Breakout 1.2 Assessing competence in practice: Quality assured diagnostic spirometry - Monica Fletcher Chief Executive Education for Health Chair European Lung Foundation Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

1. Assessing competence in practice:
Quality Assured Diagnostic Spirometry
Monica Fletcher
Chief Executive Education for Health
Chair European Lung Foundation
Most COPD is undiagnosed
70% with moderate
3.2 million people have
COPD but 2.2 million
remain undiagnosed
Shahab L, Jarvis MJ, Britton J et al.
Thorax 2006;61:1043-1047.
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2. www.rightcare.nhs.uk/index.php/atlas/respiratorydisease/2012
• 20% GP consultations are for respiratory problems
• GPs manage the majority of patients with airways disease
• Nationally about 25% on primary care COPD registers not
meeting diagnostic criteria
• West London study verifying diagnosis of COPD using a
centralised diagnostic service for primary care found 36%
misdiagnosed & therefore on inappropriate treatment 1
• Several studies have also demonstrated that asthma is also
frequently over diagnosed or misdiagnosed2,3,1
Starren et al (2011) PCRJ 2. Linden Smith et al (2004)
1.
CanRJ 3.Aaron et al (2008) CMAJ
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3. Does late diagnosis matter in COPD?
• Lung function declines progressively, but evidence this is
more rapid than we thought in early stages of the disease,1,2
• Exacerbations are common even in moderate disease (22%
GOLD stage 2 )3
• Quality of life, physical & social function are significantly
reduced in all stages of disease from mild to severe4
• 44% of people with COPD in the UK are of working age: over
half are prevented from working at all and a quarter limited
in their ability to work – lost personal & societal income
Decramer M, et al (2009) Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT):
DOI:10.1016/S0140-6736(09)61298-8 Lancet , (2009)2 Jenkins CR, et al. TORCH study. Respir Res 2009;10:59 3. Hu
rst J, et al. Susceptibility to Exacerbation in Chronic Obstructive Pulmonary Disease. NEJM 2010;363(12):1128-38.
4;Miravitlles M, et al. Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities. Thorax 2009;64:863-8.
How late is “late” diagnosis?
• A recent Canadian study found that 21% of those with
undiagnosed COPD had severe or very severe disease1
• NCROP audit 2008 – Nationally 10% of emergency
COPD admissions were undiagnosed 2
• London study 2011 - 34% admissions were undiagnosed and
one fifth of the undiagnosed patients were in respiratory
failure 3
1HillK, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care
CMAJ 2010;182:673-8 2. Royal College of Physicians, BTS, BLF. Report on the National Clinical COPD resources outcomes
Project RCP 2008 3. Bastin A, et al. High prevalence of undiagnosed and severe chronic obstructive pulmonary disease at first
hospital admission with acute exacerbation. Chronic Respiratory Disease 2010;7(2)91-7.
http://dx.doi.org/10.1177/1479972310364587
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4. Missed opportunities in primary care
38,000 patients, 2 years prior to diagnosis:
• Over half (56%) had two or more consultations
for lower respiratory tract complaints
• 27% had four or more consultations for lower
respiratory tract infections
• One third of these received two or more
prescriptions for steroids and or antibiotics
Price D, Halpin D, Winter D et al. Missed opportunities to diagnose COPD. Oral
Presentation European Respiratory Society Conference. 2011
Impact of Inaccurate Spirometry results:
Costs to the individual
• Diagnosis : be it wrong, inaccurate and correct
diagnosis (COPD, asthma, other diagnosis)
• Psychological impact on individual and family
• Disability and/or work issues
• Life insurance
• Inappropriate and expensive ongoing treatments
(with potential side effects)
• Further tests or investigations
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5. Inaccurate spirometry results:
Healthcare costs
• Under or over treatment or no treatment
including inappropriate, expensive therapies
• Inappropriate referrals
• Further unnecessary investigations
• Wrong labeling on practice registers / QOF:
Follow up and recall
An estimation of cost of misdiagnosis
(Based on a rate of 25%) Approx £28.5m
Total Stage % number Cost of annual Total cost
misdiagnosed total medication per per year
(COPD pts) patient
835,000 mild 53% 110,637 £80 £8,850,960
known
25%=208,750
moder 39% 81,412 £137 £11,153,444
ate
severe 8% 16,700 £514 £8,583,800
TOTAL £28,588,204
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6. • The diagnosis and assessment of respiratory disease
requires accurate measurement of lung function (along
with clinical history taking and physical examination)
• The most widely used test of lung function is
SPIROMETRY
• Many options which are: affordable, easy to use,
reliable, portable desktop hand held options providing
reference values & computer generated interpretation
“Yet high quality spirometry continues to prove difficult to
implement in primary care” (and other settings!)
Jenkins C (2009) Editorial Primary Care Respiratory Journal 18(3)128-129
The UK Quality & Outcomes Framework (QOF) pay
for performance scheme & spirometry
Strong M et al (2009) BMC Health Services Research
• QOF Introduced in 2003 to improve Quality in general practice
• In 2006/07 practices in Rotherham achieved 94.5% indicators
(national average 96%)
• 3217 patients randomly selected from 5,649 patients with COPD
from 38 GP practices in Rotherham
• Only 31% met BTS standards (3 consistent readings 2 within
100mls) and 12% not consistent with COPD diagnosis
Quality Outcomes Framework is rewarding the QUANTITY not
QUALITY of spirometry Substantial variation in performance and
interpretation
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7. How can we ensure earlier diagnosis?
Opportunistic assessment:
• Smoker or ex smoker over 35
• Symptoms such as breathlessness, chronic cough, regular
sputum production, frequent winter “bronchitis” and
wheeze
Systematic case finding by audit of GP register
• Symptomatic patients with airflow obstruction
• E.g. smokers or ex-smokers not known to have COPD or
asthma with history of recurrent respiratory symptoms or
infections or treatment with inhalers
Quality assured diagnostic spirometry
• Ensuring the diagnosis is correct
What can go wrong with spirometry in the
community setting?
Equipment
• Fully functioning, calibration, regular
Patient serviced…..
• Ill prepared
• Poor technique, effort
• Posture ….
Operator
• Competence, training, motivated, lack of time,
conscientious, poor instructions…….
Environment
• Temperature, privacy, distraction,
hygiene…..
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8. Misbelief
Simple test Minimum skill
required
Clinical Experience : A definition
Making the same mistakes
with increasing confidence
over an impressive
number of years
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9. A Guide to Performing
Quality Assured Diagnostic Spirometry
In publication by DH
Assessing Quality Assured Spirometry
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10. A Guide to Performing
Quality Assured Diagnostic Spirometry
1. Calibration and cleaning
2. Preparation of the patient
3. Performance of the test
4. Interpretation of results
5. Reporting – top ten tips
6. Common technical errors
7. Quality assurance
8. Ensuring competency
Performing Quality Assured Diagnostic
Spirometry in clinical practice: Assessing
competence in those performing and
interpreting the test*
*currently being formalised
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11. Who should diagnose respiratory conditions
Diagnosis should be made by a qualified medical practitioner
or an appropriately trained nurse or AHP
The diagnosis of most common respiratory disorders is based on
– comprehensive clinical history
– physical examination
– relevant additional tests e.g. FBC, CXR
– Diagnostic spirometry
Who should perform
quality assured diagnostic spirometry
• Spirometry may be performed by a range of practitioners
who may not be qualified HCPs BUT the interpretation
should only be carried out by a qualified HCP or clinical
physiologist
• Because spirometry is a practical procedure, assessment of
competence is critical
• Quality Assured Diagnostic Spirometry should only be
performed in a clinical setting by individuals who have
been assessed to the standards established by the ARTP
otherwise the accuracy of the diagnosis cannot be relied
upon
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12. Delegation of tasks
• Professionals responsible for Quality assured diagnostic
spirometry have a duty to ensure that they and the staff
they manage have the necessary skills and competence to
undertake the procedure in accordance with the nationally
agreed standards.
• This includes GPs delegating to practice nurses and practice
nurses delegating to HCAs
So what is the plan?
• Inexperienced staff will attend an approved training programme and
1 on successful completion will be entered onto a register
• Practitioners undertaking a current ARTP approved training programme
2 will be entered on to a register on successful completion of the course
• Practitioners already on a register will remain on the register for 3
3 years and will then be reassessed
• Experienced staff may have direct entry to a register by submitting a
portfolio of tests to a recognised assessment centre and upon meeting
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the qualifying criteria will be entered on to the register
• Very experienced staff may be able to access the register directly
5 through an equivalence process * To be determined
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13. Evidence for the need for training
– ‘good quality spirometry from trained and experienced staff
provides more robust and reliable results than office testing’ (Lange et
al. Respir Med 2009)
– Nurses who have undertaken a COPD diploma module were more
confident in interpreting spirometry than those who had not
undertaken the training 53% v 12% (p<0.001) (Davison BTS abstract
2012)
• Spirometry in Primary Care Practice
– 30 primary care clinics, Comparison 3.4% in usual group v 13.5% in
trained group (15 of each) met ATS acceptability and
reproducibility criteria (Eaton et al, Chest 1999; 116:416-423)
– Only 12% of nurses performing spirometry had received accredited training.
(Upton et al. PCRJ 2007)
Existing training programmes
• Need to explore opportunities to broaden certification
opportunities for all HCP including doctors, during their
training programmes both GPs and Specialist Registrars.
• Practice nursing programmes and other nursing courses
• Pharmacists
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14. Improving primary care
Spirometry
Francis Report :
• QOF & local enhanced ‘ there needs to be a clear set of
services fundamental standards of care
• Cost savings to be had which are backed by evidence,
• Satisfaction clinically informed and enforced by
• Professionalism a clear regulatory regime’
• Excellence in care: PCRS
Quality Award Care Quality Commission
• Improving Quality In Commissioning processes
Physiological diagnostic Certification courses and
Services: IQIPs individuals Registration of
individuals
During the first half of2013 will draw up detailed plans and
processes. So we can start to implement and roll out
Later in the year
LIFE AND BREATH FOR THOUSANDS
OF PATIENTS!
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