Office Spirometry

What’s the big deal all of sudden?

Paul Harkaway, M.D.

HVPA

Take Home Points PCPs should do in-office spirometry

Critical Asthma tool Helpful “COPD” tool $ on the table

Asthma is not Emphysema Anything worth doing is worth doing

right Children are not Adults Excellence can never be achieved

by a “Gizmo” alone (aka: Cyberknife Syndrome)

PCPs Should Do Office Spirometry

Critical Asthma tool

Helpful “COPD” tool

$ on the table

Asthma is Not Emphysema

Diagnosis vs. Management?

Asthma History and physical and chest x-ray Spirometry - confirmatory maybe CRITICAL MANAGEMENT TOOL

Emphysema (COPD?) History and Physical and Chest X-ray Complete PFT vs spirometry – key to

diagnosis Spirometry helpful management tool

Office Spirometry Also May Help

Diagnostic dilemmas Chronic cough Undifferentiated respiratory

symptoms Unexplained dyspnea Voice changes Fatigue

Spirometry in Asthma

You would not consider managing hypertension without a

sphygmomanometer, or diabetes without a glucometer – accurate and objective

assessment and management  of asthma is not possible without a

spirometer.

Asthma Management Handbook 2002,National Asthma Council, Melbourne, 2002

Classification of Asthma Severity

Multi-faceted severity assessment Symptoms

Daytime/ exercise tolerance Nocturnal awakenings Rescue medication use

Physiologic measure FEV1 PEFR variability

Overwhelming tendency to under-categorize severity of disease Subjective assessment often not accurate “poor

perceivers” Severity is based upon “worst” category

Utility of Spirometry in COPD Spirometry should be undertaken in all patients who

may have COPD. It is needed to make a confident diagnosis of COPD and to exclude other diagnoses that may present with similar symptoms. Although spirometry does not fully capture the impact of COPD on a patient’s health, it remains the GOLD STANDARD for diagnosing the disease and monitoring its progression. It is the best standardized, most reproducible, and most objective measurement of airflow limitation available. Good quality spirometric measurement is possible and all health care workers who care for COPD patients should have access to spirometry.Global Strategy for the Diagnosis, Management, and

Prevention of Chronic Obstructive Pulmonary Disease.

World Health Organization, National Heart, Lung, and Blood Institute;2006

Utility of Spirometry in COPD

Screening Impact on behavior ?

Smoking cessation Assessment of disease severity

Disease management Prediction of outcomes after surgery

(sorta/kinda) Component of prognostication model

BODE indexBMIObstructionDyspneaExercise tolerance

Spirometry Big Deal

Physician Quality Reporting Initiative (PQRI)

NCQA HEDIS® Billing codes

HAP recent fee schedule increases

HEDISPQRI

Use of Spirometry in the Assessment and Diagnosis of COPD

HEDIS®

Use of Spirometry Testing in the Assessment and Diagnosis of COPD Assesses whether members 40 years and

older received spirometry testing as part of work-up to confirm a new diagnosis of COPD

Pharmacotherapy Management of COPD Exacerbation Assesses whether members who were

discharged home following an exacerbation episode treated in the ED or inpatient unit were dispensed systemic corticosteroids within 7 days and/or dispensed bronchodilators within 21 days. Credit is given for preexisting prescriptions.

CMS Physician Quality Reporting Initiative (PQRI)

Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented

Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator

1.5% of total billed Medicare claims if you meet the 80% threshold for reporting on at least three measures

Estimated 2007 bonus: $400 - $1,400 per provider

Billing Codes/Reimbursement

CPT Code Description Rate

94010 Spirometry $35

94060Bronchospasm Evaluation

(Spirometry before and after bronchodilator)

$65

94375Respiratory Flow Volume Loop (includes expiratory and inspiratory portion of

loop)

$35

Background

Spirometry measures how an individual inhales or exhales a volume of air as a function of time.

Volume time

Flow-Volume

Data Obtained from Spirometry

Volumes FVC FEV1

Flows L/sec

Curves

Flow on Y axis; Volume on x axis

Normal Flow- Volume Loop

Simplified Spirometry Interpretation

Data assured to be accurate and reproducible

FEV1/FVC < LLN Obstruction

FEV1 /FVC > LLN No obstruction Not necessarily restriction

If obstruction present; grade severity based on FEV1

Look at MVV Look at flow volume loop

Step-Wise Approach to PFT Interpretation

Severity of Obstruction

Severity Percent Predicted FEV1

Mild >70

Moderate 60-69

Moderately severe

50-59

Severe 35-49

Very severe < 35

PFT Findings in Common Pulmonary Diseases

Asthma Reversible obstruction Normal/Increased DLCO

Emphysema Non-reversible obstruction Decreased DLCO

Fibrosis No obstruction Restriction

Low TLC Low VC and normal ratio alone don’t indicate

restriction Low DLCO

Low DLCO may appear before decline in TLC Obesity

Often restricted DLCO usually high but variable

Maximum Voluntary Ventilation (MVV)

Should be 35 x FEV1

Reduction in MVV out of proportion to FEV1

Poor effort Muscle weakness Upper airway obstruction

What Constitutes Change?

FVC FEV1

Within Day

Normal >5 >5

COPD >11 >13

WeeklyNormal >11 >12

COPD >20 >20

Partially reversible airflow

obstruction

FEV1 /FVC ratio below LLNImprovement in post-BD FEV1 12% or 200 cc

Severe fixed obstruction

Consistent with emphysema

Concave curve

Possible restriction

Normal or high FEV1/FVC Ratio

Would get TLC and DLCO

Upper Airway Obstruction

Anything Worth Doing is Worth Doing Right

Standardization of Office Spirometry Pilot Project

Terry Stevens, R.R.T., C.P.F.T.

“When we accept tough jobs as a challenge and wade into

them with joy and enthusiasm, miracles can happen”

- Arland Gilbert

WIIFM(What’s in it for me??)

Quality control of spirometry testing equipment that conforms to existing current ATS/ETS standards

Standardization of methodology for spirometry testing throughout the system

Staff knowledge of terminology related to, and performance of, spirometry

Spirometry test results that conform to existing ATS/ETS standards

An invaluable patient management tool

Components of Staff Training/Standardization

Quality Control Calibration Troubleshooting/maintenance Randomized review of spirometry performed

Cognitive Validation Testing staff on existing standards for

calibration/test performance Behavioral Validation

Compentency check off on specific tasks related to calibration/test performance

Components of Site Standardization

Policy & Procedure Equipment specific to site from template Incorporate infection control processes

Calibration Syringe validation and maintenance Site specific calibration log

Site specific behavioral (skills) validation from template

Pilot Training and Site Standardization Schedulingby Terry Stevens, R.R.T., C.P.F.T.

Staff Training (4 staff members per session) Cognitive and generic skills validation Wednesdays & Fridays 7:30 – 9:00 a.m.

Site Standardization One day per month beginning of the month

Cognitive Validation AARC Clinical Practice Guidelines for Spirometry &

ATS/ETS Standardization for Spirometry Testing – 80% correct scores for acceptability; real-time

review Behavioral Validation Quality Control Review

Testing Methodology

Closed circuit method: Patient able to place mouthpiece in mouth and perform tidal breathing. Test maneuver is accomplished from tidal breathing baseline. (PREFERRED METHOD)

Open circuit method: Requires that patient initiate test maneuver (inspiration to TLC, maximal expiration to RV) immediately upon placing mouthpiece in mouth. Requires higher degree of motor skills, quicker reaction time to coaching.

Spirometry Equipment Types

Microprocessor Units (stand alone) Generally hand-held units Minimal data input/output capabilities Strip printer output or docked to printer for

full page report Require separate software for PC based

data download for data storage PC Based

Generally flow device for test performance that is connected to PC via USB port

Enhanced data input/output capabilities Data storage is intrinsic to software

EquipmentType

Advantages Disadvantages

Microprocessor

ECONOMICAL Portable Ease of data entry Disposable measuring device, no sterilization User friendly; Ease of training/competence enhanced

Limited data input/output/report format options No options for trend reports Limited data storage Requires PC data transfer for long term data storage Frequently utilizes “open circuit methodology”

PC Based

Enhanced data input/output Visual incentives for pediatric testing Utilizes “closed circuit methodology” Unlimited long term data storage/archiving Trending output Networking potential

Cost Reduced portability Generally reusable flow measuring device with necessity of disposable filter. Sterilization capability required Higher degree of training/competence in performance/reporting required

What’s it going to cost me?

Fixed Costs Calibration syringe validation $100/site Site standardization visit $80/site Centralized staff training (2 staff members) $40/site Standardized spirometer $2000/site Interclinic network $500/site Central server/network set-up & maintenance $100/site

Variable Costs

Disposable supplies/spirometry $2/patient Quality control review/staff feedback $10/test (2 tests/site)

Labor Centralized training 2 hrs/staff member On-site training 0.5hrs/staff member Calibration of equipment 0.25 hrs/day Test performance 0.25 hr/test Sterilization of equiment 0.25hrs/day

(PC based system with reusables)

HVPA Pilot Funding ProposalDetails TBD

Coordinated by Terry Stevens, R.R.T., C.P.F.T 6 – 7 Pilot Offices BCBSM Physician Group Incentive Program (PGIP)

$ Stipend payment to PCP offices

Silver option Gold option Platinum option

HVPA Patient Centered Care Model

Children are not Just Little Adults

Spirometry in Children

Harvey Leo M.D.

Asthma Management Children

ATS guidelines suggest that children 5 years and older can do spirometry Practically, children 8 years and older can

produce consistent spirometry Normal values for children can be

misleading Reversibility studies may be useful if

technique is adequate Some children cannot meet full ATS criteria

Spirometry in Children

Solid coaching is essential for appropriate diagnosis

Child’s effort is essential Positioning and mouthpiece size

important FEV1 and FEV1/FVC are the main measure FEF25-75 can be useful since it is effort

independent

Other Measurement Tools

Exhaled nitric oxide can be useful in young children not able to perform spirometry if needed

If there is no improvement clinically or by spirometry, referral is needed Flexible bronchoscopy or full PFT may be

needed

General Guidelines in Children

Any child being placed on inhaled corticosteroids (ICS) should have spirometry measurements as baseline

Good measurement of height/weight are essential for comparison

If child is on ICS, visits every 4-6 months recommended

NHLBI/NAEPP Expert Panel Report 3

Guidelines for the Diagnosis and Management of Asthma

Full report released 8/29/07 440 pages!!!

Summary report due out December 2007

Specific guidance on children is addressed in this report

Excellence can never be achieved by a “Gizmo”

alone

The Advanced Medical Home Model

Informed,ActivatedPatient

ProductiveInteractions

PreparedProactivePractice Team

Continuous Healing Relationships

Kevin Taylor, M.D.

Future of Family Medicine Project

Every American should have a Personal Medical Home that serves as the focal point through which all individuals- regardless of age, sex, race, or socioeconomic status—receive their acute, chronic, and preventive medical care services.

http://www.aafp.org Family Practice Management May 2005

http://www.aafp.org Family Practice Management Oct 2004

http://www.asthmaactionamerica.org/i_have_asthma/control_test_pr.html

HVPA Goes Green

All materials will be posted on the HVPA website at

www.hvpa.com

www.hvpa.com

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