Clinicians tend to overestimate improvements in asthma control: an unexpected observation

Defining response to therapy with biologics in severe asthma: from global evaluation to super response and remission

INTRODUCTION

In recent years, monoclonal antibodies targeting Type-2 inflammatory pathways have been developed for severe asthma treatment. However, even when patients are carefully selected, the response to treatment varies.

AREAS COVERED

Different studies have evaluated response to therapy with biologics such as exacerbation reduction, symptom improvement, pulmonary function increase, improvement in QoL, or decrease of oral corticosteroids, showing that all patients do not respond to all disease aspects and leading to an extensive debate regarding the definition of response.

EXPERT OPINION

Assessing response to therapy is of great importance, but since there is no uniform definition of treatment response, the recognition of patients who really benefit from these therapies remains an unmet need. In the same context, identifying non-responding patients in which biologic therapy should be switched or substituted by alternative treatment options is of paramount importance. In this review, we present the road trip of the definition of therapeutic response to biologics in severe asthmatics by presenting the current relevant medical literature. We also present the suggested predictors of response, with an emphasis on the so-called super-responders. Finally, we discuss the recent insights regarding asthma remission as a feasible treatment goal and provide a simple algorithm for the evaluation of response.

Differing perceptions of asthma control and treatment effectiveness by patients with severe asthma and treating subspecialists in the United States

Objective: For patients with severe asthma (SA), overestimation of asthma control may lead to poorer outcomes. The objective of this study was to assess concurrent patient and specialist assessments of asthma control and treatment effectiveness among a large US cohort of SA patients.Methods: CHRONICLE is an ongoing observational study of patients with SA treated by US subspecialists. Asthma control was assessed using the patient-completed Asthma Control Test™ (ACT™) and specialist clinical assessment of control. Treatment effectiveness was measured using the Global Evaluation of Treatment Effectiveness (GETE) completed by patients and specialists.Results: 1109 patients who completed online surveys at enrollment were included. 14%, 28%, 25%, and 33% of patients had ACT™ scores of 5-9, 10-15, 16-19, and 20-25, respectively. Compared with 67% of patients with uncontrolled asthma by ACT™, 44% were uncontrolled by specialist assessment. 54% of patients who were uncontrolled according to the ACT™ were rated as controlled by specialists, demonstrating overestimation of asthma control. Based on ACT™ score, asthma control was more frequent among patients treated with biologics compared to other treatments. Using the GETE, 90% of patients reported treatment effectiveness compared with 71% of specialists. Patient and specialist treatment effectiveness categorizations agreed for 73%.Conclusion: Specialists commonly overestimated asthma control relative to ACT™ scores. Patients reported treatment effectiveness more frequently than specialists. These findings emphasize the importance of validated instruments to assess asthma control and reduce potential treatment gaps associated with patient-specialist discordance.

Patients' and physicians' attitudes and perception about asthma in the Gulf: A subset analysis from the Asthma Insights and Management Survey in the Gulf and Russia

Background: Asthma is a prevalent disorder in the Gulf region. However, available data concerning asthma control and patients' perception with regard to their disease are still insufficient. Objective: To investigate patients' perception and behavior with regard to the asthma-related burden, the level of asthma control, and asthma management in three Gulf countries. Methods: This study presented a subset analysis of the Asthma Insights and Management survey about the asthma burden and management in the Gulf region and Russia. In this subset analysis, we retrieved the data of the patients from Saudi Arabia, United Arab Emirates, and Kuwait. Results: The current survey's population was composed of 452 patients. One hundred fifty-four patients (34.1%) rated themselves as having poorly controlled asthma, whereas 60.3% of the patients perceived their asthma as completely or well controlled. However, only two patients (0.4%) had controlled asthma according to the global asthma guidelines criteria for asthma control. Most of the patients (67.7%) reported that their asthma got worse when outdoors. Almost 70% of the patients on daily control plus a quick relief regimen reported that their asthma got worse when they were outdoors. Over the past 12 months, 95 patients (21%) reported asthma exacerbation. More than half of the included patients experienced an asthma attack that stopped their activities, whereas 54.2% of the patients were forced to leave work or school due to an asthma attack, and 53.1% had to cancel an appointment or had to go to bed due to the severity of the attack. With concern to asthma management, only 30.5% of the patients were given a lung function test for the assessment of their asthma. A written action plan for asthma treatment was developed by the physician or the practice nurse for only 21.7% of the patients. Conclusion: In the Gulf region, asthma exerts a substantial burden on patients who are affected. Such a burden significantly impacted patients' quality of life.

Development and initial validation of the Asthma Severity Scoring System (ASSESS)

BACKGROUND

Tools for quantification of asthma severity are limited.

OBJECTIVE

We sought to develop a continuous measure of asthma severity, the Asthma Severity Scoring System (ASSESS), for adolescents and adults, incorporating domains of asthma control, lung function, medications, and exacerbations.

METHODS

Baseline and 36-month longitudinal data from participants in phase 3 of the Severe Asthma Research Program (NCT01606826) were used. Scale properties, responsiveness, and a minimally important difference were determined. External replication was performed in participants enrolled in the Severe Asthma Research Program phase 1/2. The utility of ASSESS for detecting treatment response was explored in participants undergoing corticosteroid responsiveness testing with intramuscular triamcinolone and participants receiving biologics.

RESULTS

ASSESS scores ranged from 0 to 20 (8.78 ± 3.9; greater scores reflect worse severity) and differed among 5 phenotypic groups. Measurement properties were acceptable. ASSESS was responsive to changes in quality of life with a minimally important difference of 2, with good specificity for outcomes of asthma improvement and worsening but poor sensitivity. Replication analyses yielded similar results, with a 2-point decrease (improvement) associated with improvements in quality of life. Participants with a 2-point or greater decrease (improvement) in ASSESS scores also had greater improvement in lung function and asthma control after triamcinolone, but these differences were limited to phenotypic clusters 3, 4, and 5. Participants treated with biologics also had a 2-point or greater decrease (improvement) in ASSESS scores overall.

CONCLUSIONS

The ASSESS tool is an objective measure that might be useful in epidemiologic and clinical research studies for quantification of treatment response in individual patients and phenotypic groups. However, validation studies are warranted.

Asthma Control Test

We compared results of a modified version of the Asthma Control Test using parent proxy report (PP-ACT) with results reported by children and parents using the validated Childhood-Asthma Control Test (C-ACT). 104 parent-child dyads with a child aged 6 to 12 years with asthma were randomized to complete PP-ACT followed by C-ACT or C-ACT followed by PP-ACT. Scores ≤19 indicated uncontrolled asthma. We calculated sensitivity, specificity, positive predictive value, and negative predictive value for the PP-ACT in comparison with the C-ACT, and calculated concordance between the 2 scales. The PP-ACT had sensitivity of 86% and negative predictive value of 88% for detecting uncontrolled asthma. More than 75% of surveys were concordant (κ = 0.54, moderate agreement). Our results suggest that while the PP-ACT missed few children with uncontrolled asthma and may simplify reporting of asthma control in circumstances when child report is not feasible or creates barriers to survey receipt, limitations of proxy reporting should be considered.

Structured pharmaceutical care improves the health-related quality of life of patients with asthma

Background

Asthma as a chronic health condition can be controlled when in addition to clinical care, adequate education and support is provided to enhance self-management. Like many other chronic health conditions improved self-management positively impacts the health-related quality of life (HRQoL). It can therefore be said that a well-structured pharmaceutical care delivery that addresses the issues related to patient education and support towards self-management stands a good chance of positively impacting asthma control.

This study evaluated the impact of a structured pharmaceutical care delivery on asthma control.

Methods

A prospective pre-/post- intervention study of a single cohort of 77 adult out-patients visiting specialist asthma clinics in Ghana were assessed for HRQoL and peak expiratory flow rates (PEFR) one month after pharmaceutical care intervention. Pharmaceutical care intervention covered education on the health condition, pharmacotherapy and self-management issues as well as correction of inhaler-use technique, where necessary and when to urgently seek medical care. The mean difference of the HRQoL and PEFR values were subjected to paired samples t-test analysis.

Results

Delivery of a structured pharmaceutical care led to a significant improvement in asthma specific quality of life and PEFR. The mean paired difference of the HRQoL for a cohort of patients with asthma post- pharmaceutical care intervention was 0.697(95% CI: 0.490 - 0.900) at t = 6.85 (p < 0.05). The mean paired difference for PEFR post intervention was 17.533 (95% CI: 2.876 - 32.190) at t = 2.384 (p = 0.02).

Conclusion

This study identified important challenges with both the pharmacologic and the non-pharmacologic management of adult asthma patients. Inadequate inhaler-use skills, widespread occurrence of preventable adverse events and irregular use of preventer medicines were prevalent among patients. At one month after pharmaceutical care intervention, patients with asthma in a cohort follow-up study showed significant improvements with regard to asthma-specific quality of life, peak flow rates and knowledge

Trial registration

GHS-ERC: 08/9/11 of October 19, 2011.

What patients really think about asthma guidelines: barriers to guideline implementation from the patients' perspective

BACKGROUND

Treatment of asthma does not always comply with asthma guidelines (AG). This may be rooted in direct or indirect resistance on the doctors' and/or patients' side or be caused by the healthcare system. To assess whether patients' concepts and attitudes are really an implementation barrier for AG, we analysed the patients' perspective of a "good asthma therapy" and contrasted their wishes with current recommendations.

METHODS

Using a qualitative exploratory design, topic centred focus group (FG) discussions were performed until theoretical saturation was reached. Inclusion criteria were an asthma diagnosis and age above 18. FG sessions were recorded audio-visually and analysed via a mapping technique and content analysis performed according to Mayring (supported by MAXQDA®). Participants' speech times and the proportion of time devoted to different themes were calculated using the Videograph System® and related to the content analysis.

RESULTS

Thirteen men and 24 women aged between 20 and 77 from rural and urban areas attended five FG. Some patients had been recently diagnosed with asthma, others years previously or in childhood. The following topics were addressed: (a) concern about or rejection of therapy components, particularly corticosteroids, which sometimes resulted in autonomous uncommunicated medication changes, (b) lack of time or money for optimal treatment, (c) insufficient involvement in therapy choices and (d) a desire for greater empowerment, (e) suboptimal communication between healthcare professionals and (f) difficulties with recommendations conflicting with daily life. Primarily, (g) participants wanted more time with doctors to discuss difficulties and (h) all aspects of living with an impairing condition.

CONCLUSIONS

We identified some important patient driven barriers to implementing AG recommendations. In order to advance AG implementation and improve asthma treatment, the patients' perspective needs to be considered before drafting new versions of AG. These issues should be addressed at the planning stage.

TRIAL REGISTRATION

DRKS00000562 (German Clinical Trials Registry).

Phenotyping of difficult asthma using longitudinal physiological and biomarker measurements reveals significant differences in stability between clusters

Background

Although the heterogeneous nature of asthma has prompted asthma phenotyping with physiological or biomarker data, these studies have been mostly cross-sectional. Longitudinal studies that assess the stability of phenotypes based on a combination of physiological, clinical and biomarker data are currently lacking.

Our objective was to assess the longitudinal stability of clusters derived from repeated measures of airway and physiological data over a 1-year period in moderate and severe asthmatics.

Methods

A total of 125 subjects, 48 with moderate asthma (MA) and 77 with severe asthma (SA) were evaluated every 3 months and monthly, respectively, over a 1-year period. At each 3-month time point, subjects were grouped into 4 asthma clusters (A, B, C, D) based on a combination of clinical (duration of asthma), physiological (FEV₁ and BMI) and biomarker (sputum eosinophil count) variables, using k-means clustering.

Results

Majority of subjects in clusters A and C had severe asthma (93 % of subjects in cluster A and 79.5 % of subjects in cluster C at baseline). Overall, a total of 59 subjects (47 %) had stable cluster membership, remaining in clusters with the same subjects at each evaluation time. Cluster A was the least stable (21 % stability) and cluster B was the most stable cluster (71 % stability). Cluster stability was not influenced by changes in the dosage of inhaled corticosteroids.

Conclusion

Asthma phenotyping based on clinical, physiologic and biomarker data identified clusters with significant differences in longitudinal stability over a 1-year period. This finding indicates that the majority of patients within stable clusters can be phenotyped with reasonable accuracy after a single measurement of lung function and sputum eosinophilia, while patients in unstable clusters will require more frequent evaluation of these variables to be properly characterized.

Control of asthma in real life: still a valuable goal?

Although studies show that control of asthma can be achieved in the majority of patients, surveys repeatedly show that this is not the case in real life. Important measures to implement in order to achieve asthma control are trained healthcare professionals, a good patient–doctor relationship, patient education, avoidance of exposure to triggers, personalised management and adherence to treatment. These measures help the majority of asthma patients but have not yet been widely implemented and there should be a concerted action for their implementation. Moreover, further and focused research is needed in severe/refractory asthma.

Achieving asthma control requires implementation of evidence-based guidelines and further research into severe asthmahttp://ow.ly/KzrOp

The Impact of Parent's Health Literacy on Pediatric Asthma Outcomes

Background: Health literacy has been associated with health disparities in many disease outcomes, including children's asthma. Parents are responsible for most of children's healthcare. Therefore, parents' health literacy may impact children's health outcomes, including asthma control. This study sought to determine the association between parent health literacy and children's asthma control among a cohort of predominately minority urban children aged between 6 and 12 years. Methods: This cross-sectional study assessed children with asthma and their parents at a single outpatient visit. English-speaking parents and their children, aged between 6 and 12 years with physician-diagnosed asthma, were eligible for this study. Healthcare providers assessed asthma control and severity, and parents completed demographic, health literacy, asthma control, and asthma knowledge measures. Children completed a pulmonary function test as part of the Asthma Control Questionnaire (ACQ) scoring. Results: A total of 281 parent-child dyads provided data, with the majority of parents being mothers and African American, with a high school level education or less. Lower parent health literacy was associated with worse asthma control as rated both by the provider (p=0.007) and the ACQ (p=0.013), despite only moderate concordance between ratings (ρ=0.408, p<0.0001). Lower parent health literacy also was associated with less asthma knowledge, which was associated with worse asthma control. Conclusions: Higher parent health literacy was associated with more parent asthma knowledge and better child asthma control. Pediatric providers should consider tailoring education or treatment plans or utilizing universal precautions for low health literacy.

Using an electronic medical record (EMR) to conduct clinical trials: Salford Lung Study feasibility

Background

Real-world data on the benefit/risk profile of medicines is needed, particularly in patients who are ineligible for randomised controlled trials conducted for registration purposes. This paper describes the methodology and source data verification which enables the conduct of pre-licensing clinical trials of COPD and asthma in the community using the electronic medical record (EMR), NorthWest EHealth linked database (NWEH-LDB) and alert systems.

Methods

Dual verification of extracts into NWEH-LDB was performed using two independent data sources (Salford Integrated Record [SIR] and Apollo database) from one primary care practice in Salford (N = 3504). A feasibility study was conducted to test the reliability of the NWEH-LDB to support longitudinal data analysis and pragmatic clinical trials in asthma and COPD. This involved a retrospective extraction of data from all registered practices in Salford to identify a cohort of patients with a diagnosis of asthma (aged ≥18) and/or COPD (aged ≥40) and ≥2 prescriptions for inhaled bronchodilators during 2008. Health care resource utilisation (HRU) outcomes during 2009 were assessed. Exacerbations were defined as: prescription for oral corticosteroids (OCS) in asthma and prescription of OCS or antibiotics in COPD; and/or hospitalisation for a respiratory cause.

Results

Dual verification demonstrated consistency between SIR and Apollo data sources: 3453 (98.6%) patients were common to both systems; 99.9% of prescription records were matched and of 29,830 diagnosis records, one record was missing from Apollo and 272 (0.9%) from SIR. Identified COPD patients were also highly concordant (Kappa coefficient = 0.98).

A total of 7981 asthma patients and 4478 COPD patients were identified within the NWEH-LDB. Cohort analyses enumerated the most commonly prescribed respiratory medication classes to be: inhaled corticosteroids (ICS) (42%) and ICS plus long-acting β₂-agonist (LABA) (40%) in asthma; ICS plus LABA (55%) and long-acting muscarinic antagonists (36%) in COPD. During 2009 HRU was greater in the COPD versus asthma cohorts, and exacerbation rates in 2009 were higher in patients who had ≥2 exacerbations versus ≤1 exacerbation in 2008 for both asthma (137.5 vs. 20.3 per 100 person-years, respectively) and COPD (144.6 vs. 41.0, respectively).

Conclusion

Apollo and SIR data extracts into NWEH-LDB showed a high level of concordance for asthma and COPD patients. Longitudinal data analysis characterized the COPD and asthma populations in Salford including medications prescribed and health care utilisation outcomes suitable for clinical trial planning.

Validation of control of allergic rhinitis and asthma test for children (CARATKids)--a prospective multicenter study

BACKGROUND

Control of Allergic Rhinitis and Asthma Test for Children (CARATKids) is the first questionnaire that assesses simultaneously allergic rhinitis and asthma control in children. It was recently developed, but redundancy of questions and its psychometric properties were not assessed. This study aimed to (i) establish the final version of the CARATKids questionnaire and (ii) evaluate its reliability, responsiveness, cross-sectional validity, and longitudinal validity.

METHODS

A prospective observational study was conducted in 11 Portuguese centers. During two visits separated by 6 wk, CARATKids, visual analog scale scales and childhood asthma control test were completed, and participant's asthma and rhinitis were evaluated by his/her physician without knowing the questionnaires' results. Data-driven item reduction was conducted, and internal consistency, responsiveness analysis, and associations with external measures of disease status were assessed.

RESULTS

Of the 113 children included, 101 completed both visits. After item reduction, the final version of the questionnaire has 13 items, eight to be answered by the child and five by the caregiver. Its Cronbach's alpha was 0.80, the Guyatt's responsiveness index was -1.51, and a significant (p < 0.001) within-patient change of CARATKids score in clinical unstable patients was observed. Regarding cross-sectional validity, correlation coefficients of CARATKids with the external measures of control were between 0.45 and -0.69 and met the a priori predictions. In the longitudinal validity assessment, the correlation coefficients between the score changes of CARATKids and those of external measures of control ranged from 0.34 to 0.46.

CONCLUSION

CARATKids showed adequate psychometric properties and is ready to be used in clinical practice.

Failure in asthma control: reasons and consequences

Clinical research showed that asthma control is an achievable target. However, real-life observations suggest that a significant proportion of patients suffer from symptoms and report lifestyle limitations with a considerable burden on patient's quality of life. The achievement of asthma control is the result of the interaction among different variables concerning the disease pattern and patients' and physicians' knowledge and behaviour. The failure in asthma control can be considered as the result of the complex interaction among different variables, such as the role of guidelines diffusion and implementation, some disease-related factors (i.e., the presence of common comorbidities in asthma such as gastroesophageal reflux disease (GERD), sleep disturbances and obstructive sleep apnea (OSA), and rhinitis) or patient-related factors (i.e., adherence to treatment, alexithymia, and coping strategies). Asthma control may be reached through a tailored treatment plan taking into account the complexity of factors that contribute to achieve and maintain this objective.

Comparison between two methods of asthma control evaluation based on individual perception

OBJECTIVE

To compare the subjective perception of asthma control reported by the patient with that measured by the score obtained on the Asthma Control Questionnaire 6-item version (ACQ-6) in patients with severe asthma and to determine whether asthma control is associated with the number of emergency room visits in the previous month.

METHODS

This was a cross-sectional study involving 528 patients treated at the Bahia State Asthma and Allergic Rhinitis Control Program Central Referral Clinic between August of 2008 and March of 2010, in the city of Salvador, Brazil. The patients completed the ACQ-6 and answered a specific additional question in order to evaluate their own perception of asthma control in the previous week.

RESULTS

We evaluated 423 patients who met the inclusion criteria. The sample was predominantly female (81.3%), and 64.3% had an income lower than two times the national minimum wage. The mean age was 49.85 ± 13.71 years, and the duration of asthma symptoms was 32.11 ± 16.35 years. The patients had been regularly treated via the program for 36.65 ± 18.10 months. Based on the subjective perception of asthma control, only 8% of the patients considered their asthma to be uncontrolled, whereas 38.8% had an ACQ-6 score > 1.5, which indicates poor control. The kappa statistic revealed poor concordance between the two methods. There was a direct association between uncontrolled asthma and the number of emergency room visits in the previous month (p < 0.001).

CONCLUSIONS

In this sample of patients, the subjective perception of asthma control differed from that measured by the ACQ-6 score, and the patients overestimated their own level of asthma control, which puts them at risk of being undertreated.

Four of a kind: asthma control, FEV1, FeNO, and psychosocial problems in adolescents

BACKGROUND

Many adolescents have poor asthma control and are at high risk for psychosocial problems. However, structured assessment of asthma control or psychosocial problems is still not implemented in routine asthma care. Pediatricians typically rely on their clinical view and physiological measurements. To date, it is unknown whether clinical and patient reported outcomes are interrelated. Furthermore, there is no consensus on who should be the informant; the adolescent or his caregiver. STUDY AIM(S): This study aimed to assess the relationship between patient and caregiver reported outcomes [Asthma Control Questionnaire and Strengths and Difficulties Questionnaire (SDQ)] and physiological parameters (FEV1 and Fractional exhaled Nitric Oxide) in adolescents (aged 11-16) with asthma.

METHODS

A multicenter observational study was performed in four Dutch pediatric outpatient departments. Association between asthma control, physiological parameters, and results of psychosocial questionnaires completed by both adolescent and caregiver was analyzed.

RESULTS

Forty-eight adolescents and their caregivers participated in this study. Asthma was uncontrolled in about 30%. Asthma control was not associated with age, gender, FEV1, FeNO, or psychosocial problems. Agreement between adolescents and caregivers about how well asthma was controlled was moderate (κ = 0.577, P < 0.01).

DISCUSSION

Asthma control, physiological parameters, and psychosocial problems are different domains of health status. It could be suggested to use validated patient and caregiver reported outcomes in routine adolescent asthma care.

CONCLUSION

Patient and caregiver reported outcomes on asthma control and the presence of psychosocial problems add valuable, unique information to physiological parameters in adolescent asthma management.

Control of Allergic Rhinitis and Asthma Test (CARAT) can be used to assess individual patients over time

BACKGROUND

The Control of Allergic Rhinitis and Asthma Test (CARAT10) has been proposed as the first tool to implement the Allergic Rhinitis and its Impact on Asthma initiative guidelines in clinical practice. To serve this purpose, it must have adequate properties to assess the control of an individual over time. This study aimed to prospectively assess the test-retest reliability, responsiveness and longitudinal validity of CARAT10.

METHODS

Adults with asthma and allergic rhinitis were enrolled at 4 outpatient clinics of Portuguese central hospitals. At each of the two visits, 4 to 6 weeks apart, patients filled out CARAT10 and additional questionnaires, followed by a medical evaluation blinded to the questionnaires' answers.

RESULTS

From the 62 patients included, 51 patients completely filled out CARAT10 at both visits. The test-retest reliability, computed as an intra-class correlation coefficient, was 0.82. Regarding responsiveness, a significant change (p = 0.002) of CARAT10 score in clinically unstable patients was observed (95%CI -5.08; -1.31) and the Guyatt's responsiveness index was 1.54. As for the longitudinal validity assessment, the correlation coefficients of the changes of CARAT10 scores with those of ACQ5 and symptoms VAS ranged from 0.49 to 0.65, while with the physician assessment of control they ranged from 0.31 to 0.41.

CONCLUSION

CARAT10 has good test-retest reliability, responsiveness and longitudinal validity. It can be used to assess control of allergic rhinitis and asthma, both to compare groups in clinical studies and to evaluate individual patients in clinical practice.

Voriconazole and posaconazole improve asthma severity in allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitization

Rationale and objectives. Severe asthma with fungal sensitization (SAFS) and allergic bronchopulmonary aspergillosis (ABPA) are progressive allergic fungal lung diseases whose effective treatment remains to be established. Current treatment with itraconazole is associated with a 40% failure rate and adverse events (AEs). We assessed the effect of voriconazole or posaconazole as second- and third-line therapies. Methods. We conducted a retrospective review of adult asthmatic patients with either ABPA or SAFS receiving voriconazole or posaconazole. Clinical, radiological, and immunological evaluation was used to assess response. Results. There were 25 patients, ABPA (n = 20) or SAFS (n = 5), 10 males, median age = 58 years. All patients had failed itraconazole (n = 14) or developed AEs (n = 11). There were 33 courses of therapy analyzed, 24 with voriconazole and 9 with posaconazole. Clinical response to voriconazole was observed in 17/24 (70%) patients at 3 months, 15/20 (75%) at 6 months, and 12/16 (75%) at 12 months compared with 7/9 (78%) at 3, 6, and 12 months for posaconazole. Eighteen of 24 (75%) patients discontinued oral corticosteroids (OCS), 12 of them within 3 months of therapy. Asthma severity was downgraded from severe to moderate (n = 8) and moderate to mild (n = 1) asthma in 9 of 24 (38%) asthmatic patients. There was a marked reduction in OCS and short-acting beta-2 agonist use, health-care utilization due to asthma, and improvement in overall health status. Furthermore, there was a statistically significant reduction in immunological markers appearing at 9 months (p = .008) for total IgE and at 12 months for radioallergosorbent test IgE for Aspergillus fumigatus (p = .0056). Six of 23 (26%) patients on voriconazole had AEs requiring discontinuation before 6 months compared with none on posaconazole (p = .15). Four relapsed (57%), one at 3 months and three at 12 months after discontinuation. Conclusion. Both voriconazole and posaconazole are potentially effective alternative treatment options for SAFS and ABPA and may improve asthma control and reduce severity, though larger prospective studies are required to support these retrospective study findings.

Real-life effectiveness of extrafine beclometasone dipropionate/formoterol in adults with persistent asthma according to smoking status

BACKGROUND

The efficacy and safety of extrafine beclomethasone dipropionate 100 μg/formoterol 6 μg (BDP/F HFA) pressurized metered dose inhaler (pMDI) in patients with moderate-to-severe persistent asthma, has been demonstrated in randomised controlled trials (RCTs). The aim of this prospective observational study was to assess real-life effectiveness in terms of asthma control in smoking (most of the time excluded from RCTs) and non-smoking asthmatics.

METHODS

Adult patients with persistent asthma, in whom treatment with an inhaled corticosteroid/long-acting β(2)-agonist (ICS/LABA) combination is indicated, were included. Pulmonary function (FEV1%pred or PEF absolute value), Asthma Control Questionnaire (ACQ) and asthma control according to GINA criteria were measured at baseline as well as 2-8 months and >8-14 months after treatment initiation with BDP/F HFA.

RESULTS

Overall, 619 patients were enrolled by 97 investigators. In the effectiveness cohort (N = 568), at baseline, smoking asthmatics (N = 123) had higher ACQ6 (p < 0.0001) and lower asthma control (p = 0.021) than non-smoking asthmatics. Treatment with BDP/F HFA pMDI was associated with significant (p < 0.0001) improvements in pulmonary function (+7.1% in FEV1% pred), ACQ6 (-1.32) and GINA asthma control (improvement of control in 49.8% of patients). Importantly, the same treatment benefits were observed in former or current smokers compared with non-smoking asthmatics. There was a reduction in the dose of ICS from 489 ± 192 μg BDP extrafine equivalents at baseline to 265 ± 125 μg after one year. The drug was well-tolerated.

CONCLUSION

This prospective cohort study demonstrates the real-life effectiveness and safety of BDP/F HFA in adult asthma patients, including smokers, in normal clinical practice.

Validation of a web-based version of the asthma control test and childhood asthma control test

RATIONALE

Recent guidelines focus on adjusting asthma treatment to the level of asthma control. The availability of a web-based asthma control questionnaire offers the possibility to assess asthma control without the need of outpatient clinic visits. The aim of this study was to evaluate the agreement between web-based and paper-based versions of the Asthma Control Test (ACT) and Childhood Asthma Control Test (C-ACT), short-term reproducibility and satisfaction with both versions.

METHODS

One hundred seventy-three children with stable asthma and a normal lung function were randomized to fill in a web-based or paper-based version of the C-ACT (4-11 years) or ACT (12-18 years). According to a cross-over design, they completed the opposite version after 1 week. Reproducibility was evaluated by repeating the 2nd version (web- or paper-based) 7 days later.

RESULTS

Eighty-eight children filled in the C-ACT, 68 children filled in the ACT. Intraclass Correlation Coefficient (ICC) for web-based versus paper-based C-ACT was 0.81 (95% confidence interval [95% CI] 0.72-0.87). For ACT this was 0.84 (95% CI 0.76-0.90). For web-based and paper-based C-ACT the reproducibility ICC was 0.82 (95% CI 0.67-0.90) and 0.75 (95% CI 0.59-0.85), respectively. The reproducibility ICC of the ACT for web- and paper-based versions was 0.93 (95% CI 0.87-0.97) and 0.77 (95% CI 0.59-0.88), respectively. Eighty-six percent of patients preferred the web-based version.

CONCLUSION

The web-based version of the C-ACT and ACT is reproducible and comparable with the paper-based version in assessing asthma control. Most children and their parents prefer the web-based version.

Relationship between asthma control status, the Asthma Control Test™ and urgent health-care utilization in Asia

BACKGROUND AND OBJECTIVE

Accurate assessment of control is an integral part of asthma management. We investigated the relationship between control status derived from the Global Initiative for Asthma (GINA), the Asthma Control Test (ACT) and urgent health-care utilization.

METHODS

Asthma Insights and Reality in Asia-Pacific Phase 2 (AIRIAP 2) was a cross-sectional, community-based survey of 4805 subjects with asthma from urban centres across Asia. A symptom control index was derived from the AIRIAP 2 questionnaire using the GINA control criteria for day- and night-time symptoms, need for rescue medication, activity limitation and exacerbations; lung function was excluded. The main outcomes were asthma control, based on these GINA criteria and the ACT, and the relationship between control and self-reported urgent health-care utilization (hospitalization, emergency room visits or other unscheduled urgent visits) related to asthma over the previous 12months.

RESULTS

Each of the symptom criteria was significantly associated with urgent health-care utilization, with odds ratios (ORs) ranging from 2.25 (95% confidence interval (CI): 1.94-2.61) for daytime symptoms to 2.57 (95% CI: 2.29-2.90) for nocturnal awakening. Similarly, control status was significantly associated with urgent health-care utilization, with ORs of 0.19 (95% CI: 0.13-0.28), 0.70 (95% CI: 0.65-0.76) and 1.00 for controlled, partly controlled and uncontrolled, respectively. The optimal ACT cut-off score for identifying uncontrolled asthma was ≤19 for subjects aged ≥12years. Urgent health-care utilization was reported by 57.2% versus 28.7% of patients scoring ≤19 versus >19 (P<0.001).

CONCLUSIONS

The GINA control classification and the ACT are valid symptom-based measures that are significantly associated with urgent health-care utilization.

Predicting moderate improvement and decline in pediatric asthma quality of life over 24 months

OBJECTIVE

To determine factors associated with 24-month change in quality of life in children with asthma and their parents during the Childhood Asthma Management Program (CAMP).

METHODS

Participants from 4 CAMP clinical centers were administered the Pediatric Asthma Quality of Life questionnaire and protocol measures of asthma symptoms, lung function, and psychological measures.

RESULTS

Multivariate logistic regression analyses determined predictors of moderate change in quality of life. Subclinical levels of depression predicted moderate improvement in child-reported quality of life. Level of depressed affect together with clinical asthma features predicted moderate decline. Improvement in parent quality of life was predicted by perception of illness burden, whereas family features and a child missing school predicted moderate decline.

CONCLUSIONS

This ancillary study provided an opportunity to examine the determinants of 24-month change in parent and child of quality of life within a subset of the CAMP participants. Moderate changes in quality of life occur in clinical studies and have both psychosocial correlates and illness characteristics.

Physician vs patient assessment of dyspnea during acute decompensated heart failure

This study assessed agreement between physician and patient self-reported measures of dyspnea severity during acute decompensated heart failure (ADHF). Both the physician and patient measured the change in dyspnea severity over 1 hour using 2 methods: (1) the difference of two static dyspnea measures (STATIC) and (2) a single transitional measure (TRANS). Likert scales and visual analog scales (VASs) were used. Data on 112 patients were analyzed. The mean difference between physician and patient VAS scores was 1 mm (limits of agreement: -54 to 56 mm) using the STATIC data. For TRANS data, the mean difference was 5 mm (limits of agreement: -75 to 86 mm). For the Likert scales, the weighted kappa was 0.13 and 0.23 for STATIC and TRANS data, respectively. The wide limits of agreement restrict our ability to substitute physician assessment for patient self-assessment of dyspnea in patients with ADHF.

Tracing uncontrolled asthma in family practice using a mailed asthma control questionnaire

PURPOSE

A substantial proportion of adult patients with asthma have inadequately controlled symptoms despite the availability of effective treatment. The Asthma Control Questionnaire (ACQ) can be used to discriminate between asthma patients with well- and suboptimally controlled asthma symptoms. The objective of this study was to investigate whether a postal mailing of the ACQ can be used to identify asthma patients with suboptimal symptom control in family practice.

METHODS

In this observational study, we sent 434 asthma patients from 6 Dutch family practices an ACQ by mail to measure control of their asthma symptoms. Both respondents and nonrespondents were characterized by information gathered from their medical records. Patients with an ACQ sum score (total score) of greater than 3 were considered to have suboptimally controlled asthma symptoms.

RESULTS

The response rate was 77%. Respondents were more likely than non-respondents to be female and to use asthma medication. The mean ACQ sum score of the respondents was 5.2. Of this group, 53.4% (95% confidence interval, 48.0%-58.8%) had suboptimally controlled asthma symptoms. Of the 168 respondents who had not visited their family physician in the 2 years before the study, 42.9% (95% confidence interval, 35.4%-50.4%) had inadequate asthma symptom control.

CONCLUSIONS

Our results show that a postal mailing of the ACQ is an effective approach for tracing asthma patients who need medical attention. It also traces patients who would otherwise not have consulted their family physician. The ACQ seems to be a useful starting point for health care professionals in family practice to improve the level of asthma symptom control in their patient population.

Assessing asthma control

Guidelines for the treatment of asthma have identified that the primary goal of management is achieving good asthma control, thus reducing the risk of exacerbations. Research has shown, however, that the accuracy with which clinicians can estimate the adequacy of control may not be very good. Nor are clinicians accurate in estimating change in asthma control between clinic visits. Simple questionnaires to measure asthma control are now available, and can be used to evaluate the adequacy of control and to monitor whether levels of control change between assessments. This article discusses selection of a questionnaire, interpretation of data obtained, and methods of administration.

Can asthma control be improved by understanding the patient's perspective?

BACKGROUND

Clinical trials show that asthma can be controlled in the majority of patients, but poorly controlled asthma still imposes a considerable burden. The level of asthma control achieved reflects the behaviour of both healthcare professionals and patients. A key challenge for healthcare professionals is to help patients to engage in self-management behaviours with optimal adherence to appropriate treatment. These issues are particularly relevant in primary care, where most asthma is managed. An international panel of experts invited by the International Primary Care Respiratory Group considered the evidence and discussed the implications for primary care practice.

DISCUSSION

Causes of poor control: Clinical factors such as exposure to triggers and concomitant rhinitis are important but so are patient behavioural factors. Behaviours such as smoking and nonadherence may reduce the efficacy of treatment and patients' perceptions influence these behaviours. Perceptual barriers to adherence include doubting the need for treatment when symptoms are absent and concerns about potential adverse effects. Under-treatment may also be related to patients' underestimation of the significance of symptoms, and lack of awareness of achievable control.

IMPLICATIONS

Three key implications for healthcare professionals emerged from the debate. First, the need for simple tools to assess asthma control. Two approaches considered were the monitoring of biometric markers of control and questionnaires to record patient-reported outcomes. Second, to understand the reasons for poor control for individual patients, identifying both clinical (e.g. rhinitis) and behavioural factors (e.g. smoking and nonadherence to treatment). Third was the need to incorporate, within asthma review, an assessment of patient perspectives including their goals and aspirations and to elicit their beliefs and concerns about asthma and its treatment. This can be used as a basis for agreement between the healthcare professional and patient on a predefined target regarding asthma control and a treatment plan to achieve this.

SUMMARY

Optimum review of asthma is essential to improve control. A key priority is the development of simple and effective tools for identifying poor control for individual patients coupled with a tailored approach to treatment to enable patients to set and achieve realistic goals for asthma control.

Identifying ‘well-controlled’ and ‘not well-controlled’ asthma using the Asthma Control Questionnaire

The 7-item Asthma Control Questionnaire (ACQ) has been validated to measure the goals of asthma management as defined by international guidelines (minimisation of day- and night-time symptoms, activity limitation, beta(2)-agonist use and bronchoconstriction). Responses are given on a 7-point scale and the overall score is the mean of the responses (0=totally controlled, 6=severely uncontrolled). The aim of this analysis was to determine the cut-point on the ACQ that best differentiates between 'well-controlled' and 'not well-controlled' for (a) clinical practice (low risk of missing 'not well-controlled') and (b) clinical trials (low risk of including 'well-controlled'). All 1323 patients who provided data sets at week 12 in the Gaining Optimal Asthma Control (GOAL) clinical trial were included in the analysis. The gold standard for 'well-controlled' was a composite based on the GINA/NIH guidelines and derived from data collected in the clinical trial diaries and clinic records. The analysis showed that the crossover point between 'well-controlled' and 'not well-controlled' is close to 1.00 on the ACQ. However, to be confident that a patient has well-controlled asthma, the optimal cut-point is 0.75 (negative predictive value=0.85). To be confident that the patient has inadequately controlled asthma, the optimal cut-point is 1.50 (positive predictive value=0.88). In conclusion, knowledge of these cut-points will enhance practising clinicians ability to identify patients whose asthma requires additional treatment, enable investigators to enroll poorly controlled patients into studies and for both clinicians and investigators to evaluate whether treatment goals are being achieved.