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Asthma Control Test and Asthma Quality of Life Questionnaire Association in

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ORIGINAL ARTICLE
Iran J Allergy Asthma Immunol
December 2012; 11(4): 301-307

Asthma Control Test and Asthma Quality of Life

Questionnaire Association in Adults
Aylin Ozgen Alpaydin1, Mine Bora2, Arzu Yorgancioglu2, Aysin Sakar Coskun2, and Pinar Celik2

1
Department of Pulmonary Diseases, Dokuz Eylul University Medical Faculty, İzmir, Turkey
2
Department of Pulmonary Diseases, Celal Bayar University Medical Faculty, Manisa, Turkey

Received: 11 July 2011; Accepted: 2 February 2012

ABSTRACT

Asthma control and quality of life are expected to be correlated. We aimed to evaluate the
association of asthma control test (ACT) with asthma quality of life questionnaire (AQLQ)
and guideline based control assessment. We also aimed to investigate the impact of therapy
adjustment according to ACT score on AQLQ
A total of 101 asthmatic patients were included. ACT, AQLQ and Global Initiative for
Asthma (GINA) based control assessments were performed. Based on ACT, treatment was
adjusted by stepping down in controlled and stepping up in uncontrolled/partly controlled
patients. In some controlled/partly controlled patients, no therapy adjustment was done.
After 3-months the same parameters were reevaluated.
We found a statistically significant association between ACT and AQLQ, a one point
increase in ACT was associated with a 0.129 point increase in AQLQ. ACT scores increased
significantly in the step-up group; however AQLQ total scores were not affected after
therapy adjustment. We found that ACT was concordant with GINA recommended control
classification in the first (kappa=0.511, 7.718) and third months (kappa=0.599, 7.912)
(p<0.001 for both).
We determined an association between ACT and AQLQ. ACT was also found fairly
concordant with GINA. However, treatment adjustment according to ACT was not found
satisfactory in terms of quality of life.

Keywords: Asthma; Quality of life; Questionnaires

INTRODUCTION world. Guidelines for the management of asthma issued

by the Global Initiative for Asthma (GINA) have
Asthma is a chronic inflammatory airway disease focused primarily on optimum disease control. The
which affects 300 million individuals throughout the absence or minimization of chronic symptoms and
exacerbations; minimal or no requirement for relievers;
Corresponding Author: Aylin Ozgen Alpaydin, MD; no limitation of daily activities; near-normal lung
Dokuz Eylul University Medical Faculty, Department of Pulmonary
Diseases, 35340 Inciraltı IZMIR/TURKEY.
functions are the control assessment parameters of
Tel: (+90 232) 4123 808, E-mail: [email protected] asthma defined by GINA guidelines.1 However, it is
recommended to evaluate all aspects of asthma control

Copyright© 2012, IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY. All rights reserved. 301
Published by Tehran University of Medical Sciences (http://ijaai.tums.ac.ir)
 A. O. Alpaydin, et al.

using multidimensional indexes such as quality of life Measurements

and inflammatory biomarkers beyond symptoms and Asthma Control Test
functional parameters in order to cover total disease Asthma control test is a self administered 5 item
control.2 questionnaire developed for assessing asthma control
It is difficult, expensive and time consuming to level. It evaluates the most recent 4 week time period;
investigate all parameters of asthma control in clinical each item is scored between 1 and 5, with the total
practice. A feasible and simple method is needed. score ranging from 5 to 25. An ACT score of 25
Asthma Control Test (ACT) has been developed to indicates that asthma is “controlled,” whereas a score
assess asthma control levels and may serve this aim. between 20 and 24 shows partially controlled asthma
ACT (a trademark of QualityMetric (Lincoln, RI)) is a and a score of <20 indicates “uncontrolled” asthma.3
questionnaire with 5 items that represent the Thus, asthmatic patients were classified as follows:
multidimensional perspective of asthma control in patients with a score of 25 as totally controlled; those
terms of activity limitation, shortness of breath, night with a score between 20-24 as partially controlled and
symptoms, and use of rescue medication and self- those with a score of ≤19 as uncontrolled asthmatics.
perception of asthma control.3 Then, the totally controlled and partially controlled
Health-related quality of life (HRQL) can determine patients were re-grouped as controlled patients
patients' perceptions of physical limitation and mental (ACT>19) and others were included in the uncontrolled
impairment related with their disease.4 The Asthma group. The Turkish version of ACT was used in this
Quality of Life Questionnaire (AQLQ) is a disease- study.11,12
specific, self-administered quality-of-life tool. It has
been developed by Juniper and designed to be used in Asthma Quality of Life Questionnaire (AQLQ)
clinical trials.5 A few studies report weak associations The Juniper AQLQ is a disease specific quality of
between conventional clinical indices and the outcomes life questionnaire comprising 32 items in four health
of the AQLQ6,7 while others have found that achieving domains: activity limitation (11 items), symptoms (12
asthma control is associated with significant items), emotional function (5 items) and environmental
improvements in AQLQ score.8-10 stimuli (4 items). This instrument measures quality of
In our study, we aimed to evaluate the association life over the two weeks prior to the interview. Each
of ACT with AQLQ as well as guideline based item within the AQLQ is equally weighted. The
control assessment. We also evaluated the impact of patients select from an ordinal scale of 7 point,-Likert
providing asthma therapy based on ACT score on type answer for every item. The domain scores are
AQLQ levels. computed as the means of domain-specifıc items and
global AQLQ score is computed as the mean of the
MATERIALS AND METHODS domain scores. The score of each domain and the
global score range from 1 to 7, corresponding to no
Between 2008 and 2009 a total of 101 (consecutive) impairment and maximum impairment, respectively, in
stable asthmatic patients with ages between 18 and 55 quality of life. The minimum clinically important
years admitted to our respiratory outpatient department difference for AQLQ has been reported as 0.52.13 The
were included in the study. They had clinically original English version of the AQLQ has already been
documented asthma and reversible airflow adapted to Turkish by four independent Turkish
limitation was demonstrated with an improvement bilingual senior translators (CS, SE, EE, HF).
equal to or greater than 15% and 200 ml of forced Translation has been made in collaboration with MAPI
expiratory volume in 1 second (FEV1) after inhalation Research Institute. In this study, this Turkish version of
of 200 µg of salbutamol or with a positive AQLQ has been used.
methacholine test. Patients with a stable disease on
medication and aged 18 to 55 years were included. GINA Classification of Asthma Ccontrol
Patients with other forms of airway obstruction or Asthma control has been defined as; no or ≤2
known acute or chronic comorbidities interfering with daytime symptoms/week, no activity limitations, no
physical and psychological performance were nocturnal symptoms, no or ≤2 reliever need/week,
excluded. normal lung functions and no exacerbations. Partly

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 Asthma Control and Quality of Life

control has been defined when any of the following RESULTS

was present in any week; >2 daytime symptoms/week,
activity limitations, nocturnal symptoms, >2 reliever Demographic, clinical data and pulmonary
need/week, PEF or FEV1<80% predicted and one or functions of the patients at the baseline visit are shown
more exacerbations/year. Uncontrolled has been in Table 1. Three patients had asthma attack, 2 of them
defined as; presence of 3 or more features of partly were pregnant and 13 were lost in the follow-up.
controlled asthma in any week.1 Therefore, there were only 83 patients in the control
visit.
Pulmonary Function Tests (PFTs) Mean AQLQ total scores were 5.31±1.05 for
PFTs were performed using Jaeger Master Screen controlled patients, 5.01±0.68 for partially controlled
Pneumo V452İ device by a single technician. The best and 4.03±0.35 for uncontrolled patients according to
test among three consecutive tests was accepted. FEV1, ACT (p<0.001). We found a statistically significant
FVC, FEV1/FVC were measured according to ATS association between ACT and AQLQ (p<0.001). A one
criteria.14 point increase in ACT was associated with a 0.129
All questionnaire data were collected by authors point increase in AQLQ which represented minimum
during face-to-face interviews. The method of filling clinically important difference of 0.25 (Figure 1). We
out the questionnaire was explained and patients also determined a significant association between ACT
provided written informed consent. The study was and all AQLQ domain scores among which activity
approved by the institutional human-research review limitation had the highest score (p<0.001), at the
board. baseline visit (Table 2).

Study Design
Measures were collected in this cohort at a baseline Table 1. Demographic and functional parameters of the
and 3-month follow-up visit. Based on ACT control study population
status, treatment was adjusted where necessary at Topics Baseline visit
baseline by stepping down (reducing the number or (n=101)
dose of medication they use) therapy in controlled Mean age±SD (year) 41.9 ± 11.4
patients (ACT=25), stepping up (increasing the number Male, % 18
or dose of medication they use) therapy for Median Disease duration (IQR) (year) 2 (1-4)
uncontrolled (ACT<20) and partly controlled (ACT Smoking status, No(%)
between 20-24) patients. In some controlled (ACT=25) Current smoker 21 (21%)
and partly controlled patients (ACT between 20-24), no Ex-smoker 9 (9%)
therapy adjustment was done. Nonsmoker 71 (70%)
Mean FEV1 (% predicted) ±SD 93.36 ± 13.88
Mean FEV1 (lt) ±SD 2.65 ± 0.63
Statistical Methods
Mean FEV1/FVC (%)±SD 78.09 ± 6.87
Statistical analyses were performed with SPSS 15.0
Comorbid diseases (present), No(%) 33 (33%)
(SPSS, Inc., Chicago, USA). Data were expressed as Control level (GINA guidelines), No(%)
median with range, or mean with standard deviation Controlled 22 (22%)
according to the distribution of the parameters. We Partly controlled 20 (20%)
constructed a linear regression model to evaluate the Uncontrolled 59 (58%)
association between ACT score and AQLQ domain and Median ACT score (IQR) 20 (16-23)
total scores, adjusting for age and sex. Mean AQLQ Mean AQLQ total score±SD 4.59 ± 0.94
total scores of the study population in different ACT Therapy Change, No(%)
categories were compared with t test. Wilcoxon signed Step up 47 (47%)
ranks test was used for evaluating ACT and AQLQ Step down 4 (3%)
No change 50 (50%)
change according to treatment adjustment. Kappa
(IQR: Interquartile range, FEV1: Forced expiratory volume in 1
measure of agreement was used to analyze the
second, FVC: Forced vital capacity, GINA: Global Initiative for
concordance of ACT and GINA control level (p>0.8
Asthma, ACT: Asthma Control test, AQLQ: Asthma Quality of Life
are considered almost perfect agreement).15
Questionnaire)

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 A. O. Alpaydin, et al.

Table 2. Linear regression models of ACT and AQLQ domains and total score at first month baseline visit.

Topics Beta1 Standard Error t P value

AQLQ total score 0.129 0.016 7.860 <0.001
Activity limitation 0.179 0.020 8.824 <0.001
Symptoms 0.167 0.016 10.465 <0.001
Emotional function 0.076 0.029 2.650 0.009
Environmental stimuli 0.095 0.026 3.692 <0.001

Table 3. ACT and AQLQ values of the study population according to treatment adjustment at baseline and 3-
month follow-up

Groups and Topics Baseline visit 3-month follow-up visit P value

(n=101) (n=83)
Step up group (n=40) (n=40)
ACT median, IQR 16 (14-17) 18 (15-21) 0.001
AQLQ mean ± SD 4.21 ± 0.92 4.18 ± 1.03 0.776
Step down group (n=4) (n=4)
ACT median, IQR 25 (25-25) 22 (20.5-23.5) 0.066
AQLQ mean ± SD 4.92 ± 1.15 4.87 ± 0.67 0.902
No change group (n=39) (n=39)
ACT median, IQR 22 (21-24) 22 (18-24) 0.158
AQLQ mean ± SD 4.96 ± 0.73 5.09 ± 0.71 0.221
(ACT: Asthma Control Test, AQLQ: Asthma Quality of Life Questionnaire, IQR: Interquartile range, SD: Standard deviation)

Figure 1. The linear regression graph of baseline ACT and AQLQ association. ACT: Asthma Control Test, AQLQ: Asthma
Quality of Life Questionnaire.

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 Asthma Control and Quality of Life

Treatment adjustment resulted in an increase in health-related quality of life. However, treatment

ACT levels in the step up group (p<0.001); however, response depends on the baseline status of the
there was an insignificant slight decrease in ACT for individuals mainly the phenotype, dose and duration of
the step down group. The AQLQ total scores were the applied treatment as well as the features of outcome
found not to be affected by therapy adjustment (Table measures.16 In our study, we adjusted the treatment of
3). the study population according to ACT control levels.
ACT was shown to be concordant with GINA In the step up subgroup, the treatment change resulted
recommended asthma control classification in the first in significant increase in ACT (clinically significant)
(kappa=0.511) and third months (7.912) (p<0.001 for but not in AQLQ total scores. In step down group ACT
both). and AQLQ total scores, were found to have a tendency
to decreasealthough it is difficult to comment on this
subgroup because there were only 4 patients. Since the
DISCUSSION minimum clinically important difference for AQLQ has
been defined as 0.52, the observed changes in AQLQ
The main finding of this study is the association of total scores in all the subgroups were clinically
asthma control assessed by ACT and AQLQ. Asthma insignificant. Therefore, our treatment adjustment
control has been defined as the removal or reduction of according to asthma control levels did not affect the
the asthma manifestations by treatment. Both, current quality of life, although ACT increased slightly. This is
clinical state and future risk of loss of asthma control a challenging result consistent with the current
are involved in asthma control concept and achieving guidelines that recommend evaluating the asthma
an optimum quality of life is the target.16 The four control by multiple outcomes, particularly according to
major characteristics of asthma (symptoms, airway phenotypes and tailoring the therapy for individual’s
obstruction, airway hyper responsiveness and airway state.
inflammation) have been reported to be weekly GINA guideline based control definition is
correlated with each other.17-19 Therefore, none of these determined by the patient’s recent clinical status
parameters are completely convenient for asthma (symptoms, night waking, reliever use, exacerbations).
control assessment and in the management of asthma Thomas M has compared asthma control measured by
they should be evaluated together. the ACT and the GINA criteria in a multicentric cross-
The ACT is a relatively simple and easy to sectional study among 2949 asthmatic patients
administer composite score. It has been validated attending primary care.23 They have shown that an
against spirometry,20 and quality of life.21 Kwon ACT score ≥20 predicted GINA-defined controlled
showed that the ACT correlated significantly with the asthma 51% of the time, while a score of <19 predicted
AQLQ and with each of the four specific domains partly controlled or uncontrolled asthma 94% of the
(activity, emotions, symptoms, and environment) in time, with a kappa statistic of 0.42, representing a
Korean population.22 They reported lower ACT scores moderate agreement. They concluded that an ACT
in patients with lower AQLQ scores as well as the score <19 was useful for identifying patients with
correlation of ACT and AQLQ changes in different poorly controlled asthma as defined by GINA. In our
visits. In our study, we also determined an association study, we did not determine a cut off point, however we
between the ACT and all domains and total score of looked for the concordance of ACT and GINA
AQLQ in Turkish population. This was also supported classifications of asthma control and we found a
by the finding that the AQLQ total scores were relatively high agreement between them both in the
different among different levels of asthma categories first and third months (kappa=0.599 and 0.511,
assessed by ACT. respectively) which also might represent the
Asthma-related quality of life is a measure of the reproducibility of these two measures.
patient’s own assessment of their level of asthma. The There were some limitations in our study. Since,
AQLQ scores between total control and well-controlled “gold standard” for asthma control has not been defined
patients classified by GINA were found different even comparisons of composite scores are somewhat
in high levels of control.10 Treatment adjustment for difficult. Another limitation of this study is the small
controlling asthma has been shown to improve the

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 A. O. Alpaydin, et al.

number of the participants which may have an 7. Carranza Rosenzweig JR, Edwards L, Lincourt W,
influence on the relation of ACT and AQLQ. Dorinsky P, ZuWallack RL. The relationship between
We determined an association between ACT and health-related quality of life, lung function and daily
AQLQ in our study. Furthermore, ACT was found symptoms in patients with persistent asthma. Respir Med
fairly concordant with GINA guidelines. However, 2004; 98(12):1157–65.
treatment adjustment according to ACT was not 8. Thoonen BP, Schermer TR, Van Den Boom G, Molema
satisfactory in terms of quality of life. Therefore, we J, Folgering H, Akkermans RP, et al. Self management of
suggest that although ACT is a feasible tool for control asthma in general practice, asthma control and quality of
assessment in asthma, it is not completely adequate for life: a randomised controlled trial. Thorax 2003;
management of asthma. 58(1):30–6.
9. Katz PP, Yelin EH, Eisner MD, Blanc PD. Perceived
ACKNOWLEDGEMENT control of asthma and quality of life among adults with
asthma. Ann Allergy Asthma Immunol 2002; 89(3):251–
We thank Dr. Atilla Uysal for his expert technical 8.
assistance. 10. Bateman ED, Bousquet J, Keech ML, Busse WW, Clark
TJ, Pedersen SE. The correlation between asthma control
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