The Asthma Therapy Assessment Questionnaire ATAQ for children and adolescents was developed to assist clinicians and health plans to identify children at risk for adverse outcomes of asthma. ATAQ is a brief, item parent-completed questionnaire that generates indicators of potential care problems in several categories, including symptom control, behavior and attitude barriers, self-efficacy barriers, and communication gaps. This paper describes testing of the internal consistency and construct validity of the instrument. A cross-sectional mail survey with telephone follow-up was conducted with parents of children aged years being treated for asthma and enrolled in three managed care organizations in the Midwestern and Northeastern United States. ATAQ scales were evaluated using correlations with measures of health status, asthma impact, and healthcare utilization. ATAQ demonstrated good internal consistency and the hypothesized relationships to corresponding measures from existing instruments.
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Both the National Asthma Education and Prevention Program Expert Panel Report 3 and the Global Initiative for Asthma guidelines identify achieving and maintaining asthma control as goals of therapy, and they emphasize periodic assessment of asthma control once treatment is established.
Accurate assessment of asthma control is difficult due to the complexity of asthma control and due to the limitations in the traditional methods of assessment, such as lung function tests, physician assessment, and patients' self-assessment. Relying solely on the role of lung function tests is insufficient to reflect the status of asthma control, since patients with asthma may have normal spirometry between exacerbations.
Clinicians often overestimate the level of asthma control. Similarly, it is not uncommon for patients to overestimate how well their asthma is controlled, and, therefore, they under-report asthma symptoms and fail to recognize the impact that asthma has on their daily life.
As a result, several tools have been developed to quantify the level of asthma control, identify patients at risk, and evaluate the effect of asthma management. This review examines the commonly used asthma control assessment tools in terms of content, psychometric properties, methods of administration, limitations, and ability to reflect the overall status of asthma control, which can aid clinicians in selecting the most appropriate tool for their needs.
Asthma continues to be a common disease associated with high mortality and high economic and social tolls despite the advances in the understanding of the pathophysiology of asthma, the availability of effective preventive therapy, and the availability of international treatment guidelines. It is estimated that million people of all ages and diverse ethnicities suffer from asthma, and about 1 in every is estimated to die from asthma worldwide.
Most of the burden of asthma is attributed to treating patients with uncontrolled asthma. Clinician assessment, patient self-assessment, and minimal invasive markers, such as spirometry and fractional exhaled nitric oxide F ENO , are the established methods for monitoring asthma. Several standardized self-administered asthma control assessment tools have been developed to quantify the level of asthma control.
These tools are simple and easily completed by patients to facilitate an objective assessment of asthma management. This review examines the tools that have established psychometric properties and have been extensively studied in terms of their content or domains, methods of administration, and ability to reflect the overall status of asthma control. The review below addressed the validity, reliability, accuracy, and responsiveness of each tool. Validity is the extent to which a tool measures what it is intended to measure.
Reliability concerns whether a tool is internally consistent or reproducible and, therefore, whether it consistently measures what it is intended to measure.
Accuracy is the ability of the tool to distinguish between different patients' categories ie, different levels of asthma control against a criterion measure.
Finally, responsiveness is the tool's ability to detect important changes over time. The ACT is a multidimensional, standardized, and validated tool and the most widely used tool for assessing asthma control in patients with asthma older than 12 y. Subsequently, responses for each of the 5 items are summed to yield a score ranging from 5 poor asthma control to 25 complete asthma control.
Overall validity of the ACT has been assessed more than any other asthma control assessment tool. Nathan et al 9 reported high internal consistency of the ACT score with specialists' ratings among subjects with controlled asthma as well as subjects with uncontrolled asthma 0. The authors reported a test-retest reliability of 0. Schatz et al 13 reported that changes in ACT scores were strongly correlated with changes in ACQ scores, moderately correlated with changes in specialist control ratings, and weakly correlated with change in percent-of-predicted FEV 1 values.
The minimum clinically important difference for a tool is the smallest change in score that can be considered clinically important. For the ACT, a difference of 3 points has been shown to be a significant minimum clinically important difference. The cACT was developed in to assess asthma control in children 4—11 y old. The child-reported questions, rated on 4-point Likert scale, include daytime and activity limitation due to asthma symptoms, nocturnal awakenings due to asthma, and self-perceptions of asthma; the caregiver-reported questions, rated on 6-point Likert scale, include asking about the child's daytime and nocturnal symptoms.
The responses summed to an overall score that ranges from 0 poor control of asthma to 27 complete control of asthma. The cACT has been validated more than any other asthma control assessment tool for children with asthma, and, therefore, it has been designated as a core outcome for NIH-initiated participant characterization and for observational studies.
Similarly, Chen et al 37 reported that mean cACT scores were significantly lower among patients with poor asthma control as compared with those who were well controlled according to specialists' rating. Those children had a lower mean percent-of-predicted FEV 1 , had more frequent prescriptions to step-up therapy, and were more frequently rated as having severe asthma compared with those who scored 13— Changes in the cACT scores correlated well with changes in specialists' ratings of asthma control but correlated poorly with changes in peak expiratory flow rate.
The ACQ is another multidimensional, standardized, patient-centered test and is the most widely used asthma control assessment tool in clinical trials. The seventh item is the percent-of-predicted FEV 1 before bronchodilator, which is recorded by a clinician.
The ACQ score is the mean of the 7 items, which gives all items equal weight. An ACQ score has a range from 0 totally controlled to 6 severely uncontrolled. Ideally, the complete 7-item ACQ should be used.
Although the ACQ was initially developed for adult patients with asthma, its ability to quantify asthma control level in children was evaluated as well.
Recent studies found that the ACQ is valid for use in children 6—17 y old. However, a trained interviewer is required to administer the questionnaire to children 6—10 y old.
Also, when the 4 versions were compared with each other, substantial concordances in both cross-sectional and longitudinal validity were noted. Thus, although each version is valid in its own right, the lack of consistent agreement between them and the guidelines may make it invalid to use them interchangeably. The ACQ has shown high reliability in adult subjects who remained clinically stable between consecutive visits to the clinic an intraclass correlation coefficient of 0.
However, a more recent study by Olaguibel et al 63 reported poor correlation between these cutoff points and the GINA guidelines' classification of asthma control. The minimum clinically important difference for the ACQ was found to be 0. The ATAQ is a brief, self-administered tool, developed to identify individuals 18 y and older with possible asthma control problems. Respondents are graded as either having or not having a control problem in each one of these 4 items; the item scores are then summed to provide a total, which ranges from 0 no asthma control problems to 4 4 asthma control problems.
This version was derived from the adult version developed by Vollmer et al. In a month prospective study, 67 subjects with ATAQ scores of 3 or 4 ie, 3 or 4 control problems were 5 times more likely to be hospitalized, 5.
The ATAQ was also used to assess the economic burden of uncontrolled asthma. Sullivan et al 68 reported that the costs for uncontrolled asthma, as indicated by the ATAQ score, were more than double those with scores indicating controlled asthma.
Also, a higher ATAQ score more control problems was associated with lower quality of life in subjects with asthma, indicated by generic and disease-specific quality of life measures, such as the SF, the standardized version of the Asthma Quality of Life Questionnaire, 12 and the Mini Asthma Quality of Life Questionnaire. The reliability of the ATAQ has not been evaluated for the adult version. An ATAQ score of 1 or greater was used as an established cutoff value for uncontrolled versus controlled asthma.
The minimum clinically important difference for ATAQ has not yet been established. The LASS has been developed to measure asthma control in both children 73 and adults 74 with asthma. Initially, the LASS was developed as an English and Spanish symptom scale to measure asthma control in children of non-English-speaking populations.
Later, an adult version was developed. The LASS is composed of 8 items that assess the frequency of cough, wheezing, shortness of breath, asthma attacks, chest pain, nocturnal symptoms, and overall perception of asthma severity over the previous 4 weeks. Each item is scored on a 5-point scale with the descriptors: never, a few days, some days, most days, and every day.
Subsequently, responses for each of the 8 items are summed to yield total scores that range from 8 to 40, with higher scores representing more severe asthma symptoms. Lara et al 73 assessed the construct validity of the children's version of the LASS score in a sample of Latino parents of children with asthma. The LASS had a high internal consistency in both adult and child populations. Although the design of the LASS specifies that a higher score indicates more symptoms, the cutoff values that distinguish between patients' different levels of asthma control have not been established.
In the developmental study, 73 the responsiveness of the LASS was assessed by measuring the changes in the total scores related to the changes in the health status. The total scores were lower after resolution of asthma exacerbation compared with the scores during the exacerbation.
The minimum clinically important difference for the LASS scores was defined for the adult population only. To facilitate an accurate and objective assessment of asthma control, tools that are multidimensional, simple, and relatively short and easy to administer have been developed. Because those tools were designed to capture the overall level of asthma control, there are many similarities in their content. Nonetheless, considerable differences between them still exist.
For instance, they use different ranges for their scoring systems. Whereas the ACQ is scored using a 7-point scale, from 0 totally controlled to 6 extremely poorly controlled , the ACT total score ranges from 5 poor control of asthma to 25 complete control of asthma.
The targeted patient age is another difference among tools. Despite the reported merits of these tools, they are not without shortcomings. This finding limits the ability to use these tools interchangeably. Also, a review by Halbert et al 10 highlighted the discrepancy between the content of most of the tools and the national and international guidelines.
Nevertheless, the LASS was the only tool reviewed above that evaluated the risk of asthma exacerbations as part of its assessment. Furthermore, the ACQ is the only tool included in the above review that comprises lung function as part of the asthma control measure. Despite the fact that measures of lung function are infrequently performed because spirometry equipment is costly and is not always available, 79 these measures are considered an essential criterion of asthma control in both the GINA and NAEPP EPR-3 guidelines.
Knowledge of the psychometric properties of asthma control assessment tools is critical to ensure that the tool selected will measure the desired outcome. Among the tools reviewed, the ACQ has been used in the majority of clinical trials, and the ACT has the most published validation data.
Both tools have been validated for use as self-administered tools in person, at home, 40 or by telephone 26 and in different languages. For instance, in the United States, studies have included mostly white patients. Furthermore, the modes and settings in which those tools can be administered vary as well ie, in-person, at home, over the telephone, in various clinical settings, or over the internet.
Thus, clinicians not only need to review the results of the psychometric properties of tools, but they need to also consider whether the tool was evaluated with a similar population and in a similar setting as their intended use. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Review Article Review. Yahya A Alzahrani.
Abstract Both the National Asthma Education and Prevention Program Expert Panel Report 3 and the Global Initiative for Asthma guidelines identify achieving and maintaining asthma control as goals of therapy, and they emphasize periodic assessment of asthma control once treatment is established. Introduction Asthma continues to be a common disease associated with high mortality and high economic and social tolls despite the advances in the understanding of the pathophysiology of asthma, the availability of effective preventive therapy, and the availability of international treatment guidelines.
Asthma Control Test The ACT is a multidimensional, standardized, and validated tool and the most widely used tool for assessing asthma control in patients with asthma older than 12 y. Reliability Nathan et al 9 reported high internal consistency of the ACT score with specialists' ratings among subjects with controlled asthma as well as subjects with uncontrolled asthma 0.
Responsiveness Schatz et al 13 reported that changes in ACT scores were strongly correlated with changes in ACQ scores, moderately correlated with changes in specialist control ratings, and weakly correlated with change in percent-of-predicted FEV 1 values.
Responsiveness Changes in the cACT scores correlated well with changes in specialists' ratings of asthma control but correlated poorly with changes in peak expiratory flow rate. Asthma Control Questionnaire The ACQ is another multidimensional, standardized, patient-centered test and is the most widely used asthma control assessment tool in clinical trials.
Asthma Control Assessment Tools
Asthma Therapy Assessment Questionnaire (ATAQ)
The Asthma Therapy Assessment Questionnaire (ATAQ) for Children and Adolescents