Dr Roger Carter Consultant Clinical Scientist Lead for Respiratory and Sleep Physiology services GG&C NHS

1. Greater Glasgow Outreach Spirometry Service:A model for closer collaboration between primary and secondary care and its impact on chronic lung disease management Dr Roger Carter Consultant Clinical Scientist Lead for Respiratory and Sleep Physiology services GG&C NHS

2. Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnea indoor/outdoor pollution è SPIROMETRY

3. Why Spirometry? • Undiagnosed airflow limitation (obstruction) is common in the general population. • It is associated with impaired health and functional status. • It is an independent predictor of morbidity and mortality. • The presence of any respiratory symptoms doubles the risk of airflow limitation. • Simple measurement of peak flow cannot substitute for spirometry, either for detecting airway obstruction or for determining its severity.

4. NICE COPD 2004: Severity of obstructionFEV1/FVC <70% • FEV1 <80% >=50% Predicted: • Mild airflow obstruction • FEV1 <49% >=30% Predicted: • Moderate airflow obstruction • FEV1 <30% Predicted: • Severe airflow obstruction

5. Spirometry in Primary Care • Unlike many medical tests during which the patients remain passive, spirometry testing requires co-operation and an almost athletic breathing manoeuvre. • With submaximal effort, the results are erroneous (false positive and false negative for disease or change in severity). • The misclassification rate is about 5% in most research and sub-speciality settings , but has been shown to be higher in primary care settings. • The most common cause of error is inadequate spirometry training and experience of the person performing the test

6. Outreach Spirometry Service:Introduction • In 1997, national guidelines (BTS) for the diagnosis and management of COPD placed emphasis on spirometry for the early and accurate diagnosis of this important disease. • Spirometers are becoming more widely used in general practice, however, training in the proper use of the spirometer and basic interpretation of the results is essential, as in untrained hands, a spirometer is likely to lead to confusion. • A novel initiative by Greater Glasgow Health Board, was used to address this problem by providing an outreach spirometry service using three trained clinical physiologists to provide spirometry (with Flow/Volume loop) and, if requested, assessment of bronchodilator response at primary and secondary care centres throughout the health board district.

9. Outreach Spirometry Flow Chart • Request Form • Received Administrative Centre • Faxed to appropriate testing centre • Glasgow Royal Victoria Infirmary Gartnavel Hospital Appointment Booked Tests Performed at designated sites • Results Returned to Administrative Centre for Interpretation • Results and interpretation returned to Primary Care

10. Sites Originally Identified • North East • Springburn Health Centre • Easterhouse Health Centre • Baillieston Health Centre • Shettleston Health Centre • Stobhill ACH • Glasgow Royal Infirmary (4 Sessions) • South • Castlemilk Health Centre • Clarkston Community Health Centre • Victoria ACH • Southern General Hospital • Govanhill Health Centre • Gorbals Health Centre • Rutherglen Primary Care Centre • Cambuslang Health Centre • North West • Clydebank Health Centre • Drumchapel Health Centre • Maryhill Health centre • Gartnavel General Hospital (1 sessions) • Western Infirmary (2 sessions)

12. Symptoms Smoking cessation 100 Healthy population Antibiotics for acute infections 80 Smokers cough Little or no dyspnoea No abnormal signs Trial Symptomatic bronchodilator therapy Trial Long acting Bronchodilators Inhaled steroid if freq exacerbations Worsening lung function 60 Exertional dyspnoea Cough & sputum Some abnormal signs Influenza vaccination Pulmonary rehabilitation FEV1 as % predicted Assessment for LTOT 40 Dyspnoea on mild exertion Hyperinflation & cyanosis Wheeze & cough 20 Death Increasing investigation and treatment Management of stable COPD

13. Outreach Spirometry Activity2003-2008Total Patients Referred 36,325 Total Patients Seen 25,428

15. Does this service help in the diagnosis and management? • Retrospective analysis of 200 consecutive complete referral forms • Interpretation of completed Spirometry results • Management advice given based on clinical information and spirometry results against the GGHB COPD Primary Care Guideline

16. RESULTS

17. Breakdown of spirometry results on the diagnosis from 200 spirometry referrals No diagnosis made 55 84 Confirmation Asthma 12 New 10 Diagnosis COPD 39 Changed Confirmed Diagnosis

19. Greater Glasgow Health Board COPD Outreach Spirometry: How does primary care view the service?

24. Conclusions • 1) The spirometry service does help to confirm specific abnormalities but also shows the need for quality spirometry in aiding the correct diagnosis of COPD • 2) Spirometry may also help to identify some patients with asthma but due to the nature of this disease, a single normal spirometry assessment can not exclude asthma. • 3) In some patients with a significant smoking history asthma may be wrongly identified as COPD. • 4) A number of patients with suspected asthma are not identified by routine screening and further assessment (Formal peak flow monitoring, assessment of bronchial reactivity) would be necessary to confirm the diagnosis if clinically appropriate. • 5) A “radiological” diagnosis of COPD or clinical impression of COPD may not be reflected by the findings on spirometry.

25. Spirometry Outcomes 2008: Total Seen 4931

26. MRC Score against %predicted FEV1 in 300 Consecutive Patients

27. MRC Score against %predicted FEV1 in patients with COPD (N= 96)

28. Conclusions • 1) These findings suggest that this service provision, especially when coupled with management advice and further treatment options, is of significant benefit to primary care physicians and specialist practice nurses • 2)The spirometric findings and consequent treatment advice given has helped to optimise the management of patients with obstructive disorders. • 3) It is used as a gateway to further management options including medication advice, full pulmonary function testing, pulmonary rehabilitation and oxygen assessment. • 4) It may also help to identify those patients with early changes associated with airways disease to allow reinforcement of smoking cessation advice and hence earlier intervention.