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Point/Counterpoint Editorials |

Counterpoint: Should Storefront Clinics Provide Case Finding and Chronic Care for COPD? NoStorefront Clinics for COPD? No FREE TO VIEW

Bartolome R. Celli, MD, FCCP
Author and Funding Information

From the Pulmonary and Critical Care Medicine Division, Brigham and Women’s Hospital; and Department of Medicine, Harvard Medical School.

Correspondence to: Bartolome R. Celli, MD, FCCP, Pulmonary and Critical Care Medicine Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; e-mail: bcelli@partners.org


Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Celli has participated in advisory boards for GlaxoSmithKline; Boehringer Ingelheim GmbH; Almirall, S.A.; AstraZeneca; Aeris; Deep Breeze Ltd; Takeda Pharmaceutical Company Limited; and Novartis Corp. The Pulmonary Division where Dr Celli is employed has received funds for research studies from GlaxoSmithKline; Boehringer Ingelheim GmbH; Forrest Medical, LLC; AstraZeneca; and Aeris. Dr Celli and his family do not have shares or interest in any company, and Dr Celli has not received tobacco money or stocks in any tobacco-related companies.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(6):1193-1194. doi:10.1378/chest.13-2862
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Published online

COPD is the cause of > 130,000 deaths in the United States alone, which is almost as many deaths as from lung cancer. Recent evidence indicates that although mortality from lung cancer is decreasing, that of COPD continues to increase.1 From this stark statistic, it is evident that we need to improve the early diagnosis of COPD and appropriately treat patients accordingly.2 It is attractive to believe that storefront clinics (SFCs) could serve as first-line resources to implement programs for detecting COPD; however, whatever evidence exists about the potential for diagnosis at an SFC, the issue of initiating and maintaining treatment at that level of care is nonexistent. Actually, I argue that management of patients based on this paradigm may be not only inappropriate but also dangerous. SFCs have sprouted in many places, and unfortunately, most states do not regulate the industry, a national registry does not exist, and the guidelines about what comprises the pulmonary care that can be provided at those sites is imaginary.

All guidelines agree that the diagnosis of COPD should be confirmed by the presence of fixed airflow obstruction based on an appropriately obtained spirometry3,4 because the clinical diagnosis of COPD simply based on questionnaires, whether standardized or developed to screen potential patients, lack the specificity needed to verify the diagnosis.5,6 For a spirometry to be valid, it needs to meet certain criteria that have been well outlined by a joint committee of experts from the European Respiratory Society and American Thoracic Society.7,8

Although several publications have reported different case detection of COPD in primary care settings, very few have actually evaluated the quality of the spirometry measurements obtained and on which the prevalence of COPD cases has been determined. Indeed, limited and highly controversial evidence indicates that adequate quality spirometry may be possible in the primary care setting.9,10 In one of the best studies, six practices mailed 312 tests to a central quality control site over 3 months. Clinically significant disagreements were identified in the interpretation of acceptability (quality) of the spirometric values, the correct diagnosis, and the degree of disease severity. The authors concluded that the quality of primary care spirometry was so unsatisfactory that a potential solution could be the remote reporting of tests through web-based systems interacting with the local site to improve the quality of the test and its value.10 Studies such as this cast doubt about the possible role of spirometry obtained in a nonmonitored center. If the evidence for testing in primary care is suspicious at best, its implementation in SFCs is unlikely to be better. In the best conducted study of case finding in SFCs (pharmacies) where the quality of the spirometry was graded, only 70% were deemed adequate11 in spite of an extensive program implemented to guarantee that the sites selected were capable of providing good-quality spirometry.

In addition to the technical aspects of spirometry, it is extremely important that they be adequately interpreted, and in this area, there is also a very large gap. Damarla et al12 showed that in 20% of patients admitted to a hospital for COPD, the spirometry was actually indicative of a restrictive physiology, and more importantly, patients were receiving treatment for the wrong disease. Similar results have been documented elsewhere in the world.13 The inadequate interpretation of spirometry results represent an important hurdle to overcome if we are to encourage the treatment of patients with complex conditions in SFCs.

If the issue of inadequate diagnosis is a problem, appropriate treatment is even more of a problem. COPD is a major killer and requires the correct evaluation and grading of the disease so that it may be adequately treated. No studies have evaluated COPD treatment in SFCs; therefore, promoting its implementation is certainly not evidence based or even observationally supported. What is very clear is that most patients with COPD are treated inadequately, even in primary care,14-17 and this should be corrected before we attempt to tackle the disease in poorly supervised environments. Very discouraging in this regard is the study by Bertella et al18 that evaluated the effect of an educational training program for 12 general practitioners. The study showed that 1 year after training, adherence to COPD guidelines and data collection remained suboptimal. The training did not change the primary care physicians’ practice, COPD diagnosis remained largely clinical and the usage of spirometry poor, and only a small proportion of patients received correct therapy that often was not related to the degree of airflow limitation. If this is the case in good primary care settings, what can be expected of SFCs?

There is no question that COPD is a large public health problem and that we need to implement measures to decrease the toll that it imposes on individuals and on society as a whole. However, we must develop sound programs that undergo adequate testing so that we do not end up with unpleasant surprises, such as the increased mortality that was detected in what everyone believed was a logical, well-planned, and directed program of action in COPD.18 COPD is not a simple disease, and patients with this condition frequently have comorbidities that influence outcomes.19 Just as patients with suspected lung cancer, coronary artery disease, and other major complex, noncommunicable diseases need comprehensive evaluations, so do patients with COPD. They deserve to be seen by well-trained health-care providers with comprehensive knowledge of COPD, its different presentations and course, and, ultimately, the many forms of therapy available. For the third largest killer of people in the world, SFC diagnosis and treatment may not quite cut it.

Thun MJ, Carter BD, Feskanich D, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368(4):351-364. [CrossRef]
 
Soriano JB, Zielinski J, Price D. Screening for and early detection of chronic obstructive pulmonary disease. Lancet. 2009;374(9691):721-732. [CrossRef]
 
Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4):347-365. [CrossRef]
 
Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23(6):932-946. [CrossRef]
 
Akamatsu K, Yamagata T, Kida Y, Tanaka H, Ueda H, Ichinose M. Poor sensitivity of symptoms in early detection of COPD. COPD. 2008;5(5):269-273. [CrossRef]
 
Kotz D, Nelemans P, van Schayck CP, Wesseling GJ. External validation of a COPD diagnostic questionnaire. Eur Respir J. 2008;31(2):298-303. [CrossRef]
 
Brusasco V, Crapo R, Viegi G; American Thoracic Society; European Respiratory Society. Coming together: the ATS/ERS consensus on clinical pulmonary function testing. Eur Respir J. 2005;26(1):1-2. [CrossRef]
 
Miller MR, Hankinson J, Brusasco V, et al; ATS/ERS Task Force. Standardisation of spirometry. Eur Respir J. 2005;26(2):319-338. [CrossRef]
 
Minas M, Hatzoglou C, Karetsi E, et al. COPD prevalence and the differences between newly and previously diagnosed COPD patients in a spirometry program. Prim Care Respir J. 2010;19(4):363-370. [CrossRef]
 
White P, Wong W, Fleming T, Gray B. Primary care spirometry: test quality and the feasibility and usefulness of specialist reporting. Br J Gen Pract. 2007;57(542):701-705.
 
Castillo D, Guayta R, Giner J, et al; FARMAEPOC group. COPD case finding by spirometry in high-risk customers of urban community pharmacies: a pilot study. Respir Med. 2009;103(6):839-845. [CrossRef]
 
Damarla M, Celli BR, Mullerova HX, Pinto-Plata VM. Discrepancy in the use of confirmatory tests in patients hospitalized with the diagnosis of chronic obstructive pulmonary disease or congestive heart failure. Respir Care. 2006;51(10):1120-1124.
 
Pellicer Císcar C, Soler Cataluña JJ, Andreu Rodríguez AL, Bueso Fabra J; Grupo EPOC de Sociedad Valenciana de Neumología. Diagnosis of COPD in hospitalised patients. Arch Bronconeumol. 2010;46(2):64-69. [CrossRef]
 
Montes de Oca M, Tálamo C, Perez-Padilla R, et al; PLATINO Team. Use of respiratory medication in five Latin American cities: The PLATINO study. Pulm Pharmacol Ther. 2008;21(5):788-793. [CrossRef]
 
Sharif R, Cuevas CR, Wang Y, Arora M, Sharma G. Guideline adherence in management of stable chronic obstructive pulmonary disease. Respir Med. 2013;107(7):1046-1052. [CrossRef]
 
Swennen MH, Rutten FH, Kalkman CJ, van der Graaf Y, Sachs AP, van der Heijden GJ. Do general practitioners follow treatment recommendations from guidelines in their decisions on heart failure management? A cross-sectional study. BMJ Open. 2013;3(9):e002982. [CrossRef]
 
Laniado-Laborin R, Rendon A, Alcantar-Schramm JM, Cazares-Adame R, Bauerle O. Subutilization of COPD guidelines in primary care: a pilot study. J Prim Care Community Health. 2013;4(3):172-176. [CrossRef]
 
Bertella E, Zadra A, Vitacca M; General Practitioners Distretto 04 ASL 02 Brescia, Italy. COPD management in primary care: is an educational plan for GPs useful? Multidiscip Resp Med. 2013;8(1):24. [CrossRef]
 
Divo M, Cote C, de Torres JP, et al; BODE Collaborative Group. Comorbidities and risk of mortality in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012;186(2):155-161. [CrossRef]
 

Figures

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References

Thun MJ, Carter BD, Feskanich D, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368(4):351-364. [CrossRef]
 
Soriano JB, Zielinski J, Price D. Screening for and early detection of chronic obstructive pulmonary disease. Lancet. 2009;374(9691):721-732. [CrossRef]
 
Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4):347-365. [CrossRef]
 
Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23(6):932-946. [CrossRef]
 
Akamatsu K, Yamagata T, Kida Y, Tanaka H, Ueda H, Ichinose M. Poor sensitivity of symptoms in early detection of COPD. COPD. 2008;5(5):269-273. [CrossRef]
 
Kotz D, Nelemans P, van Schayck CP, Wesseling GJ. External validation of a COPD diagnostic questionnaire. Eur Respir J. 2008;31(2):298-303. [CrossRef]
 
Brusasco V, Crapo R, Viegi G; American Thoracic Society; European Respiratory Society. Coming together: the ATS/ERS consensus on clinical pulmonary function testing. Eur Respir J. 2005;26(1):1-2. [CrossRef]
 
Miller MR, Hankinson J, Brusasco V, et al; ATS/ERS Task Force. Standardisation of spirometry. Eur Respir J. 2005;26(2):319-338. [CrossRef]
 
Minas M, Hatzoglou C, Karetsi E, et al. COPD prevalence and the differences between newly and previously diagnosed COPD patients in a spirometry program. Prim Care Respir J. 2010;19(4):363-370. [CrossRef]
 
White P, Wong W, Fleming T, Gray B. Primary care spirometry: test quality and the feasibility and usefulness of specialist reporting. Br J Gen Pract. 2007;57(542):701-705.
 
Castillo D, Guayta R, Giner J, et al; FARMAEPOC group. COPD case finding by spirometry in high-risk customers of urban community pharmacies: a pilot study. Respir Med. 2009;103(6):839-845. [CrossRef]
 
Damarla M, Celli BR, Mullerova HX, Pinto-Plata VM. Discrepancy in the use of confirmatory tests in patients hospitalized with the diagnosis of chronic obstructive pulmonary disease or congestive heart failure. Respir Care. 2006;51(10):1120-1124.
 
Pellicer Císcar C, Soler Cataluña JJ, Andreu Rodríguez AL, Bueso Fabra J; Grupo EPOC de Sociedad Valenciana de Neumología. Diagnosis of COPD in hospitalised patients. Arch Bronconeumol. 2010;46(2):64-69. [CrossRef]
 
Montes de Oca M, Tálamo C, Perez-Padilla R, et al; PLATINO Team. Use of respiratory medication in five Latin American cities: The PLATINO study. Pulm Pharmacol Ther. 2008;21(5):788-793. [CrossRef]
 
Sharif R, Cuevas CR, Wang Y, Arora M, Sharma G. Guideline adherence in management of stable chronic obstructive pulmonary disease. Respir Med. 2013;107(7):1046-1052. [CrossRef]
 
Swennen MH, Rutten FH, Kalkman CJ, van der Graaf Y, Sachs AP, van der Heijden GJ. Do general practitioners follow treatment recommendations from guidelines in their decisions on heart failure management? A cross-sectional study. BMJ Open. 2013;3(9):e002982. [CrossRef]
 
Laniado-Laborin R, Rendon A, Alcantar-Schramm JM, Cazares-Adame R, Bauerle O. Subutilization of COPD guidelines in primary care: a pilot study. J Prim Care Community Health. 2013;4(3):172-176. [CrossRef]
 
Bertella E, Zadra A, Vitacca M; General Practitioners Distretto 04 ASL 02 Brescia, Italy. COPD management in primary care: is an educational plan for GPs useful? Multidiscip Resp Med. 2013;8(1):24. [CrossRef]
 
Divo M, Cote C, de Torres JP, et al; BODE Collaborative Group. Comorbidities and risk of mortality in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2012;186(2):155-161. [CrossRef]
 
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