Major Variations in the Spirometry Results - Essay Example

? Analysis of variations in the spirometry results by general practitioners and hospital based services Spirometry is an indispensable tool for the detection and management of chronic obstructive disease in primary health care practices. However, variations in the results of the spirometry test procedures undertaken by a general practitioner or provided by a hospital based service leads to several misdiagnoses. As stated by previous studies, spirometry can increase the rate of diagnosis of the COPD or asthma in patients LUSUARDI M, DE BENEDETTO, PAGGIARO, SANGUINETTI, BRAZZOLA, FERRI P, & DONNER, 2006). This may become difficult to achieve as the test procedures are often undertaken in infrequent settings (Standardizations of spirometry, 1994). For reproducibility in the spirometry results comprehensive training, reliability of the equipment and, well standardized measurement procedures are crucial and without any one of these dynamics, variations in the results of the spirometry are bound to occur (John, Bulton, Walter, Baker, 2006). In this project I will explore and analyze the variations that occur in the results of spirometry under different circumstances of use. In particular, I will focus on how these variations are influenced as well as different factors affecting these discrepancies. Such a study will give insights on the working of spirometry, a testing procedure that is rapidly gaining popularity and acceptance. The study will also test its usefulness and its weaknesses or flaws. It is also unclear that whether physicians are following any kind of guidelines or using other patient characteristics to determine when to use this technique for accurate results, which ultimately reflects upon the unreliability of the results obtained from spirometry based on practice differences (JOO, FITZGIBBON, & LEE, 2011.) Misdiagnosis resulting from inadequate spirometry test procedures can lead to inappropriate treatment and suboptimal patient outcomes. To promote optimal patient management and treatment, increase awareness of the differences between testing procedures or factors affecting the results of the procedure are to be determined ( Tinkelman , Price, Nordyre, Halbert, 2006). COPD is a condition which worsens with time and leads to decline in lung function and more than half of the COPD patients are often misdiagnosed as Asthma patients(National heart, lung and, blood institute, 2003), that is why it tends to be underdiagnosed and under treated Top of Form(JOO,FITZGIBBON, & LEE, 2011.) As spirometry depends on cooperation between the subject and the examiner, thus it depends on both technical as well as personal factors. If this variability can be diminished and results accuracy can be improved, then abnormalities can be more easily detected. (Miller, 2005) Top of Form Literature review: Spirometry is used in a variety of venues ranging from small clinical settings to large testing facilities for both screening and clinical evaluations. Physicians or other health care staff conduct the tests, help others in conducting it or just evaluate the results. But results of this testing procedure depend upon multiple factors and if any of these factors are affected the results are flawed or wrongly reduced leading to misdiagnosis (Townsend,2011). In some studies, it was observed that most relevant spiromtric results measured by general practitioners were comparable to those measured in pulmonary function laboratories. (Schemer, Jacobs, Hartman, Folgering, Bottema &,Van).In another study, positive effects of training on the spirometry test results were estimated, this study also stated that spirometry in general practice does not satisfy the full criteria for acceptability and reproducibility. (Eaton, Garette, Mercer, Whitlock & Rea, 1999) But these studies were conducted as a research exercise so the findings may have some of its limitations. (SCHERMER TR, CROCKETT AJ, POELS PJ, VAN DIJKE JJ, AKKERMANS RP, VLEK HF, & PIETERS,2009). One study aimed to identify the quality of routine general practice spirometry to explore whether patient’s sex , age or presence or absence of obstruction have any impacts on results in these settings. This study identified duration of forced expiratory time as the main reason for inadequate results (Schemer, Crocketta ,poels, Van &pietters,2009). Awareness of patient characteristics highly affects the results of spirometry. This study had limited Generalizibility or external validity as it was conducted under GP’s having considerably less experience and worked with the support of an expert. Several spirometry acceptability markers, as well as old age and airflow obstruction, were observed in association with its results. Cognitive impairments in older age are the reasons of prejudiced results in spirometry as explained by previous studies (Lehmann, Volleste Nygaadra & Gulsvika, 2004) (Sherman, Kern, Richardson, Hubert, 1993). Gender based difference in the reproducibility of the results in spirometry is still confusing. Previously, male sex was associated with poorer results (BEllia,pistleer,catalano,Antonelli,Grassi,2000) but in some studies female sex show inadequate results due forced expiratory time and initial incline to peak flow (SCHERMER, JACOBS, CHAVANNES, HARTMAN, FOLGERING, BOTTEMA, & VAN WEEL,). Embarrassment is felt more in female gender while performing forced expiratory maneuvers because of a possibility that urine might leak. ORR, MCVEAN, WEBB, & DODD). Validity of the test procedure is a prerequisite for their use as an instrument to diagnose, manage or monitor the disease. In primary care settings more knowledge is required regarding the validity of the spirometric tests. It is recommended that spirometry systems are validated and evaluated using computer driven mechanical syringe or its equal, in order to examine the range of exhalations in the widespread population. Although testing the equipment is not a part of usual laboratory procedure, it has been reported that at least one third of the tests performed in general practice do not meet quality criteria which apply to pulmonary function laboratories. Attention to equipment quality control and calibration is a part of good laboratory practices. An accuracy of within 2 % must be achieved after calibrating the device (standardization of spirometry). Four different studies indicate that results obtained in general practice were considerably lower than those in laboratories due to insufficient test validity (Jonas, 1995). However, these were not peer reviewed researches and methodological limitations justify further research on the topic. Distinctions in the results in different studies might also occur due to the possibility of training divergences. Despite high ownership of spirometers, very few of the general practitioners feel confident enough to deal with it and get reproducible results (John, Burton, Walter &, Baker). Several models to provide spirometry test results are present depending upon the local settings; these include both regional primary care diagnostic services as well as hospital based lung function test laboratories. More time saving approach is the ownership of spirometers by the GP’s. Trained staff is a necessity for the maintenance and operation of the spirometers as well as ability of the GP to interpret accurate results from the procedure (BOLTON, IONESCU, EDWARDS, FAULKNER, EDWARD, &, SHALE, 2005). These limitations act as a barrier for widespread use of the technique. Ideally, once the staff has the proper training, they should be continually advised on the subject. Low rates of verification of spirometers accuracy and performance suggests the need for reliable and stable spirometers with regular training to be available to the GPs (John, Burton, Walter &, Baker). Training produces a dramatic change in the results of the spirometry (Poels, Patrick, Schemer, Tjardr, Van, Chris &, Calverley, Peter); however, affects produced by these training are only temporary. Pulmonary function laboratories produce 90% reproducibility in the results both routine care as well as in researches. Limited training, lack of quality assurance activities, deficient experience and routine are the factors affecting the results of spirometry in general practice. (Poels, Schemer, TJrdr, Chris, &, peter). However, impacts of these poor results on patient management and diagnosis are still unclear as results from trained general practitioners give a technically imperfect but, sufficient data on which GPs can base their diagnosis. Researchers suggest wide range of training programs for both nurses and physicians to produce more reliable and reproducible data. However, training alone cannot eliminate the variations in both hospital and general practice settings. Various quality assurance initiatives are also needed to improve the quality of test results. Type of spirometers used, imperfections in the data transfer between spirometers and spirometers software may also result in the variations between the two settings. As spirometry is a procedure, prone to a number of factors; both technical and patient related. Various other circumstantial factors are also there which affects its validity; coughing during the exhalation, early termination of the effort, interruptions in the air flow or a leak in mouth piece (Lee, 2009). Failure to follow instruction, anxiety, fatigue or depression, history of respiratory disease, sedatives or any other drugs which affect breathing or all body systems, time of the day: pulmonary function increase in the morning and falls in the evening and type of spirometers are some of the factors which are stated. More researches are required to determine the effect of race difference in test results. Age is also main limitation in the spirometry testing procedure as patients younger are usually considered ineligible for this procedure. However, patients younger than six years are also able to perform spirometry with reliable equipment and trained professional, this clinical application is still debatable and needs more attention (Lee, 2009). The main purpose of this evaluation is to determine how finest treatment can be provided to respiratory patients without causing misdiagnosis. This process is usually facilitated through analysis and through process of information translation from peer reviewed literature to practice (Martin, 2005). However, evidence from any type of research must be used with caution and after approval from various authorities as their might be confusion regarding the best approach or value of particular practice. Methodology: Hypothesis: To assess variations in the spirometry results of both general practitioners and hospital based services to reduce the number of misdiagnoses. In terms of research approach, the investigator can decide to use either qualitative or quantitative research designs or combination of both methods for the research study depending upon the type of research question or hypothesis. Qualitative data collecting approaches such as survey methods determine the relationship between different variables of a specific study. Quantitative studies avoid the prejudice by means of collecting the data, which is purely statistical and explores information which does not describe the subject matter. Quantitative method is more objective in approach, seeks precise measurements, analyzes target concepts to answer the inquiries and provide systemic evidence for diversity (Tashakorri& Tandali). Whereas qualitative method is more subjective in nature and help determine the behaviors or factors that tend to bring the change and generate a more realistic feeling of the research setting which can’t be obtained from statistical tests and numerical data. These data collection methods produce flexibility in assembling facts through research analysis and interpretation of the gathered information (Tashakori &, teddlie, 2010). Both of these approaches have various usefulness and limitations. Use of combined approach can limit the sources of bias which can result in a better outcome. Quantitative research is judged by the extent to which the lessons learnt are generalizable. In the beginning, researcher can identify the suitable method, which will yield Knowledge building discoveries, through literature review (Swanwick, 2010). Evidence based practice promotes health policy and clinical practice rely more on critical review of the best available evidence (Oxman, seckett, Guyatt, 1993). This indicates that qualitative primary care research can identify essential components of clinical phenomena in particular those aspects which have both clinical and social dimensions. This designates that qualitative methods can determine fundamental actors present behind a particular effect (Berkwits & Tronowits, 1995). As in this case, factors triggering variations in spirometry results could have been determined by a qualitative study. For example, qualitative data identified different factors which were causing failed interpretations of spirometry by GPs (Walters, Hansen, john, BlizzardBker, 2007). However, in medicine, qualitative research fails to answer many clinical questions as etiology, prognosis, therapy etc., and thus it has traditionally narrower scope as compared to quantitative method (Poggie, Dewalt &, Dressler, 1992). Moreover, Qualitative studies can often answer questions which cannot be determined by any other research method such as bio-psychosocial questions. However, in this study we have a research question which can only be answered after assessing statistical values. The factors behind those varying results can then be sorted out by any qualitative approach. Thus, Quantitative method is considered most favorable for this research question. Sample selection The investigator relies upon his or her decisions to determine the type and size of sample and may have to select sample on the basis of availability or willingness of the participants of the research (Singleton &, strait, 1999). It is important to select a representative sample of a population when you want to generalize your results from your sample to whole population. Its goal is to help understand the characteristics of the population based on study of the sample (Smith, 1990). In this case, simple random selection of the sample is more important because researcher needs a representative sample of a specific type of population (Cooper, Emroy, Emroy, 1995). This is the type of probability sampling and is considered suitable for quantitative research. It is an observational study where researchers just scrutinize the subjects rather than intervene. Various study designs vary in their worth of indications they provide for a cause and effect association between variables. Case and case series type of observational study designs are considered the weakest in this scenario. Observational or descriptive analysis requires a large number of sample size (almost as much as resource allows) to get a confidence interval. For the study, the proposed simple random selection technique is used to recruit the sample. This is because the number of patients with COPD is limited. The only eligibility criterion for the patients was to have the respiratory ailment and a GP referral for spirometry test. Due to which every patient with a history of COPD and spirometry test results from a general physician was included in the study. No substantial value was given to the significant information as patient’s history or the type and technique of spirometry procedure used in the GPs office, which might be the reason of variations in the results. Hence, there were no other exclusion or inclusion criteria. Primary information was collected from the patients of COPD using a form which contained their name, age, sex, height and weight. Other than basic information it also reports their spirometry results by a general physician. The form further collects FVC, FEV1 values and its ratio either by a nurse led unit or the formal pulmonary functional lab. The form helps the researcher to identify the extent of difference in the results after each referral. As spirometry is a process in which patient’s lung functioning is assessed by measuring the volume of air that can be expelled from lungs following maximal expiration (Currie, 2007). The indices derived from this forced expiratory maneuver are considered the most reliable and repeatable manner of confirming COPD (Bousquet, Khaltaev &,Cruze, 2007). To construct a diagnosis post bronchodilator forced expiratory volume in 1 second (FEV1) and forced vital capacity ratio needs to be Read More