Evidence-based medicines for children: ethical aspects.

We would like to thank P.J.P. Poels, D.P.A. Schellekens and T.R. Schermer for the interest shown in our recent paper [1] and for their comments. It is clear that we all agree that primary-care spirometry is important, albeit currently underused. However, we are unable to concur with one of the basic assumptions of the correspondents, namely that spirometry will automatically lead to improvements in management. Despite demonstrating positive effects on pharmacological and nonpharmacological management, arguably the most striking data from our study relate to undertreatment. Even after spirometric confirmation of chronic obstructive pulmonary disease (COPD), 63% of subjects were not prescribed an inhaled anticholinergic, 75% were not prescribed an inhaled long-acting b-agonist and 89% of subjects had not completed pulmonary rehabilitation. While not all of these subjects were necessarily overtly symptomatic, .20% of COPD patients with a forced expiratory volume in one second (FEV1) ,1 L, and .50% of subjects with an FEV1 ,60% predicted, were prescribed neither an anticholinergic nor a long-acting b-agonist. It is difficult to believe that these subjects were not symptomatic and would not have benefited from the treatment or referral for exercise therapy. The use of specific payments for spirometry testing in primary care is likely to increase the number of tests performed dramatically, albeit at a large financial cost. However, translating such diagnostic information into improved treatment for patients is a huge challenge, more dependent on education and use of guidelines. In our view, studies that addressed this problem would be more valuable than one that establishes the positive and negative predictive value of spirometry testing. One area in which we agree with the correspondents is the importance of aiding the interpretation of spirometry tests in primary care and of ensuring that the tests performed are accurate and of high quality. This is why we discussed in detail that our model of service was an alternative to testing within primary-care groups, where at times individuals using spirometry have had limited training in accurately performing the test or interpreting the results. In our service model, we produce accurate results and we interpret them for the referrer, and certainly there would also be scope to add general management recommendations. Whether this produces superior outcomes to within-practice testing would, in our view, be another study worth performing.