Chest
Clinical InvestigationsAsthmaLack of Correlation of Symptoms With Specialist-Assessed Long-term Asthma Severity
Study objectives
To validate three indicators of asthma severity as defined in the National Asthma Education Program (NAEP) guidelines (ie, frequency of symptoms, degree of airflow obstruction, and frequency of use of oral glucocorticoids), alone and in combination, against severity as assessed by pulmonary specialists provided with 24-month medical chart data.
Design
Cross-sectional comparison of questionnaire and clinical-based markers of asthma severity with physician-assessed severity based on chart review. The pulmonologists did not have access to the results of the baseline evaluations when making their severity assessments.
Setting and participants
Study participants were 193 asthmatic members (age range, 6 to 55 years) of a large health maintenance organization who underwent a baseline evaluation as part of a separate longitudinal study. This evaluation consisted of spirometry, skin prick testing, and a survey that included questions on symptoms and medication use. The participants in the ancillary study were selected, based on their baseline evaluation, to reflect a broad range of asthma severity.
Results
Based on the chart review, 86 of the study subjects (45%) had mild disease, 90 (45%) had moderate disease, and 17 (9%) had severe disease. This physician-assessed severity correlated highly (p ≤ 0.013) with NAEP-based indices of severity based on oral glucocorticoid use (never, infrequently for attacks, frequently for attacks, and daily use) and on spirometry (FEV1 > 80% predicted, 60 to 80% predicted, and <60% predicted). It did not, however, correlate with current asthma symptoms (≤ once/week, 2 to 6 times/week, daily) (p = 0.87). A composite severity score based on spirometry and the glucocorticoid use data still provided an overall agreement of 63%, with a weighted kappa of 0.40.
Conclusions
While current symptoms are the most important concern of patients with asthma, they reflect the current level of asthma control more than underlying disease severity. Investigators must therefore use caution when comparing groups of patients for whom severity categorization is based largely on symptomatology. This observation, that symptoms alone do not reflect disease severity, becomes even more important as health-care delivery moves closer to protocols/practice guidelines and “best treatment” programs that rely heavily on symptoms to guide subsequent treatment decisions.
Section snippets
Materials and Methods
We report on baseline, cross-sectional data collected as part of a longitudinal study to characterize risk factors for hospital-based care in asthma. All subjects gave informed consent. In the case of minors, both the children and their parents consented to the study.
Results
Selected demographic characteristics of the chart review sample are presented in Table 2. The chart review sample was deliberately stratified by age and sex. Overall, 107 of the patients (55%) in the chart review sample had a physician-assessed severity rating of moderate or severe. Table 3 contrasts these 107 subjects and the 86 mild subjects with respect to several factors noted during the chart review. As expected, patients classified as having moderate to severe disease based on the chart
Discussion
This analysis grew out of our efforts to develop a simple index of asthma severity for use in a longitudinal study of 914 individuals, aged 3 to 55 years, with asthma. Our initial scale incorporated three dimensions of severity suggested by the National Asthma Education Program (symptoms, corticosteroid use, and lung function.6 Attempts to validate this scale against expert physician opinion based on medical record review did not show significant correlation between current symptom frequency
References (23)
- WC Bailey et al.
Asthma severity: a factor analytic investigation
Am J Med
(1992) - PD Blanc et al.
Work disability among adults with asthma
Chest
(1993) - AJ Apter et al.
Common measures of asthma severity lack association for describing its clinical course
J Allergy Clin Immunol
(1994) - JM Samet
Epidemiologic approaches for the identification of asthma
Chest
(1987) - ML Osborne et al.
Diagnostic accuracy of asthma within a health maintenance organization
J Clin Epidemiol
(1992) - CP van Schayck et al.
The influence of an inhaled steroid on quality of life in patients with asthma or COPD
Chest
(1995) - CS Shim et al.
Evaluation of the severity of asthma: patients versus physicians
Am J Med
(1980) - W Busse et al.
Treatment regimen and side effects of treatment measures
Am J Respir Crit Care Med
(1994) - PL Enright et al.
Physiologic measures: pulmonary function tests. Asthma outcome
Am J Respir Crit Care Med
(1994) - W Bailey et al.
Measures for use in asthma clinical research: overview of NIH Workshop
Am J Respir Crit Care Med
(1994)
Clinical and symptom measures
Am J Respir Crit Care Med
Cited by (83)
Assessing meaningful change in the Asthma Impairment and Risk Questionnaire
2024, Annals of Allergy, Asthma and ImmunologyThe Asthma Impairment and Risk Questionnaire (AIRQ) is a 10-item, yes/no, equally weighted control tool. Lower scores indicate better control. Moreover, 7 impairment items reflect previous 2-week symptoms, and 3 risk items assess previous 12-month exacerbations. The Follow-up AIRQ for use between annual assessments has a 3-month recall period for exacerbation items.
To evaluate the responsiveness of the AIRQ over time and identify a minimal important difference (MID).
The AIRQ longitudinal study data were analyzed from patients with asthma aged 12 years and older. Anchor-based methods assessed differences in AIRQ scores relative to Patient Global Impression of Change, the accepted MIDs for St. George's Respiratory Questionnaire and Asthma Control Test, and exacerbation occurrence over 12 months. Baseline and 12-month data reflected 12-month recall AIRQ scores; Follow-up AIRQ scores were used for 3-, 6-, and 9-month analyses.
A total of 1070 patients were included. The Patient Global Impression of Change rating of “much improved” was associated with AIRQ mean score changes from baseline to months 3, 6, 9, and 12 of −2.0, −1.9, −1.9, and −1.8, respectively. The mean AIRQ score change among patients who met the St. George's Respiratory Questionnaire MID (≥4-point decrease) was −1.8 at 6 and 12 months. The AIRQ mean scores decreased from baseline by −2.2 to −2.5 points at months 3, 6, 9, and 12 for patients who met the Asthma Control Test MID (≥ 3-point increase). A 2-point higher baseline AIRQ score was associated with a 1.7 odds ratio of 12-month exacerbation occurrence (95% CI, 1.53-1.89).
A change score of 2 is recommended as the AIRQ MID.
GEMA 5.3. Spanish Guideline on the Management of Asthma
2023, Open Respiratory ArchivesThe Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide.
Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists.
Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
La Guía Española para el Manejo del Asma, mejor conocida por su acrónimo en español, GEMA, está a nuestra disposición desde hace más de veinte años. Veintiuna sociedades científicas o grupos relacionados, tanto de España como de otros países, han participado en la preparación y desarrollo de la edición actualizada de GEMA que, de hecho, se ha posicionado en la actualidad a nivel mundial como la guía de referencia sobre asma en lengua española.
Su objetivo es prevenir y mejorar la situación clínica de las personas con asma, aumentando el conocimiento de los profesionales sanitarios involucrados en su cuidado. Su propósito es convertir la evidencia científica en recomendaciones prácticas sencillas y fáciles de seguir. Por lo tanto, no se trata de una monografía que reúna todo el conocimiento científico sobre la enfermedad, sino más bien de un documento conciso con lo esencial, diseñado para ser aplicado rápidamente en la práctica clínica de rutina. Las recomendaciones son necesariamente multidisciplinares, están desarrolladas para ser útiles y una herramienta indispensable para médicos de diferentes especialidades, así como para profesionales de enfermería y farmacia.
Seguramente, los aspectos más destacados de la guía son las recomendaciones para: establecer el diagnóstico del asma utilizando un algoritmo secuencial basado en pruebas diagnósticas objetivas; el seguimiento de los pacientes, preferentemente basado en la estrategia de lograr y mantener el control de la enfermedad; el tratamiento según el nivel de gravedad del asma utilizando seis escalones, desde la menor hasta la mayor necesidad de medicamentos, y el algoritmo de tratamiento basado en fenotipos para la indicación de biológicos en pacientes con asma grave no controlada. A esto se suma ahora una novedad para su fácil uso y seguimiento a través de una aplicación informática basada en la inteligencia artificial conversacional de tipo chatbot (ia-GEMA).
The Asthma Impairment and Risk Questionnaire enhances the assessment of asthma control
2023, Annals of Allergy, Asthma and ImmunologyAsthma control is often overestimated in routine practice, and despite advances in the understanding of immunopathology and the availability of new precision therapies, the burden of disease remains unacceptably high.
To compare the performance of the Asthma Impairment and Risk Questionnaire (AIRQ) with patient and physician assessments and the Asthma Control Test (ACT) in identifying asthma control.
Baseline data from a longitudinal study of the AIRQ were analyzed. Patients with asthma in the United States aged 12 years and older followed in 24 specialty practices and 1 specialty-affiliated primary care clinic were enrolled between May and November 2019. At entry, participants completed AIRQ and ACT, and participants and physicians completed 5-point Likert scale assessments of control.
A total of 1112 participants were enrolled (mean [SD] age = 43.9 [19.3] years, 70% of the female sex, 78% White). Overall, 62% of participants rated themselves as well- or completely controlled, and 54% were rated comparably by physicians. The ACT classified 49% of participants as well-controlled, with 35% similarly categorized by AIRQ. Previous-year exacerbations were experienced by 32% of participants who self-rated as well- or completely controlled, 30% who were rated as well- or completely controlled by physicians, and 29% assessed as well-controlled by ACT, but only 15% of those classified as well-controlled by AIRQ.
The burden of asthma is substantial in patients cared for by asthma specialists, and asthma control is overestimated by patients, physicians, and the symptom-based ACT. The AIRQ assesses risk in addition to symptom control and may serve to improve asthma control determination by assessing previous exacerbations.
The effect of geographic access on severe health outcomes for pediatric asthma
2015, Journal of Allergy and Clinical ImmunologyAccess to medical care and severe pediatric asthma outcomes vary with geography, but the relationship between them has not been studied.
We sought to evaluate the relationship between geographic access and health outcomes for pediatric asthma.
The severe outcome measures include emergency department (ED) visits and hospitalizations for children with an asthma diagnosis in Georgia and North Carolina. We quantify asthma prevalence, outcome measures, and factors included in the statistical model using multiple data sources. We calculate geographic access to primary and asthma specialist care using optimization models. We estimate the association between outcomes and geographic access in the presence of other factors using logistic regression. The model is used to project the reduction in severe outcomes with improvement in access.
The association between access and outcomes for pediatric asthma depends on the type of outcome measure, type of care, and variations in other factors. The expression of this association is also different for the 2 states. Access to primary care plays a larger role than access to specialist care in explaining Georgia ED visits, whereas the reverse applies for hospitalizations. In North Carolina access to both primary and specialist care are statistically significant in explaining the variability in ED visits.
The variation in the association between estimated access and outcomes affects the projected reductions of severe outcomes with access improvement. Thus applying one intervention would not have the same level of improvement across geography. Interventions must be tailored to target regions with the potential to deliver the highest effect to gain maximum benefit.
GEMA<sup>4.0.</sup> Guidelines for Asthma Management
2015, Archivos de BronconeumologiaEl principal objetivo de la presente guía es mejorar el control y calidad de vida de las personas con asma mediante el incremento de la formación técnica de los profesionales sanitarios que deben atenderles. En particular en los aspectos relacionados con la prevención y valoración diagnóstica-terapéutica de la enfermedad.
No obstante, la GEMA es una plataforma que aglutina una serie de acciones complementarias, todas diseñadas para alcanzar el objetivo antes descrito, entre las que sobresale el presente documento: una guía de práctica clínica basada en la evidencia. Posteriormente, otros documentos (GEMA de Bolsillo. GEMA de Pacientes, GEMA Educadores, Indicadores de Calidad Asistencial del Asma, etc.) irán completando la “familia” de la GEMA.
Específicamente, el presente documento (guía de práctica clínica) y toda la estrategia que conforma la plataforma GEMA4.0, está dirigida a médicos de Atención Primaria, pediatras, neumólogos, alergólogos, pediatras neumólogos y pediatras alergólogos, otorrinolaringólogos, farmacólogos, farmacéuticos, enfermería general y especializada en patología respiratoria, educadores, profesores, pacientes y familiares de pacientes.
Búsqueda de la evidencia. Partiendo de la anterior edición de la GEMA2, editada en 2009, y siguiendo las recomendaciones para la Actualización de Guías de Práctica Clínica del Sistema Nacional de Salud3, los miembros del Comité Ejecutivo realizaron una búsqueda sistemática, con evaluación y selección de las publicaciones aparecidas sobre asma desde 2009 hasta 2014 (Proyecto Pro-GEMA). Tras la revisión de las revistas de Neumología, Alergología, Pediatría, Atención Primaria, Medicina Interna y Otorrinolaringología de elevado factor de impacto, y su clasificación entre los dos primeros cuartiles de su especialidad, se seleccionó un total de 184 trabajos (resúmenes disponibles en http://www.progema-gemasma.com/foco.html) que se consideraron de interés para la actualización de la guía y que se proporcionaron a los redactores para su consideración. Además se les animó a efectuar sus propias búsquedas bibliográficas específicas para temas concretos. Para ello, se siguió el procedimiento habitualmente establecido en la elaboración de guías de práctica clínica4. Así mismo, se revisaron los listados de referencias de las principales guías de práctica clínica internacionales5,6 para identificar las principales revisiones sistemáticas y ensayos clínicos. Estas guías se buscaron en bases de datos especializadas (National Guideline Clearinghouse, National Library of Guidelines) y en el metabuscador de literatura médica TRIP database. Se consultaron las bases de datos del Centre for Reviews and Dissemination (DARE y HTA database) y The Cochrane Library para identificar revisiones sistemáticas y evaluaciones de tecnologías adicionales. La búsqueda se completó con una actualización de las revisiones sistemáticas a partir de su fecha de búsqueda y de los estudios relevantes en las principales bases de datos electrónicas de estudios originales (MEDLINE, CENTRAL y EMBASE).
Clasificación de la evidencia. Para la evaluación de la calidad de la evidencia se utilizó la clasificación alfabética (tabla 0.1), que clasifica la calidad de la información en cuatro categorías (A, B, C, D) y que representan un gradiente de confianza en los resultados obtenidos en los estudios disponibles. La categoría A correspondería a una calidad alta y la D a una calidad muy baja. La confianza en los resultados, en el caso de la categoría A, es alta siendo improbable que estudios posteriores modifiquen los resultados disponibles. Por el contrario, en el caso de las categorías inferiores, C o D, la confianza será baja o muy baja, siendo muy probable que estudios posteriores modifiquen los resultados, o incluso la dirección del efecto. No obstante, se debe recordar que dicho sistema resulta muy útil para categorizar la evidencia de la eficacia terapéutica de fármacos u otras acciones terapéuticas, pero puede infravalorar otros. De ahí que las evidencias de los estudios que determinaron la idoneidad de algunas exploraciones diagnósticas se clasificaran con frecuencia con un nivel de evidencia C.
Teniendo en cuenta la reciente aparición de nuevos enfoques para clasificar la calidad de la evidencia basados en otros aspectos, además del diseño de los estudios7,8, se utilizaron algunas características marco GRADE (http://www.gradeworkinggroup.org/), aunque éste no se aplicó de una forma completa.
Clasificación de las recomendaciones. Para clasificar la relevancia y consistencia de las recomendaciones clínicas, se siguió el mismo método empleado en la anterior edición de la GEMA2, que las categorizaba en dos niveles: recomendaciones robustas (R1), que representan aquellas en las que el grupo elaborador de la guía confía que conlleven más beneficios que riesgos; y recomendaciones débiles (R2), aquellas en las que existe incertidumbre sobre si su aplicación conllevará más beneficios que riesgo. Para efectuar esta distribución en R1 o R2 se ponderó la calidad de la información (a partir de la clasificación mencionada), el balance entre los riesgos y los beneficios de las intervenciones, los costes (según literatura especializada disponible), así como los valores y preferencias de los pacientes (mediante la participación de miembros de la FENAER).
La categorización del nivel de recomendación se estableció mediante consenso, primero entre todos los redactores (ver más adelante método de trabajo seguido) y finalmente, con los revisores (mediante método Delphi), cuya opinión fue vinculante para la redacción final de todas las recomendaciones.
Redacción y consenso del texto y de las recomendaciones. El desarrollo del trabajo de redacción se basó en un sistema de consenso piramidal: de miniconsenso multidisciplinar temático por capítulo, a un gran consenso final entre todos los redactores y revisores. Tomando como base el documento elaborado en la anterior edición y las nuevas referencias bibliográficas sobre asma aparecidas desde 2009 hasta 2015, un grupo de redactores y coordinadores formado por expertos provenientes de las sociedades científicas participantes efectuaron una nueva redacción (incluidas la clasificación de la evidencia y de las recomendaciones) del fragmento del capítulo que se les asignó. Los redactores enviaron sus textos a cada uno de los coordinadores de cada capítulo, formado por los miembros del Comité Ejecutivo de la GEMA. Tras la unificación y revisión de los textos por el coordinador del capítulo, éste remitió el borrador del mismo a todos los redactores del capítulo, para efectuar el primer consenso parcial. Tras las modificaciones se fusionaron todos los capítulos en un solo documento, que a su vez fue de nuevo enviado a todos los redactores y coordinadores para su discusión telemática (y cuando se precisó, en grupos de trabajo, presencial) y aprobación. El documento resultante se remitió a expertos en metodología de guías de práctica clínica del INPECS (Instituto para la Excelencia Clínica y Sanitaria), que efectuaron una revisión crítica de la metodología y redacción del texto y recomendaciones. Tras dichas modificaciones y mejoras, finalmente, las recomendaciones fueron revisadas y consensuadas (mediante método Delphi) por un grupo de expertos en asma provenientes de las sociedades participantes. Las recomendaciones que no alcanzaron un determinado nivel de consenso fueron eliminadas del documento final.
Depression’s influence on the asthma control test, Japanese version
2014, Allergology InternationalDepression has been linked to poorer asthma control in asthmatic patients. Although the Japanese version of the Asthma Control Test (ACT-J) is frequently used as a simple, practical evaluation tool in clinical care settings in Japan, knowledge regarding its efficacy for assessing asthma control in asthmatic patients with depression is limited. Thus, we retrospectively investigated cut-off values of the ACT-J for well- controlled asthma, and explored depression's influence on the test with a questionnaire survey.
Data were analyzed on 1,962 adult asthmatic patients who had completed both the ACT-J and the Japanese version of the Patient Health Questionnaire-9 (J-PHQ-9) in 2008 questionnaire survey conducted by the Niigata Asthma Treatment Study Group. Patients were classified into low (LD: J-PHQ-9 score of 0-4) or high depression (HD: J-PHQ-9 score of 5-27) groups. In both groups, the efficacy of the ACT-J was confirmed. We then compared the optimal cut-off points for uncontrolled asthma in both groups by performing a receiver operating characteristic (ROC) analysis, using the original classification referred to the GlNA classification as the "true" classification.
Cronbach's alpha in the LD and HD group was 0.808 and 0.740 respectively. In both groups, the subgroup with existence of work absenteeism or frequent attacks during the previous 12 months scored lower on the ACT-J. The area under the curve and optimal cut-off point for patients with LD and HD were 0.821 and 0.846, and 23 and 20 respectively.
The efficacy of the ACT-J was confirmed in depressive patients with asthma. Because asthma control as evaluated with the ACT-J can be worse than actual control under depressive states, physicians should also pay attention to a patient's depressive state at evaluation. Further investigations focus on the association between the ACT-J and depression are required.
This project was supported by NIH grant HL 48237.