessment protocol that includes the
following criteria:
- does the quality of the performed spirometry comply with
ATS criteria13?
- does the flow volume curve show obstruction (FEV1/FVC
<0.7) and is this obstruction reversible after inhaling
bronchodilator medication? (According to the Dutch
standard the difference between FEV1before and after
bronchodilation should be >9% of the FEV1% predicted).14
- what is the conclusion based upon the patient’s lung
function curves?
1. No obstruction = no asthma/COPD;
2. No obstruction but decline in FEV1and in FVC = restriction
3. Obstruction is reversible to normal lung function = asthma
4. Irreversible obstruction = COPD
5. Obstruction is reversible but not to normal lung function
= both asthma and COPD
- (how) does the patient’s medical history (allergy, family
history, smoking behaviour, complaints) influence the final
diagnosis – for example, in a case of normal lung function
which does not necessarily exclude asthma?
- (how) does the patient’s medical history (physical shape,
complaints, exacerbations, use of medication etc.)
influence the assessment of the stability of the disease
and the patient’s condition?
Following this protocol the respiratory specialist assesses a
diagnosis and gives therapeutic advice. In case of a
discrepancy between the symptoms and the spirometry
results, advice is given to the GP to conduct additional
examinations in order to determine the final diagnosis.
Referral to a pulmonologist is recommended according to the
Dutch guidelines.15All assessment items are marked on a
structured assessment form. A complete report (Figure 1) is
then made by the AC-service and sent to the patient’s GP.
New patients and follow-up patients
For newly-referred patients (New Patients) the focus is on
being diagnosed, or (if necessary) on obtaining advice for
further diagnostic examinations. When a diagnosis of
“asthma” or “COPD” is assessed, patients can be included in
a monitoring program that invites them to visit the AC-service
every year. For these “follow-up” patients, the focus is on
assessing instability and progression of the disease and on
providing therapeutic advice. For both new and follow-up
patients the complete assessment procedure is performed:
new patients also get therapeutic advice, when applicable,
and follow-up patients are also checked for their diagnosis.
Patient data
During six months (January – July 2004) data records of 156
patients who were referred to the asthma/COPD-service were
randomly selected (the first 7-8 patients of each week). Five
respiratory specialists, who did not consult each other,
assessed the spirometry results and medical history forms of
the selected patients according to the protocol. Six months
later all five assessors examined copies of the same patient
data for a second time. These copies were mixed in with the
regular daily assessments to avoid recall bias.
Intra- and inter-observer comparison method
We first analysed the intra-observer reliability for all five
observers by comparing the assessment forms of two
assessments by each assessor of all patients. Only when the
intra-observer reliability was reasonable for all observers
(κ > 0.5) was the inter-observer reliability then assessed.
Specific items for analysing the intra- and
inter-observer agreement
To answer our first question about the reliability of the
assessed diagnoses the scores of all diagnostic options were
compared. These diagnostic options were:
1. “Normal, no asthma or COPD’
2. “Asthma”
3. “Asthma with persisting obstruction” (i.e. mixed Asthma
and COPD)
4. “COPD”
5. “Restriction, no asthma or COPD”
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Respiratory specialists diagnostic support: reliable?
179
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Fig 1. Example of a report of the diagnostic assessment by a pulmonologist based on written
information as sent to the general practitioner by the Asthma/COPD service
Cardio Control Workstation
Name patient
Number
Gender
Birth date:
Height: 166 cm
Primary Care Diagnostic Centre
Address
Postal code
Place
Date of test
Lung function assist.
xxxxxxxx
Vo40335AS
female
04 03 1935,
Weight: 82.0 kg
xxxxxxxxx
5641 AL
Eindhoven
01 10 2003, 9:07:27
JPO
Age: 68
Assessment by lung specialist:
Dr. XXXXX. For questions you can contact him at
the AC-service of the Diagnostic Centre tel:..
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Notes:
General practitioner: YYYYY, address: tel:..
Code 83093, incl. revers. Reason: DIAGNOSIS
Quality Curve: Reasonable, assessable
Vital capacity: NORMAL
Expiration:
Moderate OBSTRUCTION
Reversibility: Quantitatively it looks like a
significant improvement in FEV1 after medication,
but this can be false because of a volume response
as is seen by COPD
CONCLUSION: moderate obstructive lung
function (COPD GOLD 2)
ADVICE: consider diagnostic steroid test to
determine the optimal lung function (and to exclude
Asthma)
* consider dietary advice, (BMI is too high)
* consider extra attention physical shape (MRC)
* cheque compliance, medication to be taken daily
Patient is included in the AC-service for yearly
follow up and will be invited for lung function
test in a years time.
PATIENT HISTORY:
Known by lung specialist:Yes(brother had TBC)
Former X-Thorax: 25 years ago
History: Hay fever, bronchitis
Family History: positive
Smoke: STOPPED in 1990, PY: 36
Occupation: not relevant. Hobby: not relevant
Trigger: non-specific and specific factors
Reproduction prohibited
MRC: 3 (walks slower than peers)
Complaints: mainly in spring, autumn
Complaints mainly during daytime
FREQUENCY of COMPLAINTS: daily
Cough and/or sputum: NO
COMPLAINTS SCORE: 3 (some) (max=10)
BMI: 29,7
Exacerbations this last year: one (predn.)
Prescribed lung medication: tiotropium 1dd1
Compliance: only when dyspnoic,
Comorbidity: hypothyr. Cardiovasc.
Co-medication: euthyrax, acetosal, Furosemide
Parameter 1sttry Predicted % pred.2e try % diff.
FVC 1.872.7069.29 2.44 21.11
FIVC 2.412.82 84.47 2.66 5.31
FEV1 1.262.26 55.90 1.61 15.48
FEV1/FVC % 67.38 83.70 80.50 65.98 -1.67
FEV1/FIVC % 52.28 79.93 65.40 60.24 9.98
FEF50 1.08 3.5330.62 1.162.26
PEF 3.805.98 63.55 4.40 10.03
Figure 1. Example of a report of the diagnostic assessment by a pulmonologist based on written information as sent
to the general practitioner by the Asthma/COPD-service.
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AEM Lucas et al.
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The second research question was addressed by assessing the
agreement in the advice for additional diagnostic examinations
and the number of patients who were given this advice by each
observer. The different types of advice given were:
1. Discrepancy between spirometry results and medical
history, search for an alternative diagnosis
2. Normal lung function. When considering asthma perform
peak flow registration tests or refer for histamine
bronchoprovocation test or repeat spirometry when
complaints occur
3. Patient uses inhaled corticosteroids (ICS) but has normal
lung function and no complaints. If the diagnosis of
asthma has not been confirmed by spirometry consider
stopping the use of ICS and repeating the diagnostic
spirometry after at least three months
4. Discrepancy between spirometry results and medical
history, search for additional diagnoses
5. Spirometry shows obstruction, no reversibility. Perform a
steroid test to exclude asthma or to assess the patient’s
“personal best lung function” (at the time of the study
this was according to the Dutch guidelines)
6. Patient uses ICS and has mild obstructive lung function
(COPD GOLD 1-2). When there are no frequent
exacerbations and no complaints consider stopping the
use of ICS to be able to diagnose the actual need for ICS
To answer the third question we examined the agreement
in assessing the “stability” or “instability” of the clinical
condition of the patient. Such reliability of assessment is a
prerequisite to agreeing any adjustments in the medical
treatment. Since treatment had yet to start in new patients,
this part of the assessment only applied to patients who came
for follow-up. The options analysed were; ”patient condition
is stable” or “patient condition is unstable”, as per the
professional opinion of the respiratory specialists. They took
into account the presenting complaints, physical shape,
exacerbations, persisting reversibility in asthma patients, and
whether or not FEV1was declining by > 200 ml/year.
Statistical analysis
Using SPSS 14, κ was determined in order to qualify the intra-
observer reliability. The inter-observer reliability was expressed
as weighted κ.16
Results
Patients
Seventy-two study patients had been referred for diagnostic
reasons (“new patients”). Eighty-four patients who were
considered to have asthma or COPD by their GP were referred
for monitoring (“follow-up patients”). There was no information
about whether the diagnoses in this follow-up group were based
on spirometry tests or on clinical symptoms. Patients’ ages
ranged from 18 to 84 years old, and 46% were men.
According to the pulmonologist reports sent to the GPs,
39% of the patients had normal lung function with no
asthma or COPD, 2% had a diagnosis of restriction, 23% of
the patients were diagnosed as having asthma, 24% were
diagnosed with COPD, and 12% had a mixed diagnosis of
asthma and COPD.
Quality of spirometry and the reliability of the
assessment of reversibility
Before assessing the reliability of the diagnostic assessment,
the quality of the performed spirometry was also assessed.
According to ATS criteria17(immediate and rapid incline of the
expiration curve, expiration lasting six seconds, no hesitation
between expiration and inspiration, and uniting lines of
inspiration and expiration) all but 3 of the 156 spirometry
tests were of good or sufficient quality. There was almost
complete agreement (κ=0.92) about this. The agreement in
the assessment of reversibility was also good (κ=0.83).
Reliability of the assessment of the diagnosis asthma
and/or COPD
To analyse the intra-observer reliability of the assessed
diagnoses, the agreement between the first and the second
diagnosis of each patient was analysed for all five assessors.
Cohen’s kappas for the intra-observer reliability of each
assessor were 0.71 / 0.60 / 0.68 / 0.55 / 0.79, with an
average κ of 0.67.
The inter-observer reliability was analysed by comparing
the diagnoses of the first assessments between all five
assessors. In 114 patients (73%) there was complete (56%)
to almost complete (17%) agreement between all five
assessors (see Table 1). All types of diagnosis contributed to
the 87 fully-agreed assessments (No asthma/COPD – 39;
asthma – 18; asthma and COPD – 1; COPD – 29).
Disagreement was likely to be caused by assessment
decisions about borderline deviations of lung function from
normal: “asthma” or “(about) normal” (21%), and “COPD”
or “(about) normal” (12%). In 11 % of the patients there was
a difference in diagnoses that was difficult to interpret. None
of the assessors had a pattern of assessments that was clearly
deviant from the others.
Statistically the inter-observer reliability (κ=0.63)
approximated the reliability found in the intra-observer
analysis (see Table 2).
When comparing the diagnostic assessments of new
patients and of patients that came for follow-up, a higher
intra-observer reliability was found for the new patients. In
addition, the inter-observer reliability was better for new
patients (κ=0.69) than for follow-up patients (κ=0.48)
Assessment of the need for additional diagnostic
examinations
An average of 58% of all patients were given advice to
undergo additional diagnostic examinations (to be conducted
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Respiratory specialists diagnostic support: reliable?
181
by their GPs) after the first assessments and 68% after the
second. The number of patients recommended for referral to
a specialist because of severe problems (lung function decline
and/or symptoms) was 8% (10-25%) in the first and 7% (5-
19%) in the second series of assessments.
The intra-observer reliability for advising additional
diagnostic examinations had a reasonable average Cohen’s
kappa of 0.50 but there were big differences between
assessors, as Cohen’s κ ranged from 0.31-0.62. The advice for
new patients showed better reliability (κ=0.54-0.58) than the
advice for follow-up patients (κ=0.38-0.40), but did not meet
our criteria for assessing a weighted κ (Table 3).
Assessment of the clinical condition of the follow-up
patient
Agreement in assessing the clinical stability of the follow-up
patients scored low for intra-observer reliability: Cohen’s
kappa for each assessor was 0.64 / 0.39 / 0.35 / 0,24 / 0.28,
(mean κ: 0.38). Based on this finding the inter-observer
weighted kappa was judged to be of no value and was not
analysed any further.
Discussion
The main finding of our study is that there was moderate
agreement (inter-observer reliability) and consistency (intra-
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Distribution of similar / deviant diagnoses
assessed by 5 respiratory specialists (n=156)
Pattern of assessments:
DifferenceDiagnostic labels5 / 01
4 / 12
3 / 23
1/1/1/1/14
total
No difference 8787
(56%)
Difference in the interpretation
of the existence of “Asthma”
No asthma / COPD /
Asthma- 119
Asthma and COPD /
COPD-47
Difference in the interpretation
of the existence of “COPD”
No asthma / COPD /
COPD-58
Asthma and COPD /
Asthma-34
Complete difference between
the assessors
Asthma / COPD-41
Normal / Asthma / COPD /
Asthma and COPD
Reproduction prohibited
13
Total87 27 2913
(8%)
156
(100%) (56%)(17%) (19%)
1: 5/0 = full agreement of five assessors
2: 4/1 = agreement among 4 assessors / 1 deviant assessment
3: 3/2 = agreement among 3 assessors / 2 equal deviant assessments.
4: 1/1/1/1/1 = five deviant assessments
Table 1. Patterns of, and probable cause for, differences between diagnostic assessments by five respiratory
specialists of 156 primary care patients based on spirometry data and medical histories.
31
(21%)
20
(12%)
18
(11%)
Agreement in diagnoses
(No Asthma; Asthma; Asthma and COPD; COPD)
New patients
κ
Follow-up patients
κ
Total group
κ
a. Intra-observer reliability
(Mean κ and range)
0,660,560,67
(0,55-0,74)(0,40-0,79) (0.55-0,79)
b. Inter-observer reliability
(Weighted κ) 0,69 0,480,63
Table 2. Intra- and inter-observer reliability in diagnostic assessments performed by respiratory specialists and based
on written information about lung functions and medical histories.
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AEM Lucas et al.
182
observer reliability) in the diagnostic assessments of asthma
and COPD as performed by different assessors based on
spirometry and written information about a patient’s history,
complaints and compliance. We could not draw conclusions
about the reliability of the advice for additional diagnostic
examinations. The assessment of patients’ clinical stability
was found to be statistically not reliable; therefore, this
therapeutic advice should be treated with caution by the GP.
Comparable diagnostic assessments of asthma/COPD
Intra- and inter-observer reliability in the diagnostic
assessment of asthma/COPD is hardly ever discussed in the
literature. A previous analysis of variability in the
interpretation of spirometry tests by respiratory specialists
showed 63% agreement.18In another study, interns and
respiratory specialists reached 58% agreement.19The
concordance we found in this study (mean κ=0.64) was
comparable – which is remarkable since the respiratory
specialists combined the interpretation of medical history and
spirometry data thus making the assessment more
complicated. When compared to other complicated
diagnostic procedures such as chest radiograph interpretation
by pulmonologists (κ=0.51),20the diagnostic reliability of the
assessments in our study is not inadequate.
What is the maximum achievable reliability?
This finding of moderately good agreement was surprising,
for one would expect that diagnostic concordance would be
high. To understand this better we examined in detail the
discrepancies between the diagnoses assessed by the
pulmonologist who had the best intra-observer reliability
(k=0.79). In 25 out of 156 cases (16%) different decisions
were made. Twelve cases concerned differences in diagnosing
patients with lung function that was borderline to normal
(FEV1 around 80%, FEV1/FVC around 0.68). Other doubts
were caused by the interpretation of an improvement in FEV1
as a volume response or as ‘real’ reversible airway obstruction
that can be seen in asthmatics (N=5) and by discrepancies
between complaints and spirometry results (N=3). The use of
ICS without an obvious indication caused different diagnoses
in five out of 36 of those cases.
It is unlikely that these “real life problems” can be
completely solved by a strict assessment protocol. This might
indicate that expectations about high concordance for
diagnostic support services or outpatient clinics are not
realistic.
An interesting question is whether GPs themselves, willing
to overcome the practical problems of performing spirometry,
do better. Trained GPs have been shown to identify normal
and clearly deviant spirometry.21They also had problems in
interpreting the minor variations. Further research could show
how GPs – be they well trained or not – diagnose the
combination of spirometry and medical history and how this
compares to the paper assessments of the respiratory
specialists of the asthma/COPD-service.
Assessments in new and follow-up patients
The reliability of the diagnostic assessments was better in new
patients than in patients who came for follow-up. This can be
explained by the following problem we encountered: several
patients referred as new patients used ICS without a
diagnosis of asthma confirmed by former spirometry. In fact,
because of their use of ICS, they had to be considered as
follow-up patients. When their use of ICS could not be
explained by the results of the actual spirometry test or the
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Advice for additional diagnostic examination Agreement between repeated assessments
for each assessor mean κ (range)
1. Discrepancy between complaints and spirometry
➔ check for other diagnosis0,54 (0,32-0,65)
2. Obstruction, no diagnosis yet,
➔ perform steroid test 0,58 (0,40-0,86)
3. Normal spirometry, possibly asthma
➔ peakflow-registration test or histamine bronchoprovocation test0,56 (0,24-0,75)
4. Discrepancy between complaints and diagnosis
➔ check for additional medical problem
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0,38 (0,03-0,67)
5. Use of ICS for unclear reason
➔ stop ICS, repeat FVM after three months 0,40 (0,13-0,60)
Advice nr 1, 2 and 3 can be given to new patients, advice nr 4 and 5 to follow-up patients.
Table 2. Intra-observer reliability of the advice for additional diagnostic examinations given in case of uncertainty of
the diagnosis based on spirometry and written patient history data.
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Respiratory specialists diagnostic support: reliable?
patient’s medical history, the assessing pulmonologist had to
choose: either he accepted the presumed diagnosis (asthma
or moderate COPD with recurrent exacerbations), or he
refused to do so and postpone the diagnosis until the use of
ICS was stopped and spirometry was renewed. As we found
in another study, this dilemma exists in about 20% of all
patients referred to the diagnostic service22and the possible
conflict in decision-making can influence (negatively) the
reliability of the diagnostic assessment in follow-up patients.
Assessment of the need for additional diagnostic
examinations
The value of additional diagnostic advice was shown in a
former study where about 50% of the patients were given
advice which led to a large number of other or additional
diagnoses (rhinitis, gastric asthma, cardiac problems, etc).11
Also, more than 50% of all patients we describe in this paper
received advice regarding additional examinations. The most
important effect this advice might have had is that it
encouraged the GPs to explore differential diagnostic
considerations in case there was a discrepancy between
spirometry findings and the patient’s symptoms.
Assessment of the patients’ clinical condition and
medical advice
To classify the stability of a patient’s disease one should take
into account their complaints/symptoms, physical shape,
exacerbations, use of reliever medication, etc.23In this study
we found that the clinical stability of a patient could not be
assessed reliably from the written information. Consequently,
the (pharmacotherapeutical) treatment adjustments showed
a great intra- and inter-observer variability. To improve this, a
better algorithm will be needed for assessing clinical stability.
But even when there is such a protocol, the asthma/COPD-
service will only be supportive to the GP in identifying
instability and will not discharge the GP from taking final
responsibility and consequently
therapeutical advice offered.
Difficulties encountered in the study
In this paper we studied the regular assessment procedure of
the asthma/COPD-service without making corrections for
patients who were referred with a wrong indication (referred
for follow-up without a diagnosis). In addition, no special
instructions were given to the respiratory specialists about
how to handle specific situations such as the use of ICS by
patients without obvious reasons for that use. Therefore, our
results reflect the “every day life” reliability of the
assessments of the asthma/COPD-service to a greater extent
than the reliability of the professional assessment skills of the
pulmonologists.
Our study identified the need for a properly-assessed
diagnosis (before medical treatment) in order to monitor
reliably an asthma or COPD patient. As a result of our study
weighing up the
the asthma/COPD-service developed referral instructions for
the GPs. In addition, regular interviewing between the
respiratory specialists will be organised to develop and discuss
extra guidelines for the assessments. When these changes
have been implemented we intend to do a follow-up study
examining the expected improvements in the reliability of the
diagnostic and therapeutic assessments.
Lessons for clinical practice as a result of the study
Not all GPs have the facilities, the skills or the wherewithal to
perform adequately the diagnostic procedures necessary to
identify correctly asthma or COPD (or its absence). GPs
experience the need for ongoing support with regard to the
management of the care process24
interpretation.25Services offering such support need to
validate their procedures and need to provide the best reliable
reports to the GPs using that service. The reliability of the
advice varies. GPs referring to the service should realise that
100% reliability cannot be expected because of the
complexity of diagnostic procedures.
and spirometry
Funding
The author (AEML) is supported by an unrestricted grant from “Picasso,” an
initiative of the research institution Caphri, Pfizer Inc. and Boehringer Ingelheim Inc.
Ethics approval
Not applicable
Competing interests
None
Acknowledgements
We gratefully acknowledge the commitment of the participating pulmonologists
from the Eindhoven Catharina Hospital; and the lung function assistants, secretary
and staff of the Asthma/COPD-service in administering the study.
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Available online at http://www.thepcrj.org
CORRIGENDUM
Corrigendum to ‘Asthma Programme in Finland: the quality
of primary care spirometry is good’ (Prim Care Resp J
2008;17(4):226-231)
*Leena E Tuomistoa, Vesa Jarvinenb, Jukka Laitinenc, Marina Erholad, Minna Kailae,
Pirkko E Branderf
The authors regreat that an error occurred on page 227, Figure 2
The first box in the flow chart reads ‘Referral letters to three pulmonary units during year 200111’
should read
‘Referral letters to three pulmonary units during year 200114’
*Corresponding author: Dr Leena Tuomisto, Pulmonary Department, Seinajoki Central Hospital, Huhtalantie 53, Seinajoki, 60220, Finland
Tel: +358408457163 Fax: +35864154989 E-mail: leena.tuomisto@gmail.com
DOI of original article: doi:10.3132/pcrj.2008.00053
PRIMARY CARE RESPIRATORY JOURNAL
www.thepcrj.org
doi:10.4104/pcrj.2009.00034
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