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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 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 Daytime/ exercise tolerance 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 index BMI Obstruction Dyspnea Exercise tolerance Spirometry Big Deal Physician Quality Reporting Initiative (PQRI) NCQA HEDIS® Billing codes HAP recent fee schedule increases PQRI HEDIS 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 94060 Bronchospasm Evaluation (Spirometry before and after bronchodilator) $65 94375 Respiratory 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 Flow on Y axis; Volume on x axis L/sec Curves 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 Normal >5 >5 COPD >11 >13 Normal >11 >12 COPD >20 >20 Within Day Weekly Partially reversible airflow obstruction FEV1 /FVC ratio below LLN Improvement in post-BD FEV1 12% or 200 cc Severe fixed obstruction Concave curve Consistent with emphysema 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 “When we accept tough jobs as a challenge and wade into them with joy and enthusiasm, miracles can happen” - Arland Gilbert Terry Stevens, R.R.T., C.P.F.T. 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 Scheduling by Terry Stevens, R.R.T., C.P.F.T. Staff Training (4 staff members per session) Site Standardization One day per month beginning of the month Cognitive Validation Cognitive and generic skills validation Wednesdays & Fridays 7:30 – 9:00 a.m. 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 Equipment Type Advantages ECONOMICAL Portable Ease of data entry Disposable measuring device, no sterilization User friendly; Ease of training/competence enhanced Disadvantages Microprocessor Enhanced data input/output Visual incentives for pediatric testing Utilizes “closed circuit methodology” Unlimited long term data storage/archiving Trending output Networking potential PC Based 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” 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 Site standardization visit Centralized staff training (2 staff members) Standardized spirometer Interclinic network Central server/network set-up & maintenance Variable Costs Disposable supplies/spirometry Quality control review/staff feedback Labor Centralized training On-site training Calibration of equipment Test performance Sterilization of equiment (PC based system with reusables) $100/site $80/site $40/site $2000/site $500/site $100/site $2/patient $10/test (2 tests/site) 2 hrs/staff member 0.5hrs/staff member 0.25 hrs/day 0.25 hr/test 0.25hrs/day HVPA Pilot Funding Proposal Details 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 Continuous Healing Relationships Informed, Activated Patient Productive Interactions Kevin Taylor, M.D. Prepared Proactive Practice Team 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 Vendors