1996 OPEN FORUM Abstracts
Pulmonary Function Testing Should Be Determined by Patient-Driven Protocols, Not Package Testing'
Jack Wanger, MBA, RRT, RPFT Wednesday, November 6, 1996
Patient-driven protocols can be defined as plans or algorithms that determine the extent of a pulmonary function laboratory evaluation. They can be used by the physician, nurse, or pulmonary function laboratory technologist to determine the initial test(s) or follow-up tests. According to proponents, the objectives of these protocols are (1) to assure appropriate patient care, (2) to reduce costs for diagnostic tests, and (3) to offer the potential for increased physician referrals.
The term "package testing" refers to the practice of administering a standard set of tests on every subject. For example, every subject who comes to the pulmonary function laboratory will have spirometry before and after bronchodilator, lung volumes, and DLCO. This "package testing" approach is typically done when the diagnosis is uncertain and to assure a through assessment is performed. It is the same logic we use in ordering a blood chemistry panel. The advantages of this approach may include reduced costs (e.g., package pricing), efficient use of patient and technician time (i.e., patient not having to return for other tests), better information in cases other than the most simple and straight forward.
Proponents of protocols argue that "package testing" results in too many inappropriate tests. By providing an algorithm based on such criterion as admitting diagnosis, medical history, age, and surgical procedure only the tests that are apparently needed will be performed.
However, the protocol is only as good as the specific algorithm and may only apply to a subset of patients seen in practice. Additionally, these protocols will vary widely from hospital to hospital because of the lack of standardization, and the basis on which they were developed (e.g., biases, and financial and intellectual interests of their creators). It seems reasonable to suggest that a panel of experts (e.g., ATS) develop a few standardized patient driven protocols for common clinical situations to eliminate special interests and to assure the highest level of patient care at the lowest cost.
But the real problem is how do we get physicians to order the right test(s). The National Asthma Education Program, which was created by a panel of experts, suggests we need to educate the medical community on the diagnosis and management of asthma. The Program contains recommendations on how to take an appropriate medical history and contains an algorithms for diagnosis and management. This Program has been very successful and emphasizes educating the physician to assure better patient care.
In this controversy, we should not view patient driven protocols as the panacea. Instead, we must first and foremost educate the physician on the usefulness of the various tests. We should also provide the physicians with standardized protocols for diagnosis and treatment of pulmonary disorders, that have been created by a panel of experts. Additionally, in teaching institutions, the ordering of pulmonary function tests by residents and fellows should be overseen by a physician who has the appropriate expertise. Once these measures are implemented, we can then make meaningful progress towards closing the gap on inappropriate ordering of, and the reduction of costs for pulmonary function tests.