While I welcome the fact that Asthma UK (https://bit.ly/2muKIFh) have drawn attention to the fact that patients with severe asthma are not well managed in the UK, however, I am surprised that the authors failed to cite the well known findings of the American Thoracic Society/European Respiratory Societytask force findings on asthma control and exacerbations where the terms ‘control’ and ‘severity’ were defined and accepted in an official statement by the two organisations. (1) In the UK due to the Quality Outcomes Framework, the basis for general practitioners pay, it has become standard practice to simply assess a patient’s asthma once a year, where they are asked about current symptoms – not a good basis for assessing control in a chronic disease defined by fluctuations in symptoms and airflow obstruction from day to day throughout the year!
The report also fails to acknowledge that the international Global Initiative in Asthma (GINA) (2) Strategy document which is used as the basis for national guidelines in most countries in the world. GINA has since 2009 included a definition of asthma severity and control (the latter includes both current symptoms and future risk of attacks) ; where asthma severity is defined as the amount of treatment needed to maintain control (including the risk elements eg of previous attacks – Table 2-2 GINA many of these risk factors are included in Table 11 SIGN/BTS 153). (3)
Furthermore, the report states in conclusion that it is “worrying that, four years later, many of the problems identified in the NRAD report (4) have not been addressed”. In fact it’s not worrying, it is incomprehensible! Deaths due to asthma continue at a higher level than most developed countries (5) and is the highest for childhood asthma in Europe. (6) Of the 19 (NRAD) recommendations only one has been partially implemented nationally. The NRAD found that (similar to findings in the last 50 years) risk of future asthma attacks was not recognised, that patients were undertreated and that guidelines were not followed. Furthermore asthma severity (31% of the deaths were considered severe) was empirically defined without reference by clinicians at that stage to the only published definitions of severity detailed above.
I agree that there is a need to define severity and to accurately determine the numbers of patients with true severe asthma so they can be adequately treated, however, there is an equally pressing need to optimise therapy and management of all people with asthma by implementing the other 18 NRAD recommendations. By optimising treatment and management to include ensuring every person with asthma has a personal asthma action plan, such as the excellent one produced by Asthma UK, and also by identifying risk factors (2-4) and including their presence in defining asthma control (2) rather than simply asking patients how they are once a year, we may then progress towards reducing asthma attacks and identifying and quantifying the levels of asthma severity in the UK.
- Reddel HK, Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med. 2009;180(1):59-99. https://www.atsjournals.org/doi/full/10.1164/rccm.200801-060ST
- The Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA).2018 http://www.ginasthma.org.
- British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 153 – The British Guideline on the Management of Asthma. 2016 [Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/
- Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report Royal College of Physicians. London; 2014 https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
- Global Asthma Network. The Global Asthma Report 2014. 2014. Available from: http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf
- Wolfe I, Thompson M, Gill P, Tamburlini G, Blair M, van den Bruel A, et al. Health services for children in western Europe. The Lancet. 2013;381(9873):1224-34.