https://doi.org/10.4081/itjm.2026.2657
Agreement between general practitioners and central reviewers on spirometry interpretation in primary care
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Published: 23 October 2026
We assessed agreement between general practitioners (GPs) and central reviewers within a supported primary-care spirometry program in Piedmont, Italy. GP and central-review labels were recorded separately; reviewer blinding was not documented. Among 658 uploads dated 18 May 2022-18 January 2023, 481 from 25 GPs had paired obstruction labels. Confidence intervals (CIs) used 50,000 GP-cluster bootstrap resamples. The obstruction agreement was 92.9% (95% CI 90.3-96.0), and Cohen's κ was 0.855 (0.797-0.918); discordance comprised 28 GP-positive/reviewer-negative and 6 GP-negative/reviewer-positive records. Relative sensitivity was 96.8% and specificity 90.4%. Agreement was 95.0% for possible restriction (κ 0.818), 97.5% for recorded reversibility (κ 0.737), and 86.2% for severity (weighted κ 0.789). Four Global Initiative for Chronic Obstructive Lung Disease categories were available, but no very severe classifications were recorded. One reviewer account contributed 397/481 assessments. Incomplete pairs, the concentration of reviews, possible repeat examinations, and the limited number of GP clusters constrain interpretation. Technical-quality data and the bronchodilator-tested denominator were unavailable. High agreement describes completed pairs within this supported pathway and does not establish diagnostic accuracy or clinical benefit. Hospital-community applications require prospective evaluation.
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Global Initiative for Chronic Obstructive Lung Disease. Global strategy for prevention, diagnosis and management of COPD: 2026 report. Available from: https://goldcopd.org/2026-gold-report-and-pocket-guide/
Stanojevic S, Kaminsky DA, Miller MR, et al. ERS/ATS technical standard on interpretive strategies for routine lung function tests. Eur Respir J 2022;60:2101499. DOI: https://doi.org/10.1183/13993003.01499-2021
Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-year age range: the Global Lung Function 2012 equations. Eur Respir J 2012;40:1324-43. DOI: https://doi.org/10.1183/09031936.00080312
Graham BL, Steenbruggen I, Miller MR, et al. Standardization of spirometry 2019 update: an official American Thoracic Society and European Respiratory Society technical statement. Am J Respir Crit Care Med 2019;200:e70-88. DOI: https://doi.org/10.1164/rccm.201908-1590ST
Levy ML, Quanjer PH, Booker R, et al. Diagnostic spirometry in primary care: proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J 2009;18:130-47. DOI: https://doi.org/10.4104/pcrj.2009.00054
White P, Wong W, Fleming T, Gray B. Primary care spirometry: test quality and the feasibility and usefulness of specialist reporting. Br J Gen Pract 2007;57:701-5.
Schermer TRJ, Crockett AJ, Poels PJP, et al. Quality of routine spirometry tests in Dutch general practices. Br J Gen Pract 2009;59:e376-82. DOI: https://doi.org/10.3399/bjgp09X473088
Hegewald MJ, Gallo HM, Wilson EL. Accuracy and quality of spirometry in primary care offices. Ann Am Thorac Soc 2016;13:2119-24. DOI: https://doi.org/10.1513/AnnalsATS.201605-418OC
van de Hei SJ, Flokstra-de Blok BMJ, Baretta HJ, et al. Quality of spirometry and related diagnosis in primary care with a focus on clinical use. NPJ Prim Care Respir Med 2020;30:22. DOI: https://doi.org/10.1038/s41533-020-0177-z
Rothnie KJ, Chandan JS, Goss HG, et al. Validity and interpretation of spirometric recordings to diagnose COPD in UK primary care. Int J Chron Obstruct Pulmon Dis 2017;12:1663-8. DOI: https://doi.org/10.2147/COPD.S133891
Schermer TRJ, Jacobs JE, Chavannes NH, et al. Validity of spirometric testing in a general practice population of patients with chronic obstructive pulmonary disease. Thorax 2003;58:861-6. DOI: https://doi.org/10.1136/thorax.58.10.861
Schneider A, Gindner L, Tilemann L, et al. Diagnostic accuracy of spirometry in primary care. BMC Pulm Med 2009;9:31. DOI: https://doi.org/10.1186/1471-2466-9-31
Holton C, Crockett A, Nelson M, et al. Does spirometry training in general practice improve quality and outcomes of asthma care? Int J Qual Health Care 2011;23:545-53. DOI: https://doi.org/10.1093/intqhc/mzr039
Schermer TRJ, Akkermans RP, Crockett AJ, et al. Effect of e-learning and repeated performance feedback on spirometry test quality in family practice: a cluster trial. Ann Fam Med 2011;9:330-6. DOI: https://doi.org/10.1370/afm.1258
Parsons R, Schembri D, Hancock K, et al. Effects of the spirometry learning module on the knowledge, confidence, and experience of spirometry operators. NPJ Prim Care Respir Med 2019;29:30. DOI: https://doi.org/10.1038/s41533-019-0143-9
Averame G, Bonavia M, Ferri P, et al. Office spirometry can improve the diagnosis of obstructive airway disease in primary care setting. Respir Med 2009;103:866-72. DOI: https://doi.org/10.1016/j.rmed.2008.12.017
Burgos F, Disdier C, de Santamaria EL, et al. Telemedicine enhances quality of forced spirometry in primary care. Eur Respir J 2012;39:1313-8. DOI: https://doi.org/10.1183/09031936.00168010
Marina Malanda N, Lopez de Santa Maria E, Gutierrez A, et al. Telemedicine spirometry training and quality assurance program in primary care centers of a public health system. Telemed J E Health 2014;20:388-92. DOI: https://doi.org/10.1089/tmj.2013.0111
Thijssing L, van der Heijden JP, Chavannes NH, et al. Telepulmonology: effect on quality and efficiency of care. Respir Med 2014;108:314-8. Jankowski P, Gorska K, Mycroft K, et al. The use of mobile spirometry with feedback quality assessment in primary care: a nationwide cross-sectional feasibility study. Respir Med 2021;184:106472. DOI: https://doi.org/10.1016/j.rmed.2021.106472
Poot CC, Meijer E, Kruis AL, et al. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2021;9:CD009437. DOI: https://doi.org/10.1002/14651858.CD009437.pub3
Patel K, Pye A, Edgar RG, et al. Cluster randomised controlled trial of specialist-led integrated COPD care (INTEGR COPD). Thorax 2024;79:209-18. DOI: https://doi.org/10.1136/thorax-2023-220435
Osservatorio Nazionale sull’impiego dei Medicinali. L’uso dei farmaci in Italia. Rapporto Nazionale Anno 2024. Materiale supplementare, Sezione 6, Tabelle 3.7.1.s2-s3. Rome, Italy: Agenzia Italiana del Farmaco; 2025.
Vauterin D, Van Vaerenbergh F, Grymonprez M, et al. Medication adherence to inhalation therapy and the risk of COPD exacerbations: a systematic review with meta-analysis. BMJ Open Respir Res 2024;11:e001964. DOI: https://doi.org/10.1136/bmjresp-2023-001964
Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam Med 2005;37:360-3.
Kottner J, Audige L, Brorson S, et al. Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed. J Clin Epidemiol 2011;64:96-106. DOI: https://doi.org/10.1016/j.jclinepi.2010.03.002
von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology statement: guidelines for reporting observational studies. Ann Intern Med 2007;147:573-7. DOI: https://doi.org/10.7326/0003-4819-147-8-200710160-00010
Wu CX, Hwang CH, Tan WS, et al. Effectiveness of a chronic obstructive pulmonary disease integrated care pathway in a regional health system: a propensity score matched cohort study. BMJ Open 2018;8:e019425. DOI: https://doi.org/10.1136/bmjopen-2017-019425
Athlin A, Lisspers K, Hasselgren M, et al. Diagnostic spirometry in COPD is increasing: a comparison of two Swedish cohorts. NPJ Prim Care Respir Med 2023;33:23. DOI: https://doi.org/10.1038/s41533-023-00345-8
CRediT authorship contribution
Giuseppe Misiano, Daniele Angioni: coordination of the interpretation of the program data and manuscript development. Daniela Ferrante: supervision of the statistical methodology. All authors: interpretation, critically revision of the manuscript, approval of the final version.
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