Eaton T, Withy S, Garrett J E, Mercer J, Whitlock R M, Rea H H
Department of Respiratory Medicine and Clinical Physiology, Green Lane Hospital, Auckland, New Zealand.
Chest. 1999 Aug;116(2):416-23. doi: 10.1378/chest.116.2.416.
To determine the quality of spirometry performed in primary care practice and to assess the impact of formal training.
Randomized, controlled prospective interventional study.
Primary care practice, Auckland City, New Zealand.
Thirty randomly selected primary care practices randomized to "trained" or "usual" groups. One doctor and one practice nurse were nominated to participate from each practice.
"Trained" was defined as participation in an "initial" spirometry workshop at week 0 and a "maintenance of standards" workshop at week 12. "Usual" was defined as no formal training until week 12, when participants they attended the same "initial" workshop provided for the trained group. The study duration was 16 weeks. Each practice was provided with a spirometer to be used at their clinical discretion.
Spirometry data were uploaded weekly and analyzed using American Thoracic Society (ATS) criteria for acceptability and reproducibility. The workshops were assessed objectively with practical and written assessments, confirming a significant training effect. However, analysis of spirometry performed in clinical practice by the trained practitioners revealed three acceptable blows in only 18.9% of patient tests. In comparison, 5.1% of patient tests performed by the usual practitioners had three acceptable blows (p<0.0001). Only 13.5% of patient tests in the trained group and 3.4% in the usual group (p<0.0001) satisfied full acceptability and reproducibility criteria. However, 33.1% and 12.5% of patient tests in the trained and usual groups, respectively (p<0.0001), achieved at least two acceptable blows, the minimum requirement. Nonacceptability was largely ascribable to failure to satisfy end-of-test criteria; a blow of at least 6 s. Visual inspection of the results of these blows as registered on the spirometer for the presence of a plateau on the volume-time curve suggests that < 15% were acceptable.
Although a significant training effect was demonstrated, the quality of the spirometry performed in clinical practice did not generally satisfy full ATS criteria for acceptability and reproducibility. Further study would be required to determine the clinical impact. However, the ATS guidelines allow for the use of data from unacceptable or nonreproducible maneuvers at the discretion of the interpreter. Since most of the failures were end-of-test related, the FEV1 levels are likely to be valid. Our results serve to emphasize the importance of effective training and quality assurance programs to the provision of successful spirometry in primary care practice.
确定基层医疗实践中肺功能测定的质量，并评估正规培训的影响。
随机对照前瞻性干预研究。
新西兰奥克兰市的基层医疗实践机构。
随机选取30家基层医疗实践机构，分为“培训组”和“常规组”。每家机构提名一名医生和一名执业护士参与。
“培训组”定义为在第0周参加“初始”肺功能测定研讨会，并在第12周参加“标准维持”研讨会。“常规组”定义为在第12周之前不接受正规培训，届时他们参加为培训组提供的相同“初始”研讨会。研究持续时间为16周。每家机构都配备了一台肺功能仪，可根据临床需要使用。
每周上传肺功能测定数据，并根据美国胸科学会（ATS）的可接受性和可重复性标准进行分析。通过实践和书面评估对研讨会进行客观评估，证实了显著的培训效果。然而，对培训后的从业者在临床实践中进行的肺功能测定分析显示，在仅18.9%的患者测试中有三次可接受的吹气。相比之下，常规从业者进行的患者测试中有5.1%有三次可接受的吹气（p<0.0001）。培训组中只有13.5%的患者测试和常规组中3.4%的患者测试（p<0.0001）满足完全可接受性和可重复性标准。然而，培训组和常规组分别有33.1%和12.5%的患者测试（p<0.0001）达到了至少两次可接受的吹气，这是最低要求。不可接受性主要归因于未满足测试结束标准；吹气时间至少6秒。对肺功能仪上记录的这些吹气结果进行目视检查，查看容积-时间曲线上是否存在平台期，结果表明<15%是可接受的。
虽然证明了显著的培训效果，但临床实践中进行的肺功能测定质量总体上未满足ATS关于可接受性和可重复性的完整标准。需要进一步研究以确定其临床影响。然而，ATS指南允许解释人员酌情使用来自不可接受或不可重复操作的数据。由于大多数失败与测试结束有关，FEV1水平可能是有效的。我们的结果强调了有效培训和质量保证计划对基层医疗实践中成功进行肺功能测定的重要性。
