A mixed methods study to compare models of spirometry delivery in primary care for patients at risk of COPD

Abstract

Background: To increase recognition of airflow obstruction in primary care, we compared two models of spirometry delivery in a target group at risk of chronic obstructive pulmonary disease (COPD). Methods: A 6 month qualitative/quantitative cluster randomised study in eight practices compared opportunistic spirometry by ''visiting trained nurses'' (TN) with optimised ''usual care'' (UC) from general practitioners (GPs) for smokers and ex-smokers, aged over 35 years. Outcomes were: spirometry uptake and quality, new diagnoses of COPD and GPs' experiences of spirometry. Results: In the eligible target population, 531/904 (59%) patients underwent spirometry in the TN model and 87/ 1130 (8%) patients in the UC model (p,0.0001). ATS spirometry standards for acceptability and reproducibility were met by 76% and 44% of tests in the TN and UC models, respectively (p,0.0001). 125 (24%) patients tested with the TN model and 38 (44%) with the UC model reported a pre-existing respiratory diagnosis (p,0.0001). Three months after spirometry, when the ratio of forced expiratory volume in 1 s/forced vital capacity (FEV 1 /FVC) was ,0.7 and no prior COPD diagnosis was reported, nine (8%) participants had a new doctor recorded COPD diagnosis in practices with the TN model and two (8%) participants in practices with the UC model. Mislabelling of participants with a diagnosis of COPD when FEV 1 /FVC was >0.7 was present in both models prior to and after spirometry. GPs valued high quality spirometry and increased testing of patients at risk of COPD in the TN model. They identified limitations, including the need for better systematic follow-up of abnormal spirometry and support with interpretation, which may explain persisting underdiagnosis of COPD in practice records. Conclusions: Although opportunistic testing by visiting trained nurses substantially increased and improved spirometry performance compared with usual care, translating increased detection of airflow obstruction into diagnosis of COPD requires further development of the model.

COPD prevalence and the differences between newly and previously diagnosed COPD patients in a spirometry program

“…The underdiagnosis of COPD remains a problem in several countries, and several studies have highlighted the importance of spirometry for the identification of obstructive lung disease in primary care. 27 The current evidence that spirometry is underused by primary care physicians, 16,28 combined with the fact that the development of screening questionnaires is not yet satisfactory, 29 has led to the suggestion that the problem of COPD underdiagnosis in primary care may be addressed by the provision of good quality spirometry in the primary care setting, [30][31][32] -as is the case in our study. The implementation of current recommendations on spirometry standards in primary care may also lead to an improvement in the diagnosis of COPD.…”

A combination of the IPAG questionnaire and PiKo-6® flow meter is a valuable screening tool for COPD in the primary care setting

“…However, their self-reported confidence was not in accordance with the diagnoses, investigations and management strategies they proposed on case scenarios. A recent study in Australia 13 showed that visiting trained nurses performed spirometry in 59% of the eligible target population (76% technically correct), while in the optimised usual care model from GPs only 8% of the subjects underwent spirometry (44% technically correct). However, only 8% of the participants with airflow obstruction had an official diagnosis of COPD three months after spirometry in both models.…”

“…8 There has been increasing interest during the last decade in the early diagnosis of COPD in the primary care setting as general practitioners (GPs) rather than pulmonary specialists make the initial diagnose and treat patients with respiratory symptoms. 9,10 The widespread application of spirometry by GPs 11,12 as well as by visiting trained nurses 13 may enhance the early diagnosis of COPD. On the other hand, in a multicentre randomised trial of the feasibility of performing spirometry in the GP surgery and the improvement in COPD/asthma diagnosis compared with conventional evaluation, only 104 out of 570 GPs agreed to participate in the spirometry group while the enrollment rate was remarkably low.…”

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

“…Spirometry can be performed by any health-care worker who has undergone the appropriate training and who keeps his or her skills up to date. 188 However, a RCT in Australia, in which 26 intervention practices received comprehensive spirometry training and 14 control practices provided usual care, concluded that Re12, Re27, Re29…”