NICE calls for GPs to do extra diagnostic testing for asthma despite unclear impact
NICE experts have said they want GPs to start doing a raft of new tests to diagnose asthma, even though they are still carrying out ‘field work’ to look at whether these tests can be implemented in practice.
The latest advice comes as NICE announced it was delaying publication of final guidance on asthma diagnosis and monitoring for a second time, after agreeing to review and test their impact when GP leaders rejected the draft proposals.
The final guidelines were due to be published this month but NICE has instead launched an ‘interim’ version, which it said takes on board changes suggested during the consultation process so far.
However, they continue to recommend a number of tests – such as carrying out spirometry in over-5s suspected of asthma, and bronchodilator reversibility (BDR) and FeNO testing to confirm diagnoses in over-16s – which GP leaders have warned are not widely available or lack evidence – and will lead to increased referrals to secondary care.
Whether the tests will make the final guidance rests on ‘fieldwork’ taking place from April to November, which practices are invited to take part in.
GP experts told Pulse they felt the recommendations were valid overall but said they were concerned NICE was underestimating the complexity of the testing – and how much more resource would be needed.
Dr Dermot Ryan, an asthma GPSI in Loughborough, said that ‘as a whole these recommendations are comprehensive and valid’ but added that ‘costs, where presented, have been minimised and are barely representative of the true costs’.
For example, Dr Ryan said the costs estimated for spirometry were ‘not the real costs, particularly when then performed as an emergency’, and ‘also neglect clerical time’.
He added: ‘Implementation would require massive investment in primary care, not least in knowledge and skills but also including provision for equipment, staffing and disposables.’
Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, said for the time being most GPs would continue following the British Thoracic Society/SIGN asthma guidance published late in 2014, but said they would take the NICE interim guidance into account, ’and try to do the best for their patients’.
A NICE spokesperson said: ‘Our draft guideline on asthma diagnosis and monitoring proposed some radical and innovative changes. During our public consultation many healthcare professionals and organisations said the guideline would be a challenge to implement.
‘To address these views, we are carrying out a careful and cautious assessment of two diagnostic tests recommended in the guideline to provide evidence on whether or not the tests can be introduced into the NHS effectively and efficiently. We will review this work before we publish our final guidance.’
What will happen in the final guidelines?
The final guidelines will take in the results of ‘fieldwork’, which NICE said will ‘focus on the impact and feasibility of implementing two of the objective tests (quality-assured spirometry and fractional exhaled nitric oxide [FeNO]) which are recommended in algorithms proposed in the guideline’.
Practices are being invited to take part in the field testing, which is expected to run from April to November, after which NICE ‘will look again at whether there will be any implications to the guideline recommendations’.
As in draft proposals, the interim guidelines say GPs should start to routinely carry out spirometry in anyone over five with suspected asthma; they then recommend use bronchodilator reversibility (BDR) and FeNO testing to confirm diagnosis in those over 16, with further bronchial challenge tests recommended if there is still uncertainty.
However, the recommendations are slightly softened in recommending GPs only ‘consider’ rather than ‘offer’ BDR and FeNO tests in children aged five to 16 to help confirm diagnosis.
As before, children aged under five should be treated based on clinical judgement with a plan to review their condition once they reach five.