MedWire News: Opportunistic testing by trained, visiting nurses improves spirometry compared with usual care, but fails to increase chronic obstructive pulmonary disease (COPD) diagnosis, a study indicates.
The results, reported in advance online by the journal Thorax, showed that COPD remained substantially underdiagnosed despite a significantly greater proportion of individuals at risk for COPD being tested and better techniques being applied with the opportunistic approach.
Spirometry is essential for the diagnosis of COPD, but presents difficulties in primary care, such as lack of access to reliable equipment, lack of training, patients' reluctance to travel, and financial disincentives, note Julia Walters (University of Tasmania, Australia) and team.
The researchers tested the impact of opportunistic spirometry by trained nurses on recognition of airflow obstruction in a 6-month study conducted at eight primary care practices.
The practices were randomly assigned to either a trained nurse (TN) model or usual care (UC) model for the delivery of spirometry to patients in the "target group" of COPD, defined as age over 35 years and having ever smoked regularly.
In the TN model, nurses trained in spirometry testing visited each practice for two 3-hour sessions per week to perform opportunistic testing. Spirometry was also advertised by posters or performed at the request of doctors.
In the UC group, a spirometer was provided to the practice and education and spirometry training was given. Spirometry was then performed by a doctor or practice nurse or assistant, according to the usual practice protocol.
At the TN practices, 531 (59%) out of 904 eligible patients underwent spirometry compared with just 87 (8%) of 1130 at UC practices, a significant difference.
Furthermore, 76% of tests in the TN model met American Thoracic Society spirometry standards for acceptability and reproducibility compared with just 44% of tests in the TN and UC models.
Yet in each group the same proportion - 8% - of patients with no prior COPD diagnosis who were found to have airflow obstruction, with a forced expiratory volume/FEV1 ratio ≥0.7, had a diagnosis of COPD 3 months later.
The team concludes: "It is possible to increase spirometry for case finding in primary care using a model of testing by visiting trained nurses. However, to translate increased detection of airflow obstruction into increased COPD diagnosis requires measures to overcome issues identified by qualitative analysis and, at the very least, provide general practitioners with assistance in interpretation of spirometry."
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