Why the new UK NHS GP contract should not include incentives for spirometric assessment in smokers
A Cochrane Sistematic Review (1) concluded “Current evidence of lower quality does not … support the hypothesis that biomedical risk assessment increases smoking cessation in comparison with standard treatment”.
Exaled CO measurement and spirometry were used together in three trials, no one resulting in statistically significant differences between intervention and control groups. Two out of three trials even show a trend towards a worsening in the ORs (95% CI) of smoke quitting: 2.45 (0.73 to 8.25) and 3.50 (0.88 to 13.92) with CO measurement plus spirometry. Another RCT with only spirometry has an OR 1.21 (0,60-2,42) (and another with ultrasonography of carotid and femoral arteries performed in light smokers, smoking on average 10 to 12 cigarettes a day, significantly worsened the OR of smoke quitting: 3.15 (1.06 to 9.31), showing the actual risk to raise costs and harms at the same time (1).
Parkes et al (2) state that NICE guidelines (which do not mention spirometry testing at all) should be reviewed and that “lung age” testing should be considered a part of a brief intervention package either in all smokers over 35 or all smokers. And they recommend that the new UK NHS general practitioner contract should include incentives for spirometric assessment accompanied by individualised communication of lung age in smokers.
Conclusions (and claim) expressed in such way seem very little supported by trial results. Indeed Parkes et al performed a spirometric assessment to all participants smokers, and another after a year. What made the difference between the intervention and the control group was the communication: an information given immediately, in the form of “lung age” with a graphic display, followed by a written personalised letter in the intervention group; a letter delayed by several weeks with results given as simple FEV1 with no further explanation in the control group.
The trial does not support neither the belief that the information of a worse spirometric lung age raises the patient chances of quitting smoking. On the contrary, the opposite seems true as trend (the mean lung age deficit was 8.7 years and 9.4 years in the quitters and non-quitters).
Thus, what are the data telling us?
1) How the authors acknowledge, the success was likely to depend on communication: how the information was conveyed and understood, also using graphic displays and individualised letters. Yet, is questionable if a spirometric assessment is needed, instead of less expensive tools.
n.b.: a more effective communication has perhaps also caused, as trend, a wider use of effective clinical and pharmacological support to quit: 7.8% in control group and 10.7% in the intervention group. Anyhow, quit rates at 12 months in the intervention group (13,6%) are similar to those obtained with effective available treatments, and less than the results achieved in a trial performed in the primary care setting (3)).
2) On the basis of existing evidence it is hard to recommend a spirometric assessment (and with which interval?) for all smokers over 35 (or all smokers at all). A spirometer is a technological device involving various costs: price (about € 1000-2000 in the Italian market), necessity of training to use it correctly, reimbursement fees of € 51,65 by Italian NHS or fees payed out of pocket by patients, and a performing time (30 minutes for every spirometry) which goes unavoidably in competition with other services of proven effectiveness. If the GP wants support for his/her quitting advice and counselling, with a graphic display, this could be the illustration/delivery of risk charts (in Italy there are specific and impressive colourful charts elaborated by Superior Institute of Health, by age, sex and smoking status for COPD, for lung cancer and for global cardiovascular risk, usable also in combination). It is questionable if we need a spirometry to convey an effective message on the almost sure effects (either pulmonary, or cardiovascular, or tumoral, or overall) for smokers who do not want to quit: a more direct, simple, multimedial educational intervention may be a real research priority.
For GPs who want a technological support and to follow the evidence of Parkes’ trial, can be enough a simple FEV1 meter (about € 50 in the Italian market), which gives the essential information needed to show in colourful graphs the “lung age” (n.b.: the high reliability of measure is not the determinant factor).
Finally, in my opinion the incentives (in proper amounts) should be better deserved by GPs whose formally reported interventions can document the real outcome of interest, that is a long term quitting status in every patient who was a previously certified smoker. Instead, incentives should not be provided for services or processes which per se are not a guarantee of outcome, and that can lead to technological abuse and interest-driven behaviours of providers.
Dr. Alberto Donzelli
Director of Health Education Service
ASL Città di Milano
(1) Bize R et al. Biomedical risk assessment a san aid for smoking cessation. Cochrane Database of Systematic Reviews 2005, issue 4. Art. N°: CD004705
(2) Parkes G et al. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ 2008; 336: 598- 600
(3) Fossati R et al. A double-blind, placebo controlled, randomized trial of bupropion for smoking cessation in primary care. Arch Intern Med 2007; 167:1791-7
Competing interests: None declared
Competing interests: No competing interests