Two pathways, one patient; UK asthma guidelines

The first widely disseminated ‘asthma guideline’ came out of Australia and New Zealand in 1989,1 followed shortly by the British Thoracic Society (BTS) in 1990,2 the United States National Heart, Lung, and Blood Institute Expert Panel Report in 19913 and the Global Initiative for Asthma (GINA) strategy document in 1995.4 All have benefited from regular updates, the BTS collaborating with the Scottish Intercollegiate Guideline Network (SIGN) since 2003, most recently in 2016.5 Each new iteration of the asthma guidelines was written by experts in the field and based on best available evidence. It is not known whether these guidelines (or any others) have improved the care of people with asthma; asthma prevalence has continued to rise (although it may now have plateaued), and deaths overall have not fallen, although this statistic is driven entirely by an ageing population, as deaths in England from asthma in the young have in fact dropped dramatically.6 It is likely, however, that guidelines have reduced variation in diagnosis and treatment of this complex disease.In 2013, the National Institute for Health and Clinical Excellence (NICE) joined the guideline party, with a new approach that included consideration of health economics as well as clinical effectiveness. Their rationale included concerns that deaths were not falling, drug costs were rising and over-diagnosis and under-diagnosis still a significant issue. While the strength of evidence for each of these points varies (drug costs are rising across all areas of medicine, and over-diagnosis rates of 30% have been demonstrated repeatedly, even in recently diagnosed individuals7), all healthcare professionals involved in the care of people with asthma would recognise that each of these issues do need careful consideration. However, what had not been established was whether these failures were …