Asthma questionnaire, checklist use varies among practices
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LOUISVILLE, Ky. — Practices vary in their use of the Asthma Impairment and Risk Questionnaire in assessing asthma control, according to a study presented at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
“Around 8% of our population has asthma, and in about 60% of those, it is not well controlled, so we need to try to do something about it,” Barbara P. Yawn, MD, MSc, FAAFP, adjunct professor in the department of family and community health, University of Minnesota, told Healio.
“One of the ways to help is to use a validated instrument to assess control, because we have other data that show that the clinician and the patient think they’re in better control than they actually are,” Yawn continued.
The free and online Asthma Impairment and Risk Questionnaire (AIRQ) comprises 10 yes/no items designed to assess asthma symptom impairment and exacerbation risk. Each 1-point increase in AIRQ score indicates a greater risk for one or more exacerbations in the following 12 months.
Also, the Asthma Checklist is a decision support tool designed to help clinicians facilitate the implementation of guideline and expert opinion recommendations into practice at the point of care.
The study examined the use of the AIRQ and the Asthma Checklist among 843 patients (70.2% female; mean age, 45.4 ± 18.4 years; age range, 13-86 years) with clinician-confirmed asthma who completed baseline study visits between April 2021 and February 2022 at six primary care practices, six specialty practices and one asthma coaching program across geographically diverse areas.
Before seeing the clinician, patients completed the AIRQ, which asked them about symptoms, activity limitations, sleep, rescue medication use, social activities, exercise, difficulty controlling their asthma and exacerbations.
“This saves a tremendous amount of time and presents the clinician with a whole bunch of information they wouldn’t otherwise have,” Yawn said.
The number of “yes” responses determined if asthma was well controlled (0-1), not well controlled asthma (2-4), or very poorly controlled ( 5).
Average AIRQ scores ranged from 2.2 ± 2.3 among the 431 patients attending primary care visits to 3 ± 3 among the 279 in specialty practice and 4.6 ± 2.9 among the 133 in the asthma coaching program.
Also, 42.3% of the patients overall had well-controlled asthma, 31.4% had asthma that was not well controlled and 26.2% had asthma that was poorly controlled, based on the AIRQ results.
Specifically, 51.9% of the patients in the coaching program had poorly controlled asthma, compared with 28.3% of the specialty patients and 16.9% of those in primary care.
“These were not patients who were in good control,” Yawn said.
After reviewing the results of the AIRQ with the patient, the clinicians then completed the Asthma Checklist, indicating which asthma management choices they considered for each patient at baseline.
For example, 68.9% of the primary care clinicians, 82.1% of the specialists and 79.7% of the coaches considered adherence. Similarly, 74% of the PCPs, 78.5% of the specialists and 98.5% of the coaches considered appropriate therapy.
“Almost everybody said they were adherent and had appropriate therapy,” Yawn said. “And then you start falling off when you get to the asthma action plan and inhaler technique, especially in primary care.”
A greater proportion of coaches than PCPS and specialists considered asthma action plans (97.7% vs. 53.4% vs. 35.8%), inhaler technique (97.7% vs. 40.1% vs. 42.7%), spirometry (97% vs. 22.3% vs. 45.2%), tobacco use (96.2% vs. 23.4% vs. 29.6%) and comorbidities (94% vs. 28.1% vs. 46.6%). More specialists considering asthma phenotyping (25.4% vs. PCPs, 5.1%; coaches, 7.5%).
Other items on the checklist assessed by fewer PCPs and specialists include psychological issues, home and/or work exposures, and referrals to asthma specialty centers.
“They may not be aware of the importance of these issues, like psychological issues, or they don’t have time,” Yawn said. “They may say, ‘If I start talking to somebody about their depression, I’m going to be here an hour and a half.’”
The researchers also calculated how often checklist items were assessed based on AIRQ control levels. For example, adherence was considered for 71.7% of the patients with well-controlled asthma, 75.1% of those whose asthma was not well controlled and 80.1% of those with very poorly controlled asthma. Appropriate therapy had similarly high percentages across AIRQ classifications.
However, asthma action plans were considered for 44.8% of those with well-controlled asthma, 58.1% of those whose asthma was not well controlled and 66.1% of those with very poorly controlled asthma. The remaining items on the checklist had similarly lower percentages.
“Some of the items among the patients with very poorly controlled asthma are still really only being assessed around 50%, 60% of the time. I think that we need to think more broadly,” Yawn said.
“They certainly think about adherence and appropriate therapy. But get below that, and people are not thinking, in my opinion, broadly enough about what we need to do to impact asthma management and asthma influence,” she continued.
Although the AIRQ results indicate that more than 50% of patients had uncontrolled asthma and one in four were very poorly controlled, the researchers wrote, core asthma assessments varied in how often they were used based on the type of practice and on the level of asthma control.
In fact, there was a direct relation between consideration of the asthma checklist items and patients’ worsening level of asthma control, the researchers continued. The researchers now plan on conducting qualitative interviews with patients and providers and asking them about implementation.
“The next thing to ask is if it makes a difference. Because if it doesn’t make a difference, nobody is going to spend the time in the long term doing it,” Yawn said. “Does it make a difference to the clinician, to the patient, to outcomes, to exacerbation rates, to quality of life, to how happy I am in my practice?”
For more information:
Barbara P. Yawn, MD, MSc, FAAFP, can be reached at byawn47@gmail.com.