This is not something I have any real influence over because the tests ordered on a patient’s first visit to the PFT lab are going to be determined by the ordering patterns of the referring physician and not by what I think. It’s still a worthwhile question, however.

There are no standards for PFT ordering. There are recommendations from the ATS, ERS, ACCP and NIH regarding patient diagnosis and treatment for a variety of pulmonary diseases and buried inside of them are some guidelines for PFT tests. What I’ve seen, however, is that these guidelines are honored far more in the breach than in their observance. As an example, for asthmatics the NIH recommends spirometry during an initial visit, after asthma has been stabilized, during an exacerbation, after an exacerbation and at least every 1 to 2 years otherwise. How often do you see this guideline followed in more than spirit?

I never used to think about this too much but several years ago I had a long conversation with a Pulmonary lab manager at a tertiary care hospital in Australia. One of the things he said was that all patients newly referred to the Pulmonary division there always had a complete set of PFTs, including post-bronchodilator spirometry, MIP & MEP and an ABG before they even saw a pulmonary physician. The ABG may be a bit of overkill, but since that time I now spend a lot less time on the front lines and lot more time reviewing PFT reports. I have a more global view of patient management (or at least I like to think I do) and I have to wonder if complete PFTs on a first visit shouldn’t be a standard approach.

Most new Pulmonary patients at my hospital usually have just spirometry on the first visit. They may return for several visits, getting just spirometry each time (even when the results are abnormal) before they ever have any additional tests. I’ve talked to physicians about this a few times and the answer I’ve gotten most often is that they usually don’t feel they need more than spirometry to manage a patient’s care. The second most common answer is that this approach is more economical, that they don’t order any tests they don’t think the patient doesn’t need.

Physicians are under a great deal of pressure to contain costs so I understand why tests shouldn’t be ordered if they aren’t needed, but I also have to wonder if this approach sometimes leads to greater costs in the long run, including the cost in patient time. The time that patients spend traveling and waiting for medical care is often overlooked. Physician time is very expensive and valuable and in any department or medical office there is usually a phalanx of receptionists, medical assistants and nurses who are there to maximize a physician’s face time with patients. Patients, on the other hand, often have to take time off from work, spend considerable time traveling, wait to see a physician and then afterward wait for a diagnosis and treatment. Patient time isn’t considered part of cost containment.

This may be a somewhat extreme example, but it’s one I see frequently enough that it is not all that unusual. A new patient complaining of shortness of breath sees a pulmonary physician and has spirometry. Spirometry is normal-ish and there are no prior PFTs to compare it to. The patient, still complaining of SOB, has a follow-up visit several months later and again has spirometry, with no change. Still SOB, there is another follow-up visit months later, again with spirometry, which is again normal-ish and unchanged. Finally, six months to a year after the initial visit the patient has a complete set of PFTs and suddenly the shortness of breath is explained by a low DLCO.

That was not a fair example because I am sure that many patients are diagnosed and treated correctly during the initial visit or soon after by follow-up x-rays or something similar. Still, it is not that uncommon either. And I have to wonder that if complete PFTs were performed as part of initial visit just how much patient time would have been saved and how much better informed and focused the physician would have been the first time they saw the patient.

I would like to suggest that complete PFTs (which to me means spirometry pre- and post-bronchodilator, lung volumes and diffusing capacity; we can quibble about some of the other tests another time) should be standard for all initial pulmonary physician appointments. Yes, I also agree that in many cases this will turn out to have been unnecessary but I will also say that you don’t know for certain which patients for whom this will be the case ahead of time. The advantage will be that the physician will have much better understanding of the patient’s pulmonary status, a baseline will be established and the patient’s time will be saved.

I think the value of a baseline to a patient’s long term care is underestimated and I don’t think it is considered as a factor in cost-containment. My lab’s database goes back to 1989. Patients who had complete PFTs ten or twenty years ago are returning for new pulmonary problems and we now have a baseline for comparison. Sometimes the complaints are new but baseline shows the pulmonary problems aren’t and sometimes they show just how much lung function has declined. In either case, a baseline is invaluable.

I understand that medical costs need to be contained. At my age I am both a provider and a consumer of medical care. But I also think that this means we need to learn how to make testing less expensive and not necessarily just order fewer tests. I think that cost-containment also has to look to long-term costs. Saving a dollar now doesn’t make sense if it costs us a hundred dollars five years in the future. Pulmonary function testing is already relatively low-cost and low-overhead (particularly when compared to radiological imaging), what needs to be done is to maximize its utilization and making complete PFTs a standard part of initial patient visits would help do that.

I’ll be the first to admit that I have a narrow focus. To a hammer every problem is a nail. I’m a PFT technician, so for me the answer to every problem is a PFT. I do believe that an ounce of prevention is worth a pound of cure however, and that PFTs are definitely part of the ounce, not the pound. 

 
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