An interview with Dr. Duncan Keeley, General Practitioner, conducted by April Cashin-Garbutt, MA (Cantab) following Asthma UK’s diagnostics event: New collaboration opportunities to meet the 21st Century challenge of developing accurate asthma diagnostic tools.
What are the main problems in asthma diagnosis in primary care in the UK?
There are three kinds of problem – though we do not have any reliable quantitative data to know how common they are.
Firstly, there is sometimes a delay in making an asthma diagnosis in people who have asthma – this is less common than in the past, but it still happens.
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Secondly, people can be given an asthma diagnosis when they do not have asthma – the commonest issue being in children under five with simple viral associated wheeze.
Thirdly an asthma diagnosis is given when there is a more serious underlying problem such as cystic fibrosis in children or heart disease in adults.
How much is known about the extent of misdiagnosis of asthma in Canada?
One recent survey of adults with an asthma diagnosis in Canada found that one third of those patients who took part in the survey were able to stop treatment without recurrence of their symptoms.
It is important though to remember that asthma is a condition which sometimes resolves or becomes dormant for substantial periods of time, so it is possible that some of these people did have asthma at an earlier point in time.
It is also possible that people who doubted whether they still had asthma might have been more likely to take part in the survey.
What are the adverse consequences of misdiagnosis?
It depends on what the problem is, but there can be delay in giving effective asthma treatment, or use of asthma treatments in people who do not need them with consequent waste of resources and unnecessary side effects – or delay in the detection and treatment of more serious problems
Do you think it will be possible to develop a definitive test for asthma in the near future?
I do not know. If there were a simple reliable and affordable non-invasive test for asthma that would be wonderful – especially if that test was useful for guiding or individualizing treatment choices.
There is a major research effort to find such a test, but I don’t think we have one yet, and I think that asthma will likely remain a clinical diagnosis – where history taking, examination and supportive tests are all important.
What needs to be done to improve education around asthma?
Making a diagnosis of asthma involves taking a good thorough history and examining the person and very importantly following the person over time and assessing response to any treatments that are started.
This needs to be supported by repeated objective tests of narrowing of the airways by peak flow measurements or spirometry, although it is difficult to do these tests in small children.
Training in how to do this and in the alternative diagnoses to consider in people with cough or breathlessness is very important in the undergraduate training of doctors and nurses.
But things sometimes get missed in basic training – the curriculum for both doctors and nurses is very crowded – and health professionals may need their knowledge and skills refreshing, so postgraduate training is also important – such as the current Primary Care Respiratory Academy initiative by the Primary Care Respiratory Society UK in association with Cogora.
Good ongoing health professional education costs money – and this is another call on scarce resources. The idea that all you need are the test results to make a diagnosis is almost always wrong – and thinking this way is a common reason for diagnostic errors in medicine.
How can the organisation of care for asthma be improved?
What is needed is for well trained health professionals – doctors and nurses – to have the time to give people in order to come to a correct diagnosis. This also involves careful follow up, and it is much better for there to be continuity of care with the same health professionals seeing the person over time.
Excellent clinical records are vital since continuity of care is not always possible. Work in primary care is often undertaken under considerable time constraints and better resources are needed in primary care to allow health professionals the time they need to do a good job.
Asthma, and suspected asthma, are too common for asthma to be a condition diagnosed and managed by specialist services – though it is very important for primary care to have quick access to specialists in cases of doubt or difficulty, and to know when people should be referred.
There are also exciting developments in simple mobile phone based devices and apps for help in diagnosing and monitoring asthma.
What further research is needed?
We need to research new and better diagnostic tests, but also how best to use the tests we already have. Serial peak flow measurement – a very simple and valuable way of looking for variable airways obstruction, is under-researched because it has been around for so long.
The science of how best to combine existing tests – and the implementation science of how to translate knowledge about diagnosis into good clinical practice is also under-researched.
What do you think the future holds for asthma diagnostics?
The Chinese leader Chou en Lai once said that the future is hard to predict. I hope that we will see the development of new and better tests for asthma – ideally non-invasive tests based on inflammatory markers in exhaled air, that are reliable and sufficiently inexpensive to be put into routine use. But I think that the need for good clinical practice in the application and interpretation of the tests is likely to remain important.
Where can readers find more information?
Online resources are easiest but care is needed to use a reliable source of information: Patient.co.uk and Asthma UK are good places to start – but seeing a health professional is best.
About Dr. Duncan Keeley
Dr Duncan Keeley is a GP in Oxfordshire. He trained in Cambridge and at the London Hospital before undertaking hospital work for 10 years in the UK and in Zimbabwe – mainly in paediatrics – before becoming a GP.
He has a longstanding special interest in asthma and respiratory problems. He is Executive Committee Policy Lead for the Primary Care Respiratory Society (UK).
Innovative study on asthma inflammation funded by NIH/NIAID grant