A Randomized Controlled Trial on Office Spirometry in Asthma and COPD in Standard General Practice: Summary

A Randomized Controlled Trial on Office Spirometry in Asthma and COPD in Standard General Practice: SummaryIn the United Kingdom, an audit study was carried out in 1999 on 95 general practices in North Staffordshire. One half of the practices declared that spirometry should be available in the practice, but only 18 practices possessed a spirometer and 8 of them never used it. Lack of formal training was one of the main limitations registered. Open access to hospital spirometry services was an alternative solution preferred by GPs in North Staffordshire. This audit study was conducted in a period when office spirometry by GPs was underfinanced by the UK National Health Service. Very recent work on 72% of general practices in South Wales (of which 82% had a spirometer) concluded that despite incentives (recommendation by guidelines and the general medical services contract in the United Kingdom) to perform spirometry in general practice, lack of adequate training in use and interpretation determined a wide variability of confidence and reliability levels in COPD diagnosis. As a matter of fact, spirometry was performed more often if GPs were confident in use and interpretation, and frequency of use was related to greater training periods. Spirometric confirmation of COPD varied widely (0 to 100%; median, 37%). Indeed, different studies confirm the importance of training, repeat performance, and quality control by experienced personnel. www.mycanadianfamilypharmacy.net
In conclusion, our randomized trial shows that a conventional evaluation of patients with symptoms of chronic airways obstruction including a detailed questionnaire and physical examination is not inferior to a conventional evaluation plus office spirometry, but objective limitations must be stressed, in particular that the study was underpowered to show a difference between the two groups of patients, with a potential type II statistical error. Moreover, the study shows that where the general practice is organized as in Italy (on an individual basis without nursing or technical assistance), office spirometry is feasible; but even when automated simple and reliable devices are available along with technical instruction at the start, regular application tends to decrease progressively within a few months if there are no reinforcing recalls or retraining, despite a favorable rating on usefulness. Therefore, at present, a closer interaction between GPs and specialists with an easy referral of subjects with respiratory symptoms and asymptomatic smokers > 45 years old to specialist facilities is the best option for reducing the rate of underdiagnosis and undertreatment of chronic obstructive disorders. At the same time, studies to identify and resolve the factors preventing field implementation of office spirometry are greatly needed.

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