PM Healthcare - Summer 2022

PM Healthcare Journal 47 46 PM Healthcare Journal suspected, diagnosis is made based on history of signs and symptoms. Quality assured spirometry is then used as a supportive/ confirmatory test. The guideline spirometry should be undertaken: 1. As part of the diagnosis of COPD 2. When diagnosis is reconsidered 3. For monitoring the progression and severity of disease. COPD guidelines recommend that a diagnosis of COPD should be confirmed with a post- bronchodilator spirometry test. A post- bronchodilator FEV1/FVC ratio < 0.7 confirms the presence of persistent airflow limitation and in combination with a clinical history would be consistent with a diagnosis of COPD. Post- bronchodilator testing is appropriate for all patients with suspected COPD who display a complete reversal of baseline airflow limitation, once treatment with a bronchodilator is initiated, to exclude the possibility of asthma. ”Spirometry testing itself is not an aerosol generating procedure but may induce coughing in 50% of patients. All aspects of the testing procedure, (including staff, equipment, premises) must comply with Infection Prevention Control (IPC) measures to prevent the spread of SARS-CoV-2.” Spirometry is a non-invasive testing procedure used in the diagnosis of lung and respiratory conditions. It is used in primary, community, and secondary care settings for both adults and children and is necessary for establishing a diagnosis of and can be helpful in ongoing disease management. Spirometry measures specific lung function parameters, i.e., the volume and/or flow of air that can be inhaled and exhaled. It is also used in the diagnosis and management of pulmonary fibrosis and cystic fibrosis. Airway inflammation is a core indicator of asthma and other lung diseases. The measurement of Fractional Exhaled Nitric Oxide (FeNO) testing is a new test which supports the diagnosis and management of asthma. Historically spirometry has been provided by many GP practices, whereas FeNO testing has not. National commissioning guidance aims to ensure – ‘a standardised level of competence in the performing and interpreting of spirometry testing and aid accurate diagnosis of COPD (and asthma) in primary care’. The guidance further states that new infection control requirements should be met and that staff performing testing and interpreting results should be appropriately trained and accredited. Since the Covid-19 pandemic, there has been a suspension of respiratory services in many settings. Post Covid, the problem arises as to how to get services up and running to deal with the backlog of reviewing existing respiratory patients and to help with the diagnosis of new patients. Several options are available to restart the services. Option 1 - GP practices resume services. Option 2 - PCN can offer a Diagnostic Hub - where a suitably trained team of respiratory clinicians can offer a full suite of diagnostic tests to help with diagnosis of respiratory conditions and offer management plans. Option 3 - Secondary cared based Diagnostic Hub where patients can be referred for diagnosis and ongoing management. Looking at the options in detail: GP practices They may have suitably qualified nurses, pharmacists who can provide quality assured spirometry and interpretation along the necessary equipment. The benefits of such services are that they are based closer to the patient, some degree of continuity of care may be possible as clinicians may know their patients, existing staff with the relevant skills, experience are utilised to provide high standards of care. Existing payments via QOF would help to fund resumption of services. The limiting factor in practice may be that the rooms used to undertake spirometry may not be able to facilitate the air changes, etc, as mandated by NHS England commissioning guidance for spirometry (2020). 2 Also, the practice may/may not have access to FeNO testing, so may not be able to provide a full diagnostic service in-house. Some practices may also have capacity issues as experienced clinicians look to retirement. Practice-based pharmacists may be able to help in some cases. They could provide patient facing clinics to assess inhaler technique checks, facilitate reviews and help to optimise inhaler therapies. They may also be involved in patient education as well as clinician education. Practice-based pharmacists would also be able to stratify high risk patients who may need ‘urgent reviews’ and carry out audits related to respiratory care. PCN delivered Hub model The British Thoracic Society (BTS) suggested a service configuration which would see spirometry provided at PCN level. 3 PCNs covering populations of around 30,000- 50,000 people have been established within the English NHS and are charged with shaping how local services are delivered in response to local needs. The NHS Long-Term Plan (2019) outlined a commitment to ‘detect and diagnose respiratory problems earlier’ and supports the diagnosis of respiratory conditions through PCNs. 4 PCNs are based on GP registered patient lists and designed to understand and respond to the needs of their local community and to foster better collaboration between GP practices and others in the local health and social care system. PCNs determine how and where community respiratory services will be delivered for their local community. The primary objectives of the service as proposed could be to: • Enable the optimal management of respiratory disease though early identification and diagnosis with an emphasis on Asthma and COPD • Ensure accurate diagnosis and severity assessment • Provide local access to spirometry • Develop a care model of respiratory care provision, based on integrated pathways • Increase the number of people accurately diagnosed at an early stage of the disease • Ensure accurate and consistent interpretation of results and promote effective communication between relevant health professionals