Walker PP, Mitchell P, Diamantea F, Warburton CJ, Davies L

Eur Respir J. 2006;28:945-952.

Primary-care spirometry has been promoted as a method of facilitating accurate diagnosis of chronic obstructive pulmonary disease (COPD). The present study examined whether improving rates of diagnosis lead to improvements in pharmacological and nonpharmacological management. From 1999 to 2003, the current authors provided an open-access spirometry and reversibility service to a local primary-care area, to which 1,508 subjects were referred. A total of 797 (53%) had pre-bronchodilator airflow obstruction (AFO). Of the subjects who underwent reversibility testing, 19.3% were no longer obstructed post-bronchodilator. The results and records of a subgroup of 235 subjects with post-bronchodilator AFO were examined. Of the 235 subjects, 130 received a new diagnosis, most commonly COPD. The patients with COPD were significantly undertreated before spirometry and testing led to a significant increase in the use of anticholinergics (37 versus 18%), long-acting b-agonists (25 versus 8%) and inhaled steroids (71 versus 52%). More than three quarters of smokers received smoking cessation advice but very few were referred for pulmonary rehabilitation. In conclusion, primary-care spirometry not only increases rates of chronic obstructive pulmonary disease diagnosis, but it also leads to improvements in chronic obstructive pulmonary disease treatment. The use of bronchodilator reversibility testing in this setting may be important to avoid misdiagnosis.

Comment.

Drawing on the analogy of routine blood pressure measurement in primary care encounters, a spirometer in every primary care physician's office has been touted as an important step in improving the recognition of airways disease, especially chronic obstructive pulmonary disease. Early recognition, the logic goes, would lead to more aggressive smoking-cessation counseling, earlier bronchodilator treatment, and improved long-term outcomes. This article reports on the decade-long experience with providing open-access spirometry in a primary care clinic in northwest England directed primarily at current or ex-smokers with respiratory symptoms. Of 1,508 patients referred for testing, a little over half had evidence of airflow obstruction, and of the 497 tested further, 80% did not show bronchodilator reversibility. Not only did the recognition of airflow obstruction lead to new diagnoses of asthma and chronic obstructive pulmonary disease, but also, the severity distribution was surprising in that only 6 of 139 patients evaluated in greater detail had GOLD-defined mild disease, with the rest being roughly equally distributed between moderate and severe/very severe disease. This does underline the fact that even advanced airflow obstruction can be overlooked without objective testing. A significant cautionary aspect is that this access to spirometry became available at a time when there were major performance incentives, based on numbers of patients diagnosed and treated for chronic obstructive pulmonary disease, on offer to the region's primary care providers. This may suggest that widespread use, even if appropriate, may be influenced by more than just the availability of testing equipment and personnel; any attempt at generalization would do well to harness the positive effects of the financial carrot.

SK