Conflicting asthma guidelines cause confusion in primary care
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k29 (Published 09 January 2018) Cite this as: BMJ 2018;360:k29
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I understand clinicians' concern of having two national guidelines which give conflicting recommendations.<1> However, is this incident a wake-up call that today clinicians are too dependent on guidelines?
"The NICE guidelines said..." This is probably the trump card used whenever clinicians want to defend their judgement. But when you inquire about the rationale and evidence behind the guidelines, some clinicians can suddenly become speechless. They do not always try to learn the reasons behind the recommendations. Some recommendations can simply be opinion-based, because no better evidence is available.
Even if randomised-controlled trials and systematic reviews are available, the guidelines extrapolate these data to apply to the general population. Clinicians must understand that the clinical context of each patient is unique, and can make certain guidelines inapplicable. This makes clinicians irreplaceable, because they can apply clinical evidence, along with their patients' history, examination and investigation findings, to determine the management plans and which guidelines to follow.
Perhaps, it is time for clinicians to put their critical thinking caps on, rather than solely regurgitating guidelines. Or else, the NHS could replace clinicians with printers which reproduce guidelines, and have laymen to blindly follow the guidelines. That would be a bad cost-saving strategy that hinders patient care.<2>
After all, many clinicians learned evidence-based medicine and critical analysis during their training. There are reasons why these topics are in their school curriculum.
References
1. Keeley D, Baxter N. Conflicting asthma guidelines cause confusion in primary care. BMJ. 2018;360:k29.
2. Rimmer A. Spend more on NHS or see services deteriorate further, hospital leaders warn. BMJ. 2018;360:k175.
Competing interests: No competing interests
Keeley and Baxter (1) make a strong case for a single UK asthma guideline and for NICE to contribute its expertise in cost-benefit analysis to the widely used and respected BTS/SIGN guideline.(2)
The recent NICE guideline (3) has produced confusion rather than clarity particularly on asthma diagnosis in children. Most children with asthma are managed well in primary care. The NICE diagnostic algorithm for children over the age of 5years puts spirometry as the first diagnostic test and fails to acknowledge that the time and expertise required to achieve reproducible results in young children is unlikely to be available in most general practices. The Primary Care Respiratory Society consensus advice (4) on how to deal with the conflicting guidance is therefore most welcome.
Guidelines are time consuming and expensive to produce.
Many respiratory professionals have devoted hours of their own time as contributors to these guidelines wishing only to improve asthma care.
The statement by Mark Baxter from NICE (5) that he accepts the need for a single guideline is welcome and all respiratory professionals must hope that the “stumbling blocks” of different “methodologies” are addressed immediately so that there is no repetition of dual guidelines for asthma or any other condition.
1. Conflicting asthma guidelines cause confusion in primary care BMJ 2018;360:k29
2. British Thoracic Society/Scottish Intercollegiate Guideline Network. British guideline on the management of asthma. 2016.
3. National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management. 2017.
4. Primary Care Respiratory Society UK. Asthma guidelines briefing document. 2017.
5. “Conflicting” UK asthma guidelines should be streamlined, experts say BMJ 2018;360:k99
Competing interests: No competing interests
I welcome this editorial from the PCRS-UK, and agree with most of their points, particularly that the UK should have a single cohesive guideline for asthma care. The UK has the highest childhood death rates for asthma in Europe (1) and third highest in high income countries worldwide, (2) Furthermore the UK Government commissioned, national review of asthma deaths (NRAD) (3) demonstrated that over 60% of asthma deaths are associated with major preventable factors known for over 50 years, coupled with failure to implement the UK guidelines. Sadly, 18 of the 19 NRAD recommendations have not been implemented nationally nearly three years after publication, despite at least two subsequent high profile inquests resulting in Regulation 28 statements based on the coroners' conclusions these were preventable asthma deaths. (4, 5) In fact, the previously published National Institute for Health and Care Excellence (NICE) Quality Statement 25 (6) had not been implemented in my view, in either of these two cases; so rather than commissioning new guidelines, no doubt at considerable monetary expense and professional time, perhaps a national directive to implement existing guidelines and NRAD should have been placed!
While diagnostic hubs are a good idea, even the cash strapped NHS its unlikely that we will see these implemented in our lifetimes. It is hard to understand why NICE (7) have strongly recommended their diagnostic algorhythm despite such dismal results of their own feasibility study; which in my view should have been subjected to the same level of scientific rigour applied to the other evidence; with a logical conclusion to abandon it rather than herald its implementation - albeit phased. In particular : less than 30% of those eventually diagnosed with asthma had any evidence of airflow obstruction; 59% had an ‘uncertain diagnosis’; and it took an average of 57 minutes (range 30–100, SD 18) of scarcely available repeated consultation time in general practice to apply the algorhythm. (8)
On treatment, NICE quite correctly defines asthma as an inflammatory condition and yet, recommends, in my view, illogically and in contrast with the British Thoracic Society (BTS)/Scottish Intercollegiate Guideline Network (SIGN) guideline,(9) that short acting bronchodilator (SABA) reliever inhalers should be prescribed for newly diagnosed people with asthma. Furthermore, it is astounding that in contrast with BTS/SIGN, Global Initiative for Asthma (GINA) evidence based strategy document, (10) and systematic review evidence (11) most other international asthma guidelines in existence, NICE has recommended the addition of Leucotriene receptor antagonists (LTRAs) rather than long acting beta-agonists (LABAs) to treatment for people with poorly controlled asthma.
Hopefully, common sense will prevail and the powers that be will see fit to agree one clear, practical guideline for the UK; in my view, the evidence based, GINA Strategy, (10) which is written by experts, specifically for generalists, which is updated every six months, and free from political or industry influence, would be a good start – but then some may say I’m biased – being part of the GINA group as well as the Acute Asthma BTS/SIGN Guideline group!
Bibliography
1. Wolfe I, Thompson M, Gill P, Tamburlini G, Blair M, van den Bruel A, et al. Health services for children in western Europe. The Lancet. 2013;381(9873):1224-34.
2. Global Asthma Network. The Global Asthma Report 2014.2014. Available from: http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf.
3. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report: Royal College of Physicians. London; 2014 [Available from: http://www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-fu....
4. Terrence Carney. Regulation 28 statement in the matter of Tamara Mills (Deceased). 2015 [Available from: https://www.judiciary.gov.uk/wp-content/uploads/2016/01/Mills-2015-0416.pdf.
5. Dr Shirley Radcliffe. Regulation 28 Statement in the matter of Michael Uriely (deceased) 2017 [Available from: https://www.judiciary.gov.uk/wp-content/uploads/2017/03/Uriely-2017-0069....
6. Asthma. NICE quality standard 25 (2013): National Institute for Health and Clinical Excellence; 2013 [updated 3/6/2013. Available from: http://publications.nice.org.uk/quality-standard-for-asthma-qs25.
7. NICE Asthma Guideline - Full Evidence 2017 [Available from: https://www.nice.org.uk/Guidance/NG80/Evidence
8. Commissioned by the National Institute for Health and Care Excellence (NICE). Asthma: diagnosis and monitoring of asthma in adults, children and young people. NICE guideline NG80 Appendices A - R 2017 [Available from: https://www.nice.org.uk/guidance/ng80/evidence/appendices-a-r-pdf-465617...
9. British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 153 - The British Guideline on the Management of Asthma. 2016 [Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/a...
10. The Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA).2017. Available from: http://www.ginasthma.org/.
11. Chauhan BF, Ducharme FM. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma: John Wiley & Sons, Ltd; 2014 [Available from: http://dx.doi.org/10.1002/14651858.CD003137.pub5
Competing interests: I have no competing interest with regard to my letter which is written in the interest of people with asthma in the UK, who I believe are getting a raw deal through a lack of a national cohesive forward plan for managing asthma, preventing attacks and preventing preventable deaths. In the last two years I have accepted fees for Consultancy from Teva UK Limited, Novartis, Clement Clarke International, and Boehringer Ingelheim. For the sake of clarity: I have accepted lecture fees from - Teva UK Limited, AZ, GSK, Chiesi Pharmaceuticals, NAPP Pharmaceuticals mainly for lectures on the NRAD and lessons from asthma deaths. I have served on Drug Safety Monitoring Board for multinational studies by Chiesi Pharmaceuticals. I serve on the GINA Executive (no personal funding - however, travel and accommodation for meetings has been paid for)
Re: Conflicting asthma guidelines cause confusion in primary care
It would of course be desirable to see one single guideline for the management of asthma in the United Kingdom, but the two organisations, SIGN/BTS and NICE have two separate and differing underlying philosophies which make this highly unlikely. On the one hand we have the SIGN/BTS guidelines, internationally recognised and respected, who strive for clinical excellence, and on the other hand we have NICE, whose motives are cost minimisation to the extent that it proposes a therapeutic pathway which at best is sub-optimal and at worst could cause actual harm. Both parties agree on the need to make an accurate diagnosis of asthma and to record the grounds on which this diagnosis was made. They disagree fundamentally on the way of achieving this. NICE has not taken into account the potential costs and opportunity costs of their proposed diagnostic work up nor the cost of educating and upskillng health care professionals in new techniques (FeNO) let alone the cost of the equipment and consumables which will be needed. It is important to recognise that their recommendations for diagnosis lack a clear evidence base.
The purpose of guidelines is in essence to act as a repository of best available knowledge: the purpose of evidence based medicine was to use this evidence adapted to the needs of the individual patient using the skill and experience of the clinician to optimise outcomes. (1) It is unfortunate that guidelines have become abused by politicians and health care managers alike to force clinicians into slavish adherence. In turn such adherence blunts the skill of clinical reasoning, an essential component of good clinical practice.
The profession is thus somewhat at a crossroads: Is the purpose of medicine to help people in an evidence based fashion or does it abrogate responsibility for high quality clinical care by accepting without question that NICE has all the answers? There is a great need to have this debate as a matter of urgency.
(1) Sackett, D.L., 1997, February. Evidence-based medicine. In Seminars in perinatology (Vol. 21, No. 1, pp. 3-5). WB Saunders.
Competing interests: I was twice a member of the BTS/SIGN Asthma Guideline. I was a previous chairman of the General Practitioners in Asthma Group ( now PCRS UK). I have been sponsored to attend meetings, attend advisory panels and deliver talks on behalf of most companies in the respiratory field. I am the current President of the Respiratory Effectiveness Group http://effectivenessevaluation.org/