Spirometry is recommended for diagnosis and management of obstructive lung disease. While many patients with asthma and COPD are cared for by primary care practices, limited data are available on the use and results associated with spirometry in primary care.
To assess the technical adequacy, accuracy of interpretation, and impact of office spirometry.
A before-and-after quasiexperimental design.
Three hundred eighty-two patients from 12 family medicine practices across the United States.
Patients with asthma and COPD, and staff from the 12 practices.
Technical adequacy of spirometry results, concordance between family physician and pulmonary expert interpretations of spirometry test results, and changes in asthma and COPD management following spirometry testing.
Of the 368 tests completed over the 6 months, 71% were technically adequate for interpretation. Family physician and pulmonary expert interpretations were concordant in 76% of completed tests. Spirometry was followed by changes in management in 48% of subjects with completed tests, including 107 medication changes (>85% concordant with guideline recommendations) and 102 nonpharmacologic changes. Concordance between family physician and expert interpretations of spirometry results was higher in those patients with asthma compared to those with COPD.
US family physicians can perform and interpret spirometry for asthma and COPD patients at rates comparable to those published in the literature for international primary care studies, and the spirometry results modify care.
"The main reason for disagreement on diagnosis was that COPD was not diagnosed by GPs, while according to international criteria the test results indicated COPD. A study of Yawn et al. likewise found disagreements between GPs and pulmonologists on the interpretation of spirometry results in 88 out of 368 tests (24%) . Most common reasons for disagreement in this study were overreporting of airflow obstruction in patients with normal spirometry results by GPs, interpreting restrictive patterns in people with poor effort and diagnosing COPD in absence of spirometry results indicating COPD. "
[Show abstract][Hide abstract] ABSTRACT: Interpreting spirometry results has proven challenging in primary care practice, among others potentially leading to under- and misdiagnosis of COPD. In telepulmonology a general practitioner (GP) digitally consults a pulmonologist to support the interpretation of spirometry results. This study assessed the effect of telepulmonology on quality and efficiency of care.
Quality of care was measured by five indicators, among others the percentage of TelePulmonology Consultations (TPCs) sent by GPs for advice, percentage of those TPCs resulting in a physical referral, and educational effect of telepulmonology as experienced by GPs. Efficiency was defined as the percentage of prevented unnecessary physical referrals of patients to the pulmonologist.
Between April 2009 and November 2012 1.958 TPCs were sent by 158 GPs to 32 pulmonologists. Sixty-nine percent of the TPCs were sent for advice. Based on the advice of the pulmonologist 18% of these TPCs led to a physical referral of patients who would not have been referred without telepulmonology. Thirty-one percent of the TPCs were intended to prevent a physical referral, 68% of these actually prevented a physical referral to a pulmonologist.
The results show telepulmonology can contribute to quality of care by supporting GPs and can additionally prevent unnecessary physical referrals.
Respiratory medicine 10/2013; 108(2). DOI:10.1016/j.rmed.2013.10.017 · 3.09 Impact Factor
"In Denmark, the majority of patients with respiratory symptoms are diagnosed and managed in general practice. Spirometry has been shown to be both feasible and reliable in general practice
, but if preferred, GPs can also refer patients to spirometry testing at hospitals or outpatient clinics. Underutilisation of spirometry when diagnosing obstructive lung disease is well known
[Show abstract][Hide abstract] ABSTRACT: Spirometry testing is essential to confirm an obstructive lung disease, but studies have reported that a large proportion of patients diagnosed with COPD or asthma have no history of spirometry testing. Also, it has been shown that many patients are prescribed medication for obstructive lung disease without a relevant diagnosis or spirometry test registered. General practice characteristics have been reported to influence diagnosis and management of several chronic diseases. However, these findings are inconsistent, and it is uncertain whether practice characteristics influence spirometry testing among patients receiving medication for obstructive lung disease. The aim of this study was therefore to examine if practice characteristics are associated with spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease.
A national register-based cohort study was performed. All patients over 18 years receiving first-time prescriptions for medication targeting obstructive lung disease in 2008 were identified and detailed patient-specific data on sociodemographic status and spirometry tests were extracted. Information on practice characteristics like number of doctors, number of patients per doctor, training practice status, as well as age and gender of the general practitioners was linked to each medication user.
Partnership practices had a higher odds ratio (OR) of performing spirometry compared with single-handed practices (OR 1.24, CI 1.09-1.40). We found a significant association between increasing general practitioner age and decreasing spirometry testing. This tendency was most pronounced among partnership practices, where doctors over 65 years had the lowest odds of spirometry testing (OR 0.25, CI 0.10-0.61). Training practice status was significantly associated with spirometry testing among single-handed practices (OR 1.40, CI 1.10-1.79).
Some of the variation in spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease was associated with practice characteristics. This variation in performance may indicate a potential for quality improvement.
BMC Family Practice 08/2013; 14(1):113. DOI:10.1186/1471-2296-14-113 · 1.67 Impact Factor
"The guidelines recommend performing spirometry on all individuals with a history of repeated exposure to environmental pollutants and/or cigarette smoke exposure, a family history of COPD, or the presence of a chronic cough, sputum production, or shortness of breath. It has been suggested that “spirometry can be incorporated into family medicine practice with acceptable levels of technical adequacy and accurate interpretations”  based on the fact that improvements in spirometry equipment provide immediate feedback related to technical adequacy. We were interested in examining whether spirometry testing could be incorporated into primary care practice and potentially impact both the diagnosis and subsequent management of COPD. "
[Show abstract][Hide abstract] ABSTRACT: Background
Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease associated with significant clinical burden and is estimated to affect 15 million individuals in the US. Although a large number of individuals are diagnosed with COPD, many individuals still remain undiagnosed due to the slow progression of the disorder and lack of recognition of early symptoms. Not only is there under-diagnosis but there is also evidence of sub-optimal evidence-based treatment of those who have COPD. Despite the development of international COPD guidelines, many primary care physicians who care for the majority of patients with COPD are not translating this evidence into effective clinical practice.
This paper describes the design and rationale for a randomized, cluster design trial (RCT) aimed at translating the COPD evidence-based guidelines into clinical care in primary care practices. During Phase 1, a needs assessment evaluated barriers and facilitators to implementation of COPD guidelines into clinical practice through focus groups of primary care patients and providers. Using formative evaluation and feedback from focus groups, three tools were developed. These include a computerized patient activation tool (an interactive iPad with wireless data transfer to the spirometer); a web-based COPD guideline tool to be used by primary care providers as a decision support tool; and a COPD patient education toolkit to be used by the practice team. During phase II, an RCT will be performed with one year of intervention within 30 primary care practices. The effectiveness of the materials developed in Phase I are being tested in Phase II regarding physician performance of COPD guideline implementation and the improvement in the clinically relevant outcomes (appropriate diagnosis and management of COPD) compared to usual care. We will also examine the use of a patient activation tool - ‘MyLungAge’ - to prompt patients at risk for or who have COPD to request spirometry confirmation and to request support for smoking cessation if a smoker.
Using a multi-modal intervention of patient activation and a technology-supported health care provider team, we are testing the effectiveness of this intervention in activating patients and improving physician performance around COPD guideline implementation.
BMC Family Practice 05/2013; 14(1):56. DOI:10.1186/1471-2296-14-56 · 1.67 Impact Factor
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