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Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
Correspondence to: Patrick J.P. Poels, MD, Department of Family Practice (117), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, the Netherlands; e-mail: p.j.p.poels{at}hag.umcn.nl
To the Editor:
In a recent article in CHEST (October 2005),1 Dales et al reported on the influence of spirometry on physicians’ diagnoses of airflow obstruction and the planning of patient management. In a rural setting, the authors documented the physician’s diagnosis before and after spirometric results became available. Physicians reported that, regardless of a change in diagnosis, they would change patient management in 15% of the patients. The management changes were specially directed at counseling patients to stop smoking or at modifying medications. The authors recommended more research on the impact of spirometry on such clinically important end points as changes in diagnosis, management, and patient outcomes.
In our view, this study was directed at the role of spirometry in screening rather than the diagnostic impact of spirometry. All subjects included in the study (mean age, 59 years) visited their primary care physician for any reason and were smokers. A questionnaire was used to assess patients with respiratory symptoms and diseases whose conditions were likely to benefit from review by the physician. No information was presented on the results of physical examinations. In this screening setting, 15% of the physicians would alter their planned management regardless of the outcome of spirometry. The results confirm the conclusion of a review2 that spirometry should not be used to screen smokers for COPD in primary care because it is not yet known whether diagnosing COPD at an early stage would help patients to stop smoking.
Carrying out spirometry in the primary care setting is justified in terms of test validity, provided that the practice staff has been trained sufficiently.3 However, little is known about the diagnostic impact of spirometry,4 and it is important to get more insight into the sensitivity and specificity of spirometric testing of respiratory complaints in the primary care population. Chavannes et al5 reported in a study using simulated cases that spirometry results influence physicians’ decision making by reducing the number of alternative diagnoses, and by increasing the number of appropriate referrals and the use of diagnostic courses of prednisolone therapy. Empirical studies on the additional diagnostic value of spirometry are scarce. Preliminary results of a study by Yawn et al6 demonstrated in an experimental setting that spirometry in addition to a questionnaire administered in the primary care setting, changed the management plans in 21% of patients. Spirometry results may change the diagnosis and/or management of the disease by the demonstration or exclusion of airflow obstruction, which can be assessed through before-and-after testing. However, such designs may easily overlook the confirmative role of spirometry results. Particularly when the signs and symptoms are conflicting, spirometry improves the diagnostic accuracy in subjects in whom COPD is part of the physician’s differential diagnosis and is therefore a useful diagnostic tool. This may play a role in much more than 21% of cases. We promote the performance of further research to explore these epidemiologic and additional values of spirometry in a primary care setting.
References
University of Ottawa, Ottawa, ON, Canada
Correspondence to: Robert E. Dales, MD, University of Ottawa, 501 Smyth Rd, Box 211, Ottawa, ON, Canada K1H 8L6; e-mail: rdales{at}ottawahospital.on.ca
To the Editor:
We screened > 1,000 primary care patients for airflow obstruction and assessed the clinical impact of screening.1 This resulted in physicians making a new diagnosis of unsuspected airflow obstruction in 9% of patients, and having a prior diagnosis of airflow obstruction removed in 11%. Physicians reported that based on spirometry results, they would change management in 15%. Poels et al2 state that "the results confirm that spirometry should not be used to screen smokers for COPD because it is not yet known if [early] diagnosis will help patients stop smoking." We would agree with this if diagnosing COPD is of no benefit to the patient, if determining that a patient received a misdiagnosis of COPD is of no value, and if a physician’s decision to change management is of no consequence. Knowing a patient has airflow limitation allows the physician to consider vaccination, exercise prescription, and medication that improve quality of life.3 Discovering that a patient does not have airflow obstruction allows the physician to consider other causes of the symptoms that initially prompted the diagnosis, such as cardiac disease. Concerning future research, we agree with Poels et al2 on the importance of assessing spirometry as a diagnostic tool for primary care patients presenting with respiratory complaints. It would be helpful to develop techniques to improve the quality of the test and its interpretation in primary care. Finally, now that we know spirometry can detect new cases and physicians are willing to consider management changes, we need to assess the impact of these actions on the quality of life of the patients, the important end result.
References
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