Related editorial
Measuring childhood asthma control
Søren Pedersen, MD, PhD, DMSc Kolding, Denmark
Key words: Asthma control, assessment, Global Initiative for
Asthma, Childhood Asthma Control Test, Asthma Control Test,
quality of life, Web-based diary recordings
Several studies have documented the benefits of good asthma
control on a variety of outcomes that are important to patients and
society, such as no restriction in lifestyle, better physical fitness
and quality of life, reductions in asthma burden, health care
resource use and lower risk of exacerbations, oral steroid use,
hospitalizations, and death.1 Therefore the aims of asthma man-
agement focus on achieving and maintaining good asthma control
and reducing future risks.2 The problem with this strategy is
that correct assessment of asthma control is not straightforward.
Several studies have found that the assessment of control
varies markedly among health care professionals, as well as
patients. Generally, both physicians and patients tend to overesti-
mate the level of asthma control, with a subsequent risk of
undertreatment.3
In an attempt to facilitate correct asthma control assessment,
several simple and easy-to-use composite asthma control scores
have been developed. Most try to capture the level of control in a
single numeric value, such as the Asthma Control Test (ACT) and
Childhood Asthma Control Test (c-ACT). Because the various
tests use the same outcomes (daytime and nighttime symptoms,
limitation of activities, and use of rescue medication), it is not
unexpected that the results of these tests correlate with each other
and with the Global Initiative for Asthma (GINA) definition of
asthma control4 to some extent. However, symptoms, limitations
of activities, and use of rescue medication are not independent
variables. Physical activity is one of the most important causes
of symptoms and reliever use in children. Therefore many chil-
dren with insufficiently controlled asthma avoid strenuous
exercise.5-8 The result is fewer daytime symptoms, less rescue
use, and apparently controlled asthma. This is achieved at the
expense of poorer fitness and a higher risk of obesity. Many
parents (and children) are unaware of such changes in lifestyle.
The question remains whether the various retrospectively
collected tests capture the same information as the prospective
but more cumbersome diary recordings and also whether a single
cutoff value is sufficient or optimal in distinguishing between
controlled and uncontrolled asthma. The study by Voorend-van
From the University of Southern Denmark, Paediatric Research Unit, Kolding Hospital.
Disclosure of potential conflict of interest: S. Pedersen has received consultancy fees
from Bergen, GlaxoSmithKline, Boehringer Ingelheim, and Nycomed; has received
research support from GlaxoSmithKline; and has received lecture fees from Glaxo-
SmithKline and Boehringer Ingelheim.
Received for publication October 30, 2013; accepted for publication November 7, 2013.
Available online December 22, 2013.
Corresponding author: Søren Pedersen, MD, PhD, DMSc, Paediatric Research Unit,
Kolding Hospital, Skovvangen 2-8, 6000 Kolding, Denmark. E-mail: spconsult@
post1.tele.dk.
J Allergy Clin Immunol 2014;133:1606-7.
0091-6749/$36.00
Ó 2013 American Academy of Allergy, Asthma & Immunology
http://dx.doi.org/10.1016/j.jaci.2013.11.003
1606
Bergen9 provided some interesting additional information about
this. It was reassuring that the retrospectively collected c-ACT
and ACT scores correlated well with the prospectively collected
Web-based diary recordings. However, the researchers also used
their data to estimate c-ACT and ACT cutoff points for well-
controlled asthma. This is novel and has been given little attention
in the past. Most studies using the control tests have focused on
differences in various outcomes between patients with c-ACT or
ACT scores of less than 20 and patients with scores of greater
than 19. From such studies, we have learned that a score of less
than 20 is a significant risk factor for exacerbations, emergency
department visits, health care use, poor quality of life, absence
from school or work, and limitations in physical and social activ-
ities. Therefore, a score of less than 20 has become widely
accepted as the level for poor asthma control, which requires
treatment or treatment changes. Fewer studies have assessed
whether a c-ACT or ACT score of greater than 19 can be used
as an indication that the asthma is sufficiently or well controlled.
The findings by Voorend-van Bergen et al9 suggest that this is
probably not the case. Using sensitivity, specificity, and positive
and negative predictive values for different cutoff points of
c-ACT and ACT scores, the authors concluded that the cutoff
scores for well-controlled asthma were 22 or greater for the
c-ACT and 23 or greater for the ACT. According to the GINA
criteria, 20% of their patients had symptoms that were well
controlled, and 80% had symptoms that were not controlled
(41% partly controlled and 39% uncontrolled). In contrast, only
29% and 25% of the children had symptoms that were uncon-
trolled according to the c-ACT or ACT (data provided by the au-
thors). Similar differences have been reported in another study10:
85% had uncontrolled symptoms according to GINA criteria (un-
controlled and partly controlled) and only 40% had uncontrolled
symptoms with the ACT/c-ACT. Knowledge of these differences
between the various ways of defining controlled and uncontrolled
asthma is important when comparing results from different
studies. Children with uncontrolled asthma according to the
GINA criteria are likely to be clinically quite different from chil-
dren included in studies using a c-ACT or ACT score of less than
20 as a criterion to define uncontrolled asthma. The same will be
the case for children defined as having controlled symptoms by
using these 2 methods. On the other hand, it seems as if uncon-
trolled asthma defined by c-ACT or ACT scores is more similar
to uncontrolled asthma defined by the GINA definitions.
The clinical importance of the additional grading of the level of
control used by GINA is less well studied. However, there are
some suggestions that the additional grading might be useful.
Studies in adults found significant differences between well-
controlled and partly controlled asthma in a variety of clinically
important outcomes,11 and another study reported that an ACT
score of greater than 19 was found not to exclude poor asthma
control very well.12 Findings of fewer symptoms and more
symptom-free days in children with well-controlled asthma
than in those with partly controlled asthma and an almost clinical
J ALLERGY CLIN IMMUNOL
VOLUME 133, NUMBER 6
important difference in c-ACT or ACT scores between well-
controlled and partly controlled asthma in the study by Voor-
end-van Borgen et al9 indirectly support that the same will also
be the case for children.
Quantifying control facilitates interpretation and comparison
of clinical trials, as well as patients’ understanding of improve-
ment and deterioration. It allows assessment of a minimal
clinically important difference that will reflect a meaningful
change for the patient. This is difficult with the GINA definition of
control. Thus 77% of 548 children with uncontrolled asthma
(GINA) achieved asthma control after treatment, suggesting that
the remaining 23% did not benefit from the treatment because
their symptoms remained not well controlled at study’s end.13
However, these patients all showed marked improvements in 1
or several control outcomes, and therefore at study’s end, they
failed only half the number of the control criteria as at baseline.
If the c-ACT or ACT had been used, the majority of these patients
would have shown a clinically important improvement according
to the criteria suggested by Voorend-van Bergen et al.9 Such use-
ful information would not normally be missed when using the
GINA definitions.
The problem for all studies assessing asthma control is that we
do not have a gold standard with which the various tests can be
compared. Voorend-van Bergen et al9 used a change in the Pedi-
atric Asthma Quality of Life Questionnaire or the Pediatric
Asthma Caregiver’s Quality of Life Questionnaire results to
define a minimally important clinical difference because these
tests have previously been validated with respect to this. This is
probably the best we can do at present, but it does not necessarily
make it a gold standard. (Albert Einstein: ‘‘What counts cannot
always be measured and what can be measured does not always
count.’’) Both these tools depend heavily on symptoms, and the
number of symptom-free days correlates with quality of life.14
Symptoms are subjective and influenced by the children’s level
of perception of symptoms and the effect of the disease on the
children’s daily activities, including sports and play and social
life. Therefore good objective measures that do not depend on
these factors would be welcome. In this respect FEV1 and exhaled
nitric oxide measurement did not seem useful, but other out-
comes, such as exercise challenges, objective measurements of
daily physical activity, and specific diary recordings of daily
PEDERSEN 1607
activities, might be worth studying. The validity and feasibility
of the Web-based diary recordings reported in the study by
Voorend-van Bergen et al9 suggest that this tool might be useful
in the future for more specific prospective recordings of daily
activities and probably more reliable than retrospective record-
ings and a paper diary.
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