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Rebuttal From Drs Enright and NevinRebuttal From Drs Enright and Nevin FREE TO VIEW

Paul Enright, MD; William Nevin, MD, FCCP
Author and Funding Information

From the University of Arizona (retired) (Dr Enright); and Pulmonary Associates of Southern Arizona (Dr Nevin).

Correspondence to: Paul Enright, MD, PO Box 675, Mount Lemmon, AZ 85619; e-mail: lungguy@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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):1194-1195. doi:10.1378/chest.13-2861
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Whether we as pulmonologists like it or not, storefront clinics by the thousands are going to add diagnostic testing (or screening), treatment of exacerbations, and long-term management for COPD (and asthma) many years before any evidence for their efficacy and safety are published. We suggest that our professional societies (American College of Chest Physicians, American Thoracic Society, and American Association for Respiratory Care) quickly convene a working group to make recommendations for these convenient new resources.

We agree with Dr Celli1 that the quality and interpretation of spirometry tests done in primary care settings (as well as some hospital-based pulmonary function testing laboratories) are often suboptimal, but we believe that the solution is simple: Do not allow payment for poor-quality tests.2 Each person performing spirometry should obtain and display a performance-based spirometry certificate (a spirometer driver’s license), now available online for $50.3 Airway obstruction may be missed (false negative) when short FVC maneuvers are done, but this problem is greatly reduced when 6-s maneuvers are performed and the lower limit of the normal range is used for FEV1/FEV6.4 On the other hand, the false-positive rate for chronic airflow obstruction is greatly reduced when the goal of spirometry is to detect only clinically important COPD with an FEV1 < 60% predicted,5 not “early COPD,” which often does not progress despite continued smoking.6

Unlike Dr Celli, we believe that primary care providers provide high-quality care for the majority of patients with COPD.7 (An exception may be patients who have been hospitalized for an exacerbation.) Storefront clinics employ nurse practitioners who are more likely than primary care physicians to carefully follow current clinical practice guidelines. Regular audits of the electronic medical records of their spirometry tests, diagnoses, prescriptions, referrals, and follow-up test results will be integral to a continuous quality improvement program. Pulmonary specialists should be involved in the continuous quality improvement program for each national pharmacy chain, the results of which can be used for analyses and publications about efficacy and safety.

References

Celli BR. Counterpoint: should storefront clinics provide case finding and chronic care for COPD? No. Chest. 2014;145(6):1193-1194.
 
Enright P, Schermer T. Don’t pay for poor quality spirometry tests. Prim Care Respir J. 2013;22(1):15-16. [CrossRef]
 
Apply for the office spirometry certificate. American Association for Respiratory Care website. https://secure.aarc.org/osc/training.cfm. Accessed October 27, 2013.
 
Enright RL, Connett JE, Bailey WC. The FEV1/FEV6predicts lung function decline in adult smokers. Respir Med. 2002;96(6):444-449. [CrossRef]
 
Jithoo A, Enright PL, Burney P, et al; BOLD Collaborative Research Group. Case-finding options for COPD: results from the Burden of Obstructive Lung Disease study. Eur Respir J. 2013;41(3):548-555. [CrossRef]
 
Scanlon PD, Connett JE, Waller LA, et al; Lung Health Study Research Group. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease: the Lung Health Study. Am J Respir Crit Care Med. 2000;161(2 pt 1):381-390. [CrossRef]
 
Bellamy D, Bouchard J, Henrichsen S, et al. International Primary Care Respiratory Group (IPCRG) guidelines: management of chronic obstructive pulmonary disease (COPD). Prim Care Respir J. 2006;15(1):48-57. [CrossRef]
 

Figures

Tables

References

Celli BR. Counterpoint: should storefront clinics provide case finding and chronic care for COPD? No. Chest. 2014;145(6):1193-1194.
 
Enright P, Schermer T. Don’t pay for poor quality spirometry tests. Prim Care Respir J. 2013;22(1):15-16. [CrossRef]
 
Apply for the office spirometry certificate. American Association for Respiratory Care website. https://secure.aarc.org/osc/training.cfm. Accessed October 27, 2013.
 
Enright RL, Connett JE, Bailey WC. The FEV1/FEV6predicts lung function decline in adult smokers. Respir Med. 2002;96(6):444-449. [CrossRef]
 
Jithoo A, Enright PL, Burney P, et al; BOLD Collaborative Research Group. Case-finding options for COPD: results from the Burden of Obstructive Lung Disease study. Eur Respir J. 2013;41(3):548-555. [CrossRef]
 
Scanlon PD, Connett JE, Waller LA, et al; Lung Health Study Research Group. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease: the Lung Health Study. Am J Respir Crit Care Med. 2000;161(2 pt 1):381-390. [CrossRef]
 
Bellamy D, Bouchard J, Henrichsen S, et al. International Primary Care Respiratory Group (IPCRG) guidelines: management of chronic obstructive pulmonary disease (COPD). Prim Care Respir J. 2006;15(1):48-57. [CrossRef]
 
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