Key Point

Office spirometry is feasible in primary care settings, but its use by GPs begins to progressively decline within a few months.

CORREGGIO, ITALY—Clinicians have long supported the routine use of spirometry in primary care to facilitate the diagnosis of asthma and COPD. However, the results of the Spirometry in Asthma and COPD: a Comparative Evaluation (SPACE) study may change that.

"The SPACE program ... did not find a significant advantage of office spirometry in improving the diagnosis of asthma and COPD in the primary care setting," Paul Enright, MD, Research Professor of Medicine and Public Health at the University of Arizona in Tucson, related in an editorial.¹ He said that he now agrees with the Agency for Healthcare Research and Quality that "until more conclusive studies are performed, spirometry should currently be offered only to those smokers with dyspnea on exertion."

The SPACE study was a nine-month, prospective, randomized trial comparing the conventional (history/physical) and conventional plus spirometric methods of diagnosing asthma and COPD in primary care offices.² Of the 570 general practitioners (GPs) enrolled, most attended both of the four-hour prestudy educational sessions on correct use of the spirometer. "Approximately 13% of GPs had postgraduate training in respiratory medicine, but none had ever used a spirometer regularly in their activity as a GP," the investigators noted.

Although 85% of the GPs rated the feasibility of office spirometry as high after the educational sessions, only 104 agreed to participate further in the trial. Another 236 opted for the observational arm, which had less strict inclusion criteria and only sought GP opinions of the usefulness of spirometry in the primary care setting over time.

Of the 333 patients enrolled who had symptoms suggesting asthma or COPD, only 135 completed the trial without protocol violations. Spirometry findings were normal in 61.8% of these patients; spirometry suggested airway obstruction in 16.4%, mixed pathology in 12%, and a low FVC without obstruction in 9.8%.

Asthma, COPD, and other respiratory disease were diagnosed by the GPs in 32.1%, 29.1%, and 7.2% of the patients, respectively; coexisting asthma and COPD were diagnosed in 2.4%. No diagnosis was made in 29.1%.

When the GP diagnoses were compared to those made by specialists who also evaluated the patients, there was 78.6% agreement in the conventional diagnosis plus spirometry group versus 69.2% in the conventional diagnosis group; however, that difference was not significant. "In the intention-to-treat analysis, the respective percentages of concordant diagnosis were 57.9 and 56.7," reported the investigators.

HOW STEM CELL THERAPY WORKS

Among the GPs in the observational arm, office spirometry was rated as very useful by 57.1%, moderately useful by 15%, and useless by 0.3%. About 28% provided no opinion on the utility of office spirometry.

Although the investigators concluded that office spirometry is feasible, they acknowledged that its use tended to decline progressively after a few months in the absence of follow-up training. Thus, they recommended closer interaction between GPs and specialists as the best option for reducing the underdiagnosis and undertreatment of chronic obstructive lung diseases.

"The routine application of office spirometry, at least where general practices are run by a single GP with limited or no support by nurses, may have a severe risk of failure with waste of time and money," said Mirco Lusuardi, MD, Head of Cardiopulmonary Rehabilitation at S. Sebastiano Hospital in Correggio, Italy.

He added that the implementation of office spirometry in general practice is still an important goal, given the high prevalence and high social costs of asthma and COPD, "but an effective and efficient model for standard general practice has not yet been identified."

—Timothy Begany

Reference
1. Enright P. Does screening for COPD by primary care physicians have the potential to cause more harm than good? Chest. 2006;129:833-835.
2. Lusuardi M, De Benedetto F, Paggiaro P, et al. A randomized controlled trial on office spirometry in asthma and COPD in standard general practice: data from Spirometry in Asthma and COPD: a Comparative Evaluation Italian study. Chest. 2006;129:844-852.

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