Authors' Reply -- Re: Conflicting asthma guidelines cause confusion in primary care
We are grateful to all respondents for their comments. We thank Drs Levy, Ryan, Gaduzo, Thomson and Leung for their generally supportive observations. Dermot Ryan is entirely sceptical about the role of NICE, but we feel that judgements about the relative cost effectiveness of diagnostic approaches and therapeutic interventions are important if we are to provide the best possible care with limited resources.
It is very encouraging that that for NICE, Drs. Menzies Gow and Alexander – and Professor Mark Baker in his remarks quoted in the accompanying news piece – are in favour of a single collaborative and comprehensive UK guideline. We hope that negotiations to achieve this will proceed swiftly.
Menzies Gow and Alexander state that, with regard to the diagnosis recommendations , “objective testing is shown to be cost effective through NICE’s primary care pilot study and in robust economic models developed by our committee” but we would question this. We note the health economic modelling in Appendix M of the guideline that was carried out before the implementation study using inputs from published evidence, but we wonder whether a further analysis using inputs from the implementation study findings would still support use of the NICE algorithm.
A report from the implementation study appears as an appendix to the NICE guideline This study included 143 patients with suspected asthma and 35 patients eventually diagnosed with asthma in the seven participating practices. These highly motivated practices were provided with FeNO testing at no cost, and financial support for spirometry training for staff (which practices had difficulty in accessing). In this study –
• 59% of patients with suspected asthma remained of uncertain diagnostic status at the end of the study period (25% had asthma).
• Spirometry was normal in 73 % of those diagnosed with asthma.
• Diagnostic value of FeNO in the study is not reported.
• Fourteen ( 10% ) of the patients with suspected asthma reached the point in the algorithm of requiring bronchial provocation testing – which was in effect not available – no patient had undergone this test by the time the project closed.
The report states that six of the seven practices would continue to use the diagnostic algorithm if the guideline were issued. We attended the meeting in December 2016 at which the pilot practices reported back and came away with an impression of greater doubt over this, particularly if practices were required to fund FeNO testing and spirometry training themselves. In our view, the experience in the pilot bore out our concerns.
Importantly, NICE’s economic analysis made the unrealistic assumption that all FeNO testing and spirometry would be performed in primary care, and allowed no costs for increased referrals from primary care for asthma diagnosis. This strikes us as a major omission.
Professor Baker states that “ neither guideline is wrong”, but in respect of the recommendations for diagnosis we disagree. We think the NICE diagnostic algorithm is flawed. Spirometry is normal in most primary care patients with asthma, the role of FeNO remains controversial among experts, and bronchial provocation testing is effectively unavailable. We fully support wider use of objective testing, but think that peak flow monitoring should be the first line objective test in primary care. We remain of the view expressed in our initial submission to the NICE consultation that it would have been better not to publish this part of the guideline.
We agree with Professor Littlejohn that money is better spent supporting implementation than duplicating guidelines. But the implementation costs for the controversial NICE diagnostic algorithm would be high and there is no indication that such funding is available. We wonder why the Department of Health referred to NICE the topic of asthma which was already well covered by the highly respected and NICE approved BTS/SIGN guideline. The single national guideline that we need should indeed be co-badged, but we think it would be better for NICE to support the continuation of the comprehensive and familiar BTS/SIGN guideline.
Rapid Response:
Authors' Reply -- Re: Conflicting asthma guidelines cause confusion in primary care
We are grateful to all respondents for their comments. We thank Drs Levy, Ryan, Gaduzo, Thomson and Leung for their generally supportive observations. Dermot Ryan is entirely sceptical about the role of NICE, but we feel that judgements about the relative cost effectiveness of diagnostic approaches and therapeutic interventions are important if we are to provide the best possible care with limited resources.
It is very encouraging that that for NICE, Drs. Menzies Gow and Alexander – and Professor Mark Baker in his remarks quoted in the accompanying news piece – are in favour of a single collaborative and comprehensive UK guideline. We hope that negotiations to achieve this will proceed swiftly.
Menzies Gow and Alexander state that, with regard to the diagnosis recommendations , “objective testing is shown to be cost effective through NICE’s primary care pilot study and in robust economic models developed by our committee” but we would question this. We note the health economic modelling in Appendix M of the guideline that was carried out before the implementation study using inputs from published evidence, but we wonder whether a further analysis using inputs from the implementation study findings would still support use of the NICE algorithm.
A report from the implementation study appears as an appendix to the NICE guideline This study included 143 patients with suspected asthma and 35 patients eventually diagnosed with asthma in the seven participating practices. These highly motivated practices were provided with FeNO testing at no cost, and financial support for spirometry training for staff (which practices had difficulty in accessing). In this study –
• 59% of patients with suspected asthma remained of uncertain diagnostic status at the end of the study period (25% had asthma).
• Spirometry was normal in 73 % of those diagnosed with asthma.
• Diagnostic value of FeNO in the study is not reported.
• Fourteen ( 10% ) of the patients with suspected asthma reached the point in the algorithm of requiring bronchial provocation testing – which was in effect not available – no patient had undergone this test by the time the project closed.
The report states that six of the seven practices would continue to use the diagnostic algorithm if the guideline were issued. We attended the meeting in December 2016 at which the pilot practices reported back and came away with an impression of greater doubt over this, particularly if practices were required to fund FeNO testing and spirometry training themselves. In our view, the experience in the pilot bore out our concerns.
Importantly, NICE’s economic analysis made the unrealistic assumption that all FeNO testing and spirometry would be performed in primary care, and allowed no costs for increased referrals from primary care for asthma diagnosis. This strikes us as a major omission.
Professor Baker states that “ neither guideline is wrong”, but in respect of the recommendations for diagnosis we disagree. We think the NICE diagnostic algorithm is flawed. Spirometry is normal in most primary care patients with asthma, the role of FeNO remains controversial among experts, and bronchial provocation testing is effectively unavailable. We fully support wider use of objective testing, but think that peak flow monitoring should be the first line objective test in primary care. We remain of the view expressed in our initial submission to the NICE consultation that it would have been better not to publish this part of the guideline.
We agree with Professor Littlejohn that money is better spent supporting implementation than duplicating guidelines. But the implementation costs for the controversial NICE diagnostic algorithm would be high and there is no indication that such funding is available. We wonder why the Department of Health referred to NICE the topic of asthma which was already well covered by the highly respected and NICE approved BTS/SIGN guideline. The single national guideline that we need should indeed be co-badged, but we think it would be better for NICE to support the continuation of the comprehensive and familiar BTS/SIGN guideline.
Dr Duncan Keeley
Dr Noel Baxter
Primary Care Respiratory Society UK
Competing interests: No competing interests