Spirometry use among pediatric primary care physicians

Spirometry testing in a population of Italian children: age and gender differences

AIM

To estimate how many asthmatic children underwent spirometry testing in one year in a large Italian region, and evaluate sociodemographic determinants.

METHODS

Data were retrieved from the administrative databases that store all pharmacological and diagnostic prescriptions issued to individuals living in the Lombardy Region. The analysis involved prescriptions dispensed to all 6-17 year olds (1,047,241 subjects) during 2008. Youths were identified as asthmatics by a previously validated strategy. Number of subjects having ≥1 spirometry claims was calculated, and factors associated with the probability of undergoing spirometry were evaluated by multivariate analysis.

RESULTS

A total of 40,528 (3.9%) asthmatic subjects were identified. Only 30% of them underwent ≥1 spirometry during 2008, with differences between local health units (range 22-45%) and degree of anti-asthmatic use (26-35%). Moreover, in a multivariate analysis, the chance of undergoing spirometry was greater in boys than in girls (OR=2.3).

CONCLUSIONS

A low percentage of asthmatic children, especially girls (who are more at risk of developing severe disease in adulthood), underwent spirometry during 1-year period. This highlights a low compliance with guidelines in the monitoring of childhood asthma. Educational intervention is needed in order to encourage use of spirometry in primary care settings.

Effectiveness of Spirometry Fundamentals™ for increasing the proper use of spirometry in patients with asthma and COPD

AIM

To examine whether exposure to the Spirometry Fundamentals™ CD-ROM results in improved quality of spirometry testing in primary care.

METHODS

Spirometry tests performed in 20 intervention and 19 control practices were analysed using American Thoracic Society grades A and B for 'passing' and grades C, D and F for 'failing'. Intervention effects on spirometry quality were assessed using random effects multivariate logistic regression.

RESULTS

Adjusted analyses revealed no intervention effect. The likelihood of passing tests was higher in paediatrics-only practices (adjusted odds ratio (AOR) 2.60, 95% confidence interval (CI) 1.32 to 5.12; p=0.01). Hospital or university-based clinics had a lower performance than private or community-based practices in unadjusted analysis (7% vs. 22% passing tests; p=0.05). However, this relationship was not significant in adjusted analyses.

CONCLUSIONS

Spirometry Fundamentals™ is insufficient to improve the quality of spirometry in primary care, suggesting the need for more comprehensive multifaceted training resources.

Learning from a distance: effectiveness of online spirometry training in improving asthma care

OBJECTIVE

We evaluated the effectiveness of a virtually delivered quality improvement (QI) program designed to improve primary care management for children with asthma.

METHODS

Thirty-six physicians, nurses, and medical assistants from 14 primary care pediatric practices (7 matched practice pairs) participated in a cluster randomized trial from October 2007 to September 2008. All practices received a spirometer and standard vendor training. A 7-month QI program delivered during the study period included: 1) Spirometry Fundamentals™ CD-ROM, a multimedia tutorial; 2) case-based, interactive webinars led by clinical experts; and 3) an internet-based spirometry quality feedback reporting system. Practice pairs were compared directly to each other, and between-group differences were analyzed with the use of mixed effects regression models. Our main outcome measures were the frequency of spirometry testing, percentage of acceptable quality spirometry tests, asthma severity documentation, and appropriate controller medication prescribing.

RESULTS

Participating practices uploaded a total of 1028 spirometry testing sessions, of which 340 (33.1%) were of acceptable quality. During the 7-month intervention period, there was no difference between intervention and control practices in the frequency of spirometry tests performed. Intervention practices were estimated to have significantly greater odds of conducting tests with acceptable quality compared with matched control practices, adjusting for quality in the baseline period (odds ratio 2.85; 95% confidence interval 1.78-4.56, P < .001). Intervention providers also had significantly greater odds of documenting asthma severity during the intervention period (odds ratio 2.9, 95% confidence interval 1.8-4.5; P < .001). Although use of controller medications among patients with persistent asthma approached 100% for both groups, the proportion of asthma patients labeled as persistent increased from 43% to 62% among intervention practices, and decreased from 57% to 50% among controls (NS).

CONCLUSIONS

A multifaceted distance QI program resulted in increased spirometry quality and improved assessment of asthma severity levels. Successful participation in QI programs can occur over distance.

Effect of e-learning and repeated performance feedback on spirometry test quality in family practice: a cluster trial

PURPOSE

Spirometry has become an indispensable tool in primary care to exclude, diagnose, and monitor chronic respiratory conditions, but the quality of spirometry tests in family practices is a reason for concern. Aim of this study was to investigate whether a combination of e-learning and bimonthly performance feedback would improve spirometry test quality in family practices in the course of 1 year.

METHODS

Our study was a cluster trial with 19 family practices allocated to intervention or control conditions through minimization. Intervention consisted of e-learning and bimonthly feedback reports to practice nurses. Control practices received only the joint baseline workshop. Spirometry quality was assessed by independent lung function technicians. Two outcomes were defined, with the difference between rates of tests with 2 acceptable and repeatable blows being the primary outcome and the difference between rates of tests with 2 acceptable blows being the secondary outcome. We used multilevel logistic regression analysis to calculate odds ratios (ORs) for an adequate test in intervention group practices.

RESULTS

We analyzed 1,135 tests. Rate of adequate tests was 33% in intervention and 30% in control group practices (OR = 1.3; P=.605). Adequacy of tests did not differ between groups but tended to increase with time: OR = 2.2 (P = .057) after 3 and OR = 2.0 (P = .086) in intervention group practices after 4 feedback reports. When ignoring test repeatability, these differences between the groups were slightly more pronounced: OR = 2.4 (P = .033) after 3 and OR=2.2 (P = .051) after 4 feedback reports.

CONCLUSIONS

In the course of 1 year, we observed a small and late effect of e-learning and repeated feedback on the quality of spirometry as performed by family practice nurses. This intervention does not seem to compensate the lack of rigorous training and experience in performing spirometry tests in most practices.