Hold it, now breathe…why GPs are angry over asthma diagnosis
‘Asthma: millions wrongly diagnosed, ’ read the headline in the Daily Telegraph. ‘GPs warned that too many children are told they have disease without proper tests, ’ the article went on.
It was the latest in a long line of articles critical of GPs this year, with respiratory experts claiming asthma diagnosis has become ‘trivialised’ and inhalers are now a ‘fashion accessory’.
The accusation that GPs are over diagnosing asthma in part prompted NICE to recommend GPs use a new battery of tests to diagnose the condition, but there is anger in the profession over the repeated charges.
As RCGP chair Dr Maureen Baker pointed out in response to the Telegraph headline: ‘No single test can definitively diagnose asthma, and this can make it difficult to do in primary care.’
The Telegraph headline was based on Dutch research published in the BJGP that concluded 53% of children with asthma were incorrectly diagnosed.
In April, an opinion piece in the Archives of Disease in Childhood by Professor Andy Bush, a consultant paediatric chest physician at the Royal Brompton and Harefield, and Dr Louise Fleming, a clinical senior lecturer in respiratory paediatrics at Imperial College London, claimed children still die because of failures in basic management of the condition.
The authors said: ‘We propose that one contributing factor is that the diagnosis of asthma has been trivialised and inhalers are dispensed for no good reason, and have become almost a fashion accessory.’
They argued that symptoms – such as a cough – are being used to make an asthma diagnosis and this is leading to over diagnosis, citing an Australian study of a group of children with a chronic cough, which found only 5% had a confirmed diagnosis of asthma by the end of the study.
NICE’s intervention in January 2015 remains the most powerful, however. It reviewed a number of international studies on asthma patients, and concluding ‘that up to 30% do not have clear evidence of asthma’ – equating to around 1 million patients in the UK.
Draft guidelines published at the same time claim that diagnosing patients based only on symptoms has a moderate to low sensitivity and specificity.
They recommend objective testing for asthma, advising GPs to perform a range of assessments – including FeNO and spirometry as first-line investigations in adults and children over five – completely bypassing the option to offer a trial of therapy as a means to diagnose asthma, as advocated by British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) guidelines.5 The NICE guidelines also say that a FeNO test should be offered if diagnosis is being considered in anyone over 16 who has normal spirometry, or obstructive spirometry but negative reversibility.
GP respiratory experts at the time warned that the guidelines had ‘huge implications’ and that it could be ‘dangerous’ to claim that many people diagnosed with asthma may not have it.
The whole row has incensed GP respiratory experts, who have pointed out that asthma is a variable condition and there may be as many cases missed as there are diagnosed.
Dr Mark Levy, respiratory lead at NHS Harrow CCG and a GP in north London, says: ‘We don’t have enough data. Asthma may be over diagnosed, but it may also be underdiagnosed.’
Dr Levy dismisses NICE’s recommendation to use spirometry to diagnose asthma as ‘ill thought-out’ and impractical: ‘If spirometry is done when the person is broncho dilated, what is the GP supposed to do? Daily spirometry until variable airflow obstruction is demonstrated? I don’t think so.’
Dr Duncan Keeley, Oxfordshire GP and member of the Primary Care Respiratory Society, expressed concern at the validity of using international diagnosis data to justify a change in UK practice.
He says: ‘There are not enough recent studies based in the UK to fully assess the extent of this. NICE based some of its guideline on an Australian study from 10 years ago, but this has limited relevance to the UK and it would be interesting to know what research conducted in a UK setting would find.’
Dr Keeley adds that the NICE guidance – if approved – will increase referrals, putting pressure on the health service at a time when it least needs it.
The overall situation is confusing for GPs. With NICE currently gathering evidence to support its draft guidance via its pilots, GPs could have two potentially conflicting sets of advice, at the same time as facing criticism for their current management of asthma.
The profession cannot yet breathe a sigh of relief.
Read the full article here on Pulse Today.