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    Consultation on new and updated NICE indicators: GID-IND10330 to GID-IND10335 & GID-IND10337 to GID-IND10338

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    Asthma: annual review (high risk patients)

    GID-IND10319: The percentage of patients with asthma on the register with a risk factor for poor outcomes, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control, a recording of the number of exacerbations, an assessment of inhaler technique and a written personalised action plan.

    Indicator type

    General practice indicator suitable for use in the QOF

    Rationale

    NICE guidance recommends all people with asthma are reviewed at least annually, and this is reflected in existing NICE indicator IND273 (QOF AST007). This draft indicator has been developed as a complementary to IND273 and focuses on those most at risk of poor outcomes (including death, hospital admission, and the need for out-of-hours contacts or visits to an emergency department for asthma exacerbations). A risk factor for poor outcomes is defined as any of the following in the year preceding the current reporting period:

    • 6 or more short-acting beta2 agonist (SABA) inhalers

    • 2 or more oral corticosteroids

    • 2 or more visits to an emergency department for asthma

    • Any hospital admission for asthma.

    Testing by NICE in June 2025 of Clinical Practice Research Datalink (CPRD) Aurum found that using this definition of risk factors for poor outcomes equates to around 28% of all people aged 6 years or over with asthma. CPRD Aurum March 2025 (Version 2025.03.001) [Data set]. Clinical Practice Research Datalink. https://doi.org/10.48329/6570-ge08.

    Following stakeholder feedback on the availability of fractional exhaled nitric oxide (FeNO), this has not been included as a means of assessing asthma control within an asthma review. If progressed, the indicator will be reviewed as access to FeNO increases.

    Source guidance

    BTS / NICE / SIGN guideline on asthma: diagnosis, monitoring and chronic asthma management (2024) recommendations 1.5.1, 1.5.2, 1.14.1, 1.14.2, 1.15.1 and 1.16.1.

    Specification

    Numerator: The number of patients in the denominator who have had an asthma review in the preceding 12 months that included an assessment of asthma control, a recording of the number of exacerbations, an assessment of inhaler technique and a written personalised action plan.

    Denominator: The number of patients on the asthma register (see the NICE indicator IND186) with a risk factor for poor outcomes.

    Definition: A risk factor for poor outcomes is defined as any of the following in the year preceding the current reporting period:

    • 6 or more short-acting beta2 agonist (SABA) inhalers

    • 2 or more oral corticosteroids

    • 2 or more visits to an emergency department for asthma

    • Any hospital admission for asthma.

    Exclusions: Children aged 5 years and under.

    Personalised care adjustments or exception reporting should be considered to account for situations where the patient declines or does not attend.

    Questions for consultation:

    5. The definition of 'risk factors for poor outcomes' originates from BTS/ NICE/SIGN guideline NG245 Asthma, recommendation 1.15.1. The risk factor in the recommendation relating to SABA inhalers uses a threshold of more than 2 per year. However, the NICE Indicator Advisory Committee suggested that this would identify too many people as high risk (this concern was validated by testing in CPRD Aurum which found 45% of people with asthma were prescribed 3+ SABAs per year). Additionally, feedback from NHS England noted that for data extraction purposes, a high prescription count could cause issues for IT system suppliers. Therefore, a pragmatic cutoff of 6 or more SABA inhalers has been included in the indicator definition. Is this a suitable value to identify patients at risk of poor outcomes?

    6. For the risk factors based on visits to an emergency department or hospital admission, it would not be possible to link to Hospital Episode Statistics (HES) data if extracting data via the General Practice Extraction Service for QOF. Therefore, the proposal is for patients with these risk factors to be identified by SNOMED codes in general practice records only. It is proposed that 2 means of identifying relevant patients are used:

    (i) presence of a code for an asthma-specific emergency attendance/hospital admission; or

    (ii) presence of a generic code for emergency attendance/hospital admission plus coding of a same-day asthma/lower-respiratory tract infection diagnosis.

    Testing this approach in CPRD Aurum found that compared to HES data, CPRD data for hospital admissions for asthma may be comparable, however emergency attendance for asthma may be underestimated. The NICE Indicator Advisory Committee agreed that it would be preferable to include the identified patients even though some patients with these risk factors may be omitted. Do you agree with this approach?