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Treating asthma was a wheeze before NICE got involved

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It’s been some time since I’ve had a pop at NICE, though it hasn’t been for a lack of opportunity. But these latest draft guidelines on asthma are so outlandish that they have me coughing and spluttering myself towards status asthmaticus, assuming I really do have asthma – and, according to NICE, there’s about a one in three chance that I don’t, in which case it’s panic-induced hyperventilation, then.

Look, if you want to feel the real force of this polyinvestogram-fest heading your way, then read the whole damn thing yourself, like I just have. But to give you a potted highlight, the way we will diagnose asthma in every case in future will involve (and here I’d take a deep breath if only I could) spirometry with reversibility testing, then a Fractional Exhaled Nitrous Oxide test (no, me neither), then, depending on the results, peak flow variability monitoring for four weeks, and depending on the results of that, a histamine/methacholine challenge.

Simples, as I believe the young people say – oh, and by the way, it includes them. Apparently anyone over the age of five can cope with most of that little lot, providing, I guess, they don’t have other distractions, such as school, eating etc.

Look, as we all know, the best guidance is that which reflects what we do already, and SIGN should be congratulated here because its asthma guidance of last year allows for clinical judgement and trials of treatment. Guidance which reinforces our current approach is either an affirmation that we’ve been right all along or a collusion in poor care. In terms of asthma, NICE obviously thinks the latter. And presumably it would defend its approach through the alleged high rates of misdiagnosis.

Fine, but if there is a problem, this punishment is worse – in terms of cost, inconvenience to patients and grinding us GPs into the ground – than the crime. The signs were there with the recent draft cancer referral guidelines which will flood secondary care for the sake of a marginal improvement in the stats.

Conclusion? I’ve never been convinced that NICE was in possession of a plot. But if it was, it’s lost it.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield

 

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Readers' comments (10)

  • This is just about getting people off of expensive inailers with fancy Heath-Robinson style delivery systems. Should save a few beans somewhere.

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  • Like most NICE guidelines this won't immediately become standard practice. So no need to panic. In terms of new tests, since I have been a GP we now check serum BNP to help exclude heart failure and patients have heart failure confirmed by objective echocardiographic testing allowing the right patients to get the right treatment (whilst preventing unecessary use of treatment in patients who have the diagnosis excluded. Patients with suspected IHD are rapidly assessed and have a prognostic assessment to identify those at risk of MI. Rapid access TIA clinics and prompt vascular intervention is in place to reduce stroke. Patients with COPD have spriometry with reversibilty in their practices helping to accurately and easlily diagnose them. Serological testing for coeliac disease makes it easier to diagnose and exclude coeliac disease. Faecal calprotectin measurement can guide the referral of patients with possible IBD. This is healthcare innovation and will always happen. The tests we offer will change and the way we manage people with suspected disease will change.

    For once Tony, I disagree with what you say.

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  • Simon, I completely agree with all your points about better and more accurate diagnoses and technological tests improving our patients' lot - except in the area of asthma where I find low tech or even no tech (eg just reading the notes) is the best way of diagnosing asthma - clinical response to steroids, home serial peak flow measurements and high tech only if you need to exclude a possible confounding diagnosis.

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  • Peter, I agree that in most cases asthma is a clinical diagnosis but there are instances where it isn't straightforward and if tests are available that can help it would be great. There is also variability in clinicians skills in assessing and diagnosing asthma which is reflected in the reality that across a relatively small population there can be huge differences between practices in terms of asthma prevalence. Ranging from those who underdiagnose and have symptomatic patients and those that over diagnose and often over treat with expensive combination inhalers. As well as improving diagnosis I think we also have a lot to do in terms of educating patients about their asthma and how to use their treatments effectively

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  • What goes around comes around. In the mid to late 70s Metformin was "poisonous" and GPs were vilified by specialists for prescribing it. Around this time GPs were also vilified for not diagnosing asthma in anyone who wheezed a bit or even coughed for more than a few days. Tests are all very well but can often be asequivocal or misleading as symptoms and signs. If we lose faith in clinical judgement altogether we might as well pack in. Come to think...........

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  • Morning gentleman.
    A clinical debate, how rarefied and refreshing.
    Simon, I have no problem refining diagnoses as per coeliac, CCF etc.
    But this guidance leaves no room for common sense. Do I really need to put some poor sod through all that if he says he wheezes a bit on exertion, for example? If it doesn't make him weep, it will me.

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  • There were 1,167 deaths from asthma in the UK in 2011 (18 of these were children aged 14 and under), so we aren't getting it right yet. However, these are draft guidelines, and the majority of people responsible for them were specialists (there was one GP involved, as far as I can see). The draft guidelines are still open to consultation and comment (from GPs who may disagree with the practicalities in primary care). They also carry the disclaimer," Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of
    healthcare professionals to make decisions appropriate to the circumstances of each patient, in
    consultation with the patient and/or their guardian or carer."

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  • I've copied and pasted the best bits of Copperfield's column and sent them in to the consultation...

    "Please submit comments to asthma@nice.nhs.uk by 5pm on 11 March 2015 at the latest."

    http://www.nice.org.uk/guidance/gid-cgwave0640/documents/asthma-diagnosis-and-monitoring-guideline-consultation

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  • I have an educated articulate intelligent friend whose child has been admitted many times with asthma. The conflicting advice and contrary asthma plans given to her by each differing set of A&E docs, paediatricians, asthma educators, ward nurses, junior docs, night nurses and finally the revolving locum gps (not enough Gps NZ) has meant she really struggles to understand his asthma. Which the child DOES have. Keep it simple - these guidelines seem over complex for the patient to perform let alone surgeries whom are stretched AND They target surely a minority of complex cases more suited to secondary care to delineate. If it is cystic fibrosis, or antitrypsin, or reflux...truth will out. They could also provide a source of profit for the investigators ?conflict of interest here? If patients refuse to do them then they will go undiagnosed and unmedicated, much more dangerous. I had a very angry patient whom was charged $30 for spirometry (reversible) thought it was outrageous. Smoker all life, trying to diagnose him via guidelines...He thought a peak flow was quite adequate enough (done all his life by prior GP). Complained!

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  • Many of us on this comments page have forgotten how to take an expert history and examine the patient with core symptoms. Spirometry in itself is flawed, do it twice and you'll get 2 different readings!

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder