Spirometry in primary care practice - The importance of quality assurance and the impact of spirometry workshops

Objective: To determine the quality of spirometry performed in primary care practice and to assess the impact of formal training. Design: Randomized, controlled prospective interventional study. Setting: Primary care practice, Auckland City, New Zealand, Participants: Thirty randomly selected primary care practices randomized to "trained" or "usual" groups. One doctor and one practice nurse were nomina ted to participate from each practice. Interventions: "Trained" was defined as participation in an "initial" spiro metry workshop at week 0 and a "maintenance of standards" workshop at week 12. "Usual" was defined as no formal training until week 12, when participa nts they attended the same "initial" workshop provided for the trained grou p. The study duration was 16 weeks. Each practice was provided with a spiro meter to be used. at their clinical discretion. Measurements and results: Spirometry data were uploaded weekly and analyzed using American Thoracic Society (ATS) criteria for acceptability and repro ducibility. The workshops were assessed objectively with practical and writ ten assessments, confirming a significant training effect. However, analysi s of spirometry performed in clinical practice by the usual practitioners r evealed three acceptable blows in only 18.9% of patient tests, In compariso n, 5.1% of patient tests performed by the usual practitioners had three acc eptable blows (p < 0.0001), Only 13.5% of patient tests in the trained grou p and 3.4% in the usual group (p < 0.0001) satisfied full acceptability and reproducibility criteria. However, 33.1% and 12.5% of patient tests in the trained and usual groups, respectively (p < 0.0001), achieved at least two acceptable blows, the minimum requirement. Nonacceptability was largely as cribable to failure to satisfy end-of-test criteria; a blow of at least 6 s , Visual inspection of the results of these blows as registered on the spir ometer for the presence of a plateau on the volume-time curve suggests that < 15% were acceptable. Conclusions: Although a significant training effect was demonstrated, the q uality of the spirometry performed in clinical practice did not generally s atisfy full ATS criteria for acceptability and reproducibility. Further stu dy would be required to determine the clinical impact. However, the ATS gui delines allow for the use of data from unacceptable or nonreproducible mane uvers at the discretion of the interpreter. Since most of the failures were end-of-test related, the FEV, levels are likely to be valid, Our results s erve to emphasize the importance of effective training and quality assuranc e programs to the provision of successful spirometry in primary care practi ce.