Comment on the NICE,SIGN,BTS Guideline scope: Asthma: diagnosis, monitoring and chronic asthma management.
Dr Mark L Levy FRCGP, 28.9.2021 Clinical Lead NRAD 2011-2014 (CV at http://www.consultmarklevy.com)
- The key problems related to asthma care and the comparatively bad UK asthma outcomes worldwide have not been addressed by this scoping document. These relate to quality and consistency of care within primary and secondary sectors as well as the interface between these and the tertiary care sector. The issues have been detailed in a number of UK reports of note the NRAD (2014), the APPG report (2020), the HSIB report (2021), the NACAP results as well as in the HM Coroners Regulation 28 reports on Ella Kissi-Debra,Tamara Mills, Michael Uriely, Sophie Holman and countless others (published on HM Chief Coroners website). Furthermore the NICE QS 25 published in 2013 made a number of recommendations that are still valid. (the shortened version cut this down innapropriately in my view). To date only one of the NRAD recommendations (the NACAP) has been implemented and one has to ask whether the new guidelines will have any requirement for change in the management of asthma.
- We have seen during the SARS-COV-19 pandemic how our brilliant UK scientists have addressed and dealt with problems as they arose. So it would make far more sense, in my view, rather than relying solely on past published material intended for other purposes (including regulatory studies), to pose the key problems related to asthma care in the UK, for our scientists to address; perhaps using an adaptive type of design that so quickly and effectively identified how best to treat Covid-19 in the ICU. We were able to solve problems so quickly, and collectively during the pandemic, so its hard to reconcile this with our inability in 50 years, to make a difference to the lives of people with asthma.
- Unfortunately, in my view, this update only due in 2023, which will still result in two separate UK guidelines for asthma will not address the key issues related to poor asthma outcomes in the UK, particularly disjointed management where quality of patient’s care is subject to a postcode lottery, unacceptably high rates of admissions poor quality of life, preventable deaths due to asthma, the process of asthma care, the lack of appropriately trained personnel the care across the interface, and particularly dealing with the particular problems patients experience due to a lack of joined up thinking and approach.
- Einstein said insanity is doing the same thing over and over again and expecting different results. The new guideline process is like just shuffling the deck chairs on the titanic rather than jumping ship and starting afresh. We have shown in many publications (starting with the one by the GPIAG soon after publication of the first UK asthma guideline – British Medical Journal. 1993;306:559-62) that guidelines are not adhered to, so we need to adopt a new approach regarding their presentation. It’s time for different approaches and questions that might yield different/ improved outcomes rather than rehashing the same PICO questions over and over again.
- The key questions (particularly related to diagnosis, FeNO and Spirometry) have in the main been answered by the NHLBI update (2020), and the 2021 GINA update, so its difficult to justify the time until 2023 by reconsidering these questions and expecting different conclusions. This planned review will no doubt utilise previously published data and by 2023, that will all be out of date. Similarly the questions on drug treatment have also been recently dealt with and updated in these two publications. One large gap in the planned revision relates to the management of so called mild asthma which affects about half of the asthma population. In particular the overwhelming evidence in favour of ICS-formoterol in reducing severe attacks compared with using SABA currently advocated by NICE and SIGN/BTS. This is one area, in my view, that requires an urgent decision by this group in keeping with the NICE statement that recommendations may be made outwith current regulatory status of medications. (40 countries worldwide have advocated this approach as a population safety measure to reduce moderate and severe attacks in people aged over 12.
- The major problems with the list of key questions on diagnosis seem to be the failure to accept that there is no single diagnostic test for confirming asthma coupled with the fact that asthma is defined as a disease characterised by variable respiratory symptoms and variable airflow obstruction. So relying on a single test of lung function (spirometry or PEF) for diagnosis is simply ludicrous. The NICE feasibility study showed that less than 30% of people diagnosed with asthma had abnormal spirometry. So to expect GPs (or secondary care) to do serial spirometry in order to pick up variable airflow obstruction cannot work – so why persist with the question. Similarly, guidelines all over the world have concluded that FeNO alone cannot help in diagnosis – what’s needed is a clinician with the skills to incorporate the history, response to treatment as well as the tests to make a diagnosis – so how will a string of statements in response to this long list of questions help a generalist to make a diagnosis?
- The omission of severe and difficult to treat asthma from the scope is also a major flaw in my view. These patients t contribute significantly to the burden and cost of asthma in the UK – so why are they not being addressed. Similarly, the fact that asthma is a chronic condition requiring constant monitoring and adjustment of treatment when poorly controlled (ie risk factors like attacks as well as symptoms) is an indication that the key recommendation in NRAD ie referral to specialists after 2 attacks, plus a detailed post attack review should be done. The latter to assess and act if the attack is not resolved, as well as identification of modifiable risk factors which should be dealt with.
- In my view, our aim should be to eradicate asthma attacks (and deaths) through a completely new national approach akin to that used in Finland would be a more appropriate method for solving our UK asthma situation. This should include a personalised asthma management cycle as described in GINA (the assess, adjust, review ongoing cycle) which addresses issues related to diagnosis, identification and dealing with modifiable risk factors, patient preferences & goals, optimisation of management (not just drugs, but also education and inhaler technique) as well as appropriately timed review (not just an annual ‘ how’s your asthma’ check-up.
- So instead of wasting a lot of specialist’s time in tinkering with the current guidelines by answering these PICO questions, which don’t really address the needs of people with asthma in the UK, we would do far better by starting with a clean sheet and trying to address the problems related to asthma care in the UK. Furthermore, by ensuring we implement bundles of care, such as the recently published NHSE CYP Bundle starting immediately, we may achieve better outcomes.
- NHLBI 2020: https://www.jacionline.org/article/S0091-6749(20)31404-4/fulltext
- NRAD
- APPG report 2020
- HSIB report 2021
- Coroners Regulation 28 reports (eg Tanmara Mills, Michael Uriely, Sophie Holman, Ella Kissi-Debra etc)