Precision asthma medicine in primary care: a controversy study
(University of Oxford)
Trisha Greenhalgh (University of Oxford)
Paper short abstract:
This paper traces efforts to roll-out a new diagnostic - FENO - into primary care in the NHS. Configured as part of a package relating to precision asthma medicine, we trace how different interest groups have promoted, shaped, and contested FENO and precision asthma medicine more broadly.
Paper long abstract:
This paper tracks recent efforts to embed a controversial diagnostic technology into UK primary healthcare. In 2014, NICE published guidelines recommending FENO (Fractional Exhaled Nitric Oxide) devices be rolled-out in the diagnosis and management of asthma across primary care. The breathing test kit provides GPs with sub-clinical biomarker scores which are said to be predictive of an individual's likely steroid responsiveness. More broadly, the guidelines promise to push GPs away from symptom-led and trials of treatments-based management (said to be responsible for over-diagnosis and overprescribing of inhaled steroids), towards a more objective means of diagnosing and managing patients according to underlying disease pathways. However, this move towards "precision medicine" has so far generated heated responses among many primary care professionals. Based on documentary analysis and interviews with members of key interest groups, we pinpoint at least three tensions emerging between the precision medicine movement and existing ways of diagnosing, managing, and administering asthma care. The first centres on the contested politics of evidence surrounding use of FENO in primary care, owing to ambiguity between NICE and existing clinical guidelines. A second controversy relates to accountabilities of cost: NICE's economic models argue cost savings will be made to the NHS overall, yet GP practices are expected to purchase the expensive piece of equipment from their budgets. Finally, by privileging the diagnostic test above clinical judgement, the push towards promoting FENO as part of a broader precision medicine configuration requires redefining expertise and professional identities of GPs in relation to asthma diagnosis.
Precision medicine at the crossroads: meeting the micro and macro, the molecular and social in new medical strategies