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ASTHMA CONTROL TEST

INTRODUCTION

There is a major gap between what can b e achieved with modern asthma management

and what is currently being achieved. One of the main reasons for this is a lack of recognition of

asthma control and the requirement for more effective treatment—it is only through identifying

those patients with uncontrolled asthma that appropriate treatment will be prescribed. In part, the

difficulty in the assessment of control relates to the lack of a clear therapeutic target in asthma.

This contrasts with other chronic diseases such as hypertension or diabetes where treatment is

prescribed in order to achieve a definite therapeutic target. One approach to this difficulty is to

develop a simple test which is a screening tool to identify patients with poorly controlled asthma.

The Asthma Control Test (ACT) has been developed and validated for this purpose. It involves

patients completing a simple written questionnaire of 5 questions, from which a score (out of 25)

is obtained. It has been shown that the ACT is a simple, quick and accurate tool for assessing

asthma control and it has been shown to be responsive to changes in asthma control over time. It

can easily be incorporated into the routine assessment of patients with asthma and enable busy

healthcare professionals to more easily identify patients whose asthma control can be improved,

enabling changes to their management to be made and thereby improve outcomes.(1)

DEFINITION

Asthma is a chronic respiratory disease that is mainly managed in primary care setting. In

the global initiative for asthma (GINA) 2006 guideline, achieving and maintaining clinical

control is highlighted as the goal asthma management. So far in China, an effective and

convenient means for evaluating asthma control has not been available in primary care settings,

especially in places where in spirometry is unavailable. In 2004, Nathan et al developed an easy

assessment tool for asthma control, know as the asthma control test (ACT).(2)

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MATERIAL AND METHODS

Study Population

Participants were recruited from the outpatients of the asthma department of the ‘Amalia

Fleming’ general hospital in Athens, Greece, from January to July 2009 specified exclusion

criteria were chronic obstructive pulmonary disease (COPD),cardiovascular disease, neurological

disorders, physical disability, and inability to comprehend or complete questionnaires in Greek.

Data from 100 (n = 100 asthma outpatient (21 men and 79 women),aged from 18 to 80 years

(mean = 49.98,SD = 16.87), were used for the purposes of the present study. All patients,

clinically diagnosed according to the GINA, had at least a 12% improvement in FEV 1 after

inhalation of 200-400 πg of Albutamol and were symptomatic during the past 12 months, under

a specialist’s care, and under controlled medications including inhaled glucocosticosteroids,

long-acting inhaled β2-agonist, and other medication according to GINA. With reference asthma

severity, 58 patients suffered from mild asthma, 32 patients had moderate asthma, and 10

patients had severe asthma. Twenty patients aged 20-47 years were current smoker, 72 patients

aged 18-80 years were no smoker, and 8 patients aged 28-74 years were ex-smoker. Sixty-three

patients had asthma for more than 8 years. According to BMI, 44 patients were

normal/underweight (BMI<25 kg/m2), 34 were overweight, and 22 were obese.

The study protocol was approved by the Research Ehics Committee of the ‘Amalia

Fleming’ General Hospital while the informed consent from was signed by all participants.(3)

THE ASTHMA CONTROL TEST (ACT)

A simple 5-question test for asthma has been developed and validated in several studies.

The ACT was initially developed in a study which looked at 22 of the most common questions

that doctors ask when talking to patients about asthma control, with 5 questions standing out as

being the most accurate predictors. The 5 questions take less than a minute to answer and can be

asked by the health care professional or the patient can complete the test themselves. There is a

score of 1–5 for each question, and an overall score in the range of 5–25, with low scores

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corresponding to a high level of symptoms and therefore poor asthma control. Studies have shown

that the ACT score effectively discriminates between patients who differ in asthma control, is

responsive to changes in control, and can discriminate between groups of patients in different

lung function ranges. The ACT score is highly effective as a screen for uncontrolled asthma and

can correctly predict GINA-defined partly controlled or uncontrolled asthma in over 90% of

cases. A score of 20–25 means that a patient’s asthma is controlled. A score of 15-19 means that it

may be possible to increase the level of asthma control and a full review of the treatment plan,

including education on inhaler technique and the important of compliance with treatment, is

warranted. A score of 14 or less indicates that asthma is poorly or not controlled and that an

urgent review of and changes to the patient’s management are needed. Although there are no

randomised studies that demonstrate that use of the ACT translates into better asthma control, its

use is highly likely to improve patient outcomes as asthma therapy can be confidently adjusted up

if control is demonstrated to be poor. (1)

RESULTS

Revision of the questionnaire

The cognitive debriefing showed that most patients understood four of the five question.

However, the fourth question caused confusion as it asked rescue medication usage but

some patients answered about preventive medication.

Characteristics of study patients

A total 360 patients were invite to participate in the study; 323 (90%)of mean age 36

years (range 12-80) agreed to participate. Females comprised 57% of the participants

with a mean percentage predicted FEV1 and PEF of 86% and 88,6%, respectively, and

mean ACT score of 20,5. Other characteristics are described in table 1, in which GINA

stage 3 is prominent (28%), but in general the patients were equally distributed among

the four stage. Most of the patients were using preventive medication; the majority had

controlled asthma according to both GINA and ACT criteria and were continued on the

same treatment after their visit.

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Responsiveneses of the ACT to specialist treatment modivication

The ACT scores for groups receiving different asthma treatment decesions after medical

assessment are shown in Table 3. The mean Ac score was similar for those in whom

treatment was either maintained or stepped down (p=0,9) but much lower in those in

whom treatment was stepped up. There was a significant correlation beteween the ACT

score and asthma treatment modification (Spearman’s r=-0,36, p<0,001).Relationship

between ACT score and %FEV1 and %PEF. The pearson coefficient between the ACT

score and %PEV1 was 0,35 (p<0,001) and between the ACT score and %PEF it was

0,26(p<0,001).

Reliabity and empire validity of the ACT

Cronbach’s alpha was 0.83, indicating a high consistency among the answers to the five

question of the ACT questionnaire. The cut-off point the ACT in detecting GINA not

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controlled asthma’ was 19, which yielded the largest AUC of 0.85 with a sensitivity of

70%, specifity of 73%. PPV of 89%, NPV of 79%, positive LR of 9.6, negative LR of

0.3, and s correctly classified rate of 83%.

Agreement between ACT and GINA in classifying three levels of asthma control.

The kappa value was 0.55 ( table 2), indicating a moderate level of level of agreement

beyond chance between the two rating systems ( I=0.4-0.6). both rating system correctly

classifield 75% at three levels of asthma control. (4)

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DISCUSSION

Achieving and maintaining asthma control are fundamental elements of asthma

management. Practical tools are needed to assess asthma control in asthma management. Most

tools used to evaluate asthma control consider airflow obstruction as a criterion. However, this is

often very diffcult to perform in developing countries such as Vietnam because spirometers and

peak flow meters are not readily available. A tool is required that measures the multidimensional

nature of asthma control and that is easy and quick to administer and interpret in order to

facilitate the assessment of asthma control in clinical practice. The ACT has proved to be a valid

tool for this purpose in other settings.(4)

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CHILDHOOD ASTHMA CONTROL TEST

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