POPULATION HEALTH MANAGEMENT

Volume 12, Number 2, 2009

ª Mary Ann Liebert, Inc.
DOI: 10.1089=pop.2008.0021

Asthma: Are We Monitoring the Correct Measures?

William J. Cardarelli, R.Ph.

Abstract

The prevalence of asthma, a common chronic inflammatory disease of the airways, has risen sharply over the
past 25–30 years, with the biggest increase found in children. Currently, more than 22 million Americans have
asthma. Asthma also is associated with significant morbidity and mortality worldwide. Each year, asthma is
responsible for $16 billion in direct and indirect costs due to health care utilization and loss of productivity, with
over 14 million missed workdays. Asthma also accounts for almost 1.8 million emergency room visits and almost
500,000 hospitalizations annually. Therefore, assessment and monitoring of disease activity is critical to improve
clinical and economic outcomes for patients with asthma. To help in this endeavor, practitioners and payers rely
on evidence-based guidelines to classify disease severity, to guide treatment decisions, and to assess the degree
of asthma control. In August 2007, the National Asthma Education and Prevention Program (NAEPP) updated
its guidelines based on greater knowledge of disease pathophysiology and the development of newer thera-
peutic agents. This includes an increased emphasis on the need to establish disease severity, including the
components of impairment and risk, as well as on the level of asthma control. Despite the availability of the
NAEPP and other guidelines, asthma control often remains suboptimal. While numerous clinical and patient-
reported measures are available, it is clear that the optimal monitoring schema for patients with asthma remains
undefined. To clearly establish whether asthma control is attained, multiple measures are required and should
include clinical and patient-reported assessments. (Population Health Management 2009;12:87–94).

Introduction
A sthma is characterized by chronic airway inflam-
mation, airway hyperreactivity, reversible airway ob-
struction, and airway remodeling secondary to chronic
airway inflammation.1,2 For most patients, asthma is an epi-
sodic disease with periods of relative stability punctuated by
episodes of disease exacerbation. Whereas inflammation is
responsible for the underlying disease pathology, the causes
and etiology of asthma are multifactorial. Emerging evidence
demonstrates there is considerable variability in the pattern
of inflammation, indicating differences in phenotypes that
could potentially affect treatment response.3 Genetic (ie, pre-
disposition to developing anti-immunoglobulin E-mediated
response to common aeroallergens) and environmental fac-
tors, particularly allergic reactions, have been linked to the
disease.2,3
Symptom manifestation may vary from patient to patient,
with shortness of breath, cough, tightness of the chest, spu-
tum production, and wheezing considered hallmark symp-
toms of asthma. Disease exacerbations—caused by a
multitude of factors including viral infections, allergy, exer-
cise, airborne irritants (ie, cigarette smoke, strong odors,
dust), and other inhaled irritants—are diverse and can pro-
duce symptoms that range from transient to life-threatening
episodes of respiratory distress.1 Due to the variable nature
of asthma, the degree of disease severity, including the do-
mains of functional impairment and risk of future exacer-
bations, is an important consideration. Equally important is
the need to monitor control constantly to ensure optimal
outcomes and improve the overall quality of life (QOL) of
asthma patients.
Recently updated guidelines from the National Asthma
Education and Prevention Program Expert Panel Report 3
(NAEPP EPR-3) emphasize the need for a comprehensive
approach to asthma management to include assessment and
monitoring, education, control of environmental and other
factors that affect asthma, and patient and provider educa-
tion.3 Despite the availability of multiple guidelines to assist in
the diagnosis and management of asthma, control is subop-
timal for many patients. This may be attributable to the fact
that providers may be relying primarily on clinical measures
to determine asthma severity and control, thus potentially
under-recognizing patients who have severe uncontrolled
asthma. The NAEPP guidelines recommend an approach that
includes clinical and patient-reported measures to obtain an

Atrius Health=Harvard Vanguard Medical Associates, Watertown, Massachusetts.

87
88
accurate assessment of asthma’s impact on patient QOL.3 This
could lead to identifying those who have severe uncontrolled
asthma, who are high utilizers of health care resources.
Clinical Guidelines
Evidence-based clinical guidelines serve as current stan-
dards of practice for the management of patients with asth-
ma.3–5 Both the Global Initiative for Asthma and the NAEPP
guidelines provide practitioners with diagnostic parameters,
treatment modalities, strategies for assessment and moni-
toring, and patient education.3 Pulmonary function mea-
surements, frequency of beta-agonist use, daily symptoms,
and nighttime awakenings are used to establish disease se-
verity and to measure the effectiveness of therapy.3 The
NAEPP guidelines clearly differentiate between assessment
and monitoring and the close link between severity, control,
and treatment response. The concept of control is also further
delineated into degrees of reducing impairment (ie, func-
tional limitations due to asthma symptoms) and risk (ie,
future asthma exacerbations or decline in lung function in
adults or reduced lung growth in children).3
Although the guidelines provide a classification system for
asthma severity, both patients and physicians tend to un-
derestimate the severity of disease.6,7 Perhaps this discrep-
ancy persists because the inflammatory process is complex
and symptoms can vary from patient to patient, from day to
day, and throughout the day.
Based on previous guidelines, questions arose about
classifications of asthma severity after treatment and which
aspects of asthma should be monitored. The 2007 NAEPP
guidelines clarify this by noting that initial treatment should
be based on disease severity at diagnosis. After therapy has
been initiated, emphasis should be on how well asthma is
controlled relative to therapeutic goals and any appropriate
adjustments to obtain the desired outcome. The American
Academy of Allergy, Asthma & Immunology and the
American College of Allergy, Asthma, and Immunology
recommend that asthma management be driven by treat-
ment decisions based on assessment of control.8
Monitoring Asthma Control
Periodic monitoring of asthma control is an essential
component of the NAEPP guidelines. The NAEPP defines
the level of asthma control as ‘‘the degree to which both
dimensions of the manifestations of asthma—impairment
and risk—are minimized by therapeutic intervention.’’3
It is also important to recognize the distinction between
asthma severity and disease control.9,10 However, universal
use of available objective measures may not accurately reflect
disease severity and control in the presence of active treat-
ment. Variability of patient disease severity and heteroge-
neity of the population further limit the utility of these tests
in the overall asthma population. Interpatient and in-
trapatient differences make it difficult to apply the current
classification system universally and to employ a single,
simple monitoring parameter for patients with asthma.7,11
Traditionally, pulmonary function measures, symptoms
scores, and rescue medication use are measures to assess
patients’ medication needs to treat asthma. However, these
measures do not necessarily correlate with improvements in
the patient’s functional status (ie, QOL).12 In a study con-
CARDARELLI
ducted by Zhang and colleagues that assessed the relation-
ship of several asthma control end points, the investigators
concluded that the relationship among variables is complex
and a simple definition of asthma control is not possible;
multiple measurements over a long period are needed to
create a more precise picture of asthma control and patient
response.13
Currently there are numerous available measures of
asthma control. Each has strengths and weaknesses (Table 1),
so it is likely that incorporation of more than 1 of these
measures is necessary to provide an accurate assessment of
asthma control. This strategy will provide a much broader
picture of overall symptom management. It also will enable
clinicians and managed care organizations (MCOs) to better
identify those with severe or uncontrolled asthma and to
potentially develop treatment strategies that can lead to
optimal disease control.
Measures of pulmonary function=hyperreactivity
Measurement of pulmonary function with forced expira-
tory volume in 1 second (FEV1) is often used to monitor
patients with asthma. FEV1 is generally accepted as the
standard clinical measure of airway flow and obstruction in
patients with asthma.6,14,15 This test is considered an objec-
tive and reliable measure of airflow with reproducibility
upon repeat testing.10 Efficacy outcomes and measures of
therapeutic success in clinical trials most often rely on
changes in FEV1 following the introduction of therapy as a
measure of asthma control.16
A consensus on the optimum number and timing of FEV1
measurements has not been established and can vary with
each study design, making interpretation of the results of
multiple studies difficult. Furthermore, while this test offers
insight into airflow changes, the patient-perceived effects of
an intervention and subsequent symptom control do not
necessarily strongly correlate with FEV1 changes.16,17
The NAEPP now recommends using the ratio of FEV1 and
forced vital capacity (FVC) to assess asthma severity and
control in patients aged 5 years and older, and includes
suggested ranges for these measurements in its updated
guidelines. This change was made because FEV1=FVC may
be a more sensitive measure than FEV1 alone.3
Peak expiratory flow (PEF) rate also has been used as a
measure of pulmonary obstruction. An advantage of mea-
suring PEF is the ability of the patient to assess pulmonary
function at home with a simple and inexpensive PEF meter.
It has been suggested that PEF can be used to assess bron-
chodilator response as the specificity and sensitivity allows
for accurate, reliable measures. However, this measure is not
reliable when measuring bronchoconstriction following meth-
acholine challenge.15 Additional data question the reliability
of this measure and report that it underestimates the severity
of airflow obstruction.18 Over time, patient compliance with
long-term measurement of PEF with PEF meters diminishes,
producing a less than accurate assessment of the patient’s
status.19 The NAEPP emphasizes that peak flow and symp-
tom-based monitoring, if taught and followed correctly, can
be equally effective.
Bronchial hyperresponsiveness (BHR), a characteristic of
patients with asthma, produces symptoms of chest tightness,
breathlessness, and wheezing. BHR can be measured
 Table 1. Asthma Monitoring Strategies

Monitoring strategy Advantages Disadvantages Place in therapy

Measures of pulmonary function=hyperreactivity

FEV1 Standard measure of airflow Circadian variation Measure of efficacy
and obstruction Optimum number of measures= in clinical trials
Measures airflow from both day and timing of Used to diagnose asthma
large and peripheral airways measurements ill defined
Objective and reliable No correlation between
Reproducible patient-perceived effects
Expensive
Inconvenient for patients
FEV1=FVC May be a more sensitive
measure than
FEV1 alone
PEF Standard measure of Primarily a measure of Used for ongoing
pulmonary obstruction large airways monitoring
Simple and inexpensive May underestimate the severity Routine monitoring
Accurate and reliable measure of airflow obstruction suggested for patients
of bronchodilator response Reliability has been questioned with moderate to
Convenient for patients Patient compliance severe asthma
decreases with time
Optimum number of measures=
day and timing of
measurements ill defined
BHR Standardized Expensive Diagnostic measure
Highly sensitive for Labor intensive for asthma
asthma diagnosis Inconvenient for patients Potentially useful
Provides information adjunctive measure
into underlying of patient response
inflammatory process to anti-inflammatory
treatment
Measures of airway inflammation
Sputum eosinophil Accurate measure of Time consuming Useful for predicting
counts airway inflammation asthma deterioration
Noninvasive
Exhaled NO Simple No correlation between Potentially useful
Noninvasive FEV1 and QOL adjunctive measure
Repeatable measure of airway Larger studies need of patient severity
hyperresponsiveness to determine role and response to
Technique standardized treatment
in children
Serum IgE Provides insight into Requires physician office visit Identify candidates for
disease activity Invasive anti-IgE treatment
Monitoring response to
anti-IgE treatment
Additional measures of asthma control
Exacerbation frequency Useful measure of patient’s Inconsistencies in data Important indicator of
overall asthma control due to changes asthma control
Does not require in health plan, polypharmacy,
additional testing and poor follow-up
QOL Offers patient perspective Not a traditional measure Adds information about
Many tools have of therapy effect functional status
been validated Correlation between QOL score Focuses on issues
and severity of asthma important to patients
not consistent
Symptom scoring tools Offers patient perspective Many available tools have Identify potential
Can be used to predict not been validated improvements in
asthma outcomes Weak correlation with FEV1 asthma therapy
May be difficult to score No consensus on
the best tool

BHR, bronchial hyperresponsiveness; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; IgE, immune globulin E; NO,
nitric oxide; PEF, peak expiratory flow; QOL, quality of life.
90
through standardized bronchoprovocation tests that use
pharmacologic (ie, methacholine, histamine, mannitol,
adenosine monophosphate, hypertonic saline) or natural
(exercise) challenges.20,21 Bronchoprovocation tests are
highly predictable for the diagnosis of asthma and are con-
sidered highly sensitive.
Methacholine and histamine challenges are considered
direct stimuli that produce bronchoconstriction in individu-
als without asthma, although the degree of bronchocon-
striction is greater in patients with asthma.20,22,23 Indirect
stimuli (ie, mannitol, adenosine monophosphate, hypertonic
saline, exercise) cause a release of preformed inflammatory
mediators and offer insight into underlying inflamma-
tion.20,23 Following provocation challenge, a 20% decrease in
FEV1 from baseline is considered diagnostic for asthma.
Beyond diagnosis, the role of BHR testing in the man-
agement of asthma has been investigated.20,24,25 Unlike FEV1
and PEF, indirect bronchoprovocation challenges provide
information about the underlying inflammatory process.20
Because decreases in airway hyperresponsiveness have cor-
related with a decrease in eosinophil response and are a
measure of the inflammatory process, these tests may be a
useful adjunct for monitoring patient response to therapy
and determining if pharmacotherapy measures are control-
ling the inflammatory process.20,21
Measures of airway inflammation
Recognition of asthma as an inflammatory disease has
increased interest in monitoring tools that measure inflam-
matory activity. Exhaled nitric oxide (NO) levels increase in
patients with asthma following allergen challenge and dur-
ing exacerbations.26 Evaluation of airway inflammation
through exhaled NO offers a simple, noninvasive, repeatable
measure of airway hyperresponsiveness and has been pro-
posed as an adjunct measure to determine the severity of
asthma and response to therapy.27 The technique for mea-
suring exhaled NO has been standardized for children and
reference values are available.28
In addition, preliminary investigation in a small group of
patients indicates that other inflammatory markers (ie, IL-6,
IL-4) are elevated in the breath of patients with asthma.29
Results from this study indicate that exhaled IL-4 levels, but
not IL-6, decreased following treatment with inhaled steroids,
suggesting that exhaled IL-4 concentrations may be an adjunct
measure for assessing patient response to therapy.29 Exhaled
IL-4 and IL-6 did not correlate with FEV1, however.29
Eosinophils are important inflammatory markers found in
the sputum of patients with asthma. Eosinophil levels are
increased during exacerbations and are reduced in response
to anti-inflammatory medications.30–32 Although eosino-
philia is also seen in the peripheral blood of patients with
asthma, sputum eosinophil counts are considered more ac-
curate than serum evaluations.33 In the past, sputum eosin-
ophil evaluations in patients with asthma were reserved for
clinical study and required the use of invasive broncho-
alveolar lavage. Now, simple noninvasive sputum tests are
available with results similar to those reported with invasive
procedures—bronchoalveolar lavage and bronchial wash.
The results of sputum analysis are considered accurate en-
ough to use as a guide to adjust anti-inflammatory medica-
tions (inhaled corticosteroids) and can be used to predict
CARDARELLI
asthma deterioration following a discontinuation of inhaled
corticosteroid.30 These tests often are time consuming (in-
duction of sputum requires coughing into a sterile container
for several minutes) and at present, use remains limited to
clinical studies or for evaluation of difficult-to-treat patients.32
Additional measures of asthma control
A primary goal of asthma therapy is the reduction of risk,
which includes prevention of recurrent exacerbations and
progressive loss of lung function (in children, the prevention
of reduced lung growth), and the optimization of pharma-
cotherapy with minimal or no side effects.3 Longitudinal
assessment using spirometry is necessary to measure risk of
progressive loss of lung function; in children, the risk for
reduced lung growth is assessed by prolonged failure to at-
tain predicted lung function values for age.3
However, clinical measures alone may not be sufficient to
determine the full impact of asthma on the patient’s daily
functioning and limitation of activities. Therefore, patient-
reported measures can further guide the clinician in identi-
fying those individuals with severe uncontrolled asthma
who may require more intensive management and treat-
ment. The use of these measures may also be helpful to de-
termine which patients are at future risk of exacerbations and
have the potential to become greater consumers of health
care resources.
Symptom-scoring measures rely on patient perception of
asthma control and may not always reflect disease control as
measured with objective tools. A study by Zhang concluded
that FEV1 and daily symptoms score showed only a weak
correlation, suggesting that they measure different asthma end
points and that improvement in one parameter cannot be ex-
trapolated to overall improvement.13 Although various tools
for measuring patient control have been correlated to positive
outcomes, there is no consensus on the most appropriate
measures to include. Therefore, the NAEPP recommends using
both approaches to ensure optimal asthma management.
Patient-Reported Asthma Measures
The Asthma Control Test (ACT), a validated measure for
those with mild to moderately severe asthma, is used to
identify patients with poor disease control.34 This patient-
based questionnaire consists of 5 questions that ask the pa-
tient to assess their level of asthma control during the past
4 weeks. This questionnaire, which encompasses asthma
symptoms, use of rescue medications, and the impact of
asthma on everyday function, is considered reliable and easy
to use. Patients who score
19 on this test are considered to
have uncontrolled asthma. Initial results with this tool indi-
cate a stronger correlation between the ACT score and an
asthma specialist’s assessment of the patient than FEV1 re-
sults and the specialist’s assessment.34 Additionally, ACT
provides a more simplified assessment of asthma control
because FEV1 is not required, which is beneficial in settings
where FEV1 is not available.34 Schatz et al demonstrated that
ACT scores were responsive to changes in asthma control
over time for patients new to the care of an asthma specialist,
indicating that the test might be essential for managing
asthma patients during the course of their disease.35
The Asthma Therapy Assessment Questionnaire (ATAQ)
was developed as a disease management tool to identify
MONITORING ASTHMA
patients whose asthma is not optimally managed.36 This
brief, self-administered questionnaire comprises 5 questions
to assess asthma control in general; missed days of work,
school, or normal activities; nighttime awakening; and the
need for rescue medications. Higher scores on this test in-
dicate greater levels of uncontrolled asthma. The ATAQ
correlates highly with self-reported QOL and is predictive of
future acute care episodes.36,37 In a study by Peters et al, the
ATAQ control index helped to identify patients without re-
cent acute care who had a 6-fold greater risk for future acute
health care utilization.38 The authors also state that, when
used in conjunction with administrative claims data, the
ATAQ can be useful in predicting future health care utili-
zation, which could be helpful to clinicians and organiza-
tions interested in population-based disease management.38
Other measures that have been validated include the
Asthma Control Questionnaire (ACQ) and Asthma Control
Diary.39 The ACQ comprises 6 questions to determine asth-
ma control. This validated instrument addresses symptom
severity of asthma patients (ie, wheezing, shortness of
breath), as well as nighttime awakenings, severity of symp-
toms on awakening, limitations to daily activities, and
number of daily puffs with a short-acting bronchodilator.40
The ACQ also includes FEV1 measurement, performed by a
member of the health care team, to further determine a pa-
tient’s asthma control. A study by Juniper et al validated the
use of this instrument to identify patients whose asthma
is poorly controlled.40 After utilizing this instrument for 9
weeks, the authors found that the ACQ has strong mea-
surement properties as an evaluative and discriminative in-
strument. Additionally, completion of the ACQ in the
waiting room may save consultation time and could be used
to enhance disease management, possibly reducing health
care resource utilization for this population.40 The Asthma
Control Diary is a validated, easy-to-use instrument that asks
patients to record asthma severity upon awakening and at
bedtime; the criteria used for this evaluation are similar to
those of the ACQ. Instead of FEV1 measurement by office
staff, however, patients are asked to record their PEF rates.41
Both the ACQ and Asthma Control Diary are useful for
measuring asthma control; the reliability and responsiveness
of the ACQ, however, is better than use of a diary.41,42
Another validated instrument is the Asthma Control
Score, an easy-to-use scoring system based on a percentage
of optimal control for clinical, physiological, and inflamma-
tory assessments.43 The clinical components focus on diurnal
and nocturnal symptoms, b2-agonist use, and limitation to
physical activity; the physiologic assessment looks at FEV1 or
PEF, as well as PEF variation; the inflammatory component
evaluates the percentage of airway eosinophilia. The Asthma
Control Score is a simple, practical, and flexible instrument
that can be used by patients, providers, and researchers to
determine asthma control.43 Another advantage is that this
instrument incorporates 3 of the most typical asthma mani-
festations: respiratory symptoms, changes in expiratory
flows, and airway inflammation.43
Quality of Life
Asthma is a chronic disease that may affect a patient’s
ability to participate in normal daily routines including
work, school, and extracurricular activities. Thus, it is im-
91
portant to include the impact of a medication on QOL when
measuring its overall effect. Patient perceptions of improve-
ment often are not accurately reflected in the clinical as-
sessment of a therapy.16 Health-related quality of life
(HRQOL), like symptom scoring, incorporates the patient’s
perspective into the measure of asthma therapy. HRQOL
tools help to measure the effects of asthma on the patient’s
functional status and incorporate the patient’s satisfaction
with therapy into the overall assessment. Until recently, QOL
measures to assess efficacy of therapy were not used con-
sistently in clinical trials.
The effect of asthma therapy on patient functional status
and reduction of symptoms are important QOL parame-
ters.12,44 The Asthma Quality of Life Questionnaire (AQLQ)
and the Pediatric Asthma Quality of Life Questionnaire
(PAQLQ) have been validated and are considered reliable
measures of QOL.12,44–47
The AQLQ is a clinician-administered measure that asks
patients to assess the impact of their asthma over a 2-week
period. This questionnaire contains 32 items, including a list
of daily activities, designed to assess the degree of impair-
ment due to their asthma in 4 domains: symptoms, activity
limitation, emotional function, and environmental stimuli.
This scale asks the patient to rate on a 15-point scale (-7 to 7)
how asthma has limited their activities in the previous
2 weeks. Designed to detect small within-subject changes,
the AQLQ is reproducible even when the patient’s asthma is
stable.44 For patients whose asthma is inadequately con-
trolled with medication, the AQLQ, in addition to clinical
measures, is useful to measure HRQOL in adults with
asthma.44,45
The PAQLQ is a 23-item questionnaire designed to de-
termine the burden of illness in children aged 7 to 17 years.
This simple, easy-to-use questionnaire looks at 3 domains
related to the impact of asthma on activity limitation,
symptoms, and emotional function.46 This instrument uses a
scale of 1 to 7, with lower scores indicating a greater degree
of uncontrolled asthma. Additionally, the PAQLQ asks pa-
tients to identify 3 activities (from a list of 35) in which
asthma has limited their ability to perform. This instrument
was able to detect change in children who improved and
those who deteriorated, and to distinguish between those
who had minor and more serious QOL impairments.46
The NAEPP also identifies the Mini Asthma Quality of
Life Questionnaire (MiniAQLQ), the Integrated Therapeutics
Group Asthma Short Form (ITG-ASF), and the Asthma
Quality of Life for Children validated instruments for the
assessment of asthma-specific QOL. A correlation between
mild asthma, as defined by lung function, symptoms, and
reliever medication use, and the AQLQ score has been con-
firmed; however, this correlation did not hold for patients
whose asthma is moderate to severe.16
The MiniAQLQ is a reliable, validated measure to ascer-
tain QOL impairments due to asthma. The MiniAQLQ is a
self-administered 15-question instrument that evaluates the
same 4 domains as the AQLQ. In a clinical study, scores
between the 2 measures were similar in detecting the burden
of illness; however, between-visit scores were not as consis-
tent with the MiniAQLQ.48
The ITG-ASF is a brief, comprehensive, 15-item ques-
tionnaire designed to evaluate the impact of asthma on an
easy 5-point scale (from not at all to very severely). The
92
questionnaire, designed for those aged 14 years and older,
asks patients to respond to questions that correspond to 5
parameters: symptom-free index, functioning with asthma,
psychosocial impact, asthma–confidence in health, and
asthma energy.49 The ITG-ASF Total showed greater re-
sponsiveness to lung function changes and number of
workdays missed than the AQLQ, but was less responsive at
showing changes in NAEPP and patient-related asthma se-
verity than the AQLQ. This validated and reliable measure,
however, is a good adjunct to traditional clinical measures
(ie, FEV1) and generic outcomes measures (ie, Short Form-36)
in determining the burden of asthma.49
The recently released NAEPP EPR-3 guidelines emphasize
the importance of assessment to determine disease severity,
including risk of future exacerbations and impairment of
daily activities, as well as ongoing monitoring to determine
therapeutic effectiveness on asthma control. FEV1=FVC is a
reliable measure that enables physicians to determine disease
severity and provides a road map regarding what treat-
ment(s) may be most appropriate based on the guideline’s
recommended step-care approach. In addition, clinicians can
use the ACT to gain the patient’s perceptions of disease se-
verity and control and compare them with the FEV1=FVC
results. This also provides clinicians with an opportunity
to educate patients about the importance of disease self-
management (eg, minimizing or eliminating factors that may
exacerbate their disease), how to recognize when their dis-
ease is uncontrolled, and about the importance of medication
adherence. For payers, baseline assessment of disease se-
verity can help identify patients with severe persistent
asthma who may be high utilizers of health care resources.
These patients can then be targeted for more aggressive
treatment, which may decrease the use of rescue medica-
tions, as well as office=emergency department visits and
hospitalizations.
For maintaining asthma control, employing the ACT on
follow-up visits will provide physicians with ongoing patient
insights regarding asthma control. Greater patient monitor-
ing could be achieved through PEF, an inexpensive method
to determine control. This measure must be supplemented
with the use of a patient diary, however, to identify factors
that can precipitate or exacerbate symptoms. These data can
help clinicians reevaluate and update their pharmacologic
strategy, as appropriate, and enable continued physician-
patient discussion about how patients can effectively manage
their disease. This ongoing discussion is beneficial to payers
because better overall management by clinicians and pa-
tients, including increased medication adherence, can im-
prove outcomes and reduce the need for rescue medications,
office=emergency department visits, and hospitalizations.
Conclusion
Asthma is a dynamic inflammatory disease with multiple
factors that contribute to its severity at any particular point
in time. The impact of asthma is far-reaching and varied,
with physical, social, and economic consequences. As with
other chronic diseases, it is important to monitor disease
activity over time to identify patients whose disease is
worsening and=or determine patient response to therapeutic
interventions. The current guidelines stress the importance of
CARDARELLI
assessing disease severity and monitoring for control when
evaluating patient response to treatment. Assessing the im-
pact of asthma therapy must include parameters that mea-
sure changes in lung function and control of disease,
including impairment and risk. Effective monitoring tools
are vital to ensure that clinicians have a complete picture of
the patient with asthma. Therefore, it is important to con-
tinually evaluate existing tools to determine if their mea-
surements truly correlate with asthma severity and control.
A single optimal test for monitoring asthma patients does
not exist, however, and combinations of available measures,
including those that account for the patient’s view of asthma
control, provide a more accurate picture of disease activity.
Patient self-reporting that targets symptom severity, reduced
activities, emergency department use, and hospitalization
can be used to predict asthma outcomes for diverse patient
populations. Based on patient questionnaire results, risk
models can be developed to identify patients at risk for in-
creased asthma symptoms, disability, and avoidable use of
health care resources. As more weight is given to patient-
perceived symptoms, instruments that include patient
assessment of disease activity could provide valuable infor-
mation regarding asthma symptoms and control and identify
opportunities to improve asthma management.
Asthma is a therapeutic area in which the managed care
community can make a substantial positive contribution to
improving the overall care of this patient population. MCOs
have access to both cost and health care utilization infor-
mation and can use these data to identify those patients who
are at the highest risk. Communicating this information to
their provider network will help physicians deliver better
care management to their patients. In addition, many MCOs
publish member newsletters several times a year, which
could be used to educate members about asthma manage-
ment and the importance of medication adherence. This
newsletter could also include a simple screening tool, such as
the ACT, to help members to self-manage their disease.
Acknowledgments
The author wishes to acknowledge Charlotte Kenreigh
and Deborah Lee Ross, medical writers, Strategic Healthcare
Alliance, for their assistance with the writing and researching
of this manuscript. The author also wishes to acknowledge
Dennis Bloshuk, editor, Strategic Healthcare Alliance, for his
assistance with the editing and preparing of this manuscript.
Disclosure Statement
The author discloses no significant financial relationships
or affiliations.
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