Early this month, the American Board of Internal Medicine Foundation and 16 other medical professional organizations released their first recommendations as part of the Choosing Wisely initiative. The project is designed to “encourage physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.”
As one of the 17 partner organizations, the American Academy of Allergy, Asthma & Immunology has contributed five entries to the long list of tests and procedures that should elicit discussion between patients and physicians. Their suggestions:
• Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, to evaluate allergy.
• Don’t order sinus computed tomography or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis, since viral infections are responsible for the majority of cases of acute rhinosinusitis, it typically resolves without treatment within 2 weeks, and can usually be diagnosed clinically.
• Don’t routinely do diagnostic testing in patients with chronic urticaria.
• Don’t recommend replacement immunoglobulin therapy for recurrent infections unless patients demonstrate impaired antibody responses to vaccines.
And the one that this article focuses on:
• Don’t diagnose or manage asthma without spirometry.
The statement notes that “clinicians often rely solely upon symptoms when diagnosing and managing asthma, but these symptoms may be misleading and be from alternate causes.” So spirometry is “essential” to confirm a diagnosis.
This is the same recommendation contained in the National Asthma Education and Prevention Expert Panel Report 3, which calls for the use of spirometry in the diagnosis of all patients (including children 5 and older) “to demonstrate obstruction and assess reversibility,” with reversibility determined either by an increase in FEV1 of ≥12% from baseline or by an increase ≥10% of predicted FEV1 after short-acting bronchodilation inhalation.
Spirometry is essential for differentiating asthma from COPD in adults, for stratifying disease severity, and for monitoring control. As the “List of 5” notes, “history and physical exam alone may over- or under-estimate asthma control,” while misdiagnosing asthma delays treatment. Yet, as the authors of a 2010 editorial on the use of spirometry for managing asthma patients in family practice wrote, many primary care physicians don’t use spirometry for asthma diagnosis.1 Instead, they rely on clinical evidence for the diagnosis, labeling patients with a chronic disease they actually don’t have and subjecting them to the possibility of lifetime medication with the attendant side effects and costs. Relying on symptoms alone to assess lung function is often inadequate, the authors also assert, because symptoms typically resolve with treatment even if abnormal lung function, inflammation, and airway hyperresponsiveness still exist.
Unfortunately, spirometry is significantly underused in primary care practices, particularly for the diagnosis and monitoring of asthma and COPD. One study of Australian physicians found that while 75% had a spirometer in their office, just 12% had used it in the past year for their asthma patients.2 Another study found that less than a third of primary care physicians (27%) used spirometry to diagnose asthma in their patients, compared to 73% of specialists.3
Why? One reason appears related to education. Focus groups with medical students, interns, primary care physicians, and respiratory specialists in Great Britain found that the trainees had little familiarity with the use of spirometry and were rarely encouraged to use it.4 Only the primary care and specialist physicians who were specifically interested in undergraduate medicine “spontaneously” cited spirometry as a diagnostic tool for patients with dyspnea. Other experienced physicians said they were also unfamiliar with its use and result interpretation.
The results were similar in a survey of 360 US pediatricians and family practitioners, in which just 35% said they were comfortable interpreting the results of spirometry, and just 52% said they used spirometry in their asthma patients. (This last number was an average of 75% of family practitioners but just 35% of pediatricians). Even those physicians who did use spirometry used it just a third of the time to diagnose asthma, identify severity, or monitor control, while merely 21% said they used it for all three purposes.5
Given the publicity that the “Five Things” list has received across all media channels, clinicians should anticipate that more patients will ask about spirometry use for the diagnosis of asthma. Without access to a spirometer, staff trained to use it, and the ability to interpret the results, clinicians might need to prepare for awkward discussions with some of their patients.
1. Kaplan A, Stanbrook M. Must family physicians use spirometry in managing asthma patients? Can Family Physician. 2010; 56:126-8.
2. Barton C, Proudfoot J, Amoroso C, Ramsay E, Holton C, Bubner T, et al. Management of asthma in Australian general practice: Care is still not in
line with clinical practice guidelines. Prim Care Resp J. 2009, 18(2):100-105.
3. Janson SL, Fahy JV, Covington JK, Paul SM, Gold WM, Boushey HA: Effects of individual self-management education on clinical, biological, and adherence outcomes in asthma. Am J Med. 2003; 115(8):620-626.
4. Roberts NJ, Smith SF, Partridge MR. Why is spirometry underused in the diagnosis of the breathless patient: a qualitative study. BMC Pulm Med. 2011;11:37-43.
5. Dombkowski KJ, Hassan F, Wasilevich EA, Clark SJ. Spirometry Use Among Pediatric Primary Care Physicians. Pediatrics. 2010;126:682-687.