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GPs go forth

The BMA is wrong about NICE's asthma advice

Professor Michael Thomas writes

Pulse’s article ‘BMA wholly rejects NICE recommendations on asthma in scathing response’ states the BMA view that the NICE draft guideline contradicts and is in opposition to the BTS-SIGN guideline.

Having sat on both guidance committees, I refute this. There is nothing in the NICE draft guideline that disagrees with the BTS-SIGN guideline in letter or in spirit.

Firstly the article implies that BTS-SIGN recommends ‘trial of treatment’ as a valid diagnostic option. Close reading will show that this has a minor role in BTS-SIGN. The trial of treatment option was included to recognise that this is sometimes needed for pragmatic reasons rather than best practice, and BTS-SIGN laid down reasonable criteria for judging success. In people with intermediate probability of having asthma - those with true diagnostic doubt - objective testing is vital.

There are many areas where both guidelines converge. BTS-SIGN has advocated quality-assured spirometry with reversibility testing as the first test, rather than peak expiratory flow, which many still use, restricting spirometry to COPD. There is no justification for this outdated practice and saying it’s what BTS-SIGN recommends is false. BTS SIGN gives a prominent role to FENO, which is not implemented as GPs don’t have access to it. The NICE draft guideline supports implementation of objective testing as was intended in BTS-SIGN.
For the BMA to suggest that GPs and nurses will not be able to use objective testing as it’s too complicated or that the recommendations represent a change in practice that cannot be achieved is unhelpful if we want to deliver high-quality care to people with asthma.

We recognise there will be challenges to implementing the recommendations. NICE is planning preparatory work with commissioners to ensure these issues are tackled constructively. When done rationally and with proper resources, primary care is good at adopting change.

When I started as a GP, we diagnosed ‘heart failure’ through a stethoscope and treated with diuretics; now we routinely use a blood biomarker (BNP) and imaging scans to make the diagnosis and guide expensive targeted treatment. I don’t remember a big fuss about GPs having to order a blood test or a scan, or refer to a local fast-access clinic? This proposes a similar paradigm-shift and can be achieved as painlessly.

NICE has sought views from organisations, healthcare professionals and members of public whom the guideline will benefit. The guideline development group have considered these comments and their responses will be published on the NICE website alongside the final guideline which is anticipated for August.

Professor Thomas is a member of NICE Guideline Development Group, Asthma Diagnosis and Monitoring and the BTS-SIGN UK Asthma Guideline steering group. He’s also chair of the non-pharmacological management section and a former member of the diagnosis and monitoring section.


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Readers' comments (6)

  • Dear Professor

    ever heard of cost benefit analysis? may explain the benefits of simple blood test and benefits or focused treatment for heart failure vs marginal improvement in asthma diagnosis (theoretically) for limited clinical improvement ( if any) at huge cost ( GP/Nurse?patient time and resource ).

    Next if you're still convinced this approach to asthma is the best way, apply some simple opportunity cost rules - aren't there better improvements in health we could achieve for the additional time and cost involved!

    NICE is losing the plot, the profs response is an apt example why

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  • Does FENO have a 100% negative predictive value?I don't know.If it does it can be a very useful rule out test as the misdiagnosis rate is not insignificant.

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  • Even if it does improve asthma management, it will cost more to deliver. No more money will be coming. So until that eventful day it will not happen.

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  • Vinci Ho

    While I do think exhaled nitric oxide is a more reliable way to distinguish asthma from COPD , this is a very predictable response from a die hard fan of NICE defending its reputation . It opens some questions:
    (1) What are the fundamental principles before issuing a recommendation in NICE? Is it purely based on science and statistics e.g. cost effectiveness , amount of money per quality life years, etc . If that is the case , it fulfils the definition of this ' out of touch' , ' non real' sound bites currently being thrown to and fro , between the Secretary of State and BMA. People in NICE still have a lot to do before they can climb out of its ivory tower .
    (2) Has NICE ever commented about the crisis in general practice ? Well , that is part of the 'get real' revealation it needs to experience . Yes, you can say NICE needs to remain independent but in a political climate with a government like this, will any of the recommendations become an excuse to be used by politicians to impose more and more harsh ,unachievable targets on GPs without real time investment . (I suggest you read the latest figures of health spending as a share of GDP amongst OECD countries , article in July 2015 ,since the Chancellor is probably mumbling the letters GDP in his sleep).
    (3)Do you realise at the end , all these patients will be referred to secondary care as the chance of having a good supply of FeNO machine in general practice is remote?

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  • the waiting list for echo is >3 months -
    there is no similar blood test for asthma like bnp
    ccf is far less common then asthma
    the same will be for reversibilty testing with spirometry and thats only if the patient will attend
    its fine and frankly i doubt any gp will not mind referring but the reality will be patient will not be seen and hence the diagnos and treatment wil not be given - i mean seriously copd still remains vastly underdiagnosed due to lack of access to spirometry and chest clinic capacity

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  • Samuel Lewis

    "BTS-SIGN has advocated quality-assured spirometry with reversibility testing as the first test, rather than peak expiratory flow,
    " can the noble professor quote studies showing spirometry is superior to PEFR ?
    one-stop FEV1/FVC ratios correlate directly with PEFR ( the max gradient of the volume/time spirometry curve ).

    Most asthmatics are easily diagnosed by a peak-flow diary. Those stuck in an exacerbation will need 'trial of steroids' amountiing to a diagnostic test as well as effective therapy.

    How often do we miss Asthma ? Rarely. Does it matter ?? yes - but only if you withhold or delay the treatment (trial).

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