|
Indian Pediatr 2017;54:746-748 |
|
Evaluation of Asthma
Control in Children Using Childhood– Asthma Control Test (C-ACT)
and Asthma Therapy Assessment Questionnaire (ATAQ)
|
AR Somashekar and KG Ramakrishnan
From Department of Pediatrics, MS Ramaiah Medical
College and Hospitals, Bengaluru, Karnataka, India.
Correspondence to: Dr AR Somashekhar,
Department of Pediatrics, Ramaiah Medical College, Bengaluru, Karnataka,
India.
Email:
[email protected]
Received: April 22, 2016;
Initial review: January 28, 2017;
Accepted: June 28, 2017.
|
Objectives: To evaluate the efficacy of Childhood-asthma control
test (C-ACT) and the Asthma therapy assessment questionnaire by (ATAQ)
checking its consistency with Global Initiative for Asthma (GINA)
criteria. Method: Asthma control of 97 children was assessed
using C-ACT, ATAQ and GINA criteria separately, and their results were
compared. Result: C-ACT had better performance for evaluating
control as per GINA criteria with sensitivity of 48.3%, specificity of
68.9%, and area under the receiver operative curve (ROC) of 0.647. The
above parameters for ATAQ were: 93.1%, 17.2% and 0.552, respectively. A
cut-off score of 20 for C-ACT is more suitable as it has maximum ROC
area (0.667), and higher kappa score (0.315); P= 0.001.
Conclusion: C-ACT can be validity used to monitor asthma control.
However, the cut-off score 20 is more accurate for the Indian
population. The performance of ATAQ in evaluating asthma control is not
satisfactory.
Keywords: Asthma control, Pediatric asthma, Questionnaire
assessment, Self-assessment.
|
T he goal of asthma care is to achieve and maintain
control of symptoms for prolonged periods [1-3]. The Global initiative
for asthma (GINA) offers a framework to do so through the GINA criteria,
which requires the measurement of pulmonary functions [1]. As effective
asthma care requires periodic assessment of asthma control, it is not
feasible to perform pulmonary function tests (PFT) repeatedly in
resource-poor settings. A quick screening method such as a questionnaire
would reduce the need of repeated assessment by PFT. A commonly used
questionnaire for the age group of 4-12 years is the childhood asthma
control test (C-ACT), which includes questions directed to both
caregiver and the child, formulated based on the observation that poor
association exists poor co-relations between the symptom reports of
parents and children [4,5]. Results of various studies conducted to
validate C-ACT are mixed and conflicting [6-9]. Another questionnaire
available is the asthma therapy assessment questionnaire (ATAQ) whose
efficacy remains unclear.
The objective of this study was to determine the
efficacy of these questionnaires for asthma control assessment.
Methods
This cross-sectional validation study was conducted
in the Department of Pediatrics M.S. Ramaiah Medical College and
Hospitals, Bengaluru, India, over a period of six months (April 2014 to
June 2014).The study sample consisted of 97 patients with clinically
established bronchial asthma, belonging to the age group of 4-12 years,
visiting or admitted to the hospital. Children with co-existing
pulmonary anomalies, or other co-morbid conditions were excluded from
the study.
Informed consent was obtained from the guardians of
all the children. A complete history for the past 4 weeks of illness was
taken. Each caregiver and child was asked to fill out the C-ACT and ATAQ
questionnaires appropriately. Spirometry and Peak expiratory flow rate
(PEFR) were performed and anthropometry was recorded. The child’s asthma
control status was independently determined by the GINA criteria and the
questionnaires. As the GINA criteria divides asthma control status into
three categories (controlled, partially controlled and uncontrolled),
the category, partially controlled’ was considered as controlled asthma’
for the purpose of comparison of finding with the questionnaires [2].
Statistical analysis was carried out by SPSS software
and Receiver operative curves (ROC) were generated using MedCalc
software. Performance of C-ACT and ATAQ in evaluating asthma control in
comparison with GINA criteria was analyzed with sensitivity,
specificity, positive predictive value, negative predictive value, kappa
statistics and area under ROC. McNemor’s test was used to compare the
sensitivity of C-ACT and ATAQ. The above were calculated for each new
cut-off score in comparison with GINA criteria to determine the most
suitable cut-off score.
Results
Among the 97 children (64 boys) included in the
study, C-ACT, ATAQ and GINA criteria based evaluation showed that 62%,
10% and 33% of the children had controlled asthma.
Considering GINA criteria as the gold standard, the
sensitivity, specificity positive predictive value and negative
predictive value for the C-ACT and ATAQ are represented in Table
I. The kappa statistics provided a kappa value of 0.1865 and 0.255
for agreement of ATAQ and C-ACT with GINA criteria respectively. The
performance of C-ACT was better than that of ATAQ (difference of 42.5%,
P<0.001).
TABLE I Comparative Performance of C-ACT and ATAQ
Parameter |
C-ACT
|
ATAQ |
Specificity |
69.0% |
17.2% |
Sensitivity |
48.3% |
93.1% |
Positive predictive value |
78.5% |
69.2% |
Negative predictive value |
44.4% |
55.6% |
Area under ROC curve |
0.647 |
0.552 |
At significance level of |
0.0061 |
0.1897 |
C-ACT: Childhood asthma control test; ATAQ: Asthma;
therapy assessment questionnaire; ROC: Receiver operator curve. |
TABLE II Performance of C-ACT at Different Cut-off Scores
Cut-off Score for C-ACT |
|
|
|
|
|
Parameter |
19 (standard) |
17 |
18 |
20 |
21 |
Specificity |
69.0% |
93.1% |
82.8% |
58.6% |
27.6% |
Sensitivity |
48.3% |
34.5% |
47.4% |
74.1% |
86.2% |
Positive predictive value |
78.6% |
90.9% |
84.9% |
78.2% |
70.4% |
Negative predictive value |
44.4% |
41.5% |
44.4% |
53.1% |
50% |
P value |
0.05 |
<0.001 |
<0.001 |
0.0003 |
0.0259 |
Kappa |
0.255 |
0.210 |
0.255 |
0.319 |
0.659 |
Area under the ROC curve |
0.647 |
0.638 |
0.655 |
0.664 |
0.569 |
C-ACT: Childhood asthma control test; ROC: Receiver operator
curve. |
The diagnostic performance of C-ACT for cut-off
scores 17, 18, 19, 20 and 21 is presented in Table II.
When a ROC curve was generated for the C-ACT in comparison to the GINA
criteria, the automatically generated statistically best cut-off was
found to be 20 with the area under the curve of 0.706 at significance
level of 0.0003 as (Fig. 1).
|
Fig. 1 Composite ROC curve for
diagnostic performance of C-ACT in evaluating asthma control.
|
Discussion
The present study suggests that C-ACT is a fairly
valid tool for evaluating asthma control in children, with best
performance at a cut-off of 20. ATAQ, on the other hand, seems to have
unsatisfactory performance in evaluating control of asthma in our
setting.
The major limitations of the study were language
barrier, and varied education level and socioeconomic stata of the
caregivers; these factors may play a role in determining the quality of
responses. A single center - based enrolment and small sample size were
the other limitations.
Although the current study shows that C-ACT is a
fairly valid tool, the results of this study are not as favorable as the
studies conducted in other geographic regions [6-9]. While the
sensitivity of C-ACT was found to be higher then that reported by Koolen,
et al. [7] Chalise, et al. [10] have demonstrated higher
sensitivity. Our study showed that the cut-off score of 20 is more
suitable; in a study conducted in California also suggested need for a
different cut-off for Hispanic children [10]. Performance of ATAQ was
found to be less satisfactory in the present study, which is in contrast
to the findings of the study by Skinner, et al. [11].
We conclude that the C-ACT questionnaire is in fair
agreement with GINA criteria, and has satisfactory performance in
evaluation of asthma control. However, the current standard cut-off
score of 19 tends to underestimate asthma control and a cut-off score of
20 may be better.
Acknowledgements: Dr Roopakala, Secretary of
Student Research Committee for scientific advice through the process;
Dr. Chandrika Rao, Head of Department of Pediatrics, for the constant
support and encouragement; and Mrs Radhika, Statistician, for
statistical support.
Contributors: KGR: data collection, statistical
analysis and manuscript writing; ARS: conceptualization of study,
collection of data, and critical inputs into manuscript writing. Both
authors take accountability for all aspects of the work ensuring
appropriate investigation for accuracy and integrity of any part of the
work in response to any question that may arise.
Funding: ICMR-STS and MS Ramaiah Scientific
Committee. Competing interest: None stated.
What This Study Adds?
• C-ACT is a satisfactory tool for
measurement of asthma control. The cut-off score of 20 seems to
be a more suitable for the Indian population.
• ATAQ has unsatisfactory performance as an independent tool
for asthma control.
|
References
1. Global Initiative for Asthma: Pocket Guide
for Asthma Management and Prevention. Available from:
www.ginasthma.org. Accessed May 21, 2014.
2. Graham LM. Classifying
asthma. Chest. 2006;130:13S-20S.
3. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen
JM, FitzGerald JM, et al. Global strategy for asthma management
and prevention: GINA executive summary. Eur Respir J. 2008;31:143-78.
4. Deschildre A, Pin I, El A K, Belmin-L S, El MS,
Thumerelle C. Asthma control assessment in a pediatric population:
Comparison between GINA/NAEPP guidelines, Childhood Asthma Control Test
(C-ACT), and physician’s rating. Allergy. 2014;69:84-90..
5. Lara M, Duan N, Sherbourne C, Lewis MA, Landon C,
Halfon N, et al. Differences between child and parent reports of
symptoms among latino children with asthma. Am Acad Paediatr.
1998;102:68.
6. Erkoçoðlu M, Akan A, Civelek E, Kan R, Azkur D,
Kocabaº CN. Consistency of GINA criteria and childhood asthma control
test on the determination of asthma control. Pediatr Allergy Immunol.
2012;23:34-9.
7. Koolen BB, Pijnenburg MWH, Brackel HJL, Landstra
AM, Van den Berg NJ, Merkus SPJFM. Comparing global initiative for
asthma (GINA) criteria with Childhood Asthma Control Test (C-ACT) and
Asthma Control Test (ACT). Eur Respir J. 2011;38:561-6.
8. Yu H, Niu CK, Kuo HC, Tsui KY, Wu CC, Ko CH, et
al. Comparison of the Global Initiative for Asthma guideline-based
Asthma Control Measure and the Childhood Asthma Control Test in
evaluating asthma control in children. Paediatr Neonatol. 2010;51:273-8.
9. Andrew HL, Robert Z, Christine S, Todd M, Nancy O,
Somali B, et al. Development and cross-sectional validation of
the Childhood Asthma Control Test. J Allergy Clin Immunol.
2007;119:817-25.
10. Shi Y, Tatavoosian AV, Aledia AS, George SC,
Galant SP. The cut-points for asthma control tests are higher in Mexican
children in Orange County, California. Ann Allergy Asthma Immunol.
2012;109:108-13.
11. Skinner EA, Diette GB, Algatt-Bergstrom PJ,
Nguyen TT, Clark RD, Markson LE et al. The Asthma Therapy
Assessment Questionnaire (ATAQ) for Children and Adolescents. Disease
Manag. 2004;7:305-13.
|
|
|
|