Qualitative study of practices and challenges when making a diagnosis of asthma in primary care

Misdiagnosis (over-diagnosis and under-diagnosis) of asthma is common. Under-diagnosis can lead to avoidable morbidity and mortality, while over diagnosis exposes patients to unnecessary side effects of treatment(s) and results in unnecessary healthcare expenditure. We explored diagnostic approaches and challenges faced by general practitioners (GPs) and practice nurses when making a diagnosis of asthma. Fifteen healthcare professionals (10 GPs and 5 nurses) of both sexes, different ages and varying years of experience who worked in NHS Lothian, Scotland were interviewed using in-depth, semi structured qualitative interviews. Transcripts were analysed using a thematic approach. Clinical judgement of the probability of asthma was fundamental in the diagnostic process. Participants used heuristic approaches to assess the clinical probability of asthma and then decide what tests to do, selecting peak expiratory flow measurements, spirometry and/or a trial of treatment as appropriate for each patient. Challenges in the diagnostic process included time pressures, the variable nature of asthma, overlapping clinical features of asthma with other conditions such as respiratory viral illnesses in children and chronic obstructive pulmonary disease (COPD) in adults. To improve diagnostic decision-making, participants suggested regular educational opportunities and better diagnostic tools. In the future, standardising the clinical assessment made by healthcare practitioners should be supported by improved access to diagnostic services for additional investigation(s) and clarification of diagnostic uncertainty.