COPD case finding by spirometry in high-risk customers of urban community pharmacies: A pilot study

  • D. Castillo
    Correspondence
    Corresponding author. Servei de Pneumologia, Hospital del Mar, Institut Municipal d'Investigació Mèdica (IMIM), Passeig Marítim 25-29, 08003 Barcelona, Spain. Tel.: +34 93 2483138; fax: +34 93 2483425.
    Affiliations
    Department of Respiratory Medicine, Hospital del Mar, Institut Municipal d'Investigació Mèdica (IMIM), Barcelona, Spain

    CIBER Enfermedades Respiratorias, Spain
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  • R. Guayta
    Affiliations
    Official College of Pharmacists of Barcelona (COFB), Barcelona, Spain
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  • J. Giner
    Affiliations
    Lung Function Unit, Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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  • F. Burgos
    Affiliations
    Lung Function Unit, Department of Respiratory Medicine, Hospital Clínic i Provincial, IDIBAPS, Universitat de Barcelona, Barcelona, Spain

    CIBER Enfermedades Respiratorias, Spain
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  • C. Capdevila
    Affiliations
    Official College of Pharmacists of Barcelona (COFB), Barcelona, Spain
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  • J.B. Soriano
    Affiliations
    Program of Epidemiology and Clinical Research, Fundació Caubet-CIMERA Illes Balears, Bunyola, Spain

    CIBER Enfermedades Respiratorias, Spain
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  • M. Barau
    Affiliations
    Official College of Pharmacists of Barcelona (COFB), Barcelona, Spain
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  • P. Casan
    Affiliations
    Lung Function Unit, Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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  • on behalf of the FARMAEPOC group
Open ArchivePublished:February 06, 2009DOI:https://doi.org/10.1016/j.rmed.2008.12.022

      Summary

      Background

      COPD case finding is currently recommended at primary and tertiary care levels only.

      Aim

      To evaluate the feasibility of a community pharmacy program for COPD case finding in high-risk customers by means of spirometry.

      Methods

      Pilot cross-sectional descriptive study in 13 urban community pharmacies in Barcelona, Spain, from April to May 2007. Customers >40 years old with respiratory symptoms and/or a history of smoking were invited to participate in the study during pharmacists' routine work shifts. High-risk customers were identified by means of a 5-item COPD screening questionnaire based on criteria of the Global Initiative for Chronic Obstructive Lung Disease, and were invited to perform spirometry accordingly. Those with an FEV1/FVC ratio less than 0.70 were referred to the hospital for a repeat spirometry.

      Results

      Of the 161 pharmacy customers studied, 100 (62%) scored 3 or more items in the COPD screening questionnaire, and after spirometry, 21 (24%) had an FEV1/FVC ratio<0.7. When these subjects with airflow limitation were offered referral to a hospital respiratory function laboratory for further assessments, 11 (52%) attended the appointment. Over 70% of spirometries were rated as being of acceptable quality. No significant differences were observed in lung function parameters between the pharmacy and hospital measurements.

      Conclusions

      COPD case finding by spirometry in high-risk customers of urban community pharmacies is feasible. Similarly to primary care practitioners, pharmacists have access to high-risk, middle-aged subjects who have never been tested for COPD. Pharmacists can help with early detection of COPD if they are correctly trained.

      Keywords

      Introduction

      Early diagnosis of COPD is important because smokers with demonstrated airway obstruction are more likely to quit smoking.
      • Bednarek M.
      • Gorecka D.
      • Wielgomas J.
      • Czajkowska-Malinowska M.
      • Regula J.
      • Mieszko-Filipczyk G.
      • et al.
      Smokers with airway obstruction are more likely to quit smoking.
      Recently, the U.S. Preventive Services Task Force (USPSTF) recommended against screening the general population for chronic obstructive pulmonary disease (COPD) using spirometry (grade D recommendation).
      • U.S. Preventive Services Task Force
      Screening for chronic obstructive pulmonary disease using spirometry: U.S. preventive services task force recommendation statement.
      However, the same document recognised that individuals presenting respiratory symptoms (chronic cough, increased sputum production, wheezing, or dyspnea) should be tested. This position is consistent with the recommendations of other relevant groups: the American Thoracic Society (ATS) and the European Respiratory Society (ERS) advise performing spirometry on all persons with smoking exposure, a family history of chronic respiratory illness, or respiratory symptoms,
      • Celli B.R.
      • MacNee W.
      ATS/ERS Task Force. Standards for the diagnosis and a treatment of patients with COPD: a summary of the ATS/ERS position paper.
      and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends that clinicians consider a diagnosis of COPD ‘in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease’ and that the ‘diagnosis should be confirmed by spirometry’.
      • Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006
      Global strategy for diagnosis, management, and prevention of COPD.
      At present, detection of COPD is limited to case finding at the primary or tertiary care levels, a strategy that has proven largely inadequate. One large population-based survey showed that a high percentage (63%) of subjects with airflow limitation had never received a diagnosis of obstructive lung disease.
      • Mannino D.M.
      • Gagnon R.C.
      • Petty T.L.
      • Lydick E.
      Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988–1994.
      In Spain, underdiagnosis has been estimated to be around 80%.
      • Sobradillo Peña V.
      • Miravitlles M.
      • Gabriel R.
      • Jimenez-Ruiz C.A.
      • Villansante C.
      • Masa J.F.
      • et al.
      Geographic variations in prevalence and underdiagnosis of COPD: results of the IBERPOC multicentre epidemiological study.
      Pharmaceutical care, which has been useful in the management of ambulatory patients with chronic diseases such as asthma,
      • Armour C.
      • Bosnic-Anticevich S.
      • Brillant M.
      • Burton D.
      • Emmerton L.
      • Krass I.
      • et al.
      Pharmacy asthma care program (PACP) improves outcomes for patients in the community.
      might offer a new approach to COPD case finding. Community pharmacists trained to perform spirometry have been successful in improving access to lung function measurement in rural communities,
      • Burton M.A.
      • Burton D.L.
      • Simpson M.D.
      • Gissing P.M.
      • Bowman S.L.
      Respiratory function testing: the impact of respiratory scientists on the training and support of primary health care providers.
      and we hypothesized that they might also be able to help in an urban general population. For such an approach to work, the pharmacist would need to be able to select high-risk individuals in whom spirometry should be performed. The aim of this pilot study was to assess the feasibility of a program of case finding of COPD by spirometry in community pharmacies.

      Methods

       Pharmacist selection and training

      To recruit pharmacist participants, we contacted community pharmacies in a smoking prevention group formed through the professional association for this sector (Official College of Pharmacists, COFB) in Barcelona, Spain. The study had been approved by the ethics committee of Hospital Clinic i Provincial, Barcelona. Thirteen of the 19 members of the smoking prevention group accepted, agreeing that a staff pharmacist would attend a four-day spirometry training course in February and March 2007. Training was based on the guidelines of the National Institute for Occupational Safety and Health (NIOSH),
      • National Institute of Occupational Safety and Health, Division of Respiratory Disease Studies
      NIOSH spirometry training guide.
      the ERS/ATS,
      • Miller M.R.
      • Hankinson J.
      • Brusasco F.
      • Burgos F.
      • Casaburi R.
      • Coates R.
      • et al.
      Standardisation of spirometry.
      and the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR).
      • Sanchis J.
      • Casan P.
      • Castillo J.
      • González N.
      • Palenciano L.
      • Roca J.
      Normativa para la práctica de la espirometría forzada.
      The volunteer pharmacists recruited subjects from among customers arriving during their regular work shifts of about 8 h per day and they conducted interviews and tests between attending customers. The daily routine of the pharmacy was not modified so that our results would not overestimate the number of new cases of COPD that can be found by this route in real conditions.

       Spirometer and assessment procedures

      The portable spirometer (Easy-One Spirometer, ndd Medical Technologies, Zürich, Switzerland) was chosen because it is easy to handle and has been used in other population screening studies.
      • Menezes A.M.
      • Pérez-Padilla R.
      • Jardim J.R.
      • Muino A.
      • López M.V.
      • PLATINO Team
      • et al.
      Chronic obstructive pulmonary disease in five Latin American cities (the PLATINO study): a prevalence study.
      Calibration was checked at the beginning of the study and did not have to be re-checked daily. The device has built-in software that ranks spirometry quality (grades A–F) in accordance with standard European classifications.
      • Miller M.R.
      • Hankinson J.
      • Brusasco F.
      • Burgos F.
      • Casaburi R.
      • Coates R.
      • et al.
      Standardisation of spirometry.
      An A or B rating indicated acceptable quality, because both levels supposed three good manoeuvres with at least two readings of forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) differing by <150–200 ml. In addition, an expert in lung function (F.B.) reviewed and rated all spirometry curves according to the same criteria.
      Lung function measurements included FEV1, FVC and the FEV1/FVC ratio. FEV1 and FVC were expressed in liters and as the percentage of reference values for the Spanish population.
      • Roca J.
      • Burgos F.
      • Sunyer J.
      • Saez M.
      • Chinn S.
      • Antó J.M.
      • et al.
      Reference values for forced spirometry.
      According to the Spanish COPD guidelines,
      • Barberà J.A.
      • Peces-Barba G.
      • Agustí García-Navarro A.
      • Izquierdo J.L.
      • Monsó E.
      • Montemayor T.
      • et al.
      Clinical guidelines for the diagnosis and treatment of chronic obstructive pulmonary disease.
      and as recently proposed elsewhere for mass screening programs,
      • Mannino D.M.
      Defining chronic obstructive pulmonary disease… and the elephant in the room.
      we used pre-bronchodilator lung function to classify airflow limitation, defined by an FEV1/FVC ratio<0.70.

       Subject selection and evaluation

      During April and May 2007, customers who entered the participating community pharmacies and who seemed to be in the targeted age range (>40 years) were approached with opening questions about respiratory symptoms or smoking. If a candidate expressed interest in the topic, the pharmacist explained the objectives of the research and the voluntary nature of participation. Participants signed a consent form if interested, and the pharmacist then asked about previous diagnoses of lung disease or use of inhaled medication and sociodemographic data as stipulated by a written questionnaire. Individuals aged<40 years or who had a history of lung disease or use of inhalers were excluded at this time. To assess the risk of COPD, we used the GOLD screening questionnaire, as recommended in the 2006 guidelines.
      • Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006
      Global strategy for diagnosis, management, and prevention of COPD.
      This questionnaire consisted of questions on five items referring to more breathlessness than people of the same age, chronic cough, chronic sputum, age>40 years, and smoking. Subjects with ≥3 affirmative answers were offered spirometry. Those in whom the FEV1/FVC ratio was <0.70 were referred to a lung function unit in a university hospital (Hospital de la Santa Creu i Sant Pau or Hospital Clinic I Provincial, both in Barcelona). Within 24–48 h spirometry was repeated by an expert nurse using the same brand of spirometer. Refusal to continue participating in the study was recorded with the specified reason. Smokers were also encouraged to quit smoking through a cessation program, as giving this advice was part of the normal routine for these volunteer community pharmacists.

       Statistical methods

      Descriptive data of participants and subgroups are presented as mean and standard deviation unless otherwise stated. We compared participants with a low and high COPD risk, and spirometry data in the normal and abnormal groups, using t-tests for normally distributed parametric data and the Kolmogorov–Smirnov test for non-parametric data (quality spirometry, gender, tobacco exposure and GOLD screening score). Using the Wilcoxon rank sum test we compared each subject's expiratory flow rates measured at the pharmacy and the hospital. A Bland–Altman graph was also created to show individual differences between pharmacy and hospital FEV1 values. Statistical significance was set at P0.05 for comparisons between groups. All analyses were performed using the Statistical Package for Social Sciences (SPSS) for Windows, version 15.0 (SPPS Inc., Chicago, Illinois, USA).

      Results

      A total of 254 customers approached by the pharmacists expressed interest in the study; 188 (74%) agreed to participate by signing the consent form after the nature of the study was explained. Reasons given by the 66 subjects who declined to participate included no time to wait (n=28, 42%), no interest (n=12, 18%), already diagnosed with a respiratory condition (n=14, 21%) and others (n=12, 18%). Twenty-seven of these 188 initial participants were excluded by the pharmacists when criteria were reviewed; reasons for exclusion at this time were age<40 years or previous lung disease (Fig. 1).
      Figure thumbnail gr1
      Figure 1Flow chart showing subject processing from pharmacy to hospital referral.
      The 161 remaining volunteers agreed to fill in the GOLD screening questionnaire for COPD. The average age of these participants was 55±11 years, 94 (58%) were women, and 124 (77%) were smokers or ex-smokers. The mean GOLD screening score was 3.0±1.2. Sixty-one of the 161 respondents (38%) had a score<3 and 100 (62%) a score of ≥3, indicating they were at high risk for COPD (Table 1). The age and proportion of women in the two groups were similar. More high-risk customers were smokers or ex-smokers, and they also had a higher mean GOLD screening score than those at low risk. Those in the high-risk group were offered spirometry; only three refused and one was excluded because she was ill with a respiratory infection at that time. Customers who attended spirometry had at least one symptom. Chronic cough was the most common (66%) but each symptom was present in about half the subjects (chronic sputum 54%, breathlessness 63%). Low-risk subjects were more frequently asymptomatic (chronic cough 6%, chronic sputum 5%, breathlessness 3%).
      Table 1Characteristics of the participating pharmacy customers.
      All customers (n=161)Low risk (n=61)High risk (n=100)
      Age, mean±SD55±1156±1155±11
      Women, n (%)94 (58)38 (62)56 (56)
      Smoking history, n (%)124 (77)36 (59)88 (88)
      Significant differences were found between low-risk and high-risk groups for smoking history (smokers or ex-smokers) (P=0.01) and GOLD score (P=0.01). GOLD=Global Initiative for Chronic Obstructive Lung Disease.
      GOLD score, mean±SD3.0±1.21.7±0.43.8±0.8
      Significant differences were found between low-risk and high-risk groups for smoking history (smokers or ex-smokers) (P=0.01) and GOLD score (P=0.01). GOLD=Global Initiative for Chronic Obstructive Lung Disease.
      a Significant differences were found between low-risk and high-risk groups for smoking history (smokers or ex-smokers) (P=0.01) and GOLD score (P=0.01). GOLD=Global Initiative for Chronic Obstructive Lung Disease.
      Thus, 96 high-risk subjects performed spirometry in the pharmacy. Sixty-five (68%) had an FEV1/FVC% ratio0.70 and 21 (22%) had an FEV1/FVC% ratio<0.70, indicating airflow limitation. The distribution of airflow limitation by age is shown in Fig. 2. Ten were unable to perform the manoeuvres correctly. Personal characteristics and spirometry results for those who performed a correct spirometry are shown in Table 2. According to our pre-bronchodilator data, airflow limitation was mild in 13 (62%) of the subjects in whom it was detected, moderate in 7 (33%) and severe in 1 (5%).
      Figure thumbnail gr2
      Figure 2Distribution of percent predicted FEV1 by age for all participants (subjects with airflow limitation are represented by filled circles).
      Table 2Characteristics and respiratory function data for subjects who performed spirometry correctly and were classified by FEV1/FVC ratio as having normal (ratio0.70) or reduced airflow.
      All spirometries (n=86)Normal spirometry (n=65)Airflow limitation (n=21)
      Women, n (%)49 (57)37 (57)12 (57)
      Age (y)55±1154±1057±12
      Smoking history, n (%)74 (86)56 (86)18 (86)
      GOLD score3.8±0.83.8±0.83.7±0.8
      BMI27.1±5.127.8±4.725±5.7
      Significant differences in BMI (P=0.03), FEV1 (P=0.01), FEV1% (P=0.01) and FEV1/FVC ratio (P=0.01) were found between the normal and abnormal spirometry groups. FEV1=forced expiratory volume in 1s; FVC=forced vital capacity; and GOLD=Global Initiative for Chronic Obstructive Lung Disease.
      FEV1 (l)2.5±0.72.7±0.62.1±0.7
      Significant differences in BMI (P=0.03), FEV1 (P=0.01), FEV1% (P=0.01) and FEV1/FVC ratio (P=0.01) were found between the normal and abnormal spirometry groups. FEV1=forced expiratory volume in 1s; FVC=forced vital capacity; and GOLD=Global Initiative for Chronic Obstructive Lung Disease.
      FEV1 (% ref. val.)86±0.291±0.172±0.1
      Significant differences in BMI (P=0.03), FEV1 (P=0.01), FEV1% (P=0.01) and FEV1/FVC ratio (P=0.01) were found between the normal and abnormal spirometry groups. FEV1=forced expiratory volume in 1s; FVC=forced vital capacity; and GOLD=Global Initiative for Chronic Obstructive Lung Disease.
      FVC (l)3.4±0.93.4±0.93.24±1.0
      FVC (% ref. val.)89 (0.2)90 (0.2)85 (0.1)
      FEV1/FVC ratio0.76 (0.1)0.79 (0.1)0.64 (0.1)
      Significant differences in BMI (P=0.03), FEV1 (P=0.01), FEV1% (P=0.01) and FEV1/FVC ratio (P=0.01) were found between the normal and abnormal spirometry groups. FEV1=forced expiratory volume in 1s; FVC=forced vital capacity; and GOLD=Global Initiative for Chronic Obstructive Lung Disease.
      Data are expressed as mean±SD unless otherwise noted.
      a Significant differences in BMI (P=0.03), FEV1 (P=0.01), FEV1% (P=0.01) and FEV1/FVC ratio (P=0.01) were found between the normal and abnormal spirometry groups.FEV1=forced expiratory volume in 1 s; FVC=forced vital capacity; and GOLD=Global Initiative for Chronic Obstructive Lung Disease.
      Out of the 86 patients who underwent spirometry, airflow limitation (FEV1/FVC ratio<0.70) was detected in 21 (24%), and they were invited for referral to a hospital pulmonary function laboratory for further assessment. Only 11 (52%) subjects both accepted referral and actually went to the laboratory. In all cases, the airway obstruction was confirmed. Moreover, the lung function values recorded in the community pharmacy and in the hospital pulmonary function laboratory were similar in both settings (FEV1, P=0.5; FVC, P=0.89; and FEV1/FVC ratio, P=0.14) (Fig. 3). Of note, among those referred to the hospital, two presented a pre-bronchodilator FEV1<60%.
      Figure thumbnail gr3
      Figure 3Bland–Altman graph for comparison of the pharmacy- versus hospital-obtained percent predicted FEV1.
      Finally, spirometric curves in the pharmacy were of acceptable quality overall, with 70% rated as A or B quality by the spirometer software and 73% were considered of acceptable quality by the lung function expert. The quality rating tended to be even better in subjects with airflow limitation, 76% of whom were considered to have A or B quality curves, but the difference was not significant (P=0.71).

      Discussion

      Individuals at high risk for COPD can be detected by spirometry screening undertaken by adequately trained pharmacists in urban community pharmacies. Our data show that pharmacists were able to identify customers with respiratory symptoms and/or smokers in a population in which the majority were middle-aged subjects who had never been tested for COPD. Furthermore, the pharmacists were able to supervise high quality spirometry manoeuvres in 70% of subjects, finding one case of airflow limitation for every five individuals tested, a rate that was similar to that reported for the UK primary care setting.
      • Van Schayck C.P.
      • Loozen J.M.
      • Wagena E.
      • Akkermans R.P.
      • Wesseling G.J.
      Detecting patients at a high risk of developing chronic obstructive pulmonary disease in general practice: cross-sectional case finding study.
      Spirometry in the primary care setting has been shown to be useful in screening for COPD and it continues to be promoted as the means for diminishing the population underdiagnosis of this disease.
      • Enright P.L.
      • Studnicka M.
      • Zielinski J.
      Spirometry to detect and manage chronic obstructive pulmonary disease and asthma in the primary care setting.
      Additionally, the usefulness of reporting individual lung age to smokers has been elegantly confirmed recently.
      • Hueto J.
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      • Pascal I.
      • Cascante J.A.
      • Eguia V.M.
      • Teruel F.
      • et al.
      Spirometry in primary care in Navarre, Spain.
      However, lack of technical or human resources in primary care is a limiting factor,
      • Parkes G.
      • Greenhalgh T.
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      Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial.
      compounded by primary care physicians' low rate of request for spirometry.
      • Miravitlles M.
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      • Naberan K.
      • Lanban M.
      • Gobartt E.
      • Martin A.
      • et al.
      Attitudes toward the diagnosis of chronic obstructive pulmonary disease in primary care.
      Therefore, underdiagnosis in the primary care setting continues to be inordinately common.
      • Bednarek M.
      • Maciejewski J.
      • Wozniak M.
      • Kuca P.
      • Zielinski J.
      Prevalence, severity and underdiagnosis of COPD in the primary care setting.
      In this pilot study, our finding that the community pharmacy can provide a complementary setting for COPD case finding in the general population offers hope of improving the health care system's screening potential.
      Widespread use of spirometry in screening for COPD has been questioned.
      • U.S. Preventive Services Task Force
      Screening for chronic obstructive pulmonary disease using spirometry: U.S. preventive services task force recommendation statement.
      The current recommendations are to study subjects at high risk.
      • U.S. Preventive Services Task Force
      Screening for chronic obstructive pulmonary disease using spirometry: U.S. preventive services task force recommendation statement.
      • Celli B.R.
      • MacNee W.
      ATS/ERS Task Force. Standards for the diagnosis and a treatment of patients with COPD: a summary of the ATS/ERS position paper.
      • Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006
      Global strategy for diagnosis, management, and prevention of COPD.
      All subjects offered spirometry in our study were in fact symptomatic as detected by the questionnaire, suggesting that inappropriate resource consumption can be kept under control by applying a GOLD-criteria-based screening questionnaire. Our use of the GOLD screening questionnaire to assess the risk of COPD followed recommendations in the 2006 guidelines,
      • Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006
      Global strategy for diagnosis, management, and prevention of COPD.
      although recently validated questionnaires with the same goal are available elsewhere.
      • Kotz D.
      • Nelemans P.
      • van Schayck C.P.
      • Wesseling G.J.
      External validation of a COPD diagnostic questionnaire.
      Our study also shows that pharmacists can obtain valid spirometries if they are well-trained and highly motivated. Seventy percent of the spirometry curves were judged to be of A- or B-level quality after review by an expert in lung function testing; that success rate was higher than the reported 63% in a previous pharmacy study.
      • Burton M.A.
      • Burton D.L.
      • Simpson M.D.
      • Gissing P.M.
      • Bowman S.L.
      Respiratory function testing: the impact of respiratory scientists on the training and support of primary health care providers.
      Only 10% of the subjects who were invited to perform spirometry in the community were unable to produce correct manoeuvres under the pharmacists' supervision, a situation quite similar to that reported for the primary care level.
      • Rea H.H.
      • Eaton T.
      • Withy S.
      • Garrett J.E.
      • Mercer J.
      • Whitlock R.M.
      The impact of spirometry workshops. Spirometry in primary care practice: the importance of quality assurance.
      The quality of spirometry was also reflected in the lack of differences in results in pharmacy and hospital measurements for the same subjects.
      An interesting finding was the predominance of women among the pharmacy customers. Given that the prevalence of COPD in Spain has been found to be 14.3% in men and 3.9% in women in a population-based study,
      • Sobradillo Peña V.
      • Miravitlles M.
      • Gabriel R.
      • Jimenez-Ruiz C.A.
      • Villansante C.
      • Masa J.F.
      • et al.
      Geographic variations in prevalence and underdiagnosis of COPD: results of the IBERPOC multicentre epidemiological study.
      we expected males to predominate among the tested subjects. However, women accounted for 58% of the subjects and 57% of the positive spirometries. The pharmacy seems to be a particularly good setting, therefore, to find cases in women, among whom the prevalence of COPD seems to be rising.
      • Soriano J.B.
      • Maier W.C.
      • Egger P.
      • Visick G.
      • Thakrar B.
      • Synes J.
      • et al.
      Recent trends in physician diagnosed COPD in women and men in UK.
      A limitation of this study was the absence of a bronchodilator test. Although most guidelines recommend the use of post-bronchodilator spirometry to diagnose and stage COPD, other authors call for simplicity, especially for large-scale screening.
      • Mannino D.M.
      Defining chronic obstructive pulmonary disease… and the elephant in the room.
      • Celli B.R.
      • Halbert R.J.
      • Isonaka S.
      • Schau B.
      Population impact of different definitions of airway obstruction.
      • Enright P.
      Provide GPs with spirometry, not spirometers.
      We ruled out the use of post-bronchodilator tests in pharmacies because of evident concerns about practicality, safety, and efficiency. Should this approach be implemented, we continue to consider that bronchodilator tests should be performed in the hospital laboratory after referral. Another limitation and the main logistical problem of this study is related to referral of subjects with possible COPD from the community pharmacy to the hospital. In our study, nearly half of those with spirometry results indicating airflow limitation declined a hospital appointment. No time or lack of interest were the reasons most often stated. We suspect that declining referral may reflect either a lack of interest in quitting smoking or milder disease. The general population has little knowledge about COPD,
      • Miratvilles M.
      • De la Roza C.
      • Morera J.
      • Montemayor T.
      • Gobartt E.
      • Álvarez-Sala J.L.
      Chronic respiratory symptoms, spirometry and knowledge of COPD among general population.
      in comparison with other conditions such as cardiovascular disease, and they, therefore, do not consider respiratory disease to be a serious personal threat.
      To conclude, in this pilot study, we have shown that COPD case finding by spirometry in urban community pharmacies is feasible. Pharmacists have access to high-risk, middle-aged subjects who have never been tested for COPD, and if the pharmacists are correctly trained, they can detect airflow limitation by spirometry with results that are similar to those previously reported at primary care level. Pharmacists are health service professionals who are not presently involved in screening for COPD but whose participation may represent a useful complementary strategy for early case finding.

      Conflict of interest statement

      Dr. Diego Castillo: Research grant: Boehringer–Ingelheim.
      Dr. Rafael Guayta, Jordi Giner, Felip Burgos, Carme Capdevila, Dr. J.B. Soriano, Merce Barau and Dr. Pere Casan: none of these authors have a conflict of interest to declare in relation to this work.
      The funding sources made no contribution to the manuscript and did not review it before submission for publication or at any point in the writing or publication process.

      Acknowledgements

      We sincerely thank the community pharmacists who participated in this study: E. Baro, M.T. Bregante, M.R. García, M.M. Gine, R.M. Janer, E. Mestre, P. Moreno, F. Pegueroles, M. Pons, S. Ricarte, I. Roig, R.M. Tarré, and T. Videllet. Statistical advice: F. Aparicio. Editorial assistance with the manuscript: M. E. Kerans.
      FarmaEPOC group: Hospital del Mar (Barcelona): D. Castillo; Hospital Sant Creu i Sant Pau (Barcelona): J. Giner, and P. Casan; Hospital Clinic i Provincial (Barcelona): F. Burgos; Fundació Caubet-CIMERA (Illes Balears): J.B. Soriano; Col. legi Oficial Farmaceutics Barcelona (Barcelona): R. Guayta, C. Capdevila, C. Rodríguez, and M. Barau; Boehringer-Ingelheim (Barcelona): E. Gobartt, E. Mas, and X. Ribera; Son-Médica S.A. (Barcelona): J.M. Vázquez; and ndd Medical Technologies (Switzerland): J. Anderauer.
      Study financed by: Boheringer–Ingelheim, FIS 04/2728, PII-EPOC (SEPAR) and Ciber Enfermedades Respiratorias.

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