AIRQ may better identify patients with current, future asthma morbidity
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Key takeaways:
- The Asthma Impairment and Risk Questionnaire (AIRQ) measures current control and future exacerbation risk.
- 35% of patients had well-controlled asthma based on AIRQ vs. 49% based on the Asthma Control Test.
Patients, physicians and the symptom-based Asthma Control Test overestimate asthma control, but the Asthma Impairment and Risk Questionnaire does not, according to a study published in Annals of Allergy, Asthma & Immunology.
The Asthma Impairment and Risk Questionnaire (AIRQ) also assesses risks for exacerbations, Bradley E. Chipps, MD, medical director of respiratory therapy and the cystic fibrosis center at Sutter Medical Center in Sacramento, California, and colleagues wrote.
The study involved 1,112 patients (mean age, 43.9 years; 70% female; 78% white) with asthma, including 947 (85%) who were age 18 years and older and 165 (15%) who were aged 12 to 17 years, recruited from 24 specialty practices and one specialty-affiliated primary care clinic between May and November 2019.
During the enrollment visit, patients completed the AIRQ and the Asthma Control Test (ACT), as well as a sociodemographic questionnaire. Also, patients and physicians both completed 5-point Likert scale assessments of control.
Researchers assessed each patient’s exacerbation history during the previous 12 months, lung function via pre-bronchodilator and post-bronchodilator spirometry, peripheral blood eosinophil count, serum IgE and fractional exhaled nitric oxide.
Each month for the next 12 months, patients received a link to a web-based survey of their oral corticosteroid use related to asthma exacerbations, visits to the ED or urgent care and hospitalizations during the previous month.
Control assessments
Among the 1,108 patients who had all four assessments of control, 686 (62%) said their asthma was completely or well controlled. Also, 598 (54%) were rated completely or well controlled by their physicians.
On the other end of the scale, 76 (7%) said their asthma was poorly or not controlled, with 145 (13%) of patients considered poorly or not controlled by their physicians.
The researchers said assessments of completely or well-controlled asthma were relatively well aligned, with 84% of patients agreeing with their physicians and 73% of physicians agreeing with their patients.
But among patients with assessments in the poorly or not controlled range, 50% of patients agreed with their physicians, and 26% of physicians agreed with their patients.
According to the ACT, 540 (49%) had well-controlled asthma, 286 (26%) were not well controlled and 280 (25%) were very poorly controlled.
The ACT scores in the well-controlled range aligned with patients who considered themselves well controlled in 75% of cases. Similarly, the ACT scores in the very poorly controlled range aligned with patients who considered themselves poorly or not controlled in 92% of cases.
The assessments of completely or well-controlled asthma from physicians aligned with ACT scores in the well-controlled range in 72% of cases, and the physician assessments of poorly or not controlled asthma aligned with ACT scores in the very poorly controlled range in 70% of cases.
AIRQ assessments found 389 (35%) patients whose asthma was well controlled, 423 (38%) whose asthma was not well controlled at 300 (27%) whose asthma was very poorly controlled.
Alignments included 53% between AIRQ well-controlled asthma and patients who assessed themselves as completely or well controlled and 87% between AIRQ very poorly controlled asthma and patients who assessed themselves as poorly or not controlled.
Also, alignments included 53% between AIRQ well-controlled asthma and physicians who assessed patients as completely and well controlled and 67% between AIRQ very poorly controlled asthma and physicians who assessed patients as poorly or not controlled.
Numbers of exacerbations
The 1,106 patients with all four control assessments included 41% with one or more and 22% with two or more chart-documented asthma exacerbations in the 12 months before the study.
Additionally, in the previous year, 220 (32%) patients called their asthma well or completely controlled, 177 (30%) patients had physicians that said their asthma was well or completely controlled, and 159 (29%) patients with ACT scores in the well-controlled range had experienced exacerbations.
However, 60 (15%) of the patients with AIRQ scores indicating well-controlled asthma had an exacerbation during the previous year. Further, 5% of patients with AIRQ scores indicating well-controlled asthma and 14% with ACT scores indicating well-controlled asthma had one or more exacerbations in the previous year.
There were multiple exacerbations for 112 (16%) patients who assessed their asthma as well or completely controlled, 90 (15%) patients whose physicians said their asthma was well or completely controlled, 79 (15%) who had ACT scores in the well-controlled range and 21 (5%) with AIRQ scores in the well-controlled range.
Similarly, 7% of patients had multiple exacerbations during the previous year and ACT scores in the well-controlled range, and 2% of patients had multiple exacerbations and AIRQ scores in the well-controlled range.
Based on these findings, the researchers said that AIRQ was significantly less likely than ACT to qualify asthma as well controlled if patients had one or more (P < .001) or two or more (P < .001) exacerbations in the year before the study.
During the 12 months following the initial assessment, 106 of 215 (49%) patients who rated their asthma as well or completely controlled, 82 of 169 (49%) patients whose physicians rated their asthma as well or completely controlled, 69 of 155 (45%) of patients with ACT scores in the well-controlled range and 22 of 59 (37%) of patients with AIRQ scores in the well-controlled range had one or more exacerbations.
The proportion of patients with two or more exacerbations during the study period was smaller among those whose AIRQ scores in the well-controlled range compared with the well-controlled patients based on self-assessments, physician assessments and ACT scores.
Patients with two or more exacerbations in the previous year who then had two or more during the study period included 34 of 111 (31%) patients who rated themselves as well or completely controlled, 26 of 86 (30%) whose physicians rated their asthma as well or completely controlled, 21 of 78 (27%) with ACT scores in the well-controlled range and five of 21 (24%) with AIRQ scores in the well-controlled range.
Overall, 40% of patients reported coughing, wheezing, shortness of breath or chest tightening during the day on more than 4 days, in the 2 weeks before the study. Also, 34% woke from sleep more than once, 29% limited their daily activities and 24% used rescue medication every day in the 2 weeks before the study. Plus, 23% reported impaired social activities, 54% experienced limitations in exercise and 24% had difficulty controlling their asthma in the 2 weeks before the study.
Patients who had ACT scores in the well-controlled range experienced these symptom impairments more often than those patients whose AIRQ scores were in the well-controlled range.
Conclusions
Noting how patients, physicians and ACT scores all overestimated asthma control, the researchers said AIRQ includes impairment and exacerbation risks, which may improve identification of patients with unrecognized current and future asthma morbidity.
Patients and physicians who overestimate asthma control likely will not address poor treatment adherence, comorbid conditions, or needs for steps up in treatment, the researchers continued, impacting quality of life.
AIRQ also may inform shared decision-making about educational and therapeutic interventions, the researchers continued, by increased patients’ and physicians’ awareness of uncontrolled asthma and risks associated with exacerbations.
Perspective
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Angela Duff Hogan, MD, FAAAAI, FACAAI, FAAP
As pointed out in the article, the ACT is a self-assessment tool used to determine asthma control in patients and helps to make informed treatment decisions. It is widely used in primary and subspecialty settings. In some health systems, continued monitoring of this patient metric is used as a quality indicator to evaluate providers. Its use has been established since 2004.
This article favors a “better” tool, the AIRQ, published in 2020. The authors argue that we need better tools to access asthma control since many patients and their providers often overestimate asthma control. The difference cited between the two tools is that the ACT only assesses asthma impairment, whereas the AIRQ also includes risk impairment to determine asthma control better.
It was surprising when the authors found that more patients who were scored as well controlled by ACT despite having had a prior-year exacerbation at the study enrollment visit went on to have one or more or two or more subsequent exacerbations in the next year, which was three times more than what was experienced by those with prior year exacerbations who were considered well controlled by the AIRQ score at the enrollment visit. This study suggests that the AIRQ was better at identifying patients we need to monitor better.
The NHLBI 2020 guidelines did not cover assessment tools or the best interval for assessing asthma control. If we return to the 2007 guidelines, well-controlled asthma was defined as zero or one exacerbation in 12 months, asthma that was not well controlled was defined as two or three per year, and poorly controlled asthma was considered more than three exacerbations in 12 months.
The AIRQ is a series of yes/no questions, so it does not ask how many exacerbations the patient had in the past year, only if there were any. This questionnaire could overestimate the number of patients who are not well controlled because it does not discriminate between the number of exacerbations in the preceding year.
More studies are needed to see how this questionnaire correlates with spirometry and biomarkers such as fractional exhaled nitric oxide. I often use the ACT as a starting point for discussion with patients about how their asthma has been and not as an absolute value to influence asthma care. I have the luxury of spirometry and FeNO for patients who can afford it or whose insurance covers it. However, many primary care and emergency rooms depend on these self-assessment tools to manage asthma patients. Neither assessment tool as a standalone measurement is adequate.
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