Improving Primary Care for Patients with Asthma or COPD: The Case for Spirometry as a QI Tool December 6th, Spirometry 360 © University of Washington James W Stout MD, MPH Lead, Spirometry 360 Professor of Pediatrics and Health Services University of Washington

Disclosure Slide I have no conflicts of interest. 2Spirometry 360 © University of Washington

Background  Asthma and COPD are two of the most common chronic diseases in the United States and all developed nations.  Most patients with asthma and COPD, including children and adults, are managed exclusively or almost exclusively by their primary care providers.  There is ample evidence that many patients are not receiving care consistent with national or international guidelines. 3Spirometry 360 © University of Washington

Background, continued…  There is also ample evidence that adherence to national guidelines would markedly improve the quality of life of patients with asthma and COPD, and save significant costs.  Thus far, standard CME programs and other QI initiatives have only been moderately effective in improving care.  Many of the guidelines are not being universally followed. 4Spirometry 360 © University of Washington

Objectives  Why office spirometry is an important management tool:  The clinical case  The business case  The quality improvement case Spirometry 360 © University of Washington5

Objectives  Why office spirometry is an important management tool:  The clinical case  The business case  The quality improvement case Spirometry 360 © University of Washington6

Classification of asthma severity in children: The contribution of pulmonary function testing Study Question: After using symptom frequency to categorize asthma severity in children, does pulmonary function increase the severity category? Stout JW, Visness CM, Enright P, Lamm C, Gail Shapiro GG, Gan VN, Adams GK III, Mitchell HE. Classification of Asthma Severity Testing in Children: The Contribution of Pulmonary Function Testing. Archives of Pediatrics and Adolescent Medicine, 2006;160:

Asthma severity distribution according to symptom frequency NCICASICAS 32% 43%

Asthma severity distribution according to symptom frequency and lung function NCICASICAS 32% 54% 43% 63%

Conclusions 1. Using FEV1 or PEF in addition to symptom frequency, one-third of participants were reclassified into higher severity categories. 2. In certain populations, under-use of spirometry may have direct implications for the under-treatment of asthma.

Spirometry in the Management of Asthma (and/or COPD): The Clinical Case Spirometry 360 © University of Washington11  Spirometry permits an objective measurement of the degree of airway obstruction (impairment and risk)  Patients’ perceptions of obstruction are notoriously inaccurate  Significant obstruction can be present even when the chest is clear on physical examination  Clinical symptoms alone will underestimate severity ~30% of the time in primary care  PEF testing alone is highly variable, is not a very sensitive measure of obstruction, and is no longer recommended for diagnosis 1. Stout JW, et al., Archives of Pediatrics and Adolescent Medicine 2006;160: Cowen M, et al., Journal of Asthma 2007; 44: Fuhlbrigge AL, et al., J Allergy Clin Immunol 2001;107:61-67.

Use of Spirometry for Asthma and COPD Care in the Primary Care Setting  …is often missing in the U.S.  …enables accurate diagnosis and management  …is easy to do poorly, but not hard to do well  …is a potent leverage tool for improving chronic care, thus reducing morbidity and lowering hospitalization and ED rates Spirometry 360 © University of Washington12

Diagnostic Spirometry and the National Asthma Guidelines (NAEPP EPR-3) Spirometry 360 © University of Washington13  EPR-3 Recommends Spirometry to be Performed:  At the time of initial evaluation (diagnosis)  Pre- and post-bronchodilator testing is very helpful.  After treatment is initiated and symptoms (and peak flows) have stabilized  During periods of progressive or prolonged loss of control  At least every 1 – 2 years  (In practice, spirometry is typically done at each planned visit)

Lung Function FEV1 % Predicted FEV1/FVC Symptom Frequency Day and Night SABA Use Oral Steroid Bursts Fall 2012Spirometry 360 © University of Washington14

Role of Spirometry with COPD ACP Clinical Practice Guideline (August 2011): All patients with symptoms suggestive of COPD should receive spirometry testing to CONFIRM the diagnosis of COPD  Spirometry testing should be done at time of suspected diagnosis (with bronchodilator testing)  Satisfies HEDIS measure pairing COPD and spirometry  Spirometry should NOT be used to screen asymptomatic patients Ann Intern Med 2011;155; Spirometry 360 © University of Washington15

Objectives  Why office spirometry is an important management tool:  The clinical case  The business case  The quality improvement case Spirometry 360 © University of Washington16

Spirometry in the Management of Asthma (and/or COPD): The Business Case Spirometry 360 © University of Washington17  From the practice perspective:  Spirometry is a reimbursible procedure in the primary care office.  Improving care increases provider and patient satisfaction.  Better care should lead to better health outcomes.

The Business Case for Spirometry April 2012Spirometry 360 © University of Washington18  * Most commonly used CPT codes for spirometry. Additional codes may be found in the Current Procedural Terminology (CPT) Manual published by the American Medical Association. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines.  ** Medicare allowable amounts vary by geographic region. See CPT Code*DescriptionUnadjusted 2012 Medicare Allowable** 94010Forced Expiratory Capacity test $ Evaluation of wheezing (Pre- and post- bronchodilator) $ Respiratory flow volume loop $ Aerosol Administration$14

Spirometry in the Management of Asthma (and/or COPD): The Business Case Spirometry 360 © University of Washington19  From the health plan perspective:  Reduce unnecessary specialty referrals by improving primary care for straightforward and common conditions  “Raise the floor” for appropriate referrals (severe disease, r/o restriction, or other abnormality discovered via spirometry )  Reduce acute visit use (ED visits and hospitalizations) through improved preventive care

Objectives  Why office spirometry is an important management tool:  The clinical case  The business case  The quality improvement case Spirometry 360 © University of Washington20

Training matters… Spirometry 360 © University of Washington21 This is the way it should look!

Barriers to Performing Spirometry in Primary Care  Lack of training for support staff and providers  Lack of a spirometer (or its use)  Lack of time (problems with work flow and lack of planned visits)  Lack of interest or enthusiasm in learning a new procedure Spirometry 360 © University of Washington22

Trial of online spirometry training and feedback  Small RCT (14 pediatric practices in NY State) of online program: 1. Spirometry Fundamentals 2. Case-Based Learning Labs 3. Monthly Feedback Reports Increase in proportion of acceptable spirometry tests Increase in asthma severity labeling rates, thereby improving treatment* * Stout JW, Smith K, Zhou C, Solomon C, Dozor AJ, Garrison MM, Mangione-Smith R. Learning from a Distance: Effectiveness of online spirometry training in improving asthma care: a cluster randomized trial. Academic Pediatrics. 12(2): 88-95, March/April Spirometry 360 © University of Washington23

Mission of Spirometry 360  Improve the care delivered in general practice to patients with asthma and COPD.  Focus both on properly performing and interpreting the spirometric maneuver, and delivering planned care.  Emphasize reaching safety net practice populations, where the burden of asthma and COPD is greatest.  Make our training available to geographically isolated practices.  Spirometry 360 © University of Washington24

Sending Spirometry Tests 25 Using EasyWare and Spirometry 360 Feedback Agent Spirometry 360 © University of Washington Spirometry 360 Feedback Reporting System

Visual Teaching Aid….. April 2012Spirometry 360 © University of Washington26

April 2012Spirometry 360 © University of Washington27

Keisha is a 8-year old who presents to my office today for follow-up. She is an African American female with a history of known asthma, currently with no symptoms. She has had 2 ER visits in last 6 months, both for asthma. Currently she is on no meds, although she was given inhalers at the last ER visit. 28Spirometry 360 © University of Washington CASE BASED LEARNING:

Keisha’s spirometry Spirometry 360 © University of Washington29 (No BD testing performed)

Today you classify Keisha’s asthma “control” as: A. Well Controlled B. Not Well Controlled C. Very Poorly Controlled D. It is difficult to say with the information provided CHAT in your response 30Spirometry 360 © University of Washington

SEVERITY CONTROL TREATMENT Age 0-4 Age 5-11 Age Spirometry 360 © University of Washington Another Goal of our program is to review the NIH guidelines and teach primary care providers through a case-based approach how useful they really can be.

EPR-3 (8/28/07): p76, 310 ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY 32 Spirometry 360 © University of Washington Spirometry is required for best assessment

Lung Function FEV1 % Predicted FEV1/FVC Symptom Frequency Day and Night SABA Use Oral Steroid Bursts Fall 2012Spirometry 360 © University of Washington33