Intended for healthcare professionals

Letters Conflicting asthma guidelines

Authors’ reply to Ryan, Menzies-Gow and Alexander, and Littlejohns

BMJ 2018; 360 doi: (Published 08 March 2018) Cite this as: BMJ 2018;360:k973
  1. Duncan Keeley, executive committee policy lead,
  2. Noel Baxter, chair
  1. Primary Care Respiratory Society UK, Solihull, UK
  1. duncan.keeley{at}

Ryan is sceptical about the role of the National Institute for Health and Care Excellence in producing guidelines, but judgments about the relative cost effectiveness of diagnostic approaches and treatments are important if we are to provide the best possible care with limited resources.12

We are encouraged that Menzies-Gow and Alexander3—and Baker in his remarks quoted in the accompanying news piece4—are in favour of a single collaborative and comprehensive UK guideline and hope that negotiations to achieve this will proceed swiftly.

We question Menzies-Gow and Alexander’s statement that “objective testing is shown to be cost effective in NICE’s primary care pilot study and in robust economic models developed by our committee.” The health economic modelling in appendix M of the guideline was carried out before the implementation study using inputs from published evidence—would further analysis using inputs from the implementation study findings still support use of the NICE algorithm?

Appendix Q to the NICE guideline is a report from the implementation study. This feasibility project included 143 patients with suspected asthma and 35 patients eventually diagnosed with asthma in seven participating practices. These highly motivated practices were provided with fractional exhaled nitric oxide (FeNO) testing equipment at no cost and financial support for spirometry training for staff (which practices had difficulty accessing). At the end of the study period, 59% of patients with suspected asthma remained of uncertain diagnostic status (25% had asthma). Spirometry was normal in 73% of those diagnosed with asthma, and 14 (10%) of the patients with suspected asthma reached the point in the algorithm of requiring bronchial provocation testing, which was not available—no patient had undergone this test by the time the project closed. The diagnostic value of FeNO testing was not reported.

The report states that six of the seven practices would continue to use the diagnostic algorithm if the guideline were issued, but at a meeting we attended in December 2016 the pilot practices did not seem so positive, particularly if they were required to fund FeNO testing and spirometry training themselves. The pilot experience seems to substantiate our concerns.

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 is a major omission.

We agree with Littlejohns that money is better spent supporting implementation than duplicating guidelines.5 But 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 the topic of asthma to NICE when it was already well covered by the British Thoracic Society and Scottish Intercollegiate Guideline Network’s (BTS/SIGN) highly respected and NICE approved guideline. The single national guideline that we need should be a collaboration, but it would be better for NICE to support the continuation of the comprehensive and familiar BTS/SIGN guideline.


  • Competing interests: The Primary Care Respiratory Society, a multiprofessional organisation promoting optimal primary respiratory care, is funded by membership subscriptions and support grants from drug companies. Both authors are GPs, and NB is a member of the NICE chronic asthma management guideline committee.


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