Quantifying asthma symptoms in adults: The Lara Asthma Symptom Scale

doi:10.1016/j.jaci.2007.09.025

Journal of Allergy and Clinical Immunology

Volume 120, Issue 6, December 2007, Pages 1368-1372

https://doi.org/10.1016/j.jaci.2007.09.025 Get rights and content

Background

Accurate assessment of asthma symptoms is critical in research and clinical settings. A multidimensional asthma control questionnaire could provide more accurate information about asthma symptoms than global assessments, which often overestimate asthma control.

Objective

We sought to evaluate the efficacy of the Lara Asthma Symptom Scale (LASS) in adults with persistent asthma.

Methods

Participants were 18 to 64 years of age with persistent asthma. Data were collected at baseline, 6 months, and 12 months. We described the construct and predictive validity of the LASS by comparing it with measures of pulmonary function (FEV₁), asthma-specific quality of life (Juniper's Asthma Quality of Life Questionnaire [AQLQ]), and health care use (emergency department [ED] visits and hospitalizations).

Results

Three hundred eighty-three participants provided baseline data. The LASS had high internal consistency reliability (Cronbach α = .84). LASS scores correlated significantly with baseline measures of FEV₁ (−0.20, P = .0002), AQLQ (−0.68, P < .0001), ED visits (0.17, P = .002), and hospitalizations (0.15, P = .008). Baseline LASS scores were associated significantly with ED visits (P = .03) and hospitalizations (P = .04) over the subsequent 12 months. Change in LASS scores over time correlated significantly with changes in FEV₁ (−0.22, P = .001) and AQLQ (−0.70, P < .001).

Conclusions

Clinical implications

This study validates a simple multidimensional asthma questionnaire as a clinical tool in the assessment of asthma control in adults.

Section snippets

Participants

Data for this study were obtained from the baseline and follow-up evaluations of adult participants in the South Texas Asthma Management Project, a large, single-center, prospective, randomized controlled trial of disease management interventions to improve clinical asthma outcomes.¹³ The institutional review boards of all participating institutions approved this study. All participants signed a written informed consent form. Adult participants were between 18 and 64 years of age with a

Results

We enrolled 429 adults, of whom 383 (89%) spoke English as their primary language. Three hundred seventy-five had complete LASS data at baseline and verified asthma health care use data (n = 224 had valid questionnaire data at both baseline and 12 months). At baseline, subjects who failed to complete the 12-month questionnaires were similar to completers in symptom score, severity, health care use, quality of life, and most demographic variables. Noncompleters were younger (mean age, 39 vs 45

Discussion

The LASS demonstrated good internal consistency, excellent validity based on concurrent criterion validity and longitudinal predictive validity, and good discriminatory properties in a heterogeneous sample of adults with persistent asthma. The internal consistency reliability (Cronbach α = .84) was in the same range as previously reported values for another validated questionnaire, the ACT (0.79-0.85).6, 23 Our findings of strong correlations with other measures of asthma health status are

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Clinical asthma studies across different age groups (ie, cross-age studies) can potentially offer insight into the similarities, differences, and relationships between childhood and adult asthma. The National Institutes of Health's Asthma Research Network (AsthmaNet) is unique and innovative in that it has merged pediatric and adult asthma research into a single clinical research network. This combination enhances scientific exchange between pediatric and adult asthma investigators and encourages the application of cross-age studies that involve participants from multiple age groups who are generally not studied together. The experience from AsthmaNet in the development of cross-age protocols highlights some of the issues in the evaluation of cross-age research in asthma. The aim of this review is to summarize these challenges, including the selection of parallel cross-age clinical interventions, identification of appropriate controls, measurement of meaningful clinical outcomes, and various ethical and logistic issues.
Asthma control measurement using five different questionnaires: A prospective study
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Citation Excerpt :
Whether these scores are categorical or continuous, predicted values have been proposed to define two or three levels of control. Although several scores have been published [2–10], they differ by the factors that were considered and the weight that was given to each item [1]. They are mainly used according to local preference for the everyday management of asthma but are also the pillar of asthma assessment in many studies on asthma treatment or monitoring modalities.
Questionnaires play a key place in the assessment of asthma control. Different questionnaires have been developed. However, it remains largely unknown whether they can be used interchangeably. We wondered whether the panel of frequently used scores would give similar measurement of asthma control. The present study aimed to assess the agreement between five specific questionnaires.
In this prospective study, ninety-nine patients completed five commonly used asthma control scores: the GINA, the Asthma Control Test™, the Royal College of Physician score, the Asthma Therapy Assessment Questionnaire (ATAQ), and the Asthma Control Questionnaire^© (ACQ). The kappa coefficient was used to assess the agreement between questionnaires.
The agreement between the GINA and other scores was only moderate (kappa coefficients amounted from 0.41 to 0.60). With respect to the “controlled” level, all the other scores gave higher results than GINA. All other scores also tended to underestimate GINA “uncontrolled level”. For the “partly controlled level” defined by 3 of the 5 questionnaires, ACQ identified the same percentage of patients than GINA while ATAQ overestimated this percentage.
This study shows only moderate agreement between five commonly used asthma control scores. The GINA score showed the lowest percentage of controlled and the highest percentage of uncontrolled asthma. As a consequence, all these scores do not seem to evaluate the same symptoms.
Trial Registration number: NCT01350661.
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Older adults with asthma have worse quality of life, asthma control and increased health care utilization than do healthy peers. Factors that contribute to this are currently unknown.
To identify demographic, psychological or physiologic characteristics associated with asthma quality of life, control and health care utilization in older adults.
By using a cross-sectional design, subjects older than 65 years with a history of physician-diagnosed asthma were enrolled. Demographic, psychological and physiological characteristics (including spirometry, atopy testing and exhaled nitric oxide) were collected. Correlations between these factors and the mini Asthma Quality of Life Questionnaire, Asthma Control Questionnaire and health care utilization were assessed.
Seventy subjects were enrolled in the study, with a mean age of 73.3 years and mean duration of asthma diagnosis of 28.5 years. Higher depression screening scores and self-reported depression were strongly correlated with poorer quality of life and asthma control after controlling for confounding effects through a regression model. In addition, worse overall functional status was correlated with poorer asthma quality of life (P < .01), presence of atopy was associated with decreased health care utilization (P < .01) and subjects who lived alone were more likely to have unscheduled visits to a physician's office (P = .06).
Comorbid depression is strongly associated with poorer asthma quality of life and control in older adults. In addition, worse functional status and living alone may be associated with poorer outcomes. Screening for these conditions is important in the care of the elderly asthmatic population.
Asthma outcomes: Quality of life
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“Asthma-related quality of life” (QOL) refers to the perceived impact that asthma has on the patient’s QOL.
National Institutes of Health institutes and other federal agencies convened an expert group to recommend standardized measures of the impact of asthma on QOL for use in future asthma clinical research.
We reviewed published documentation regarding the development and psychometric evaluation; clinical research use since 2000; and extent to which the content of each existing QOL instrument provides a unique, reliable, and valid assessment of the intended construct. We classified instruments as core (required in future studies), supplemental (used according to the study’s aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011.
Eleven instruments for adults and 6 for children were identified for review. None qualified as core instruments because they predominantly measured indicators of asthma control (symptoms and/or functional status); failed to provide a distinct, reliable score measuring all key dimensions of the intended construct; and/or lacked adequate psychometric data.
In the absence of existing instruments that meet the stated criteria, currently available instruments are classified as either supplemental or emerging. Research is strongly recommended to develop and evaluate instruments that provide a distinct, reliable measure of the patient’s perception of the impact of asthma on all of the key dimensions of QOL, an important outcome that is not captured in other outcome measures.
Asthma outcomes: Composite scores of asthma control
2012, Journal of Allergy and Clinical Immunology
Citation Excerpt :
Responsiveness over time (with no specifically prescribed therapeutic intervention) has been demonstrated for 8 instruments in at least 1 sample (Table VII), and responsiveness to specific therapy has been demonstrated for 3 instruments (Table VII). Minimal clinically important differences (MCIDs) have been defined for the ACQ (0.5 point),13 the ACT (3 points),14 and the Lara Asthma Symptom Scale in adults (7 points).15 Asthma control score instruments that are clinically useful in individual patients may not be effective for measuring differences between populations in clinical trials and vice versa.
Current asthma guidelines recommend assessing the level of a patient’s asthma control. Consequently, there is increasing use of asthma control as an outcome measure in clinical research studies. Several composite assessment instruments have been developed to measure asthma control.
National Institutes of Health institutes and federal agencies convened an expert group to propose the most appropriate standardized composite score of asthma control instruments to be used in future asthma studies.
We conducted a comprehensive search of PubMed using both the National Library of Medicine’s Medical Subject Headings and key terms to identify studies that attempted to develop and/or test composite score instruments for asthma control. We classified instruments as core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at a National Institutes of Health–organized workshop convened in March 2010 and finalized in September 2011.
We identified 17 composite score instruments with published validation information; all had comparable content. Eight instruments demonstrated responsiveness over time; 3 demonstrated responsiveness to treatment. A minimal clinically important difference has been established for 3 instruments. The instruments have demographic limitations; some are proprietary, and their use could be limited by cost.
Two asthma composite score instruments are sufficiently validated for use in adult populations, but additional research is necessary to validate their use in nonwhite populations. Gaps also exist in validating instruments for pediatric populations.
Effect of age on asthma control: Results from the National Asthma Survey
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Citation Excerpt :
Although much research and public attention has focused on children and young adults, there has been little research on older adults (>65 years) with asthma.3 In fact, many asthma trials4–7 have routinely excluded participants older than 65 years. It is estimated that approximately 2 million adults older than 65 years in the United States carry a diagnosis of asthma.
Two million US citizens older than 65 years have asthma, but little is known about asthma control in this population.
To compared short- and long-term asthma control in elderly (≥65 years old) and young adult (18–64 years old) populations from the National Asthma Survey.
Data from the National Asthma Survey (sponsored by the Centers for Disease Control and Prevention) were analyzed. Demographic variables, health insurance status, smoking status, indoor allergen exposure, and asthma education were compared between the young adult and elderly populations. Asthma control was examined based on short-term measures (recent oral corticosteroid bursts or symptoms) and long-term measures (asthma attacks, urgent care visits, hospitalizations, and activity limitation in the previous year).
A total of 2,557 young and 398 elderly asthmatic patients were included. Elderly patients had a lower income, were less educated, were more obese, were more insured, had less indoor exposure, and were more likely to be former smokers. They were less educated about asthma attack interventions and asthma action plans (P < .05 for both). On multivariate analysis, elderly patients had worse control of asthma based on short-term measures (daytime symptoms in the previous month [odds ratio (OR), 1.73; 95% confidence interval (CI), 1.25–2.35] and any short-term measure [OR, 1.48; 95% CI, 1.11–1.97]) and long-term measures (activity limitation in the previous year [OR, 1.50; 95% CI, 1.12–2.01]).
Elderly asthmatic patients have worse short- and long-term asthma control compared with the young adult population. Further studies are needed to elucidate whether these findings are due to pathophysiologic differences and whether tailored education or other novel strategies can provide better asthma control.

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: Supported by the US Department of Health and Human Services (DHHS), the Office of Minority Health (OMH), grants no. D52MP03114-01-0 and D52MP03114-02-0, and the Centers for Disease Control and Prevention (CDC), grant no. R01 EH000095-01.

: Disclosure of potential conflict of interest: M. Lara is employed by Rand Corporation. J. I. Peters has received grant support from the National Institutes of Health and Centocor and is on the speakers' bureau for Merck, GlaxoSmithKline, Boehringer Ingelheim, and Pfizer. The rest of the authors have declared that they have no conflict of interest.

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Health care education, delivery, and qualityQuantifying asthma symptoms in adults: The Lara Asthma Symptom Scale

Background

Objective

Methods

Results

Conclusions

Clinical implications

Section snippets

Participants

Results

Discussion

Asthma prevalence and control characteristics by race/ethnicity—United States, 2002

MMWR Morb Mortal Wkly Rep

The burden of asthma in the United States. Level and distribution are dependent on interpretation of the National Asthma Education and Prevention Program Guidelines

Am J Respir Crit Care Med

Asthma control and differences in management practices across seven European countries

Respir Med

Lack of correlation of symptoms with specialist-assessed long-term asthma severity

Chest

Development of the Asthma Control Test: a survey for assessing asthma control

J Allergy Clin Immunol

Development and cross-validation of the Childhood Asthma Control Test

J Allergy Clin Immunol

Measurement properties and interpretation of three shortened versions of the asthma control questionnaire

Respir Med

Association of asthma control with health care utilization and quality of life

Am J Respir Crit Care Med

The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents

Dis Manage

An English and Spanish pediatric asthma symptom scale

Med Care

Development and validation of an instrument to measure asthma symptom control in children

J Asthma

Impact of two disease management strategies in an underserved asthma population

Am J Respir Crit Care Med

National asthma education and prevention program. Expert panel report: guidelines for the diagnosis and management of asthma update on selected topics—2002

Validation of a standardized version of the Asthma Quality of Life Questionnaire

Chest

Comparison of the standard gamble, rating scale, AQLQ and SF-36 for measuring quality of life in asthma

Eur Respir J

Is the asthma quality of life questionnaire a useful measure for low-income asthmatics?

Am J Respir Crit Care Med

Health care education, delivery, and quality
Quantifying asthma symptoms in adults: The Lara Asthma Symptom Scale