Asthma (AST) - QOF indicator

Asthma in QOF 2026/27

The asthma indicators cover objective testing around diagnosis and the content of ongoing asthma reviews. Notable features of the 2026/27 guidance include alignment with the joint BTS, NICE and SIGN guideline published in November 2024, alongside specific requirements for recording tests and reviews.

Indicators

Why asthma is included

• Most asthma care takes place in primary care. The condition is common, and suitable management can achieve a good response.

AST014: objective testing at diagnosis

Basis for the indicator

AST014 is based on NICE IND272.

• The indicator draws on the joint asthma guideline issued by the British Thoracic Society (BTS), NICE and the Scottish Intercollegiate Guidelines Network (SIGN) in November 2024.

• Its purpose is to promote confirmation of asthma through objective testing alongside a compatible clinical history. The testing pathway differs between adults and children and young people aged 5 to 16. More accurate diagnosis should mean fewer attacks in people whose asthma has gone untreated, and less unnecessary medication for people who do not have asthma.

• Although the guideline places particular tests earlier in the diagnostic pathway, any of the eligible objective tests can satisfy the indicator.

Diagnostic testing in adults and young people aged over 16 years

For patients aged over 16 years whose history points towards asthma, BTS, NICE and SIGN set out this testing sequence:

• Start with a blood eosinophil count or fractional exhaled nitric oxide (FeNO) measurement. Either an eosinophil count exceeding the laboratory reference range or FeNO of 50 ppb or more supports a diagnosis of asthma.

• Where these tests have not confirmed asthma, use spirometry to assess bronchodilator reversibility (BDR). Asthma is diagnosed when forced expiratory volume in one second (FEV1) rises by 12% or more and 200 ml or more compared with the pre-bronchodilator value, or by 10% or more of predicted normal FEV1.

• When spirometry cannot be accessed or is delayed, ask for peak expiratory flow (PEF) measurements twice daily for 2 weeks. Variability of 20% or more, calculated as amplitude percentage mean, supports the diagnosis.

• If clinical suspicion remains despite no confirmation from eosinophils, FeNO, BDR or PEF variability, refer for assessment of whether a bronchial challenge test is needed. Demonstrated bronchial hyper-responsiveness confirms asthma.

Diagnostic testing in children aged 5 to 16

For children and young people aged 5 to 16 years with a history pointing towards asthma:

• Begin with FeNO: a result of 35ppb or more supports the diagnosis. If FeNO is not elevated, or testing cannot be accessed or carried out, assess BDR using spirometry. Diagnostic criteria are an FEV1 rise of 12% or more against baseline, or 10% or more of predicted normal FEV1.

• If spirometry is unavailable or delayed, record PEF twice daily for 2 weeks. A diagnosis is supported by variability of 20% or more, expressed as amplitude percentage mean.

• If FeNO, BDR and PEF variability have not established the diagnosis but asthma remains clinically likely, arrange either skin prick testing for house dust mite or measurement of blood total immunoglobulin E (IgE) and eosinophils.

• A skin prick test showing no house dust mite sensitisation, or a total serum IgE that is not elevated, excludes asthma.

• Sensitisation or an elevated total IgE, together with an eosinophil count of more than 0.5 x 109 per litre, supports a diagnosis of asthma.

• Any remaining diagnostic uncertainty warrants referral to a paediatric specialist to consider bronchial challenge testing.

Further considerations

• For an adult, young person or child aged 5 or over with a suggestive history who cannot undertake any objective test, use inhaled steroids and arrange regular reviews. Reattempt testing every 6-12 months until satisfactory results can be obtained. Personalised Care Adjustments (PCAs) can be used where a patient declines testing or does not attend, or where testing is unsuitable or not feasible.

• NICE advises looking for an occupational contribution in adult-onset asthma, established asthma with poor control, or childhood asthma that has returned. Suspected occupational asthma requires referral to a specialist in occupational asthma; this is addressed in section 1.4 of the guideline.

• NHS England is helping systems expand community access to objective tests, particularly spirometry. Commissioning standards describe how services can be commissioned to provide equitable access to quality-assured spirometry for all ages.

When a different diagnosis is suspected

• If another condition appears more likely, use the relevant guidance for its investigation and management.

Coexisting asthma and COPD

• Some patients have both asthma and COPD. For example, marked reversibility may be present even though airflow obstruction does not fully return to normal.

AST014 reporting and verification

• The indicator definition sets the qualifying requirements. For measurement, the 3 months before diagnosis are counted as 93 days.

AST015: ongoing asthma review

Basis for the indicator

AST015 is based on NICE IND273.

• The joint NICE, BTS and SIGN asthma guideline underpins this indicator.

• AST015 assesses review coverage among patients on the asthma register over the preceding 12 months. Its focus is on care processes associated with better outcomes: assessing control, documenting exacerbation numbers and providing a written personalised action plan, with inhaler technique assessment also required by the indicator definition.

• An annual review offers an opportunity to recognise patients at greater risk of poor outcomes and use the findings to shape support for self-management and future health. Before initiating or changing medication, discussion with the patient should include adherence checks using prescription records, assessment of control and direct observation of inhaler technique. Validated symptom tools may help assess control, including the Asthma Control Questionnaire, Asthma Control Test and Childhood Asthma Control Test. Also explore other explanations for poor control, including smoking, workplace exposures and psychosocial, seasonal or environmental influences.

• Section 1.15 of the joint guideline recommends considering proactive identification of patients at risk of poor outcomes so that their care can be adapted accordingly.

• Sections 1.5 (monitoring asthma control) and 1.14 (self-management) provide more detail on assessing control and creating personalised action plans, including the need to update those plans.

• The joint guideline also introduces several recommendations on drug treatment for asthma.

• At any age, a short-acting beta2 agonist must be accompanied by a prescription for an inhaled corticosteroid (ICS), as set out in recommendation 1.6.3. Treatment algorithms are available for people aged 12 years and over and for children aged 5 to 11 years.

• People aged 12 years and over whose asthma remains uncontrolled despite treatment containing a high dose of ICS should be referred to an asthma specialist (1.7.11). For children aged 5-11, referral is required if control is not achieved with paediatric moderate-dose Maintenance and Reliever Therapy (MART), or paediatric moderate-dose ICS/Long-acting beta-2 agonist (LABA) maintenance treatment. The latter may be used with or without a Leukotriene receptor antagonist (LTRA), according to previous response (1.8.7).

• PCAs may apply when a patient declines or misses the review, or when an annual review is inappropriate.

• Alongside NICE's Tools and resources, support for implementing AST015 and AST014 is available from:

• Asthma + Lung UK

• British Thoracic Society

• Primary Care Respiratory Society

• beatasthma.co.uk, for children and young people

• The National Review of Asthma (NRAD) provides further material on asthma care and recommendations aimed at preventing future asthma deaths.

AST015 reporting and verification

• Use the indicator definition to establish eligibility and requirements. Children under 5 do not count towards AST015.

• To satisfy the business rules, contractors must code the asthma review, the number of exacerbations in the month before the asthma review, and provision of a written personalised asthma plan. All must be recorded on the same day as the asthma review.