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Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE

18 Dec, 17 | by rtaylor

John White, James Paton, Robert Niven, Hilary Pinnock
On behalf of the British Thoracic Society

The British Thoracic Society first produced a guideline on asthma and its management in 1990. The first collaborative guideline with the Scottish Intercollegiate Guideline Network (SIGN) using evidence-based medicine methodology was published in 2003 (1). It has since become a mainstay of asthma management across the UK and beyond, with updates published regularly every 18 to 24 months. The latest BTS/SIGN guideline for the management of asthma was published in 2016 (2).  Both BTS and SIGN are committed to continuing updates with the next update planned for publication in 2019.

Following publication of NICE Guidelines for diagnosis and monitoring, and for management of asthma (3, 4, 5) there are now two if not three national guidelines, for England at least, with some (apparently) striking differences. This statement considers the similarities and differences to assist clinical colleagues in the care of people with asthma.

The evidence base considered by the BTS/SIGN and NICE guideline development groups is broadly the same for each guideline, but the methodology used to produce recommendations is significantly different:

  • SIGN methodology is a multidisciplinary clinically-led process which employs robust critical appraisal of the literature, coupled with consideration of pragmatic studies to ensure that guidelines provide clinically-relevant recommendations;
  • NICE methodology overlays critical appraisal of the literature with health economic modelling, with interpretation supported by advice from a multidisciplinary Guideline Development Group.

These different processes have resulted in some discrepancies in recommendations made by BTS/SIGN and NICE.  This article seeks to provide some context to these differences in the key areas of:

  1. Diagnosis
  2. Pharmacological management
    • Treatment at diagnosis
    • The introduction of leukotriene receptor antagonists (LTRA) after low dose inhaled corticosteroids (ICS)
    • Maintenance and reliever therapy (MART)
    • Treatment beyond combined inhaler therapy
    • Some other issues in managing asthma in children

The BTS/SIGN guideline also provides recommendations for important aspects of asthma management that are not addressed within NICE guidelines. These include guidance on inhaler devices, the management of acute asthma attacks in both adults and children, the management of difficult asthma, guidance on asthma in adolescents, in pregnant women and on occupational factors.

Read the full article here.

This article is currently in press. It may subject to minor content and format changes before publication in the February 2018 issue of Thorax.

Reflective Practice, Comfort Zones, And Mistakes.

2 Feb, 14 | by tomfardon

Doc2Doc user OmarhBore posted a blog this week on the futility of the current reflective practice system for junior doctors, suggesting alternative media for reflection, including poetry, amusing musings on NHS computer screens, and interpretive dance. He felt that the enforced reflections were too contrived, and there was more to be gained from reflection than the current system allows. Reflective practice wasn’t ‘invented’ when I was a lad, or at least, it wasn’t particularly encouraged. Not that I remember, that is.

But I agree with our Doc2Doc FY-Blogger. There’s a lot to be learnt from our experiences, particularly our mistakes. And it’s easy to make mistakes – I made a mistake today – but it’s harder to talk about it, learn something from it, and move forward.

A common complaint from consultant colleagues is the feeling that we do more and more tasks that were previously carried out by more junior doctors. I’m sure I’ve ticked that box on surveys at some point. So today when I needed to write out a prescription for a patient to collect opiate based drugs from pharmacy I was in that position – doing something that is usually done by the junior doctors, and something that I’ve not done for a few years. The patient was complex, the prescription was complex, I was already thinking about the next job for the day, perhaps even the next after that, so I finished the prescription, handed it over to the nurse, and wandered off to the next task of the day.

The prescription had mistakes in it, and fortunately the nurse I gave it to realised very quickly. She caught up with me and I had the opportunity to correct the prescription. No-one likes making mistakes, least of all me, but I was relieved that she took the time to read it, and call me back.

So, I’ve reflected on it. Why didn’t I get it right? Couldn’t I be bothered? No – I want to get things right. Did I know what to do? I *thought* I remembered what to do, but I was clearly out of my comfort zone, having not written out an opiate prescription for some time. At that point, I should have asked for help, shouldn’t I? Of course I should. I spend my days teaching medical students that there’s really only one rule – Know when you don’t know what you’re doing, and know to ask for help. So why didn’t I? Why did I just scribble the prescription, and move onto the next thing in my busy day? Too many things going on? Too busy? Too proud to ask for help from someone more junior? Preoccupied, I think, with many many other tasks to do in the rest of the day, and not enough focus on the job in hand.

I had the opportunity to rewrite the prescription, and certainly the pharmacists would have called me up about it, but I was saved those blushes. When I was rewriting it, I felt suddenly very stressed. Stressed about getting it wrong again? Stressed that I got it wrong in the first place? Not sure – but stressed, for ceratin. I wonder if the juniors feel similar levels of stress when they are asked to do things outwith their comfort zone – surely they do, and surely we ask them to do this on almost a daily basis.

Come October it’ll be 20 years since I started medical school: 6 years later I was a house officer. So today, faced with something out of my comfort zone, and not stopping to ask for help, blundering on and making a mistake, only to be rescued by a nurse – I remembered very clearly what it was like to be a PRHO in 2000.

So what have I learned in those 14 years? Perhaps not enough, as I still made the mistake today, but I’ve certainly learnt that getting worked up about it, or trying to forget it, or brush it under the metaphorical rug, is not the way to move on – reflective practice makes us all better doctors. I have the opportunity to share my mistake, and my reflection on it, with a reader, perhaps an FY1 who feels stressed, or perhaps another consultant who made a mistake when rushed, and didn’t take the time required. Or perhaps it only helps me, to realise that sometimes the best thing to do is ask for help, and get it right first time.

So thanks to the nurse for picking me up on my mistake, and to OmahrBore for his poetry, and interpretive dance*. I encourage him to continue to reflect on his experiences, and particularly his mistakes, and to share them, as if only one person reads, or hears, and avoids the same pitfall in the future, it will have been worth the time and the effort – even if the person who reads it, is the person who wrote it.

I’ve kept a copy of my hastily penned prescription, and I’ll be using to teach the medical students – an example of what not to do. I’ve kept a copy of the second version, to remind me what I should have done in the first place.

*Citation needed

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