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Rebuttal From Dr CelliRebuttal From Dr Celli 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):1195-1196. doi:10.1378/chest.13-2863
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A click on the first reference provided by the proponents of storefront clinics (SFCs) for COPD case finding and chronic care1 takes us to one-stop care for everything: from an appointment for a perfect haircut to obtaining a walker.2 The site is extensive in proposed services but limited in details. I was unable to obtain any objective evaluation of the quality and proven outcomes of health-care delivery in diabetes, hypertension, gastroesophageal reflux disease, and ostheoarthritis as mentioned by Drs Enright and Nevin.1 As I have documented in the opening statements of my argument, the adequate performance and interpretation of spirometry, even in the best centers, remains a problem.3 We, the supposed experts, do not even agree on the correct diagnosis of obstruction in a valid spirometry test. Is it the fixed ratio or the lower limit of normal?4-6 How are we to direct others in this endeavor? Extending these problems to SFCs without previous efforts to improve the existing gaps may actually worsen rather than help the current efforts to have an impact on the COPD epidemic.

In spite of our differences, we do agree on proposals that could improve COPD detection and treatment. First, use technology to improve actual spirometry testing. Intelligent spirometers are available that will monitor adequate performance of the test. As proven in the Understanding Potential Long-term Impacts on Function With Tiotropium (UPLIFT) study, > 99% of > 100,000 spirometry tests were considered adequate on the basis of a system that monitored the quality of the tests.7 Furthermore, it is possible to have the signal transmitted to a central monitoring location where quality, appropriate supervision, and reading can be provided, as proven in the Latin American Project for Research in Pulmonary Obstruction (PLATINO) study, where tests completed in South America were transmitted to Mexico for quality control.8 Second, conduct a demonstration project that takes this technology to the field.9 Including several sites in various settings would go a long way in making feasible a more ambitious extension plan.

The professional societies, academia, and health-care authorities should work together not only to promote primary (prevent smoking) and secondary (smoking cessation) prevention but also to address questions such as the following: What elements represent the minimal evaluation of a patient with airflow obstruction? What criteria make a patient a candidate for referral to a specialist? Currently, none of these is objectively supported by the guidelines. I would argue that although effective treatment of COPD does exist, current guidelines are unduly complex and somewhat impractical. Compared with guidelines such as those for the detection and treatment of hypertension, COPD guidelines are convoluted and lengthy, leading to their poor understanding and implementation.

I agree with Drs Enright and Nevin that we should promote the availability of spirometry and involve more health-care professionals in the diagnosis and treatment of COPD. To achieve this, however, we must have the right approach and an effective strategy. Do no harm remains at the center of our training, and expanding our currently controversial beliefs to SFCs needs a little more thinking because, as always, the devil is in the details.

References

Enright P, Nevin W. Point: should storefront clinics provide case finding and chronic care for COPD? Yes. Chest. 2014;145(6):1191-1193.
 
Pharmacy & health. Walgreen Co website. http://www.walgreens.com/pharmacy/healthcareclinic. Accessed November 15, 2013.
 
Celli BR. Counterpoint: should storefront clinics provide case finding and chronic care for COPD? No. Chest. 2014;145(6):1193-1194.
 
Mannino DM, Sonia Buist A, Vollmer WM. Chronic obstructive pulmonary disease in the older adult: what defines abnormal lung function? Thorax. 2007;62(3):237-241. [CrossRef]
 
Wollmer P, Engström G. Fixed ratio or lower limit of normal as cut-off value for FEV1/VC: an outcome study. Respir Med. 2013;107(9):1460-1462. [CrossRef]
 
Celli BR, Halbert RJ, Isonaka S, Schau B. Population impact of different definitions of airway obstruction. Eur Respir J. 2003;22(2):268-273. [CrossRef]
 
Tashkin DP, Celli B, Senn S, et al; UPLIFT Study Investigators. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med. 2008;359(15):1543-1554. [CrossRef]
 
Pérez-Padilla R, Vázquez-García JC, Márquez MN, Menezes AM; PLATINO Group. Spirometry quality-control strategies in a multinational study of the prevalence of chronic obstructive pulmonary disease. Respir Care. 2008;53(8):1019-1026.
 
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]
 

Figures

Tables

References

Enright P, Nevin W. Point: should storefront clinics provide case finding and chronic care for COPD? Yes. Chest. 2014;145(6):1191-1193.
 
Pharmacy & health. Walgreen Co website. http://www.walgreens.com/pharmacy/healthcareclinic. Accessed November 15, 2013.
 
Celli BR. Counterpoint: should storefront clinics provide case finding and chronic care for COPD? No. Chest. 2014;145(6):1193-1194.
 
Mannino DM, Sonia Buist A, Vollmer WM. Chronic obstructive pulmonary disease in the older adult: what defines abnormal lung function? Thorax. 2007;62(3):237-241. [CrossRef]
 
Wollmer P, Engström G. Fixed ratio or lower limit of normal as cut-off value for FEV1/VC: an outcome study. Respir Med. 2013;107(9):1460-1462. [CrossRef]
 
Celli BR, Halbert RJ, Isonaka S, Schau B. Population impact of different definitions of airway obstruction. Eur Respir J. 2003;22(2):268-273. [CrossRef]
 
Tashkin DP, Celli B, Senn S, et al; UPLIFT Study Investigators. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med. 2008;359(15):1543-1554. [CrossRef]
 
Pérez-Padilla R, Vázquez-García JC, Márquez MN, Menezes AM; PLATINO Group. Spirometry quality-control strategies in a multinational study of the prevalence of chronic obstructive pulmonary disease. Respir Care. 2008;53(8):1019-1026.
 
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]
 
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