Quality statement 5 (developmental): Suspected severe asthma

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 with suspected severe asthma are referred to a specialist multidisciplinary severe asthma service. [2013, updated 2018]

Rationale

People with suspected severe asthma need specialist assessment to confirm a diagnosis of severe asthma. Specialist assessment is important to revisit adherence to treatment, exclude other causes of persistent symptoms and ensure the most appropriate treatment. Specialist care can help to improve asthma control, prevent asthma attacks and reduce harmful long-term dependence on oral corticosteroids.

Quality measures

Structure

a) Evidence that specialist multidisciplinary severe asthma services are available for people with suspected severe asthma.

Data source: Local data collection, for example, service specifications for children and young people, and adults.

b) Evidence of local arrangements to ensure that people with suspected severe asthma are referred to a specialist multidisciplinary severe asthma service.

Data source: Local data collection, for example, service protocols and referral pathways.

Process

Proportion of people with suspected severe asthma who are referred to a specialist multidisciplinary severe asthma service.

Numerator – the number in the denominator who are referred to a specialist multidisciplinary severe asthma service.

Denominator – the number of people with suspected severe asthma.

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

Outcome

a) Rate of hospital attendance or admission for an asthma attack.

Data source: NHS Digital's Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attack.

b) Proportion of people with asthma who have 2 or more courses of high-dose oral corticosteroids per year.

Data source: Local data collection, for example, electronic prescribing data.

What the quality statement means for different audiences

Service providers (such as hospitals) ensure that processes are in place to identify people with suspected severe asthma so that they can be referred to a specialist multidisciplinary severe asthma service. Service providers ensure that a diagnosis of asthma is made, and adherence and comorbidities are addressed before a referral is made.

Healthcare professionals (such as doctors and nurses) are aware of local referral pathways for severe asthma and refer people with suspected severe asthma to a specialist multidisciplinary severe asthma service. Healthcare professionals ensure that a diagnosis of asthma is made, and adherence and comorbidities are addressed before making a referral. Healthcare professionals ensure that people with suspected severe asthma know what to expect when they are referred.

Commissioners (NHS England) commission specialist multidisciplinary severe asthma services for adults and children and young people and ensure referral pathways are in place. Commissioners ensure that providers identify people with suspected severe asthma so that they can be referred. Commissioners ensure that specialist services have sufficient capacity to meet the demand for assessments for people with suspected severe asthma.

People with suspected severe asthma are referred to a service that specialises in managing severe asthma so that the reasons for their asthma and their treatment can be reviewed.

Source guidance

British guideline on the management of asthma (2019) BTS/SIGN 158, recommendation 10.1

Definitions of terms used in this quality statement

Severe asthma

When a diagnosis of asthma is confirmed and comorbidities have been addressed, severe asthma is defined as asthma that needs treatment with the medicines suggested for steps 4 to 5 in the Global Initiative for Asthma (GINA) guideline (a high-dose inhaled corticosteroid [ICS] with a long-acting beta 2‑agonist [LABA] or leukotriene modifier or theophylline) for the previous year or systemic corticosteroids for 6 months or more of the previous year to prevent it from becoming 'uncontrolled' (that is, controlled asthma that worsens on tapering of these high doses of ICS or systemic corticosteroids [or additional biologics]) or that remains 'uncontrolled' despite this therapy. 'Uncontrolled' is defined as at least 1 of the following:

  • Poor symptom control: Asthma Control Questionnaire consistently greater than 1.5 or Asthma Control Test less than 20.

  • Frequent severe exacerbations: 2 or more bursts of systemic corticosteroids in the previous year.

  • Serious asthma attacks: at least 1 hospitalisation, ICU stay or mechanical ventilation in the previous year.

  • Airflow limitation: after appropriate bronchodilator withhold FEV1 less than 80% predicted (in the face of reduced FEV1/FVC defined as less than the lower limit of normal).

[Global Initiative for Asthma Global strategy for asthma management and prevention, European Respiratory Society/American Thoracic Society International guidelines on definition, evaluation and treatment of severe asthma, and expert opinion]

Specialist multidisciplinary severe asthma service

A dedicated multidisciplinary service with a team experienced in the assessment and management of severe asthma. The service requirements for adults are set out in NHS England's specification for specialised respiratory services (adult) – severe asthma. The service requirements for children are set out in NHS England's specification for paediatric medicine: respiratory with additional information provided in the 2016/17 Prescribed Specialised Services Commissioning for Quality and Innovation (CQUIN) scheme for difficult to control asthma assessment in 12 weeks.

Equality and diversity considerations

Healthcare professionals should ensure that people with learning disabilities are referred to a specialist service if severe asthma is a possibility but it has not been possible to assess all relevant criteria.