Spirometry in chronic obstructive pulmonary disease in Norwegian general practice

Spirometry services in England post-pandemic and the potential role of AI support software: a qualitative study of challenges and opportunities

BACKGROUND

Spirometry services to diagnose and monitor lung disease in primary care were identified as a priority in the NHS Long Term Plan, and are restarting post-COVID-19 pandemic in England; however, evidence regarding best practice is limited.

AIM

To explore perspectives on spirometry provision in primary care, and the potential for artificial intelligence (AI) decision support software to aid quality and interpretation.

DESIGN AND SETTING

Semi-structured interviews with stakeholders in spirometry services across England.

METHOD

Participants were recruited by snowball sampling. Interviews explored the pre- pandemic delivery of spirometry, restarting of services, and perceptions of the role of AI. Transcripts were analysed thematically.

RESULTS

In total, 28 participants (mean years' clinical experience = 21.6 [standard deviation 9.4, range 3-40]) were interviewed between April and June 2022. Participants included clinicians (n = 25) and commissioners (n = 3); eight held regional and/or national respiratory network advisory roles. Four themes were identified: 1) historical challenges in provision of spirometry services; 2) inequity in post- pandemic spirometry provision and challenges to restarting spirometry in primary care; 3) future delivery closer to patients' homes by appropriately trained staff; and 4) the potential for AI to have supportive roles in spirometry.

CONCLUSION

Stakeholders highlighted historic challenges and the damaging effects of the pandemic contributing to inequity in provision of spirometry, which must be addressed. Overall, stakeholders were positive about the potential of AI to support clinicians in quality assessment and interpretation of spirometry. However, it was evident that validation of the software must be sufficiently robust for clinicians and healthcare commissioners to have trust in the process.

Spirometry practice by French general practitioners between 2010 and 2018 in adults aged 40 to 75 years

In France, most spirometries are performed by pneumologists. Spirometry is difficult to access due to the distance to medical office and long delays for appointments. This lack of accessibility contributes to the underdiagnosis of chronic obstructive pulmonary disease (COPD) among patients aged between 40 and 75 years. In recent years, general practitioners (GPs) have been performing spirometry in private practice. However, the extent of this practice is unknown. A French retrospective, repetitive transversal study analysed data from the "Système National des Données de Santé" (SNDS) database. The targeted population was GPs in primary care that performed spirometries between 2010 and 2018, in patients aged between 40 and 75 years. Between 2010 and 2018, 302,674 (7.2%) spirometries were performed in France by GPs in private practices, in patients 40 to 75 years old. 5.4% by "expert GPs" (>60 spirometries/year) and 1.8% by "non-expert GPs". In "non-expert GPs" (2.8% of French GPs in 2018), the annual number of spirometries increased by 701 each year (p < 2.104), the annual number of GPs performing spirometries increased by 114 each year (p < 2.10-5). Overall, 24.9% of the spirometries performed by GPs were referrals from other GPs. The number of spirometries performed by GPs and the number of GPs performing spirometries has gradually increased over time. However, this increase is inadequate considering the need to early detect and follow up respiratory disorders.

Identifying airway obstruction in primary care: is there a role for physiotherapists?

AIMS

To examine the implementation of a physiotherapist-driven spirometry case finding service in primary care to identify new cases of COPD and confirm diagnosis of existing cases of COPD.

METHODS

Four general practices were recruited. 'At risk' participants (aged ≥ 40 years, current/ex-smoker) and people with 'existing' COPD were identified from practice databases and invited to attend an assessment with a cardiorespiratory physiotherapist in each general practice. The physiotherapist performed pre/post-bronchodilator spirometry to identify or confirm a diagnosis of COPD (FEV1/FVC < 0.7). Outcome measures included number (%) of new cases of COPD, number (%) confirmed diagnosis of COPD and number (%) of high quality spirometry assessments with accurate interpretation.

RESULTS

One hundred forty eight participants (mean age 70 years (SD 11.1), 57% female) attended a baseline assessment (117 'at risk', 31'existing' COPD) from 748 people invited. Physiotherapists performed 145 pre/post bronchodilator spirometry assessments. Obstruction on post-bronchodilator spirometry was confirmed in 17% (19/114) of 'at risk' and 77% (24/31) of 'existing' COPD. Majority of cases were classified as GOLD Stage II (63%, n = 27). Quality of pre/post bronchodilator spirometries for FEV1 were classified as A (68%), B (19%) and C (5%).

CONCLUSION

Physiotherapists integrated into primary care performed high quality spirometry testing, successfully case finding 'at risk' patients and identifying potential misdiagnosis of obstruction in some 'existing' COPD cases.

TRIAL REGISTRATION

ANZCTR, ACTRN12619001127190. Registered 12 August 2019 - Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx.

Chronic bronchitis in the 50-year follow-up of the European cohorts of the Seven Countries Study: prevalence, mortality and association with cardiovascular diseases

OBJECTIVES

To study prevalence of chronic bronchitis (CB) in residential populations and its relationship with mortality in a 50-year follow-up.

MATERIAL AND METHODS

In the late 1950's-early 1960's, 7047 men aged 40-59 years were enrolled in 10 European cohorts of the Seven Countries Study (in Finland, the Netherlands, Italy, Serbia and Greece). After baseline examination, follow-up for mortality was extended during 50 years (45 year in the Serbian cohorts). Prevalence of CB, and 50-year mortality from CB and other major causes of death were used as end-points to identify their determinants using multivariate models.

RESULTS

Prevalence of CB was directly associated with smoking habits and inversely associated with high socio-economic status (SES), forced expiratory volume in ¾ sec (FEV) and the ratio FEV/vital capacity (VC). Fifty-year mortality from CB was directly predicted by CB prevalence (from a minimum hazard ratio [HR] 2.35, 95% confidence limits [CI] 1.70-3.24, to a maximum HR 3.01, CI 2.18-5.20, depending on diagnostic criteria and different models) and age, and inversely by high SES, FEV and FEV/VC. The same applied in models predicting mortality from coronary heart disease (HR for prevalent CB: 1.53, CI 1.24-1.88), major cardiovascular diseases (HR 1.43, CI 1.23-1.67) and all-cause mortality (HR 1.48, CI 1.34-1.64) all adjusted for age, high SES, smoking habits and FEV.

CONCLUSIONS

CB is strongly associated with major cardiovascular disease and all-cause mortality while FEV and FEV/VC seem to carry at least partly an independent role from CB in predicting long-term mortality.