1. Enabling online spirometry training and feedback from the US to Australia: E-Quality Program results 24 May, 2013 1Spirometry 360 © University of Washington J Stout, K. Hancock, A. Crockett IPCRG Scientific Meeting Uppsala Sweden

2. Disclosure Slide Project implementation was funded through the IPCRG E-Quality Programme. I have no financial conflicts of interest. 2Spirometry 360 © University of Washington

3. Spirometry in the Management of Asthma (and/or COPD): The Clinical Case Spirometry 360 © University of Washington3  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;160:844-850. 2. Cowen M, et al., Journal of Asthma 2007; 44:711-715 3. Fuhlbrigge AL, et al., J Allergy Clin Immunol 2001;107:61-67.

4. 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 incorporating a new device and procedure  Lack of incentives Spirometry 360 © University of Washington4

5. Training matters… Spirometry 360 © University of Washington5 This is the way it should look!

6. Evidence for the “Spirometry 360” Intervention  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 2012. Spirometry 360 © University of Washington6

7. 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 Washington7

8. Discussion Paper: Most Recent International Thinking Attributes of QI trainings resulting in improved care:  Carefully designed, theory-based  Multi-faceted QI strategies  Provide ongoing support over time  Sensitive to local circumstances Spirometry 360 cited as a successful example of applying these principles. McDonnell J, Williams S, Chavannes N, Correira de Sousa J, Fardy H, Fletcher M, Stout J, Tomlins R, Yusuf O, Pinnock H. Effecting Change in primary care management of respiratory conditions: a global scoping exercise and literature review to inform the IPCRG’s E-Quality initiative. Prim Care Respir J 2012: 21 8Spirometry 360 © University of Washington

9. E-Quality project goals:  Distribute online spirometry training resources from Seattle, USA to primary care sites in Adelaide AU, in order for their staffs to:  View Spirometry Fundamentals Tutorial.  View Archived Learning Lab webinars.  Participate in test quality interpretation training.  Grade tests from local Australia practices using this resource.  Use “train the trainer” resources, and our staff as needed. Spirometry 360 © University of Washington9

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11. Seattle, USA – Adelaide, AU Spirometry 360 © University of Washington11

12. Spirometry Fundamentals Spirometry 360 © University of Washington12

13. Feedback on Spirometry Fundamentals:  “The tutorial was easy to access (once you knew where it was!). Short modules are user friendly.  Nursing staff were frequently coming and going and did not have enough “quarantined time” to complete the program due time pressures to undertake clinical duties.  In my opinion I think the Fundamentals course needs to be “Australianised” to make it more acceptable to an Australian health care audience. Spirometry 360 © University of Washington13

14. Pediatric PROVIDER LEARNING LAB Faculty 14 Family Practice PROVIDER LEARNING LAB Faculty Greg Ledgerwood, MD Family Physician Eastern Washington Bruce Culver, MD Professor of Medicine University of Washington James Stout, MD Our Leader Karen Smith, MD Expert in QI and Adult Learning Before losing weight Spirometry 360 © University of Washington

15. Learning Lab Content (90 minutes each) offered through self-paced, interactive LMS Spirometry 360 © University of Washington15  Coach Learning Lab 1  ATS rules for producing a good test  Coach Learning Lab 2  Common errors and how to correct them  Provider Learning Lab 1  Case-based practice and incorporating test into asthma or COPD care.  Provider/ Coach Combined Learning Lab  Putting it all together into a planned visit model, and more case-based practice

16. Feedback on Learning Labs Spirometry 360 © University of Washington16 “I only intermittently accessed the learning labs; I often had problems getting around the website and knowing where to access resources and which password I had to use. I kept having to go back to previous emails and click on links that I knew had worked before. Because it wasn’t something I was doing frequently I would have to take time to work it out again!”

17. Spirometry 360 Dashboard Dedicated to Dr. Kerry Hancock Spirometry 360 © University of Washington17

18. Key to the Success of Spirometry 360 Over-reading and Feedback Reports Spirometry 360 © University of Washington18 Feedback is crucial to successfully performing spirometry. This activity represents 75-80% of the work involved in delivering Spirometry 360.

19. Sending Spirometry Tests 19 Using EasyWare and Spirometry 360 Feedback Agent Spirometry 360 © University of Washington Spirometry 360 Feedback Reporting System

20. Feedback on FRS use and training: (The bad news) Spirometry 360 © University of Washington20  “Some practices and staff we were trying to recruit wanted to be paid to be involved! Recruitment of primary care practices, even for service delivery programs, tends to be difficult in Australia.”  “Despite the enthusiasm of the practice manager at one site, the project failed to be implemented due to the doctors’ concerns about privacy, cost, time, and the uploading software.”

21. Feedback on FRS use and training: (The good news) Spirometry 360 © University of Washington21  “The uploading software at CHS and FMC worked well without any hitches.”  “The tutorials that Anne and I had with Drew worked extremely well and improved our skills in using the FRS. Drew’s flexibility in availability to do the tutorials was very much appreciated.”  “The feedback reports were clear and easy to interpret and were very useful to gain insight into performance.”

22. Feedback on use of resources and remote support Spirometry 360 © University of Washington22  “The teleconferences that we had with the Seattle team were supportive and encouraged us to keep pursuing involvement of the other practices.”  “Due to the international time differences it was great that the US team could be so accommodating in their availability for the teleconferences.”  “Skype seemed to work well to undertake the teleconferences.”

23. Final Report – Flinders Medical Centre Spirometry 360 © University of Washington23

24. Final Report – Flinders Medical Center Spirometry 360 © University of Washington24

25. Final Report – Flinders Medical Center Spirometry 360 © University of Washington25

26. Final Report – Chandlers Hill Surgery Spirometry 360 © University of Washington26

27. Final Report – Chandlers Hill Surgery Spirometry 360 © University of Washington27

28. Lessons learnt Spirometry 360 © University of Washington28 1. Make it easy to access resources 2. Interactive Learning Labs improve the training experience.

29. Message for others Spirometry 360 © University of Washington29 1. Implementing spirometry in a general practice setting can be facilitated by online training and feedback. 2. Prerequisites include enthusiasm, internet, and a spirometer. 3. New test over-readers can be remotely trained to grade tests for technique.