COPD case finding by spirometry in high-risk customers of urban community pharmacies: a pilot study

Stakeholders' Acceptability of Pharmacist-Led Screening in Community Pharmacies: A Systematic Review

INTRODUCTION

Community pharmacists are among the most accessible healthcare providers. Community pharmacist-led screening may facilitate the early detection of illnesses/medical risk factors, optimizing health outcomes. However, it is important to assess the acceptability of screening services to ensure uptake by key stakeholders. The aim of this review was to explore the acceptability of community pharmacist-led screening by all stakeholders (i.e., patients, pharmacists, and other healthcare professionals) and identify the methods used to evaluate the acceptability of screening.

METHODS

A systematic search was conducted in Embase, MEDLINE, International Pharmaceutical Abstracts, and Scopus in April 2020 since inception. Studies that explored the acceptability of pharmacist-led screening for any risk factor/medical condition(s) within community pharmacies were included.

RESULTS

A total of 44 studies met the inclusion criteria. A total of 17 studies identified community pharmacies as appropriate screening locations. Seven studies reported that patients were comfortable with participating in pharmacist-led screening. Eight studies explored acceptability from the perspective of medical practitioners and other healthcare professionals, with 6 reporting high recommendation acceptance rates and/or acceptability of pharmacist-led screening. Barriers to pharmacist-led screening included time and privacy constraints, whereas adequate remuneration was considered an important enabler.

DISCUSSION

Community pharmacist-led screening appears to be acceptable to patients, pharmacists, and other healthcare professionals. However, no uniform psychometrically sound measure of acceptability was used consistently across studies, rendering comparisons difficult and showing the need for future research exploring the psychometric properties of acceptability measures. Findings, including barriers and enablers to pharmacist-led screening, are important to consider when providing screening services in community pharmacies.

Pharmacist Provided Spirometry Services: A Scoping Review

Purpose

Despite international guidelines' recommendations, spirometry is underutilized in the diagnosis and management of asthma and COPD. Spirometry may be an opportunity for trained pharmacists to meet the needs of patients with suspected or diagnosed lung conditions. The aim of this scoping review is to describe the literature including pharmacist provided spirometry services, specifically to identify: 1) the models of pharmacist provided spirometry services, and additional services commonly offered alongside spirometry, 2) pharmacist training and capability to obtain quality results, and (3) pharmacist, physician, and patient perspectives.

Methods

In September 2020, a comprehensive literature search in PubMed and EMBASE was conducted to identify all relevant literature on the topic of pharmacist provided spirometry services using the search term: "pharmacist or pharmacy" and "spirometry or pulmonary function test or lung function test." Literature was screened using inclusion/exclusion criteria and selected articles were charted and analyzed using the themes above.

Results

A total of 27 records were included. The scoping review found that pharmacist provided spirometry has been conducted around the world in community pharmacies and clinic settings. Community pharmacists may increase access to spirometry screening; the lack of communication with primary care providers and remuneration are barriers that need to be overcome to optimize the utility of the service. Clinic-based services are interprofessional and collaborative, allowing a patient to receive the test, results, diagnosis, and medication changes in one visit. Following comprehensive training, pharmacists felt confident in their ability to perform spirometry and met quality standards at acceptable rates.

Conclusion

Spirometry is an opportunity for pharmacists to improve evidence-based practice for screening and diagnosing lung conditions along with providing comprehensive services to complement testing. Data around provider and patient perspectives is limited and should be further investigated to determine if providers and patients would value and collaborate with pharmacists providing spirometry services.

Predictive value of spirometry in early detection of lung disease in adults: a cohort study

BACKGROUND

Spirometry is essential to identify cases with obstructive lung diseases (OLDs) in primary care. However, knowledge about the long-term prognostic outcome among younger individuals is sparse.

AIM

To describe the predictive value of spirometry among individuals in the age groups 30-49 years and 45-64 years.

DESIGN & SETTING

A population-based cohort study supplied with data from Danish national registries.

METHOD

Spirometry was performed in 905 adults aged 30-49 years in 1991 and in 1277 adults aged 45-64 years in 2006. The participants were categorised into three groups: forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) <70, 70-75, and >75. They were followed throughout 2017 using Danish national registries. Lung disease was defined as fulfilling at least one of the following: two prescriptions for respiratory medicine were redeemed within a year; one lung-related contact to the hospital; or lung-related death.

RESULTS

In the 1991 cohort, 21% developed lung diseases and in the 2006 cohort 17% developed lung diseases throughout 2017. The probability of developing lung disease if FEV1/FVC 70-75 was 35% (95% confidence interval [CI] = 25% to 44%) in the 1991 cohort and 23% (95% CI = 17% to 28%) in the 2006 cohort. The positive predicted value (PPV) was higher for both cohorts when focusing on smoking history and self-reported respiratory symptoms.

CONCLUSION

The initial spirometry has a high predictive value to identify cases of future lung diseases. In addition, the group with FEV1/FVC 70-75 had a high risk of developing lung diseases later in life, suggesting this group would be a meaningful target of special interest.

Promoting Community Pharmacy Practice for Chronic Obstructive Pulmonary Disease (COPD) Management: A Systematic Review and Logic Model

Purpose

This study aimed 1) to identify and analyse the professional services provided by community pharmacists for chronic obstructive pulmonary disease (COPD) management; and 2) to develop a logic model for community pharmacy practice for COPD management.

Methods

A systematic review with a logic model was applied. English-language databases (PubMed, Web of Science, Embase, and Scopus) and a Chinese database (CNKI) were searched for articles published between January 2009 and June 2019. Studies concerning pharmacists and COPD were identified to screen for studies that focused on professional services provided at a community pharmacy level. Evidence on economic, clinical, and humanistic outcomes of interventions was summarized.

Results

Twenty-five articles were included in this study. Four categories of COPD-related interventions by community pharmacists were identified: 1) primary prevention; 2) early detection; 3) therapy management; and 4) long-term health management. The most common outputs examined were improvement in inhaler technique, medication adherence, and rate of smoking cessation. The clinical (improved quality of life, reduced frequency and severity of symptoms and exacerbation), humanistic (patient satisfaction), and economic (overall healthcare costs) outcomes were tested for some interventions through clinical studies. Contextual factors concerning pharmacists, healthcare providers, patients, facilities, clinic context, and socio-economic aspects were also identified.

Conclusion

Studies in the literature have proposed and examined different components of professional services provided by community pharmacists for COPD management. However, relationships among outcomes, comprehensive professional services of community pharmacists, and contextual factors have not been systematically tested. More well-designed, rigorous studies with more sensitive and specific outcomes measures need to be conducted to assess the effect of community pharmacy practice for COPD management.

Role and impact of pharmacists in Spain: a scoping review

Background The role of the pharmacist has evolved greatly over the last decades, expanding to patient-oriented activities, administrative tasks and public health functions. However, considerable differences emerge across regions. Aim of the review To gather evidence in order to describe and highlight the different characteristics of the pharmacists' role and the impact of their activities in Spain. Method A review of the existing literature was conducted. The literature search was undertaken in PubMed between 01/01/2006 and 15/08/2017. Results were screened and reviewed to extract previously established criteria such as author(s), publication year, language, study design, setting, pharmaceutical activity, patient care programs, targeted diseases and intervention description using DEPICT2 tool. Pharmaceutical intervention were classified into eight outcome measures and categorized by types of outcomes reported: descriptive or impact evaluation regarding the effect of the service (positive, neutral or negative). Results The search strategy resulted in 473 articles and 108 articles met the inclusion criteria. The most common design was observational (n = 76, 70%). Most articles were published after 2011 (75%), in English (69%). Studies were conducted in hospitals (60%) and community pharmacies (30%). Of the 24 pharmaceutical activities identified, medication review was the activity most frequently studied (n = 42), followed by patient education (n = 29), risk and prevention (n = 27) and medication reconciliation (n = 19). Only 39 articles (36%) had outcome measures with impact evaluation. Of the 223 impact outcome measures, 48% (107/223) had a positive effect. Conclusion This review shows the substantial scientific production focusing on pharmacy practice in Spain over the last years. The evidence reviewed reflects the pharmacist role at various professional settings, providing a wide variety of activities on diverse targeted diseases and patient care programs, in line with the increasing specialization of clinical pharmacists over the last years.

The Challenge of Controlling the COPD Epidemic: Unmet Needs

Many unmet needs still remain in the assessment and treatment of patients with chronic obstructive pulmonary disease (COPD), particularly in relation to its under- and misdiagnosis, which lead to under- and mistreatment. This paucity of knowledge about the importance and presence of COPD, as well as its treatment, is seen among patients and carers as well as health care providers. This review considers areas of key educational need, including the clinical characteristics of COPD; factors that contribute to the disease, effective diagnosis, and clinical management of patients; and the implementation of treatment guidelines. As COPD remains the third most frequent cause of death in the world, researchers must continue to expand the scope and reach of their efforts to improve outcomes of this debilitating disease.

The role of community pharmacists in the identification and ongoing management of women at risk for perinatal depression: A qualitative study

BACKGROUND

While pharmacists are among the most accessible primary health professionals within a mother's healthcare team to identify potential cases of perinatal depression (PND), very little in the literature suggests that this role has been explored.

AIM

The aim of this study was to explore community pharmacists' perspectives on their potential roles in perinatal mental health promotion (recognition and health education) and the factors affecting these roles.

METHODS

In total, 20 semi-structured, in-depth interviews were conducted with community pharmacists.

RESULTS

Most pharmacists highlighted their significant roles in recognising PND symptoms and providing medication-related support to perinatal mothers. Barriers to service provision included inter-professional role boundaries, the lack of established referral systems and service remuneration and the lack of adequate training in mental health.

CONCLUSION

Pharmacists could potentially reinforce their involvement in mental health promotion activities.

Impact of a Pharmacist-driven Spirometry Clinic Service within a Community Family Health Center: A 5-year Retrospective Review

Objective:

This study was designed to describe the impact of a trained pharmacist in performing quality spirometry testing within a community family health center.

Methods:

This was a retrospective, cohort study of 150 physician-referred patients who attended their scheduled spirometry office appointment between November 2008 and December 2013. Information obtained included type of the disease (patients with obstructive or restrictive pulmonary disease), calculated lung age decline due to smoking history, quality of spirometry testing, and percentage of patients requiring pulmonary drug regimen alterations due to spirometry results. Pearson correlation and descriptive statistics were used to address study objectives.

Findings:

Spirometry testing performed by a pharmacist resulted in 87% of tests meeting guidelines for quality. Testing identified patients with reversible airway disease (39%), chronic obstructive pulmonary disease (21%), restrictive (11%), and mixed obstructive/restrictive (11%) lung defect. Patients with abnormal spirometry demonstrated a greater smoking pack-year history and calculated lung age than patients with normal spirometry (29.1 pack-years vs. 17 pack-years; P = 0.024 and 76.3 years vs. 54.6 years; P < 0.001, respectively). A weak correlation was found between a 29.1 smoking pack-year history and forced vital capacity (r = −0.3593, P = 0.018). The pharmacist assisted in modifying pulmonary drug regimens in 69% of patients based on evidence-based guidelines.

Conclusion:

A pharmacist-driven spirometry service was associated with quality testing results, identified respiratory disease abnormalities, and helped modifications of pulmonary drug regimens based on evidence-based guidelines. Future direction of this service may include collaborative practice agreements with physicians to expand services of pharmacists to include spirometry testing.

Community pharmacy-based case finding for COPD in urban and rural settings is feasible and effective

BACKGROUND AND OBJECTIVE

Case finding of patients at risk of COPD by community pharmacists could identify a substantial number of people with undiagnosed COPD, but little is known about the feasibility and effectiveness of pharmacy-based COPD case finding using microspirometry. The objective of this study was to assess the feasibility and effectiveness of COPD case-finding service provided by community pharmacists, utilizing a combination of risk assessment questionnaire and microspirometry.

METHODS

A 6-month service was conducted in 21 community pharmacies in Australia. Pharmacists trained in COPD case finding, including lung function test (LFT), invited their patients aged ≥35 years with a history of smoking and/or respiratory symptoms to participate. High-risk patients were identified via a COPD risk assessment questionnaire (Initial Screening Questionnaire [ISQ]) and underwent LFT. Pharmacists referred patients with a forced expiratory volume in 1 second (FEV1)/forced expiratory volume in 6 seconds (FEV6) ratio <0.75 to their general practitioner (GP) for further assessment and diagnosis.

RESULTS

In all, 91 of 167 (54%) patients had an ISQ score >3 indicating high COPD risk. Of the 157 patients who were able to complete LFT, 61 (39%) had an FEV1/FEV6 ratio of <0.75 and were referred to their GP. Patients with high ISQ symptoms scores (>3) were at a significantly higher risk of an FEV1/FEV6 ratio of <0.75, compared to patients with fewer COPD symptoms. A total of 15 (10%) patients were diagnosed with COPD by their GP. Another eight (5%) patients were diagnosed with other medical conditions and 87% of these were initiated on treatment. Although only half of all screened patients lived in regional areas, 93% of those diagnosed with COPD were from regional areas.

CONCLUSION

A brief community pharmacy-based COPD case-finding service utilizing the ISQ, LFT and GP referral is feasible and may lead to identification and diagnosis of a substantial number of people with COPD. This might be an important strategy for reducing the burden of COPD, particularly for those living in rural locations.

Community pharmacy COPD services: what do researchers and policy makers need to know?

COPD is a leading cause of morbidity and mortality across the world and is responsible for a disproportionate use of health care resources. It is a progressive condition that is largely caused by smoking. Identification of early stage COPD provides an opportunity for interventions, such as smoking cessation, which prevent its progression. Once diagnosed, ongoing support services potentially provide an opportunity to assist the patient in managing their condition and working more closely with the rest of the primary care team. While there are a number of robust studies which have demonstrated the role which pharmacists could undertake to identify and prevent disease progression, adoption of such services is currently limited. As a service that would seem to be appropriate for adoption in all societies where smoking is prevalent, we have performed a review of reported approaches that have been used when setting up and evaluating such services, and therefore aim to inform researchers and policy makers in other countries on how best to proceed. Implementation science has been used to further contextualize the findings of the review in terms of components that are likely to enhance the likelihood of implementation. With reference to screening services, we have made clear recommendations as to the identification of patients, structure and smoking cessation elements of the program. Further work needs to be undertaken by policy makers to determine the approaches that can be used to motivate pharmacists to provide this service. In terms of ongoing support services, there is some evidence to suggest that these would be effective and cost-effective to the health service in which they are implemented. However, the capability, opportunity and motivation of pharmacists to provide these, more complex, services need to be the focus for researchers before implementation by policy makers.

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background

Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings.

Objectives

Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.

Review methods

We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.

Results

We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.

Conclusions

In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.

Limitations

We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.

Future work

There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Evaluating the appropriateness of a community pharmacy model for a colorectal cancer screening program in Catalonia (Spain)

Background

The traditional model of community pharmacy has changed, with patients, caregivers and consumers having access to many cognitive services other than the traditional dispensing and supply of medicines. In December 2009, a population-based colorectal cancer screening program started in Barcelona, introducing the community pharmacist and the professional expertise of the pharmacist into the organisational model.

Aim

To evaluate the program implementation process in the pharmacies, identify barriers and facilitators, and know the opinion of the professionals involved in the colorectal cancer screening program in Catalonia (Spain).

Methods

Cross-sectional study of the pharmacies that participated in the first round of the program during the first and second trimester of 2010 in Barcelona. A validated questionnaire was used to analyse several functional aspects in the implementation process. Qualitative aspects about the opinion of the pharmacist were studied. A descriptive and bivariate analysis was performed.

Results

All the pharmacies involved in the program (n = 74) participated in the study. The majority of the sample population was composed of women (70.3%), mean age 44.9 years, and most of them (74%) had attended a specific training session. Pharmacists considered their participation in the program to be an added value to their professional role and a way to increase consumer’s confidence on this kind of services. The average time to provide the service was estimated to be less than 10 minutes per consumer. Only three (4.1%) pharmacists considered that the program involved a lot of extra work in the daily activities of the pharmacy. The level of satisfaction of the pharmacists was very high.

Conclusions

Community pharmacies can be a successful alternative and great resource to implement a population cancer screening program. This functional model can improve the accessibility and participation rates on target population. The level of motivation of the community pharmacist, the specific training program and the perception to give a better care for their patients can be an enabler.

Determinants of underdiagnosis of COPD in national and international surveys

BACKGROUND

COPD ranks within the top three causes of mortality in the global burden of disease, yet it remains largely underdiagnosed. We assessed the underdiagnosis of COPD and its determinants in national and international surveys of general populations.

METHODS

We analyzed representative samples of adults aged ≥ 40 years randomly selected from well-defined administrative areas worldwide (44 sites from 27 countries). Postbronchodilator FEV1/FVC < lower limit of normal (LLN) was used to define chronic airflow limitation consistent with COPD. Undiagnosed COPD was considered when participants had postbronchodilator FEV1/FVC < LLN but were not given a diagnosis of COPD.

RESULTS

Among 30,874 participants with a mean age of 56 years, 55.8% were women, and 22.9% were current smokers. Population prevalence of (spirometrically defined) COPD ranged from 3.6% in Barranquilla, Colombia, to 19.0% in Cape Town, South Africa. Only 26.4% reported a previous lung function test, and only 5.0% reported a previous diagnosis of COPD, whereas 9.7% had a postbronchodilator FEV1/FVC < LLN. Overall, 81.4% of (spirometrically defined) COPD cases were undiagnosed, with the highest rate in Ile-Ife, Nigeria (98.3%) and the lowest rate in Lexington, Kentucky (50.0%). In multivariate analysis, a greater probability of underdiagnosis of COPD was associated with male sex, younger age, never and current smoking, lower education, no previous spirometry, and less severe airflow limitation.

CONCLUSIONS

Even with substantial heterogeneity in COPD prevalence, COPD underdiagnosis is universally high. Because effective management strategies are available for COPD, spirometry can help in the diagnosis of COPD at a stage when treatment will lead to better outcomes and improved quality of life.

Pharmacists performing quality spirometry testing: an evidence based review

BACKGROUND

The scope of pharmacist services for patients with pulmonary disease has primarily focused on drug related outcomes; however pharmacists have the ability to broaden the scope of clinical services by performing diagnostic testing including quality spirometry testing. Studies have demonstrated that pharmacists can perform quality spirometry testing based upon international guidelines.

AIM OF THE REVIEW

The primary aim of this review was to assess the published evidence of pharmacists performing quality spirometry testing based upon American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines. In order to accomplish this, the description of evidence and type of outcome from these services were reviewed.

METHODS

A literature search was conducted using five databases [PubMed (1946-January 2015), International Pharmaceutical Abstracts (1970 to January 2015), Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews] with search terms including pharmacy, spirometry, pulmonary function, asthma or COPD was conducted. Searches were limited to publications in English and reported in humans. In addition, Uniform Resource Locators and Google Scholar searches were implemented to include any additional supplemental information.

RESULTS

Eight studies (six prospective multi-center trials, two retrospective single center studies) were included. Pharmacists in all studies received specialized training in performing spirometry testing. Of the eight studies meeting inclusion and exclusion criteria, 8 (100%) demonstrated acceptable repeatability of spirometry testing based upon standards set by the ATS/ERS guidelines. Acceptable repeatability of seven studies ranged from 70 to 99% consistent with published data.

CONCLUSION

Available evidence suggests that quality spirometry testing can be performed by pharmacists. More prospective studies are needed to add to the current evidence of quality spirometry testing performed by pharmacists and to measure health outcomes of the pulmonary patient.

The reliability and utility of spirometry performed on people with asthma in community pharmacies

OBJECTIVE

To investigate the reliability and the utility of spirometry generated by community pharmacists participating in two large asthma intervention trials of 892 people.

METHODS

The Pharmacy Asthma Care Program (PACP) and the Pharmacy Asthma Management Service (PAMS) involved up to four visits to the pharmacy over 6 months for counseling and goal setting. Pharmacists performed spirometry according to ATS/ERS guidelines to inform management. The proportion of A-E, F quality tests, as per EasyOne QC grades, were recorded. Lung function results between visits and for participants referred/not referred to their general practitioner on the basis of spirometry were compared.

RESULTS

Complete data from 2593 spirometry sessions were recorded, 68.5% of spirometry sessions achieved three acceptable tests with between-test repeatability of 150 ml or less (A or B quality), 96% of spirometry sessions included at least one test that met ATS/ERS acceptability criteria. About 39.1% of participants had FEV1/FVC values below the lower limit of normal (LNN), indicating a respiratory obstruction. As a result of the service, there was a significant increase in FEV1 and FEV1/FVC and asthma control. Lung function values were significantly poorer for participants referred to their general practitioner, compared with those not referred, on the basis of spirometry.

CONCLUSIONS

Community pharmacists are able to reliably achieve spirometry results meeting ATS/ERS guidelines in people with asthma. Significant improvements in airway obstruction were demonstrated with the pharmacy services. Pharmacists interpreted lung function results to identify airway obstruction for referral, making this a useful technique for review of people with asthma in the community.

Is generalization of exhaled CO assessment in primary care helpful for early diagnosis of COPD?

Background

COPD is largely under-diagnosed and once diagnosed usually at a late stage. Early diagnosis is thoroughly recommended but most attempts failed as the disease is marginally known and screening marginally accepted. It is a rare cause of concern in primary care and spirometry is not very common. Exhaled carbon monoxide (eCO) is a 5-seconds easy-to-use device dedicated to monitor cigarette smoke consumption. We aimed to assess whether systematic eCO measurement in primary care is a useful tool to improve acceptance for early COPD diagnosis.

Methods

This was a two-center randomized controlled trial enrolling 410 patients between March and May, 2013. Whatever was the reason of attendance to the clinic, all adults were proposed to measure eCO during randomly chosen days and outcomes were compared between the two different groups of patients (performing and not performing eCO). Primary outcome was the rates of acceptance for COPD screening.

Results

Rate of acceptance for COPD screening was 28% in the eCO group and 26% in the other (P = 0.575). These rates increased to 48 and 51% in smokers (current and former). eCO significantly increased the rate of clinics during which a debate on smoking was initiated (42 vs. 24%, P = 0.001). eCO at 2.5 ppm was the discriminative concentration for identifying active smokers (ROC curve AUC: 0.935). Smoking was the only independent risk factor associated with acceptance for early COPD screening (OR = 364.6 (82.5-901.5) and OR = 78.5 (18.7-330.0) in current and former smokers, respectively) while eCO measurement was not.

Conclusions

Early COPD diagnosis is a minor cause of concern in primary care. Systematic eCO assessment failed to improve acceptance for early COPD screening.

Economic Assessment and Budgetary Impact of a Telemedicine Procedure and Spirometry Quality Control in the Primary Care Setting

OBJECTIVE

To evaluate the economic impact of a telemedicine procedure designed to improve the quality of lung function testing (LFT) in primary care in a public healthcare system, compared with the standard method.

MATERIALS AND METHODS

The economic impact of 9,039 LFTs performed in 51 health centers (2010-2013) using telespirometry (TS) compared to standard spirometry (SS) was studied.

RESULTS

TS costs more per unit than SS (€47.80 vs. €39.70) (2013), but the quality of the TS procedure is superior (84% good quality, compared to 61% using the standard procedure). Total cost of TS was €431,974 (compared with €358,306€ for SS), generating an economic impact of €73,668 (2013). The increase in cost for good quality LFT performed using TS was €34,030 (2010) and €144,295 (2013), while the costs of poor quality tests fell by €15,525 (2010) and 70,627€ (2013).

CONCLUSION

The cost-effectiveness analysis concludes that TS is 23% more expensive and 46% more effective. Healthcare costs consequently fall as the number of LFTs performed by TS rises. Avoiding poor quality, invalid LFTs generates savings that compensate for the increased costs of performing LFTs with TS, making it a cost-effective method.

Integrated care services: lessons learned from the deployment of the NEXES project

Objectives

To identify barriers to deployment of four articulated Integrated Care Services supported by Information Technologies in three European sites. The four services covered the entire spectrum of severity of illness. The project targeted chronic patients with obstructive pulmonary disease, cardiac failure and/or type II diabetes mellitus.

Setting

One health care sector in Spain (Barcelona) (n = 11.382); six municipalities in Norway (Trondheim) (n = 450); and one hospital in Greece (Athens) (n = 388).

Method

The four services were: (i) Home-based long-term maintenance of rehabilitation effects (n = 337); (ii) Enhanced Care for frail patients, n = 1340); (iii) Home Hospitalization and Early Discharge (n = 2404); and Support for remote diagnosis (forced spirometry testing) in primary care (Support) (n = 8139). Both randomized controlled trials and pragmatic study designs were combined. Two technological approaches were compared. The Model for Assessment of Telemedicine applications was adopted.

Results

The project demonstrated: (i) Sustainability of training effects over time in chronic patients with obstructive pulmonary disease (p < 0.01); (ii) Enhanced care and fewer hospitalizations in chronic respiratory patients (p < 0.05); (iii) Reduced in-hospital days for all types of patients (p < 0.001) in Home Hospitalization/Early Discharge; and (iv) Increased quality of testing (p < 0.01) for patients with respiratory symptoms in Support, with marked differences among sites.

Conclusions

The four integrated care services showed high potential to enhance health outcomes with cost-containment. Change management, technological approach and legal issues were major factors modulating the success of the deployment. The project generated a business plan to foster service sustainability and health innovation. Deployment strategies require site-specific adaptations.

Detection of COPD in a high-risk population: should the diagnostic work-up include bronchodilator reversibility testing?

Background

Underdiagnosis of chronic obstructive pulmonary disease (COPD) is widespread. Early detection of COPD may improve the outcome by timely smoking cessation, a change in lifestyle, and treatment with an inhaled bronchodilator (BD). The objective of this study was to evaluate the diagnostic role of BD reversibility testing in early COPD case finding.

Methods

General practitioners (n=241) consecutively recruited subjects aged ≥35 years with relevant exposure (history of smoking, and/or occupational exposure) and at least one respiratory symptom. Information on age, smoking status, body mass index, dyspnea score (Medical Research Council scale), and spirometry was obtained. Individuals with airway obstruction (forced expiratory volume in one second [FEV₁]/forced vital capacity [FVC] <0.70) underwent a BD test with an inhaled β₂ agonist, which was considered positive if ΔFEV₁ was >0.20 L and >12%. Asthma and COPD were, respectively, defined as an FEV₁ increase >0.50 L and a post-BD FEV₁/FVC <0.70.

Results

In total, 4,049 subjects (51% male) were included (mean age 58 years, body mass index 27, 32 pack-years of smoking). A significant BD response was found in 143 (15%) of the 937 subjects (23%) with airway obstruction at screening spirometry. In 59% of these subjects, the post-BD FEV₁/FVC remained <0.70. In 24% of the subjects with pre-BD airway obstruction, the post-BD FEV₁/FVC ratio was within the reference range. In subjects with confirmed COPD, the mean increase in FEV₁ following BD was 0.11 L±0.10 L. The subjects with COPD and a significant BD response were characterized by a higher prevalence of dyspnea (72% versus 57%, P=0.02) but less cough (55% versus 75%, P=0.001) when compared with COPD subjects without BD reversibility.

Conclusion

Administration of a BD in COPD case finding is important in order to determine the post-BD FEV₁/FVC ratio. Exclusion of subjects with a significant BD response may result in underdiagnosis of COPD, and we question the need for the BD reversibility test in the diagnostic screening algorithm in early COPD case finding.

Airflow obstruction case finding in community-pharmacies: a novel strategy to reduce COPD underdiagnosis

BACKGROUND

Community pharmacies (CP) have access to subjects at high-risk of suffering Chronic Obstructive Pulmonary Disease (COPD). We investigated if a COPD case finding program in CP could be a new strategy to reduce COPD underdiagnosis.

METHODS

Prospective, cross-sectional, descriptive, uncontrolled, remotely supported study in 100 CP in Barcelona, Spain. Pharmacists were trained in a four-day workshop on spirometry and COPD, and each was provided with a spirometer for 12 weeks. The program included questionnaires and forced spirometry measurements, whose quality was controlled and monitored by web-assistance.

FINDINGS

Overall 2295 (73.5%), of 3121 CP customers invited to participate in the program accepted, and 1.456 (63.4%) were identified as "high risk" for COPD using the GOLD questionnaire. Only 33 could not conduct spirometry, and a pre-bronchodilator airflow limitation (FEV1/FVC ratio <0.7) was confirmed in 282 (19.8%); 244 of these were referred to their primary care (PC) physician for further diagnostic and therapeutic work-up, but only 39 of them (16%) fed-back this information to the pharmacist. Clinically acceptable quality spirometries (grade A or B) were obtained in 69.4% of the cases.

CONCLUSION

This study shows that adequately trained and supported community pharmacists can effectively identify individuals at high risk of having COPD and can thus contribute to ameliorate underdiagnosis in this disease. Links between PC and CP should be improved to achieve a useful program.

ALAT-2014 Chronic Obstructive Pulmonary Disease (COPD) Clinical Practice Guidelines: questions and answers

ALAT-2014 COPD Clinical Practice Guidelines used clinical questions in PICO format to compile evidence related to risk factors, COPD screening, disease prognosis, treatment and exacerbations. Evidence reveals the existence of risk factors for COPD other than tobacco, as well as gender differences in disease presentation. It shows the benefit of screening in an at-risk population, and the predictive value use of multidimensional prognostic indexes. In stable COPD, similar benefits in dyspnea, pulmonary function and quality of life are achieved with LAMA or LABA long-acting bronchodilators, whereas LAMA is more effective in preventing exacerbations. Dual bronchodilator therapy has more benefits than monotherapy. LAMA and combination LABA/IC are similarly effective, but there is an increased risk of pneumonia with LABA/IC. Data on the efficacy and safety of triple therapy are scarce. Evidence supports influenza vaccination in all patients and anti-pneumococcal vaccination in patients <65years of age and/or with severe airflow limitation. Antibiotic prophylaxis may decrease exacerbation frequency in patients at risk. The use of systemic corticosteroids and antibiotics are justified in exacerbations requiring hospitalization and in some patients managed in an outpatient setting.

Clinical Decision Support Systems (CDSS) for preventive management of COPD patients

BACKGROUND

The use of information and communication technologies to manage chronic diseases allows the application of integrated care pathways, and the optimization and standardization of care processes. Decision support tools can assist in the adherence to best-practice medicine in critical decision points during the execution of a care pathway.

OBJECTIVES

The objectives are to design, develop, and assess a clinical decision support system (CDSS) offering a suite of services for the early detection and assessment of chronic obstructive pulmonary disease (COPD), which can be easily integrated into a healthcare providers' work-flow.

METHODS

The software architecture model for the CDSS, interoperable clinical-knowledge representation, and inference engine were designed and implemented to form a base CDSS framework. The CDSS functionalities were iteratively developed through requirement-adjustment/development/validation cycles using enterprise-grade software-engineering methodologies and technologies. Within each cycle, clinical-knowledge acquisition was performed by a health-informatics engineer and a clinical-expert team.

RESULTS

A suite of decision-support web services for (i) COPD early detection and diagnosis, (ii) spirometry quality-control support, (iii) patient stratification, was deployed in a secured environment on-line. The CDSS diagnostic performance was assessed using a validation set of 323 cases with 90% specificity, and 96% sensitivity. Web services were integrated in existing health information system platforms.

CONCLUSIONS

Specialized decision support can be offered as a complementary service to existing policies of integrated care for chronic-disease management. The CDSS was able to issue recommendations that have a high degree of accuracy to support COPD case-finding. Integration into healthcare providers' work-flow can be achieved seamlessly through the use of a modular design and service-oriented architecture that connect to existing health information systems.

Chronic obstructive pulmonary disease case finding by community pharmacists: a potential cost-effective public health intervention

Objectives

This study aims to pilot a community pharmacy chronic obstructive pulmonary disease (COPD) case finding service in England, estimating costs and effects.

Methods

Patients potentially at risk of COPD were screened with validated tools. Smoking cessation was offered to all smokers identified as potentially having undiagnosed COPD. Cost and effects of the service were estimated.

Key findings

Twenty-one community pharmacies screened 238 patients over 9 months. One hundred thirty-five patients were identified with potentially undiagnosed COPD; 88 were smokers. Smoking cessation initiation provided a project gain of 38.62 life years, 19.92 quality-adjusted life years and a cost saving of £392.67 per patient screened.

Conclusions

COPD case finding by community pharmacists potentially provides cost-savings and improves quality of life.

[Accesibility and use of spirometry in primary care centers in Catalonia]

Objetivo

Conocer la accesibilidad y la utilización de la espirometría forzada (EF) en los dispositivos públicos de atención primaria en Cataluña.

Diseño

Estudio transversal mediante encuesta.

Participantes

Trescientos sesenta y seis equipos de atención primaria (EAP) de Cataluña. Tercer trimestre de 2010.

Mediciones

Encuesta con información relativa a los espirómetros, la formación, la interpretación y el control de calidad, y el grado de prioridad que la calidad de la espirometría tenía para el equipo. Se analizaron: media de EF/100 habitantes/año; índice de EF/mes/EAP; índice de EF/mes/10.000 habitantes.

Resultados principales

Porcentaje de respuesta: 75%. El 97,5% de los EAP dispone de espirómetro y realiza una media de 2,01 espirometrías/100 habitantes (34,68 espirometrías/EAP/mes). El 83% dispone de profesionales formados y más del 50% de los centros realizan formación reglada, pero no se dispone de información sobre la calidad de la misma. En el 70% se hace algún tipo de calibración. La interpretación la realiza el médico de familia en el 87,3% de los casos. En el 68% de los casos no se lleva a cabo ningún tipo de control de calidad de la exploración. En dos tercios de los casos se introducen manualmente los datos en la historia clínica informatiza. Más del 50% se atribuye una prioridad alta para las estrategias de mejora de la calidad de la EF.

Conclusiones

A pesar de la accesibilidad a la EF deben realizarse esfuerzos para estandarizar la formación, incrementar el número de exploraciones y promover el control de calidad sistemático.

New developments in the assessment of COPD: early diagnosis is key

Chronic obstructive pulmonary disease (COPD) is the most common chronic lung disease in the world, and its associated health burdens and costs are mounting. Until recently, it was generally accepted that targeting the diagnosis of COPD early in its course was a relatively fruitless effort, since treatments other than already ubiquitous smoking-cessation efforts were unlikely to alter its course. However, there is strong evidence to suggest that the majority of patients with objective COPD are not aware of their condition, and this leads to a significant delay in diagnosis, more aggressive smoking-cessation intervention, and potential treatment. Novel methods of diagnostic testing, community health programs, and primary-care provider recommendations hold promise to expand the recognition of COPD in its incipient stages - where recent evidence suggests a rapid decline in lung function occurs and may be prevented if acted upon. This review explores the evidence to support the efforts to justify programs aimed at early diagnosis, alternative diagnostic strategies that may augment traditional spirometry, therapeutic modalities that could potentially be used in the future to alter early lung-function decline, and emphasizes the necessary cooperative role that physicians, patients, communities, and governments need to play to realize the significant health impact that stands to be gained.

Case finding for chronic obstructive pulmonary disease in primary care: a pilot randomised controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. However, much of the disease burden remains undiagnosed.

AIM

To compare the yield and cost effectiveness of two COPD case-finding approaches in primary care.

DESIGN AND SETTING

Pilot randomised controlled trial in two general practices in the West Midlands, UK.

METHOD

A total of 1634 ever-smokers aged 35-79 years with no history of COPD or asthma were randomised into either a 'targeted' or 'opportunistic' case-finding arm. Respiratory questionnaires were posted to patients in the 'targeted' arm and provided to patients in the 'opportunistic' arm at routine GP appointments. Those reporting at least one chronic respiratory symptom were invited for spirometry. COPD was defined as pre-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)<0.7 and FEV1<80% of predicted. Primary outcomes were the difference in the proportion of patients diagnosed with COPD and the cost per case detected.

RESULTS

Twenty-six per cent (212/815) in the 'targeted' and 13.6% (111/819) in the 'opportunistic' arm responded to the questionnaire and 78.3% (166/212) and 73.0% (81/111), respectively, reported symptoms; 1.2% (10/815) and 0.7% (6/819) of patients in the 'targeted' and 'opportunistic' arms were diagnosed with COPD (difference in proportions = 0.5% [95% confidence interval {CI} = -0.5% to 3.08%]). Over a 12-month period, the 'opportunistic' case-finding yield could be improved to 1.95% (95% CI = 1.0% to 2.9%). The cost-per case detected was £424.56 in the 'targeted' and £242.20 in the 'opportunistic' arm.

CONCLUSION

Opportunistic case finding may be more effective and cost effective than targeting patients with a postal questionnaire alone. A larger randomised controlled trial with adequate sample size is required to test this.

The role of community pharmacists in screening and subsequent management of chronic respiratory diseases: a systematic review

OBJECTIVE

The purpose of this review was to evaluate the role of community pharmacists in provision of screening with/without subsequent management of undiagnosed chronic obstructive pulmonary disease (COPD) and uncontrolled asthma.

METHODS

An extensive literature search using four databases (ie. Medline, PubMed, International Pharmaceutical Abstracts (IPA) and Scopus) with search terms pharmacy, screening, asthma or COPD was conducted. Searches were limited to the years 2003-2013, those in English and those reporting research with humans. Data retrieval, analysis and result presentation employed a scoping review method.

RESULTS

Seventeen articles met the inclusion/exclusion criteria, of which fifteen studies were based on people with asthma and two were based on people with COPD. Only seven asthma studies and one COPD study involved screening followed by subsequent management. More than half of the people screened were found to be poorly controlled and up to 62% of people were identified at high risk for COPD by community pharmacists. The studies varied in the method and type of asthma control assessment/screening, the type of intervention provided and the outcomes measured. The limitations of the reviewed studies included varying definitions of asthma control, different study methodologies, and the lack of long-term follow-up. While many different methods were used for risk assessment and management services by the pharmacists, all the studies demonstrated that community pharmacists were capable of identifying people with poorly controlled asthma and undiagnosed COPD and providing them with suitable interventions.

CONCLUSIONS

The literature review identified that community pharmacists can play an effective role in screening of people with poorly controlled asthma and undiagnosed COPD along with delivering management interventions. However, there is very little literature available on screening for these chronic respiratory conditions. Future research should focus on development of patient care delivery model incorporating a screening protocol followed by targeted management interventions delivered by the community pharmacist.

Screening for major diseases in community pharmacies: a systematic review

OBJECTIVES

The aim of this systematic review was to assess the published evidence about the feasibility and acceptability of community pharmacy-based screening for major diseases.

METHOD

Studies published between January 1990 and August 2012 involving community pharmacy-based screening interventions, published in the English language, were identified from electronic databases. Reference lists of included studies were also searched.

KEY FINDINGS

Fifty studies (one randomised controlled trial, two cluster randomised studies, five non-randomised comparative studies and 42 uncontrolled studies) were included. The quality of most of these was assessed as poor. Screening was mostly opportunistic and screening tools included questionnaires or risk assessment forms, medical equipment to make physiological measurements, or a combination of both. Few studies assessed the accuracy of pharmacy-based screening tools. More than half of the screening interventions included an element of patient education. The proportion of screened individuals, identified with disease risk factors or the disease itself, ranged from 4% to 89%. Only 10 studies reported any economic information. Where assessed, patient satisfaction with pharmacy-based screening was high, but individuals who screened positive often did not follow pharmacist advice to seek further medical help.

CONCLUSION

Available evidence suggests that screening for some diseases in community pharmacies is feasible. More studies are needed to compare effectiveness and cost-effectiveness of pharmacy-based screening with screening by other providers. Strategies to improve screening participants' adherence to pharmacist advice also need to be explored. This systematic review will help to inform future studies wishing to develop community pharmacy-based screening interventions.

Questionnaires and pocket spirometers provide an alternative approach for COPD screening in the general population

BACKGROUND

In response to the Agency for Healthcare Research and Quality statement questioning the usefulness of “screening spirometry,” the National Heart, Lung, and Blood Institute and the COPD Foundation held a consensus conference in June 2008 to establish a procedure to detect cases of COPD in the general population. Conference participants developed a three-stage approach, using a brief questionnaire, peak flow measurement with a pocket spirometer, and diagnostic quality spirometry. The overall objective of this study was to examine the usefulness of a simple questionnaire and peak flow measurement in screening for COPD in a self-selected population. We hypothesized that this combination would efficiently screen for clinically relevant COPD.

METHODS

We queried individuals attending public events regarding the presence of wheeze and/or asthma, mucus production, dyspnea, exposure to irritants, and tobacco use. Peak expiratory flow (PEF) was then measured with a pocket spirometer. If PEF was < 70% predicted, spirometry was performed. In order to estimate the false-negative rate, a random sample of every 10th participant was also selected for spirometry.

RESULTS

Between June 2008 and December 2009, 5,761 adults completed the risk assessment questionnaire. The mean age of the respondents was 54 years, 58% were women, and 88% were white. Of these, 5,638 participants completed pocket spirometry, and 315 (5.6%) had PEF < 70% predicted. Of 5,323 with normal PEF, 651 underwent spirometry. The performance of PEF was assessed via positive and negative predictive values relative to a diagnosis of clinically significant airflow obstruction, defined as FEV(1)/FEV(6) < the lower limit of normal and FEV(1) < 60% predicted. Of 4,238 subjects with at least two risk factors, 267 (6.3%) had PEF < 70%, compared with 48 of the 1,400 subjects (3.4%) with fewer than two risk factors (P < .001). Based on 729 participants with acceptable spirometry, 63.1% (113 of 179) of those with abnormal PEF tested positive for clinically significant airflow obstruction, compared with 5.5% (30 of 550) with normal PEF (P < .001). The estimated prevalence of significant COPD among the 5,638 screened was 8.7%, and sensitivity and specificity were 40.7% and 97.7%, respectively.

CONCLUSIONS

A staged approach to COPD screening in adults is useful for detecting clinically significant airflow obstruction in our study population.

Review of services provided by pharmacies that promote healthy living

BACKGROUND

The recognition that community pharmacies have the potential to make a greater contribution to promoting public health has led to a new concept, called the Healthy Living Pharmacy (HLP). These are designed to meet public health needs through a tiered commissioning framework delivering health and well being services through community pharmacy, tailored to local requirements for tackling health inequalities.

AIM

To search the literature for quality evidence to support the inclusion of services in the HLP portfolio and suggest areas where more evidence is required.

METHOD

A systematic review of the research literature covering the period January 1990-August 2011 inclusive, using MEDLINE, EMBASE, Pharmline, NHS Evidence and the Cochrane databases. On-line searching of the grey literature (e.g. conference proceedings) was also carried out. Standard methods of assessing quality were employed.

RESULTS

A total of 377 papers were included. Over time, there was a marked increase in frequency of publications reflecting a growing pharmacy interest in the public healthcare agenda; over a third (35 %) of papers appeared in the last three-year study period. The body of research had a wide geographical basis; contributions were as follows: UK (51.5 %), US (20.4 %), Australia/New Zealand (9.8 %), Europe (7.7 %) and Canada (7.2 %). The topics of contraception, cardiovascular disease prevention, diabetes and smoking cessation accounted for 40 % of included papers. The literature supports the introduction of specific community pharmacy services, targeted at customer groups, both with and without pre-existing diseases. Good evidence exists for smoking cessation, cardiovascular disease prevention, hypertension and diabetes. Some good evidence exists for interventions on asthma and heart failure. The evidence supporting weight management, sexual health, osteoporosis detection, substance abuse and chronic obstructive pulmonary disease is weak and needs development.

CONCLUSION

There is strong evidence for the role of community pharmacy in a range of services, not only aimed at improving general health, but also maintaining the health of those with existing disease. In other areas, the evidence is less strong and further research is required to justify their inclusion in a HLP portfolio.

Issues in pulmonary function testing for the screening and diagnosis of chronic obstructive pulmonary disease

PURPOSE OF REVIEW

The purpose of this review article is to provide an up-to-date summary on the current evidence for or against the use of lung function tests as screening and diagnostic tools for airflow obstruction in chronic obstructive pulmonary disease (COPD), and to consider the relevant issues in context.

RECENT FINDINGS

COPD is characterized by chronic respiratory symptoms and airflow limitation with only partial reversibility on lung function testing. However, screening on a population basis or of an enriched 'at-risk' subset like chronic smokers is not supported by findings from previous epidemiological studies, screening trials or in currently published clinical management guidelines by professional societies and review bodies. The definition of airflow obstruction and the classification of disease severity of COPD also differ slightly between guidelines and statements from different professional societies.

SUMMARY

Given the experience from previous screening trials and controversial classification of airflow obstruction by severity, it is impossible to have accurate screening results for COPD based on lung function tests alone. Clinical respiratory symptoms should be taken into consideration in terms of the diagnosis and management of COPD, as well as in any screening trial or programme that is to be attempted or implemented.

Assessment of a pharmacist-driven point-of-care spirometry clinic within a primary care physicians office

Objective

To assess value-added service of a pharmacist-driven point-of-care spirometry clinic to quantify respiratory disease abnormalities within a primary care physicians office

Methods

This retrospective, cohort study was an analysis of physician referred patients who attended our spirometry clinic during 2008-2010 due to pulmonary symptoms or disease. After spirometry testing, data was collected retrospectively to include patient demographics, spirometry results, and pulmonary pharmaceutical interventions. Abnormal spirometry was identified as an obstructive and/or restrictive defect.

Results

Sixty-five patients with a primary diagnosis of cough, shortness of breath, or diagnosis of asthma or chronic obstructive pulmonary disease were referred to the spirometry clinic for evaluation. A total of 51 (32 patients with normal spirometry, 19 abnormal spirometry) completed their scheduled appointment. Calculated lung age was lower in normal spirometry (58.1; SD=20 yrs) than abnormal spirometry (78.2; SD=7.5 yrs, p<0.001). Smoking pack years was also lower in normal spirometry (14.4; SD=10.7 yrs) than abnormal spirometry (32.7; SD=19.5 yrs, p=0.004). Resting oxygen saturation of the arterial blood (SaO2) was higher in normal spirometry than abnormal spirometry (98.1% vs 96.5%, p=0.016). Mean change in the forced expiratory volume in one second (FEV1) after administration of bronchodilator was greater in patients with abnormal spirometry compared with normal spirometry (10.9% vs 4.1%, p<0.001). Spirometry testing assisted in addition, discontinuation or altering pulmonary drug regimens in 41/51 patients (80%) and the need for further diagnostic testing or physician referral in 14/51 patients (27.4%).

Conclusions

Implementation of a pharmacist-driven spirometry clinic is a value-added service that can be integrated with other clinical pharmacy services within the ambulatory care setting. Further studies are needed to determine the role of pharmacists in performing spirometry testing and measuring performance outcomes of the pulmonary patient.

Technical requirements of spirometers in the strategy for guaranteeing the access to quality spirometry

Access to quality spirometry is an essential objective in order to be able to minimize the underdiagnosis of respiratory diseases, especially in those that are most frequent, such as COPD and asthma. This objective can be reached in the short term, but it requires the simultaneous integration of different strategies: training of the health-care professionals who perform spirometry, definition of standards for the transmission of the information, technical requirements for acquiring apparatuses and the correct interpretation of the results. This present study shows the use of standards for the electronic exchange of clinical information. In order to normalize the treatment of the data related with spirometry and to enable the exchange of information, we have used the standard CDA R2 (Clinical Document Architecture, Release 2) of HL7 (Health Level Seven), version 3. HL7 is a product by HL7 International, a non-profit organization that deals in the production of standards in the health-care setting in order to facilitate interoperability. Furthermore, defining these standards is essential for ensuring that they are adopted by spirometer manufacturers. Be means of this process, the base is set for facilitating access to spirometry at the health-care level, while at the same time it is a fundamental technical element for designing quality control programs of the explorations.

[Publications in respiratory nursing and physiotherapy]

The Respiratory Nursing and Physiotherapy Section of the Spanish Society of Pneumology and Thoracic Surgery, established as a working group more than 19 years ago, has been characterized by a high degree of involvement and collaboration with all the research studies requiring nursing and physiotherapy techniques. However, publication of articles by this collective is scarce compared with that of the rest of the Society and the characteristics, attitudes and limitations of this section pose an obstacle to increasing the number of its publications. This article aims to explain some of the possible reasons that could have given rise to this situation. The new tendencies and the attitude of this collective and the rest of the Society are encouraging and suggest that the work of the Respiratory Nursing and Physiotherapy Section will be better reflected in the future.

New horizons in early stage COPD--improving knowledge, detection and treatment

Early stage COPD carries a significant healthcare burden that is currently underrecognised, underdiagnosed and undertreated. Furthermore, patients at this stage can rapidly decline to advanced disease, especially if they continue to smoke. The natural history of the disease in early stages remains largely unknown, and emerging evidence indicates that we are able to reduce lung function decline and exacerbations, and improve quality of life, in early stage COPD, mainly through smoking cessation. But new evidence from randomised clinical trials also suggests an impact of pharmacotherapy on clinical outcomes in early disease. Guidelines need to be updated to reflect this greater understanding of early stage disease, and trials need to be conducted to definitively show the benefits of intensive treatment so that we can meet the large, unmet clinical needs of this important patient group.

Screening for and early detection of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a substantially underdiagnosed disorder, with the diagnosis typically missed or delayed until the condition is advanced. Spirometry is the most frequently used pulmonary function test and enables health professionals to make an objective measurement of airflow obstruction and assess the degree to which it is reversible. As a diagnostic test for COPD, spirometry is a reliable, simple, non-invasive, safe, and non-expensive procedure. Early diagnosis of COPD should provide support for smoking cessation initiatives and lead to reduction of the societal burden of the disease, but definitive confirmation of both proves elusive. Despite substantial effort and investment, implementation of quality spirometry is deficient because of several hurdles and limitations, described in this Review. All in all, spirometry is recognised as the essential test for diagnosis and monitoring of COPD.