September 15, 2014

Opinion Piece

The opinions expressed in this article are those of the author and not necessarily those of Lung Foundation Australia.

Spirometry in General Practice – It’s all about having fun

Associate Professor Ian Charlton, GP, Kincumber, NSW

ian on bike  jpeg 720General Practice is lots of things, but one of the main attractions is the challenge of solving problems, sorting out a case, setting a patient on a particular path and then being able to review them to see if your solutions have been successful. Some of us see ourselves as Sherlock Holmes (Holmes’ author was a physician) and spirometry is a great tool for enhancing the investigative process.

It is well recognised that asking a patient about their respiratory symptoms does not always provide an accurate picture of their underlying lung condition 1-3.  Certain groups of patients, (some studies suggest 40%4), are also recognised to be poor perceivers, reporting that “everything is alright” when in fact they may be on the brink of respiratory failure.5,6

There is a large body of research and opinion to support the use of spirometry to diagnose lung disease and as a test to measure the severity of lung disease and effectiveness of treatment. 7,8.9  In addition, an area that has perhaps not been previously recognised is the value of using spirometry as an education tool with patients.

Spirometry is able to show the patient that they may be functioning below their optimum and that their reduced lung function may account for not only their symptoms of cough, wheeze and breathlessness, but also fatigue, headaches and poor stamina. The patient can also see the benefits of their medicines as they see their lung function improve as a consequence of treatment.  Even more importantly, in patients with asthma, it can demonstrate the need to sustain treatment until the inflammatory process is fully resolved, a process which can take up to 18-24 months in adults.  This is important, as many patients have often been operating at less than ideal lung function and may not appreciate the need for continuing treatment to not only achieve optimal lung function but also reduce the risk of flare ups which might lead to further lung damage.

The Economics of Spirometry

MBS item 11506

MEASUREMENT OF RESPIRATORY FUNCTION involving a permanently recorded tracing performed before and after inhalation of bronchodilator – each occasion at which 1 or more such tests are performed

Fee: $20.55 Benefit: 75% = $15.45 85% = $17.50

 

It is often commented that spirometry is poorly remunerated under the Medicare Benefits Schedule (MBS), particularly when compared to similar activities such as ECGs and so there is little incentive for GPs to carry out spirometry in their practices.  There is significant evidence to support the use of spirometry for diagnosis of COPD and Asthma, and this can be found within the respective guidelines for each disease.  Currently, there is a lack of evidence about the role of spirometry in ongoing monitoring of patient care. There are only two Australian studies in this area.10,11

In the last financial year, 255,877 spirometry tests costing $4, 813, 572 were carried out by 18, 398 FTE doctors in Australia.  That is, 14 spirometry tests per year, earning each doctor on average $18.80 each in Medicare payments. This totals about $260 per year12

As a doctor interested in asthma and COPD I undertake approximately 85 spirometry tests per year.  Over five years I have performed 425 spirometry tests, at $17.50 each.  Added to this is the additional $6.15 bulk billing rebate.  I estimate that I have made over $10,000 from my device which cost $1000.  While it is not as profitable as some of the other activities that I undertake in general practice, it is a better return than BHP shares!  However more appropriate remuneration for this important diagnostic test is required due to the time and level of skill required to perform and interpret.

More recently the software is now available so your Spirometer can talk to your practice software saving you a lot of time in filling in patient details and allowing  you to share your results with other practice members.

Interpretation of Spirometry

One of the barriers to GPs using spirometry is the thought of trying to understand all the numbers, graphs and percentages that come with the modern machines.  In truth, the greatest information comes from “eyeballing” the flow volume graph comparing the graph to that of an average patient and then following the results over time.

An essential component to accurate interpretation is getting the patient to perform the manoeuvre accurately and reproducibly. Like all our investigations, it is just one part of the jigsaw and so results are never to be treated in isolation.  The old adage, “never treat the ECG, treat the patient” applies just as well to spirometry.

Conclusions

Spirometry adds another dimension to a GP’s diagnostic and treatment skills and patients also value seeing their lung function displayed on the screen.  It can be financially sustainable and certainly makes general practice more fun.

 

References

1. McFadden ER JrKiser RDeGroot WJ.Acute bronchial asthma. Relations between clinical and physiologic manifestations. N Engl J Med. 1973 Feb 1;288(5):221-5.

2. Burdon JGJuniper EFKillian KJHargreave FECampbell EJ.  The perception of breathlessness in asthma. Am Rev Respir Dis. 1982 Nov;126(5):825-8.

3. Rubinfeld AR, Pain MC.  Perception of asthma. Lancet. 1976 Apr 24;1(7965):882-

4. Rushford N1, Tiller JWPain MC.   Perception of natural fluctuations in peak flow in asthma: clinical severity and psychological correlates. J Asthma. 1998;35(3):251-9.

5. Sabin BR, Greenberger PA.  Chapter 13: Potentially (near) fatal asthma.

Allergy Asthma Proc. 2012 May-Jun;33 Suppl 1:S44-6

6. Davenport KL, Huang CH, Davenport MP, Davenport PW.  Relationship between Respiratory Load Perception and Perception of Nonrespiratory Sensory Modalities in Subjects with Life-Threatening Asthma. Pulm Med. 2012;2012:310672. doi: 10.1155/2012/310672. Epub 2012 Jun 13.

7. Buffels J, Degryse J, Heyrman J et al. Office spirometry significantly improves early detection of COPD in general practice: the DIDASCO Study. Chest 2004; 125: 1394–9

8. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma: a national clinical guideline. Thorax 2008; 63(Suppl. IV): iv1–121.

9. National Asthma Council Australia. Australian Asthma Handbook, Version 1.0. National Asthma Council Australia, Melbourne, 2014. Website. Available from: http://www.asthmahandbook.org.au

10.  Abramson MJ1, Schattner RLSulaiman NDBirch KESimpson PPDel Colle EAAroni RAWolfe RThien FC   Do spirometry and regular follow-up improve health outcomes in general practice patients with asthma or COPD? A cluster randomised controlled trial. Med J Aust. 2010 Jul 19;193(2):104-9.

11. Oei SM1, Thien FCSchattner RLSulaiman NDBirch KSimpson PDel Colle EAAroni RAWolfe RAbramson MJ. Effect of spirometry and medical review on asthma control in patients in general practice: a randomized controlled trial. Respirology. 2011 Jul;16(5):803-10. doi: 10.1111/j.1440-1843.2011.01969.x.

12.  Medicare website