A two-pronged solution for COPD testing: respiratory hubs and mandatory spirometry in WA
The problem
Limited access to a testing option that is free for patients meant that some patients with suspected COPD were unable to access spirometry. For those patients:
- GPs didn’t have a clear diagnosis to guide treatment
- Respiratory specialists didn’t have the spirometry results that, together with symptom severity, they need to prioritise patients in greatest need of urgent outpatient review.
Respiratory Care WA establishes paediatric respiratory hubs
Rael Rivers, Executive Manager of Strategic Programs at Respiratory Care WA, was well aware of the lack of lung testing services both from advocacy work for the non-profit organisation and as a mother of three children with severe asthma. 'We first established the respiratory diagnostic hubs as a paediatric service, and later expanded them to include adults with COPD,' Ms Rivers said.
A combination of funding makes free testing viable
The expense of equipment, consumables and staff for spirometry testing means a combination of philanthropic donations to Respiratory Care WA and MBS funding is required to make the service free for patients. Since the first hub opened in Perth in 2020, another four hubs have been established in Perth and a regional hub in Bunbury. An outreach service to the outer South West region has also been introduced, but the distances involved mean many remote areas of WA are still underserved for spirometry, she said.
Lack of spirometry was a safety and quality issue
Frustrated with seeing patients referred for specialist care for COPD who hadn’t undergone spirometry, Dr Li Ping Chung was determined to make testing mandatory before outpatient clinic appointments. Dr Chung, head of the WA Respiratory Health Network and a respiratory consultant at the Fiona Stanley Hospital in Perth, said a WA Health initiative to prioritise and minimise waiting time for public hospital-based specialist appointments was a starting point for the requirement. Lack of spirometry results at the time of referral to confirm and assess for severity of COPD in primary care meant some patients with severe COPD were waiting longer than they should for appointments.
The diagnosis of COPD is mostly made in primary care, with national and global guidelines stating the need for spirometry as the diagnostic test. ‘Yet, the literature tells us spirometry is consistently under-utilised,’ said Dr Chung. As head of the WA Respiratory Health Network, Dr Chung also relayed to WA Health that the lack of spirometry testing was a safety and quality issue for the majority of patients, who are mostly managed in primary care. ‘The Heads of Respiratory Departments from all tertiary hospitals, as well as other respiratory experts, unanimously agreed that spirometry should be included as a crucial test from GPs to encourage uptake of appropriate testing in primary care and to guide how we prioritise and manage these patients,’ she said.
You wouldn’t send someone to an endocrinologist for poorly controlled diabetes without confirmation of diagnosis by getting a fasting blood glucose or glycated haemoglobin done, and yet for all these years we’ve accepted that we’ll take patients with suspected COPD without having a spirometry as the recommended diagnostic test.
Dr Li Ping Chung
Head of the WA Respiratory Health Network, Department of Health and Respiratory Consultant, Fiona Stanley Hospital, WA
The requirement of spirometry for diagnosis in the COPD Clinical Care Standard (the Standard), released in 2024, was another lever for action. ‘It’s the number one quality statement in the Standard, and if we allow patients to be referred to a specialist without the right diagnostic test, we are ignoring it rather than taking steps to encourage the use of spirometry in primary care.’
Distinguishing asthma from COPD in a patient with breathlessness, cough and wheezing isn’t possible without spirometry, says Dr Chung. For a patient with ongoing respiratory symptoms, having a spirometry test can mean the difference between getting effective treatment or not. While inhaled corticosteroids are an early treatment option in asthma, in COPD they should be reserved for patients with frequent exacerbations and persistent symptoms, partly due to the increased risk of pneumonia.
Demand pushes the system to get ready
Initially the proposal to introduce mandatory spirometry testing for patients making appointments with respiratory outpatient clinics was met with concerns about a lack of available services to provide the testing. ‘But once the demand is there, you’re in a better position to make the system ready,’ says Dr Chung.
The added demand helped make the expansion of the respiratory hubs to include adults with COPD possible for Respiratory Care WA, Ms Rivers said.
If you don’t mandate it, people don’t see the need and they just carry on their usual way with COPD. For most patients, this means being started on a treatment before the right test is done, potentially a treatment they don’t need.
Dr Li Ping Chung