Quality and Outcomes Framework guidance for 2025/26

The QOF Guidance for 25/26 has just been released with the latest update for Asthma diagnosis and management. The following section has been taken from this guidance, you can view the full document here.

3.8 Asthma (AST)

Indicator Points Thresholds
Initial diagnosis    
AST012. The percentage of patients with a new diagnosis of asthma on or after 1 April 2025 with a record of an objective test between 3 months before or 3 months after diagnosis 15 45–80%
Ongoing management    
AST007. The percentage of patients with asthma on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control, a recording of the number of exacerbations, an assessment of inhaler technique and a written personalised action plan 20 45–70%

 

AST – rationale for inclusion of indicator set

  1. Asthma is a common condition which responds well to appropriate management and is principally managed in primary care.

AST012 (based on NICE IND272) AST012 Rationale

  1. This indicator was updated from AST011 in 2024/25 to reflect the recommendations made within the new combined asthma guideline produced by the British Thoracic Society (BTS), NICE and the Scottish Intercollegiate Guidelines Network (SIGN) in November 2024.
  2. The aim of this indicator is to encourage use of objective tests to confirm an asthma diagnosis. A combination of a suggestive clinical history and a supporting objective test is needed to diagnose asthma, with different objective testing sequences for adults, and children and young people aged 5 to 16. Improving the accuracy of diagnosis will reduce incidences of patients with untreated asthma having an asthma attack and patients who do not have asthma receiving unnecessary drugs.

iii. The guideline recommends that specific tests are used first in the sequence. The indicator allows the full range of possible tests to count as a success.

Diagnosing asthma in adults and young people (aged over 16 years) with a history suggesting asthma

  1. BTS, NICE and SIGN recommend the following order in which objective tests should be carried out when diagnosing asthma in adults and young people (aged over 16 years) with a history suggestive of asthma32:
  • Measure the blood eosinophil count or fractional exhaled nitric oxide (FeNO) level in adults and young people (aged over 16 years) with a history suggestive of asthma. Diagnose asthma if the eosinophil count is above the laboratory reference range or the FeNO level is 50 ppb or more
  • If asthma is not confirmed by eosinophil count or FeNO level, measure bronchodilator reversibility (BDR)33 with spirometry. Diagnose asthma if the FEV134 increase is 12% or more and 200 ml or more from the prebronchodilator measurement (or if the FEV1 increase is 10% or more of the predicted normal FEV1)
  • If spirometry is not available or it is delayed, measure peak expiratory flow (PEF)35 twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more.
  • If asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability but still suspected on clinical grounds, refer for consideration of a bronchial challenge test36. Diagnose asthma if bronchial hyper-responsiveness37 is present.

Diagnosing asthma in children aged 5 to 16 with a history suggestive of asthma

  1. Measure FeNO level in children and young people aged 5 to 16 years with a history suggestive of asthma. Diagnose asthma if the FeNO level is 35ppb or more. If the FeNO level is not raised or if FeNO testing is not available or not feasible, measure bronchodilator reversibility (BDR) with spirometry. Diagnose asthma if the FEV1 increase is 12% or more from baseline (or if the FEV1 increase is 10% or more of the predicted normal FEV1).
  2. If spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more.

iii. If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds, either perform skin prick testing to house dust mite or measure blood total IgE and blood eosinophil count.

  • Exclude asthma if there is no evidence of sensitisation to house dust mite on skin prick testing or if the total serum IgE is not raised.
  • Diagnose asthma if there is evidence of sensitisation or a raised total IgE and the eosinophil count is more than 0.5 x 109 per litre.
  1. If there is still doubt about the diagnosis, refer to a paediatric specialist for consideration of a bronchial challenge test.

Additional information

  1. If an adult, young person or child aged 5 or over with a history suggestive of asthma cannot perform any objective tests, treat with inhaled steroids, review on a regular basis and try to do the tests again every 6-12 months until satisfactory results are obtained. PCAs are available for situations where the patient declines or does not attend, or if objective tests are not appropriate or feasible.
  2. In people with adult-onset asthma, poorly controlled established asthma, or reappearance of childhood asthma, NICE recommend checking for a possible occupational component and referring people with suspected occupational asthma to an occupational asthma specialist (section 1.4).

iii. NHS England is supporting systems to make objective testing, and spirometry in particular, available in the community. Commissioning standards have been produced that set out best practice in commissioning spirometry services to support systems to deliver equitable access to quality assured spirometry testing for their population across all ages38.

If another diagnosis is more likely

  1. If an alternative diagnosis is suspected, investigation and management are to follow guidelines for that condition.

Co-morbidity: asthma and COPD

  1. A proportion of patients with asthma will have both asthma and COPD, e.g. they have airway obstruction that does not reverse to normal but also have substantial reversibility39.

    AST012 Reporting and verification

    1. See indicator wording for requirement criteria. For measurement purposes, three months prior to diagnosis is defined as 93 days.
    2. This indicator covers the percentage of patients with asthma on the register who have had an asthma review in the preceding 12 months that includes an assessment of asthma control, a recording of the number of exacerbations and a written personalised action plan. It measures the quality of care processes linked by evidence to improved outcomes.

    iii. Annual asthma reviews can help identify people at increased risk of poor outcomes so that support can be provided based on information from their review to help them self manage their asthma and maximise their future health. This should include, in discussion with patients, checking medicines adherence using prescription records, assessing asthma control (which could be by using a validated symptom questionnaire such as the Asthma Control Questionnaire, the Asthma Control Test or the Childhood Asthma Control Test), observing inhaler technique and checking other possible reasons for uncontrolled asthma (such as smoking, occupational exposures, and psychosocial, seasonal and environmental factors) before starting or adjusting medicines.

    1. BTS, NICE and SIGN also recommend considering actively identifying people with asthma who are at risk of poor outcomes and tailoring care to their needs (section 1.15). v. Further detail on monitoring asthma control and developing personalised action plans, along with the importance of keeping them up to date, can be found at sections 1.5 (Monitoring asthma control) and 1.14 (self-management) of the combined guideline.
    2. The BTS, NICE and SIGN guideline also contains a number of new recommendations for the pharmacological treatment of people with asthma.

    vii. Short-acting beta2 agonists should not be prescribed to people of any age with asthma without a concomitant prescription of an ICS (1.6.3) and algorithms have been produced for the pharmacological management of asthma in people aged 12 years and over41 and the pharmacological treatment of children aged 5 to 11 years42.

    viii. For those people aged 12 years and over, referral to a specialist in asthma care should be made if their asthma that is not controlled on treatment containing a high dose of ICS (1.7.11). For those aged 5-11 a referral should be made if asthma is not controlled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA maintenance treatment (with or without an LTRA, depending on previous response) (1.8.7).

    1. PCAs are available for situations where the patient declines or does not attend, or if an annual review is not appropriate.
    2. In addition to the resources provided by NICE (Tools and resources | Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) | Guidance | NICE), further information to support the implementation of both AST007 and AST012 can be found at:
    3. Healthcare professionals | Asthma + Lung UK,

    xii. Asthma | British Thoracic Society | Better lung health for all

    xiii. Asthma | Primary Care Respiratory Society

    xiv. beatasthma.co.uk (for children and young people)

    32 NICE NG245 (2024) Asthma: Algorithm A http://www.nice.org.uk/guidance/ng245/resources/bts-nice-andsign-algorithm-a-summary-of-objective-tests-for-diagnosing-asthma-pdf-13556516365

    33 NICE NG245 (2024) Bronchodilator reversibility https://www.nice.org.uk/guidance/ng245/chapter/recommendations#bronchodilator-reversibility

    34 NICE NG245 (2024) FEV1 https://www.nice.org.uk/guidance/ng245/chapter/recommendations#fev1

    35 NICE NG245 (2024) Peak expiratory flow (PEF) variability https://www.nice.org.uk/guidance/ng245/chapter/recommendations#peak-expiratory-flow-pef-variability

    36 NICE NG245 (2024) Bronchial challenge test https://www.nice.org.uk/guidance/ng245/chapter/recommendations#bronchial-challenge-test

    37 NICE NG245 (2024) Bronchial hyperresponsiveness https://www.nice.org.uk/guidance/ng245/chapter/recommendations#bronchial-hyperresponsiveness

    38 NHS England (2024) Commissioning standards for spirometry https://www.england.nhs.uk/longread/commissioning-standards-for-spirometry/

    39 NICE NG115 (2018, updated 2019) Chronic obstructive pulmonary disease in over 16s. https://www.nice.org.uk/guidance/NG115

    40 NICE NG245 (2024) Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). https://www.nice.org.uk/guidance/ng245

    41 NICE NG245 (2024) Algorithm C https://www.nice.org.uk/guidance/ng245/resources/algorithm-cpharmacological-management-of-asthma-in-people-aged-12-years-and-over-bts-nice-pdf-13556516367

    42 NICE NG245 (2024) Algorithm D https://www.nice.org.uk/guidance/ng245/resources/algorithm-dpharmacological-management-of-asthma-in-children-aged-5-to-11-years-bts-nice-sign-pdf-13556516368

    43 Royal College of Physicians (2016) Why asthma still kills https://www.rcp.ac.uk/improvingcare/resources/why-asthma-still-kills/