Lung disease is the UK’s third biggest killer.1 But unlike other major disease areas, mortality rates haven’t decreased in more than a decade. One in five people in the UK lives with asthma, COPD or other respiratory disease – nearly 13 million people – and respiratory conditions are a major part of the gap in life expectancy between the poorest and the wealthiest.1
The journey to better care starts at the beginning – the diagnosis. Diagnostic spirometry is being performed in primary care but evidence tells us that we are not doing it well enough. COPD is diagnosed on an accurate history of symptoms but relies on quality assured diagnostic spirometry to confirm the diagnosis.2 The results of The National COPD Audit in Wales3 (now operating as The National Asthma and COPD Programme [NACAP]) found that only 54.3% of newly diagnosed patients had a FEV1/FVC ratio coded in their records, only 11.1% were coded as post bronchodilator FEV1/FVC ratio, and of those, only 8.5% had a result consistent with obstructive disease.
This demonstrates a number of potential factors – poor performance, poor interpretation of the test results and poor ability to consider spirometry in the clinical context. Consider the effect on morbidity, mortality, cost to patients through scripts and impact on lifestyle, impact on healthcare systems in use of (often repeated) unscheduled care and cost of treatments that are ineffective if diagnosis is incorrect.
The picture in asthma diagnosis is similar. The evidence tells us that overdiagnosis is problematic4 and we know that people with symptoms of asthma may not always reach a timely diagnosis. Although spirometry may not clarify a diagnosis of asthma, it can contribute to an inaccurate diagnosis or delay appropriate treatment if done poorly.
A Parliamentary review board met following the publication of the National Review of Asthma Deaths Report5 in 2015 to see what could be done better. One recommendation was the formation of a national register for those performing and interpreting diagnostic spirometry.
The NHS Long Term Plan6 is also working to improve the quality of diagnostic spirometry. It clearly states: ‘The NHS will do more to detect and diagnose respiratory problems earlier. Currently around a third of people with a first hospital admission for a COPD exacerbation have not been previously diagnosed. From 2019 we will build on the existing NHS RightCare programme to reduce variation in the quality of spirometry testing across the country. Primary care networks will support the diagnosis of respiratory conditions. More staff in primary care will be trained and accredited to provide the specialist input required to interpret results.’
The plan also describes the work of primary care networks. Working in this way means there may not need to be a qualified person in every practice if the patient is referred to a professional who has undergone training. Spirometry is a part of the diagnostic jigsaw. Demonstrating competence in diagnostic spirometry is a part of respiratory competence. Cervical cytology training was accepted as compulsory and the spirometry register could be going the same way.
Carol Stonham is an advanced nurse practitioner in Gloucestershire and member of the Primary Care Respiratory Society
1 Lung Disease in the UK. British Lung Foundation statistics.blf.org.uk/?_ ga=2.136267059.38826871 .1547811212-2010399124. 1536053665
2 NICE. NG115: COPD. London: NICE; 2018
3 Royal College of Physicians. Planning for Every Breath. rcplondon.ac.uk/projects/outputs/primary- care-audit-wales-2015-17-planning-every-breath
4 Pakhale S et al. Correcting misdiagnoses of asthma: a cost-effectiveness analysis. BMC Pulmon Med 2011;11:27
5 Royal College of Physicians. Why Asthma Still Kills. The National Review of Asthma Deaths. rcplondon.ac.uk/projects/outputs/why- asthma-still-kills
6 NHS England. NHS Long Term Plan. January 2019. england.nhs.uk/long-term-plan/