Quality statement 1 (developmental): Objective tests to support diagnosis

Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

People aged 5 years and over with suspected asthma have objective tests to support diagnosis. [2013, updated 2018]

Rationale

Asthma can be misdiagnosed, which means that people with untreated asthma are at risk of an asthma attack, and people who do not have asthma receive unnecessary drugs. Following taking an initial history and assessment, objective tests can help healthcare professionals to diagnose asthma correctly in people over 5 years. There is no single objective test to diagnose asthma and the correct initial test may identify the need for further tests. The basis on which a diagnosis of asthma is made should be documented. Children under 5 are unable to perform objective tests, and treatment should be based on observation and clinical judgement until the child is old enough for objective testing.

Quality measures

Structure

a) Evidence of local arrangements or referral pathways to asthma diagnostic hubs to ensure that people aged 5 years and over with suspected asthma have objective tests to support diagnosis.

Data source: Local data collection, for example, service protocol or referral pathways.

b) Evidence of local arrangements to ensure that healthcare professionals are trained and competent to carry out and interpret objective tests to support diagnosis of asthma.

Data source: Local data collection, for example, training records and competency assessments.

c) Evidence of local processes to ensure that the basis for a diagnosis of asthma is documented.

Data source: Local data collection, for example, service protocol.

Process

a) Proportion of adults aged 17 years and over with newly diagnosed asthma who have a record of a fractional exhaled nitric oxide (FeNO) test to support diagnosis.

Numerator – the number in the denominator who have a record of a FeNO test to support diagnosis.

Denominator – the number of adults aged 17 years and over with newly diagnosed asthma.

Data source: Local data collection, for example, audit of patient health records.

b) Proportion of people aged 5 years and over with newly diagnosed asthma who have a record of a spirometry test to support diagnosis.

Numerator – the number in the denominator who have a record of a spirometry test to support diagnosis.

Denominator – the number of people aged 5 years and over with newly diagnosed asthma.

Data source: Local data collection, for example, audit of patient health records.

c) Proportion of people aged 5 years and over with newly diagnosed asthma who have a record of the objective tests used to support diagnosis.

Numerator – the number in the denominator who have a record of the objective tests used to support diagnosis.

Denominator – the number of people aged 5 years and over with newly diagnosed asthma.

Data source: Local data collection, for example, audit of patient health records.

Outcome

Prevalence of asthma.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services and hospitals) ensure that processes are in place for people aged 5 years and over with suspected asthma to have objective tests to support diagnosis. Depending on local arrangements, this may involve referral to a local asthma diagnostic hub. Service providers ensure that healthcare professionals are trained and competent in performing and interpreting objective tests, and that processes are in place to record the basis for a diagnosis of asthma (for example, see NICE's asthma diagnosis implementation data collection sheet).

Healthcare professionals (such as doctors, nurses and pharmacists) are aware of local arrangements for accessing objective tests for asthma and ensure that people aged 5 years and over with suspected asthma have objective tests to support diagnosis. Healthcare professionals record the basis for a diagnosis of asthma.

Commissioners (clinical commissioning groups and NHS England) commission services that ensure that people aged 5 years and over with suspected asthma have objective tests to support diagnosis. Commissioners consider whether local diagnostic hubs for asthma would optimise investment in equipment and staff training.

People aged 5 years and over with suspected asthma have tests to confirm if they have asthma. An accurate diagnosis will make sure they get the treatment they need.

Source guidance

Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80, recommendations 1.1.2 and 1.3.22

Definitions of terms used in this quality statement

Objective tests to diagnose asthma

Tests carried out to help determine whether a person has asthma, the results of which are not based on the person's symptoms, for example, tests to measure lung function or evidence of inflammation. There is no single objective test to diagnose asthma. Objective tests should be performed in accordance with the algorithms in the NICE guideline.

The initial test for children and young people aged 5 to 16 years is spirometry. A bronchodilator reversibility (BDR) test should be considered if spirometry shows an obstruction. If diagnostic uncertainty remains after spirometry and BDR, consider a FeNO test. If diagnostic uncertainty remains after FeNO, monitor peak flow variability for 2 to 4 weeks.

The initial tests for adults aged 17 years and over are FeNO followed by spirometry. A BDR test should be carried out if spirometry shows an obstruction. If diagnostic uncertainty remains after FeNO, spirometry and BDR, monitor peak flow variability for 2 to 4 weeks. If diagnostic uncertainty remains after measuring peak flow variability, refer for a histamine or methacholine direct bronchial challenge test.

[NICE's guideline on asthma, terms used in this guideline and algorithms B and C]

Suspected asthma

A potential diagnosis of asthma based on symptoms and response to treatment that has not yet been confirmed with objective tests.

[NICE's guideline on asthma, terms used in this guideline]

Equality and diversity considerations

If a child is unable to perform objective tests when they are 5 years, healthcare professionals should continue treatment based on observation and clinical judgement and should try doing the tests again every 6 to 12 months until the child is able to perform the tests. If it is decided that a child, adult or young person with symptoms suggesting asthma cannot perform a particular test, healthcare professionals should try to perform at least 2 other objective tests and diagnose suspected asthma based on symptoms and any positive objective test results.

Some people with learning disabilities or mental health problems may need additional support to help them to perform objective tests to diagnose asthma.