P.J.P. Poels

Variation in spirometry utilization between trained general practitioners in practices equipped with a spirometer.

Objective. To explore spirometry utilization among general practitioners and identify practitioner and practice-related factors associated with spirometry utilization. Design. Multivariate multilevel cross-sectional analysis of a questionnaire survey. Setting. Some 61 general practices involved in a spirometry evaluation programme in the Netherlands. All practices owned a spirometer and were trained to perform spirometry. Subjects. A total of 144 general practitioners and 179 practice assistants. Main outcome measures. Extent of spirometry utilization for five indications from national COPD/asthma guidelines, practitioner and practice-related factors associated with spirometry utilization. Results. The response rate was 97%. General practitioners used spirometry mostly to evaluate treatment with inhaled steroids (58%). Significant practitioner-related factors associated with spirometry utilization were: general practitioners’ job satisfaction, general practitioners’ general interest in research, and prior participation in spirometry training. Practice-related factors associated with spirometry utilization were: presence of a practice nurse, delegation of medical tasks to practice assistants, use of spirometry in different rooms, and use of protocols in practice. Conclusion. Practitioner- as well as practice-related factors were associated with the extent of spirometry utilization. In particular, it is essential to improve practice-related factors (e.g. presence of a practice nurse, more delegation of medical tasks to the practice assistant).

Spirometry in chronic obstructive pulmonary disease

Is available, yet underused in general practice

Quality of routine spirometry tests in Dutch general practices.

BACKGROUND Spirometry is an indispensable tool for diagnosis and monitoring of chronic airways disease in primary care. AIM To establish the quality of routine spirometry tests in general practice, and explore associations between test quality and patient characteristics. DESIGN OF STUDY Analysis of routine spirometry test records. SETTING Fifteen general practices which had a working agreement with a local hospital pulmonary function laboratory for spirometry assessment regarding test quality and interpretation. METHOD Spirometry tests were judged by a pulmonary function technician and a chest physician. Proportions of test adequacy were analysed using markers for manoeuvre acceptability and test reproducibility derived from the 1994 American Thoracic Society spirometry guideline. Associations between quality markers and age, sex, and severity of obstruction were examined using logistic regression. RESULTS Practices performed a mean of four (standard deviation = 2) spirometry tests per week; 1271 tests from 1091 adult patients were analysed; 96.4% (95% confidence interval [CI] = 95.6 to 97.2) of all tests consisted of ≥3 blows. With 60.6% of tests, forced expiratory time was the marker with the lowest acceptability rate. An overall 38.8% (95% CI = 36.0 to 41.6) of the tests met the acceptability as well as reproducibility criteria. Age, sex, and severity of obstruction were associated with test quality markers. CONCLUSION The quality of routine spirometry tests was better than in previous reports from primary care research settings, but there is still substantial room for improvement. Sufficient duration of forced expiratory time is the quality marker with the highest rate of inadequacy. Primary care professionals should be aware of patient characteristics that may diminish the quality of their spirometry tests. Further research is needed to establish to what extent spirometry tests that are inadequate, according to stringent international expert criteria, result in incorrect clinical interpretations in general practice.

Diagnostic accuracy of pre-bronchodilator FEV1/FEV6 from microspirometry to detect airflow obstruction in primary care: a randomised cross-sectional study

Background:Forced expiratory volume in 1s/forced expiratory volume in 6 s ( FEV1/FEV6) assessment with a microspirometer may be useful in the diagnostic work up of subjects who are suspected of having COPD in primary care.Aim:To determine the diagnostic accuracy of a negative pre-bronchodilator (BD) microspirometry test relative to a full diagnostic spirometry test in subjects in whom general practitioners (GPs) suspect airflow obstruction.Methods:Cross-sectional study in which the order of microspirometry and diagnostic spirometry tests was randomised. Study subjects were (ex-)smokers aged ⩾50 years referred for diagnostic spirometry to a primary care diagnostic centre by their GPs. A pre-BD FEV1/FEV6 value <0.73 as measured with the PiKo-6 microspirometer was compared with a post-BD FEV1/FVC (forced vital capacity) <0.70 and FEV1/FVC<lower limit of normal (LLN) from diagnostic spirometry.Results:One hundred and four subjects were analysed (59.6% males, 42.3% current smokers). Negative predictive values from microspirometry for airflow obstruction based on the fixed and LLN cut-off points were 94.4% (95% confidence interval (CI), 86.4–98.5) and 96.3% (95% CI, 88.2–99.3), respectively. In all, 18% of positive microspirometry results were not confirmed by a post-BD FEV1/FVC <0.70 and 44% of tests were false positive compared with the LLN criterion for airflow obstruction.Conclusions:Pre-bronchodilator microspirometry seems to be able to reliably preselect patients for further assessment of airflow obstruction by means of regular diagnostic spirometry. However, use of microspirometry alone would result in overestimation of airflow obstruction and should not replace regular spirometry when diagnosing COPD in primary care.

General practitioners’ needs for ongoing support for the interpretation of spirometry tests

Background: Although one out of three general practitioners (GPs) carries out spirometry, the diagnostic interpretation of spirometric test results appears to be a common barrier for GPs towards its routine application. Methods: Multivariate cross-sectional analysis of a questionnaire survey among 137 GPs who participated in a spirometry evaluation programme in the Netherlands. We identified characteristics of GPs and their practice settings associated with GPs’ need for ongoing support for spirometry interpretation. Results: Response rate on the survey questionnaire was 98%. The need for ongoing support among the participating GPs was 69%. GPs’ recent spirometry training showed a statistically significant association with the need for ongoing support for the interpretation of spirometry (odds ratio 0.43, 95% CI 0.20–0.92). Conclusion: There is a need for ongoing support for spirometry interpretation among GPs. Recent spirometry training partially diminished this need.

Accuracy and precision of desktop spirometers in general practices.

Background: Spirometry has become an essential tool for general practices to diagnose and monitor chronic airways diseases, but very little is known about the performance of the spirometry equipment that is being used in general practice settings. The use of invalid spirometry equipment may have consequences on disease diagnosis and management of patients. Objectives: To establish the accuracy and precision of desktop spirometers that are routinely used in general practices. Methods: We evaluated a random sample of 50 spirometers from Dutch general practices by testing them on a certified waveform generator using 8 standard American Thoracic Society waveforms to determine accuracy and precision. Details about the brand and type of spirometers, year of purchase, frequency of use, cleaning and calibration were inquired with a study-specific questionnaire. Results: 39 devices (80%) were turbine spirometers, 8 (16%) were pneumotachographs, and 1 (2%) was a volume displacement spirometer. Mean age of the spirometers was 4.3 (SD 3.7) years. Average deviation from the waveform generator reference values (accuracy) was 25 ml (95% confidence interval 12–39 ml) for FEV1 and 27 ml (10–45 ml) for FVC, but some devices showed substantial deviations. FEV1 deviations were larger for pneumotachographs than for turbine spirometers (p < 0.0031), but FVC deviations did not differ between the two types of spirometers. In the subset of turbine spirometers, no association between age and device performance was observed. Conclusions: On average, desktop spirometers in general practices slightly overestimated FEV1 and FVC values, but some devices showed substantial deviations. General practices should pay more attention to the calibration of their spirometer.

Spirometrie in de Nederlandse huisartsenpraktijk.

SamenvattingSchellekens D, Poels P, Pellegrino A, Cretier R, Smeele I, Schermer T. Spirometrie in de Nederlandse huisartsenpraktijk: Resultaten van een landelijke survey. Huisarts Wet 2008;51(9):434-9. Spirometrie is onmisbaar bij het diagnosticeren van chronische luchtwegaandoeningen, maar uit buitenlands onderzoek is gebleken dat de meting lang niet in alle huisartsenpraktijken optimaal toegepast wordt. Wij stelden ons ten doel de Nederlandse situatie te evalueren. Hoeveel huisartsenpraktijken beschikken over een eigen spirometer? Heeft de aanwezigheid van een praktijkondersteuner daarop enige invloed? Is het aantal spirometrietests dat in de eerste lijn wordt uitgevoerd de laatste jaren gestegen of gedaald? Uit een aselecte steekproef van 277 huisartsenpraktijken, genomen uit de databank van het NIVEL, benaderden wij 269 praktijken voor een telefonisch interview. Daarvan waren er 250 (93%) bereid informatie te verstrekken.Bijna tweederde (64%) van de benaderde praktijken beschikte over praktijkondersteuners, die in meerderheid (87%) ook COPD- en astmazorg verleenden. Bijna evenveel praktijken (62%) beschikten over een eigen spirometer. Van de praktijken zonder spirometer liet 75% de tests in een ziekenhuislaboratorium uitvoeren, 14% in een huisartsenlaboratorium en 10% afwisselend bij een van deze of bij andere faciliteiten (bijvoorbeeld een andere praktijk in de buurt). Slechts 1 praktijk had geen enkele spirometriefaciliteit. Het spirometerbezit bleek het hoogst in Limburg (87%), Friesland (76%) en Noord-Brabant (73%), het laagst in Noord-Holland (45%), Overijssel (43%) en Groningen (35%). Praktijken met een praktijkondersteuner bezaten vaker een eigen spirometer (OR 4,7; 95%-BI 2,7 tot 8,3) en besteedden de spirometrie minder vaak uit (OR 0,07; 95%-BI 0,02 tot 0,30). Ruimeen derde van deze praktijken controleerde echter nooit of de spirometer wel accuraat mat.De Nederlandse huisartsenpraktijken beschikken dus vrijwel zonder uitzondering over een faciliteit voor spirometrie. Praktijken die beschikken over een praktijkondersteuner, hebben meestal ook een spirometer in huis. Aan controle en onderhoud van de apparatuur besteden de praktijken echter onvoldoende aandacht.

Point of care microspirometry to facilitate the COPD diagnostic process in primary care: a clustered randomised trial

We studied if pre-bronchodilator FEV1/FEV6 determinations with microspirometers by GPs improve the diagnostic process for COPD in a 6–8 month clustered randomised controlled trial in Dutch general practices (http://www.trialregister.nl: NTR4041). GPs allocated to microspirometry (MI) used COPD-6® microspirometers in patients ≥50 years old with a smoking history and respiratory complaints that could indicate undiagnosed COPD and ask to refer patients for full spirometry if MI was positive (FEV1/FEV6 <0.73). Introduction of the COPD-6® was postponed in the usual care (UC) group. GPs of both study arms were asked to list all patients that fulfilled study criteria and at the end of the study we screened the electronic medical record system for number of patients that fulfilled study criteria and visited their GP within the study period. Main end point was a documented diagnostic conclusion of COPD within 3 months after the patient’s visit. We used multilevel logistic regression with correction for relevant covariates. Next, we described the process of care. 21 practices (88 GPs) participated and 416 possible undiagnosed COPD patient visited these practices in the study period. 78 (of 192 visiting) subjects were listed by MI GPs and diagnostic conclusions were documented in 77%, compared to 61 listed (of 224 visiting) subjects and 44% with documented diagnostic conclusions by UC GPs (Odds Ratio: OR: 4.3, 95%CI: 1.6–11.5). Microspirometry improved the diagnostic process for possible underlying COPD in patients who consulted their GP with respiratory symptoms, but the majority of possible undiagnosed COPD patients remained unrecognised by GPs.Chronic lung disease: Quick test may help identify potential sufferersA quick, simple test that can be used by family doctors may help identify patients suffering from chronic obstructive pulmonary disease (COPD). The small, inexpensive microspirometry (MI) kit enables doctors conducting routine appointments to measure the volume of air expelled from patients’ lungs. Lisette van den Bemt at Radboud University Medical Center, the Netherlands, and co-workers worked with two groups of doctors in local practices. Both groups were asked to identify patients over 50 with a smoking history, respiratory problems and no diagnose of asthma and COPD, and start a diagnostic process for COPD. One group was given microspirometers to aid diagnoses. Of 192 patients visiting the MI doctors, 78 were identified and 77 per cent were later listed as COPD or COPD was ruled out. In the other group, 61 out of 224 patients were identified with only 44 per cent listed.

Effect of spirometry on COPD management in primary care: where are the studies that we really need?

To the Editors: In the November 2006 issue of the European Respiratory Journal , Walker et al. 1 reported on the effects of the use of spirometry to diagnose chronic obstructive pulmonary disease (COPD) in primary care and the resulting benefits for patient management. In patients referred to an open-access spirometry service by their general practitioner, the diagnosis and current management of the patients was assessed before and after spirometry testing. Walker et al. 1 observed a change of diagnosis after spirometry in: 71% of patients who had no respiratory diagnosis at the time of the referral; 48% of patients who had previously been diagnosed with asthma; and 23% of patients with a COPD diagnosis. Drug prescription changed in 49% of the COPD patients, with a …

[Good wine needs no bush: quality spirometry in a primary care setting is possible].

To the Editor: In the July 2006 issue of Archivos de Bronconeumologia Hueto et al reported on the use and quality of spirometry in a primary care setting in Spain. Despite the good availability of spirometers (90%), the authors found underuse of spirometry in daily practice and low quality of the measurements due to a low training level and absence of continuity in the staff at the practice setting. The authors concluded that supplying spirometers in primary care settings will be insufficient as long as spirometry test performance is inadequate. Those results are somewhat disappointing, as carrying out spirometry in general practice seems justified in terms of test validity, provided that staff members have been trained sufficiently. Probably the baseline training level of staff members was the limiting factor in the Navarre region. We agree with the authors that a more comprehensive mode of continuous support of performance feedback after initial spirometry training may contribute to improved test quality, although evidence that this is indeed the case is not available at this time. We recently found that the quality of the spirometric tests performed in general practice settings was adequate for situations that do not involve spirometry research activities. The variability of forced expiratory volume in 1 secondand forced vital capacity was less than 5% and less than 200 mL for 85% and 82% of the 1282 spirometry tests that were available for review. Therefore, we do not agree with the recommendation by Hueto et al that there is no place for spirometry in the primary care setting. Once a primary care physician is convinced that spirometry is a helpful tool in diagnosing COPD, the most practical and best appreciated solution is to have a spirometer available in the practice. Although there clearly is variation in the organization and utilization of spirometry between countries and practices, there are several options for increasing test performance, such as a simple intervention of scheduling a periodic outreach visit by a lung function technician. Still, we need to be aware of the fact that there is a lack of evidence that quality assurance for spirometry in primary care settings is indeed effective.