Questionnaire a ‘powerful predictor’ of future asthma exacerbations
Key takeaways:
- The Asthma Impairment and Risk Questionnaire (AIRQ) comprises 10 yes/no items designed to assess both symptom impairment and exacerbation risk.
- Each 1-point increase in AIRQ score was associated with a greater risk for one or more exacerbations in the following 12 months.
- The tool is available for free online with additional resources to help practices integrate it into their model of assessment.
The Asthma Impairment and Risk Questionnaire predicted exacerbation risks for the next year and can help inform shared decision-making, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
By combining exacerbation history with current symptom impairment, the tool can predict the probability of time to first exacerbation, the researchers wrote.
“We need to do better with asthma in the United States and globally,” David A. Beuther, MD, PhD, professor of medicine, chief medical information officer and pulmonologist at National Jewish Health in Denver, told Healio, adding that an interdisciplinary team of 190 health care professionals addressed unmet needs for asthma, leading to the development of the Asthma Impairment and Risk Questionnaire (AIRQ).
“The AIRQ was developed by this team of experts to represent an assessment of impairment and future risk, incorporating diverse feedback including the patient voice, available published guidelines and evidence, and a desire to ensure any new instrument was practical and easy to use in the real world,” Beuther said.
The design of the AIRQ
The AIRQ comprises 10 yes/no items that address symptoms, activity limitation, sleep, rescue medication use, social activities, exercise, difficulty in asthma control and exacerbations for patients aged 12 years and older.
“While there are many validated asthma control instruments, there was not a single validated composite control tool for adults and children that was easy to use and incorporated domains of impairment and risk of exacerbation,” Beuther said.
“In addition, tools in common use such as [Asthma Control Test (ACT)] miss many patients at risk of exacerbation. For example, 15% to 20% of those classified as well-controlled asthma by ACT can experience an exacerbation in the next year.”
The AIRQ uses a cumulative scale of 0 to 10, with each yes answer equal to 1 point (composite scores, 0-1: well-controlled asthma [WC]; 2-4: not well controlled [NWC]; 5-10: very poorly controlled [VPC]).
Previously published studies have shown that AIRQ has face and construct validity and that it is easy to use, is acceptable to patients, has low literacy demand and is effective at properly classifying asthma control.
“This study represents a very important step in the development and validation of the AIRQ. We sought to evaluate whether the AIRQ could predict the future risk of asthma exacerbations,” Beuther said.
The study’s design, results
During an enrollment clinic visit, 1,112 patients (mean age, 43.9 years; female, 70.5%; white, 78.6%) at 25 participating sites completed the AIRQ, ACT and a sociodemographic questionnaire.
At enrollment, 35.2% were categorized as WC, 38.1% as NWC and 26.6% as VPC, with significant differences between these groups in terms of age, sex and race (P < .05).
Over the next 12 months, 1,070 patients completed one or more monthly follow-up email surveys about their asthma symptoms and related issues, with 76.4% completing 11 months or more of follow-up surveys.
According to the surveys, 45.6% had one or more exacerbation during the follow-up period, and 26.6% had two or more (median, 0; interquartile range, 0-2).
Also, 55.1% of the patients classified as NWC or VPC had one or more exacerbations, and 35.2% had two or more. Specifically, 28.4% of the WC group, 46.3% of the NWC group and 67.7% of the VPC group had one or more exacerbations in the next 12 months (P < .001).
Worsening control appeared significantly associated with more exacerbation occurrences, exacerbations requiring oral corticosteroids, outpatient unscheduled visits for exacerbations and hospitalizations for asthma over the next 12 months (all, P < .001).
Results of a univariate model with AIRQ total score as a continuous variable showed each one-point increase in the score at baseline was associated with increased risk for one or more exacerbations (OR = 1.3; 95% CI, 1.24-1.38; area under the curve [AUC], 0.68) as well as two or more exacerbations (OR = 1.33; 95% CI, 1.26-1.41; AUC, 0.71) over the next 12 months.
Also, NWC (OR = 2.18; 95% CI, 1.62-2.93; AUC, 0.67) and VPC (OR = 5.29; 95% CI, 3.79-7.4; AUC, 0.67) categorization predicted the occurrence of one or more exacerbations in a univariate model of AIRQ as a categorical variable. This finding persisted in a multivariate logistic regression model that used age, sex, BMI and race as covariates (NWC: OR = 2.14; 95% CI, 1.58-2.89; VPC: OR = 4.6; 95% CI, 3.26-6.5).
Kaplan-Meier curves showed patients with worse asthma control at enrollment experienced exacerbations significantly sooner and more often than patients with better asthma control through each month of follow-up (P < .001).
Overall, the researchers wrote, the NWC group had more than twice the risk for experiencing one or more exacerbations in the next year and the VPC group had more than 4.5 times the risk compared with the WC group.
“AIRQ is a powerful predictor of future asthma exacerbation,” Beuther said.
“Throughout our work, the consistency and strength of this tool in assessing current asthma control and predicting exacerbations has exceeded our expectation,” he added.
Conclusions, next steps
According to the researchers, the AIRQ’s performance was similar to that of other models that may not perform well in various clinical environments or may be too complex or expensive for most health care providers to implement successfully.
As a simple, patient-friendly tool, the researchers continued, AIRQ is designed to assess a patient’s risk for exacerbation at the point of care so providers can engage in shared decision-making about educational, behavioral or therapeutic interventions to achieve and maintain asthma control and reduce the risk for exacerbations.
Paper and digital versions of the AIRQ are available online for free at airqscore.com.
“There you can also download an AIRQ implementation guide to adapt your specific practice to incorporate this powerful tool,” Beuther said.
Patients identified with uncontrolled asthma can find support at theasthmaresourcecenter.com, including an asthma checklist linked to AIRQ control category and other provider resources that link components of the checklist to asthma guidelines for further education and opportunities for intervention, Beuther said.
“We cannot improve asthma control and asthma outcomes without better support and engagement of both the patient and the provider,” Beuther said.
“The AIRQ is a simple and powerful starting point for this engagement, and for the shared conversation between patient and provider. Asthma is a complex chronic condition that requires ongoing collaboration and patient engagement to achieve success,” he added.
The researchers are continuing their work, including investigations into whether the AIRQ score predicts frequency and severity of exacerbations in a dose-dependent manner. They also are continuing to study the implementation science around incorporation of the AIRQ into practice.
“We have work to assess and compare the AIRQ directly with other validated instruments like ACT. We are working to determine when and how AIRQ might be incorporated into asthma guidelines in the future,” Beuther said. “And importantly, we are looking to ongoing validation and real-world studies in diverse practices and populations to build upon what we have already accomplished.”
For more information:
David A. Beuther, MD, PhD, can be reached at beutherd@njhealth.org.