NICE claims on asthma overdiagnosis are 'misleading’, say respiratory experts
Respiratory experts have attacked reports put out by NICE that over a million people may be receiving treatment for asthma unnecessarily, saying the message was ‘misleading’ and could lead to complacency about under-treatment of the condition.
In an open letter to Pulse, the experts say the media reports – triggered by a NICE press release publicising the launch of draft NICE guidelines on asthma diagnosis – had ‘left millions of patients feeling uncertain about their diagnosis and care’.
The NICE draft guidelines propose a radical overhaul of the way asthma is diagnosed, recommending GPs carry out a battery of new tests to make sure patients are given an ‘objective’ diagnosis and are then monitored more closely to check whether they truly have asthma.
Most news coverage coinciding with their launch focused on NICE background information explaining why asthma needs to be diagnosed more carefully, suggesting as many as 30% of people treated for asthma may not actually have the condition.
But a letter, signed by a list of respiratory clinicians led by Dr Robert Niven, senior lecturer in respiratory medicine at the University of Manchester, and including GPSI in respiratory medicine Dr Dermot Ryan, a GP in Loughborough, says this was ‘misleading and unhelpful’.
The letter states: ‘Recent assertions that over one million people may have been wrongly diagnosed with asthma, which accompanied the release of the NICE draft guidance on asthma diagnosis, are misleading and unhelpful.
‘In reality, asthma diagnosis is complex, and many people who do have it may not show clear signs on clinical testing. We are concerned that millions of people with asthma who do need treatment have now been left with uncertainty about their diagnosis and care.’
The letter goes on to highlight there are also concerns around under-treatment of asthma, after the National Review of Asthma Deaths (NRAD) showed two-thirds of asthma deaths were preventable with routine care, and adds ‘healthcare professionals must remember there is no room for complacency’.
Dr Stephen Gaduzo, chair of the Primary Care Respiratory Society, told Pulse that the change in emphasis in media coverage springing from the NICE press release was ‘dangerous’.
Dr Gaduzo said: ‘If people are being misdiagnosed then obviously that’s not good, but there has been a complete change of emphasis. We had the NRAD report, which said we are failing to meet the standards of care in some of these patients because they’re not being followed up and encouraged to use their inhalers properly.
‘To suddenly follow that with a statement that so many patients may be unnecessarily on inhalers, to me that is a difficult and dangerous sequence of press.
‘Some of the press is going to jump on that – quite rightly – and say, what’s going on, 30% of people are on treatment they shouldn’t be? At a time we’re moaning that the NHS budget is so stretched?’
Dr Andrew Green, chair of the GPC clinical and prescribing subcommittee, said GPs felt criticised from both sides and that NICE’s press release was either naïve or deliberately provocative.
Dr Green said: ‘[GPs] are criticised both for asthma overdiagnosis and undertreatment at the same time.
‘The opening sentence of the press release from NICE was always going to create waves and demonstrates either naïveté or a worrying desire to create headlines. This contrasts markedly with the measured comments from Professor [Mark] Baker himself which I would support.’
Dr Green added that consultations would be more productive if ‘views are expressed less forcefully and less publicly at the start’.
He added: ‘This enables alteration in viewpoints without any appearance of defeat, and will result in better guidance more likely to have the support of doctors.’
However, NICE rejected the criticisms of its approach, pointing out this was backed by ‘consistent evidence’ of over-diagnosis and over-treatment of asthma.
A NICE spokesperson said: ‘The speculation that NICE’s approach may foster complacency is unfounded. The draft guidance and the press release emphasised clearly that appropriate diagnosis requires supportive tests. The guideline is intended to shape best practice.
‘The press release highlighted the need for effective monitoring and treatment of asthma. It pointed out that there may be many patients (30%) being treated for asthma were no longer showing signs of the condition.
‘To reach these figures, the guideline development group drew on consistent evidence they were aware of (five references were cited in the full draft guideline) that suggest a large proportion of people treated for asthma at a single point in time do not have objective supportive evidence, nor had normal objective tests.’
The spokesperson added that NICE issues press releases on consultations ‘because it wants to hear from all people interested its guidance – including members of the public’ and that it is ‘in the interests of the BMA and its members for the patients they serve to have a voice in these consultations’.