Common measures of asthma severity lack association for describing its clinical course

doi:10.1016/0091-6749(94)90181-3

Journal of Allergy and Clinical Immunology

Volume 94, Issue 4, October 1994, Pages 732-737

https://doi.org/10.1016/0091-6749(94)90181-3 Get rights and content

Abstract

Background and Objective: To address the problems of increasing asthma morbidity and mortality rates, reliable severity measures must be identified. Accordingly, we compared three measures and their relationship to beclomethasone compliance.

Methods: Three clinical measures (symptom scores, morning peak expiratory flow rates, and number of as needed albuterol inhalations with Nebulizer Chronologs [Forefront Technologies, Inc., Lakewood, Colo.]) were assessed daily in 13 adults with asthma for 8.9 ± 2.1 weeks. The relationships among these three variables were analyzed in terms of Pearson correlation coefficients. These were evaluated for each of the three possible pairs of the three clinical measures for each of the 13 patients. The relationship between inhaled beclomethasone compliance and the pairwise correlations was studied with the use of nonparametric statistical procedures.

Results: In four of the 13 patients, no pairwise correlations between any of the three severity measures were observed. The peak expiratory flow rate-symptom score relationship was observed in eight patients, whereas peak expiratory flow rate-albuterol use and albuterol use-symptom score correlations were each seen in four patients. Mean beclomethasone compliance was 64% and was greatest in those patients whose albuterol use increased concurrently with symptom scores (94% vs 50%,p = 0.02).

Conclusions: The commonly used measures of asthma severity, symptom scores, peak flow rate, and β-agonist use may not be interchangeable in describing the clinical course. Patients whose β-agonist use is driven by symptoms tend to be more compliant with use of inhaled corticosteroids.

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We enrolled adults living in low-income neighborhoods who had required a hospitalization, an emergency department visit, or a prednisone course for asthma in the prior year. Trust was a dichotomized measure derived from a 5-item questionnaire with a 5-point Likert scale response. The items were translated to the binary variable “strong” versus “weak” trust. Communication was measured using a 13-item questionnaire with a 5-point Likert scale. Logistic regression was used to examine the association between communication and trust, controlling for potential confounders.
We enrolled 102 patients, aged 18 to 78 years; 87% were female, 90% were Black, 60% had some post–high school education, and 57% were receiving Medicaid. Of the 102 patients, 58 were enrolled before the March 12, 2020, pandemic start date, and 70 (69%) named doctors as their most trusted source of health information. Strong trust was associated with a negative response to the statement “It is hard to reach a person in my doctor’s office by phone.” There was no evidence of an association between the overall communication scores and trust. Satisfaction with virtual messaging was weaker among those with less trust.
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To our knowledge, this study is the first of its kind to examine links between parent-child conflict and prospective asthma-related health across time with a multi-method/multi-informant approach. Prior work has repeatedly observed discrepancies between different informants for the same construct (e.g., parent and child reports of parenting behavior) and among objective and subjective measures of asthma health [49–53]. As such, there has been general consensus that along with longitudinal designs, multi-informant and multi-method approaches (e.g., including both subjective and objective measures) should be utilized within asthma studies whenever possible [52,54,55].
To investigate the role of caregiver- and youth-reports of parent-child conflict on trajectories of asthma-related health outcomes over 2 years.
In a sample of 193 youth with asthma (42.7% female; M age = 12.78) and their primary caregivers, we used a multi-method and multi-informant approach to assess self-reported parent-child conflict from youth and caregivers at both the daily and global levels at baseline. Next, we annually assessed subjective (i.e., youth self-reported asthma symptoms) and clinical (i.e., peak flow) asthma health outcomes for 2 years.
Latent growth curve models revealed an effect of baseline youth-reported global family conflict on peak flow trajectories such that youth who reported greater parent-child conflict at baseline experienced less of an increase in peak flow over time than youth who reported less parent-child conflict at baseline (standardized β = −0.27, p = .003).
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This method has been used in asthma research to assemble indicators of emergency care for asthma11 and to establish minimally important differences in asthma clinical trials.3,12 The multidimensional nature of asthma presents unique challenges when assessing asthma outcomes.13-15 Not only does asthma manifest itself differently from person to person, but it is highly variable across time and symptoms can be dramatically influenced by medication use.16,17
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Development and validation of a new instrument, the Composite Asthma Severity Index (CASI), which can quantify disease severity by taking into account impairment, risk, and the amount of medication needed to maintain control. At present, there is no instrument available to measure and assess the multidimensional nature of asthma.
Twenty-six established asthma investigators, who are part of the National Institutes of Health–supported Inner City Asthma Consortium, participated in a modified Delphi consensus process to identify and weight the dimensions of asthma. Factor analysis was performed to identify independent domains of asthma by using the Asthma Control Evaluation trial. CASI was validated by using the Inner City Anti-IgE Therapy for Asthma trial.
CASI scores include 5 domains: day symptoms and albuterol use, night symptoms and albuterol use, controller treatment, lung function measures, and exacerbations. At Asthma Control Evaluation trial enrollment, CASI ranged from 0 to 17, with a mean of 6.2. CASI was stable, with minimal change in variance after 1 year of treatment. In external validation, CASI detected a 32% larger improvement than did symptoms alone.
CASI retained its discriminatory ability even with low levels of symptoms reported after months of guidelines-directed care. Thus, CASI has the ability to determine the level of asthma severity and provide a composite clinical characterization of asthma.
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Weak and inconsistent correlations between measurements of asthma health status suggest that the disease is composed of nonoverlapping components.
Factor analysis was used to explore the relationships between measures of asthma morbidity and to identify heterogeneous components of asthma health status in children 5 to 12 years old. Results were compared across time (baseline and 48-month visit) and treatment arms.
Analyses were conducted in 7 different study windows in a database from a large clinical trial of children with mild to moderate asthma (n = 1041). Measurements of lung function, symptoms, and health care utilizations from daily diary cards, serum IgE levels, total eosinophil count, skin test positivity, and airway hyperresponsiveness were included. Data on fractional exhaled nitric oxide and sputum eosinophil cationic protein were included in a subgroup of patients.
In each of the study windows, factor analysis identified 5 factors that explained between 50% and 60% of the common variance. Factors identified included (1) inflammatory markers, (2) symptoms/medication use, (3) asthma exacerbations, and measures of lung function, which subdivided into (4) FEV₁ and forced vital capacity, and (5) bronchodilator response and the FEV₁/forced vital capacity ratio. Exploratory analyses suggest that fractional exhaled nitric oxide account for the atopy/inflammatory marker factor, and sputum measurements account for a sixth, separate factor.
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Outpatients (51 men, 62 women), aged (m±SD) 42.9±16.3 years with (% patients) mild intermittent (6.2), mild persistent (15.9), moderate (65.5) and severe (12.4) asthma.
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Both OS (rated by doctors) and PS (rated by patients) were rated as mild intermittent, mild persistent, moderate, or severe. Variables involved in OS assessment, variables self-assessed by patients (dyspnea, perceived treatment efficacy, asthma-related quality of life questionnaire [AQLQ]), patients’ sociodemographic characteristics, and asthma characteristics, were evaluated with questionnaires. These variables were pooled, and considered as potential variables patients might use to determine their PS. They were tested against the PS measurement using FDMA. This identified variables patients actually used to determine PS.
On the day of consultation, 68.1% of patients classed their asthma as mild intermittent or mild persistent, 23.9% as moderate persistent, and 8.0% as severe persistent. There was a significant discrepancy (p<0.01) between PS and OS with a clear patient tendency to underestimate asthma severity as compared to OS. Patients determined PS level according to variables assessing their asthma perception, i.e., AQLQ measures and dyspnea, but not variables involved in OS assessment, such as symptom frequency or knowledge of their peak flow rates. Duration of asthma and treatment characteristics were also involved.
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: Presented in part at the American Academy of Allergy and Immunology Annual Meeting. Chicago, Illinois, March 1993.

View full text

Common measures of asthma severity lack association for describing its clinical course

Abstract

Asthma—United States, 1980–1987

MMWR

Changing patterns of asthma mortality, identifying target populations at high risk

JAMA

National Asthma Education Program Expert Panel Report. Guidelines for the diagnosis and management of asthma

J Allergy Clin Immunol

The role of the peak flow meter in the diagnosis and management of asthma

J Allergy Clin Immunol

Patient and physician behavior models related to asthma care

Med Care

The diagnosis of potentially fatal asthma

Patient use of peak flow monitoring

Am Rev Respir Dis

Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma

Am Rev Respir Dis

Compliance of patients with asthma with an experimental aerosolized medication: implications for controlled clinical trials

J Allergy Clin Immunol

The perception of breathlessness in asthma

Am Rev Respir Dis