Published online July 3, 2006
PEDIATRICS Vol. 118 No. 1 July 2006, pp. 322-329 (doi:10.1542/peds.2005-2576)
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REVIEW ARTICLE

Assessment of Asthma Severity and Asthma Control in Children

Barbara P. Yawn, MD, MSca, Susan K. Brenneman, PhDb, Felicia C. Allen-Ramey, PhDb, Michael D. Cabana, MD, MPHc and Leona E. Markson, ScDb

a Department of Research, Olmsted Medical Center, Rochester, Minnesota
b Outcomes Research and Management, Merck & Co, Inc, West Point, Pennsylvania
c Division of General Pediatrics, University of California, San Francisco, California


   ABSTRACT
TOP
 ABSTRACT
MEASUREMENT OF ASTHMA SEVERITY
 MEASUREMENT OF ASTHMA CONTROL
 IMPLICATIONS FOR TREATING...
 CONCLUSIONS
 REFERENCES
 
National and international guidelines for asthma recommend the assessment and documentation of severity as the basis for patient management. However, studies show that there are problems with application of the severity assessment to children in clinical practice. More recently, asthma control has been introduced as a method to assess the adequacy of current treatment and inform asthma management. In this article we review the application and limitations of the severity assessment and the asthma-control tools that have been tested for use in children. A system of using asthma severity for disease assessment in the absence of treatment and using asthma-control assessment to guide management decisions while a child is receiving treatment appears to be a promising approach to tailor treatment to improve care and outcomes for children with asthma.

Key Words: asthma • assessment • asthma severity • asthma control • children

Abbreviations: NAEPP—National Asthma Education and Prevention Program • GINA—Global Initiative for Asthma • FEV1—forced expiratory volume in 1 second • ATAQ—Asthma Therapy Assessment Questionnaire • ACT—Asthma Control Test

Asthma is the most common chronic childhood illness, affecting >4.8 million children in the United States and resulting in high levels of preventable morbidity and mortality.1 National and international guidelines for asthma have been published to assist in managing this common disease.2–8

A fundamental component of the asthma guidelines is the assessment of asthma "severity" used to describe the underlying disease state. Guidelines link the assessed level of asthma severity to appropriate medications, the frequency and methods of monitoring symptoms, lung function, a patient's educational needs, and content of an asthma action plan. Studies of physicians' care of asthma have shown incomplete adoption of the asthma guidelines.9–15 The challenges in understanding and translating the guidelines into clinical practice and ongoing clinical management of asthma seem to be reasons for the gaps in guideline adoption.16,17

More recently, asthma "control," defined as the patient's response to his or her current asthma management, has been introduced as a method to assess adequacy of current treatment and inform asthma management. Control is assessed while the patient is being treated and, therefore, may be easier for clinicians, patients, and parents to understand and incorporate into asthma-management plans.

In this article we review the evolution and limitations of the concepts of severity and control in children with asthma and highlight potential barriers that may need to be overcome for these concepts to be translated into routine primary care. The review is based on the published medical literature as well as the authors' experience in trying to adopt current asthma-management recommendations for primary care practice. We searched Medline for relevant English-language articles using the search terms "asthma and children," "asthma and severity," "asthma and control," "asthma measurements," "FEV," "pulmonary function test," "patient management," and "disease management" for literature published between 1996 and July 2005. Additional sources included key references cited in these articles, national and international guidelines for the diagnosis and management of asthma, and other references identified.


   MEASUREMENT OF ASTHMA SEVERITY
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 ABSTRACT
 MEASUREMENT OF ASTHMA SEVERITY
MEASUREMENT OF ASTHMA CONTROL
 IMPLICATIONS FOR TREATING...
 CONCLUSIONS
 REFERENCES
 
The Evolution of Measurement of Asthma Severity
The concept of asthma severity has evolved since first being published with the 1991 National Asthma Education and Prevention Program (NAEPP) guidelines for the diagnosis and management of asthma. The original 1991 severity classification separated asthma into mild, moderate, and severe categories on the basis of symptoms, frequency of exacerbations, and (for children) school attendance. The degree of exercise tolerance (good, diminished, and very poor) and pulmonary function tests were also included in the severity assessment, all measured before asthma treatment was begun. After treatment was established, severity could also be assessed by the response to and duration of therapy. The characteristics for each severity level were reported to be "general" and, because of the variable nature of asthma, a patient's disease could overlap >1 severity category.2

The 1997 version of the NAEPP asthma guidelines2 introduced the concept of intermittent and persistent asthma with 4 categories: mild-intermittent, mild-persistent, moderate-persistent, and severe-persistent asthma (Table 1). The severity classification was based on symptom frequency (daytime or nighttime), activity limitations, peak expiratory flow, and day-to-night peak-flow variability, again all before treatment. Severity was assigned on the basis of the highest category reached for any measure. For children under 5 years of age, only symptom data were used for the severity assessment. How severity was to be assessed and modified over time was unclear. The 2002 update of the NAEPP guidelines did not modify the severity classification.3


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  		TABLE 1 Classification of Asthma Severity According to Clinical Features Before Treatment2,4

 
Other groups have modified the NAEPP guidelines in an attempt to expand measures of severity to include severity assessment on the basis of the type of current treatment and the presence of symptoms while on treatment.4–7 For example, the Canadian guidelines6 recommend that, after asthma treatment has begun, severity be assessed on the basis of the level of medication needed to keep asthma symptoms and pulmonary function measurements within a prespecified level. The Global Initiative for Asthma (GINA) guidelines4 also recommend a measure of severity that is based on daily medication regimen and response to treatment.

Applying Severity to Asthma Practice: Limitations and Gaps
The concept of severity remains important for determining the initial level or step of asthma therapy, initiating communication and education with children and parents, selecting the immediacy of follow-up, and enrolling patients into research studies. Once a patient is treated, its value is less clear. Lack of clarity regarding when to change the severity assignment, how to incorporate the frequency and intensity of exacerbation into the severity assessments, or how to measure severity in treated patients limits the utility of asthma-severity assignment in clinical practice. For children, this is a particularly troubling issue, because as they grow and develop, it is not known whether their baseline condition will tend to stay the same, get worse, or get better. Increasing evidence that the underlying disease is dynamic and variable makes a static asthma-severity classification for a patient at a single point in time misleading and not helpful in adjusting therapy.18,19

Classifying asthma severity has been shown to have limited reproducibility among both primary care and childhood asthma specialists,9,20 and the distinction between severity-classification levels has not been validated as clinically important or relevant. These problems, as well as the variable nature of asthma, may have undermined physicians' belief and confidence in the utility of this aspect of the tool. Furthermore, it is unclear whether the cut points for frequency of symptoms or lung function used to grade severity apply equally to children and adults.

Inadequate appraisal of symptom intensity and frequency may contribute to underutilization of the asthma-severity assessment.21–23 Factors that may affect appraisal and interpretation of symptoms include intensity, episodicity or chronicity of illness, psychological variables such as denial or defensive style, parent-child interaction, level of child development, and intelligence.24–26 Symptom appraisal in younger children is a unique challenge, because children may not be aware of symptoms, capable of verbalizing asthma symptoms, or able to recall symptom information to the same extent as older children or adults.27 Events occurring in the time directly before clinical examination are perhaps most salient to younger children (ie, <8–10 years old), whereas the parent may be better at reporting patterns of symptoms over time.28 The presence of a parent during a visit may also affect what the child can or wishes to recall. Even as children age and gain knowledge about their condition, parent and child perceptions about asthma symptoms are not consistent.29 Data show that parents and school-aged children report differing levels of symptoms and medication use.30,31 Some of these differences are anticipated, because parents seldom accompany their children to school or play and seldom sleep in the same room. The youngest age at which children begin to be the best source of symptoms is difficult to determine; therefore, the preschool-aged child may be the secondary source of information, whereas the parents become the secondary source in older school-aged children and adolescents.

Currently, only one objective measure is included in the severity assessment: pulmonary function testing. The availability of inexpensive and portable spirometry equipment has made measurement of forced expiratory volume in 1 second (FEV1), FEV1/forced vital capacity ratios, and reversibility theoretically feasible in the primary care office. Yet, the value of lung function test results for informing severity assessment in children is controversial. Few children can adequately complete forced expiratory maneuvers such as spirometry before the age of 5, with most being able to do so by 7 years of age.2,32,33 Even when testing is feasible, several studies have found inconsistent or poor relationships between FEV1 and asthma symptoms in children, because most children have near-normal FEV1 values even when they are markedly symptomatic.34–39 The NAEPP FEV1 values reported to distinguish between mild, moderate, and severe-persistent asthma are based on experts' opinions and, in light of new study results, may need to be calibrated differently for adults and children.34,40 Emerging technologies show promise as objective clinical measures of asthma disease activity and, therefore, underlying severity but have not been validated for treatment decision-making.41–45 Therefore, in children it seems that self-reported or parent-reported information is the main resource for assessing disease status.

Another challenge with the current severity-classification system is the failure to address exacerbations and exercise-associated problems. Disease-severity assessment may be misrepresented as mild in a child with life-threatening asthma exacerbations or severe exercise-induced symptoms but who is otherwise asymptomatic. The same problem with underestimating disease burden can occur when assessing severity in seasonal asthma during asymptomatic periods. A static severity assessment that is performed at a single point in time often misses important aspects of the patient's experience with his or her asthma.

Despite considerable educational efforts over the past 13 years, the difficulties of using the severity classification and its lack of face validity for physicians have resulted in a lack of implementation of the assessment and treatment recommendations of asthma care guidelines.9,46,47 These difficulties in applying the asthma-severity assessment within clinical practice (the lack of correlation between lung function and symptoms, the variable nature of asthma, the inability to determine severity posttreatment, and the common failure to assess symptom frequency) have fostered an increasing interest in moving from severity assessment after the initial disease assessment to a measure more consistent with the goals of asthma management, namely assessment of symptom and disease burden and the impact of treatment on disease burden.


   MEASUREMENT OF ASTHMA CONTROL
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 ABSTRACT
 MEASUREMENT OF ASTHMA SEVERITY
 MEASUREMENT OF ASTHMA CONTROL
IMPLICATIONS FOR TREATING...
 CONCLUSIONS
 REFERENCES
 
The concept of asthma control is also evolving. In 1996, Cockcroft and Swystun48 emphasized that asthma control is related to the appropriateness of therapy. Subsequent reviews of the concept of asthma control have emphasized that asthma control is a short-term evaluation of the adequacy of patient management and determines the need for clinical intervention.49,50 Thus, control is a function of underlying severity plus the adequacy of management.49 The primary goals of asthma treatment according to the guidelines are identical for patients regardless of disease severity. Although no specific method of asthma-control assessment is specified, the goals in current guidelines reflect asthma control: minimal or no symptoms, minimal or no use of rescue medication, no activity limitations, and (near) normal lung function with no adverse treatment effects.

Methods for Measuring Control
Several validated instruments for assessing asthma control are currently available, each capturing multiple aspects of asthma burden. Unlike severity scores, which are clinician derived, most control scores are based on patient- or parent-completed surveys51–57 or a daily diary.58 Bateman et al59 derived a measure of asthma control by assigning numerical values to the elements of the GINA treatment goals. Most control measures have been studied in adults with only the Asthma Therapy Assessment Questionnaire (ATAQ), the Asthma Control Test (ACT), and the guideline-based control measure being studied in children.

The ATAQ for children and adolescents is a brief questionnaire designed for completion by parents of children aged 5 to 17 years.60 The ATAQ instrument includes questions regarding several aspects of asthma management in addition to asthma control, including satisfaction with patient-provider communication, patient attitudes and behaviors, and perceived self-efficacy. The instrument was designed to assist clinicians and health plans with identifying children with poorly controlled asthma who may be candidates for additional asthma-management support. Asthma control is assessed by using 7 questions about recent (past 4 weeks) or chronic (past 12 months) symptoms and consequences of asthma. For each completed survey, a score of 0 on the control domain indicates no control issues, and a nonzero score suggests control problems. Through a cross-sectional survey involving 3 managed care organizations, Skinner et al60 found that the ATAQ demonstrated good internal consistency and strong relationships with existing validated measures of childhood health status, asthma impact, and health care utilization. The ATAQ has been used in a variety of other studies investigating the care of children with asthma.11,61–66 Implementation of the ATAQ into clinical practice for children requires development of a system to obtain the ATAQ score and determine how it will be linked to treatment modifications.65,67

The ACT was developed as a population-screening and -monitoring tool.57 The 5-item self-administered survey is designed for use by patients 12 years of age and older. The ACT is scored by summing responses for each of 5 items, referring to the past 4 weeks, to produce a final score ranging from 5 (poor control) to 25 (complete control). A score of ≤19 points indicates that a patient's asthma may not be controlled. Studies68,69 including children 12 to 17 years of age have reported significant correlations between the ACT score and changes in asthma control as measured by physician global ratings and FEV1 values. In addition, study results highlight the ability of ACT to identify high-risk adolescent patients with or without the use of lung function testing.69 As with the ATAQ, little information describing the use of this tool in clinical decision-making in everyday practice has been published.

In an effort to closely link the GINA and National Heart, Lung, and Blood Institute asthma guidelines with an operational definition of asthma control, Bateman et al59 defined 3 potential levels of asthma control (totally controlled, well controlled, or uncontrolled) that could be achieved by patients with asthma of varied severity levels. Results of a 1-year randomized, parallel-group study including patients 12 years of age or older revealed that asthma control can be achieved and maintained with intensive intervention. Data specifically describing the utility or feasibility of using of this guideline-based control assessment in adolescents and children was not presented. No formal validation work or specific control measure development using this methodology has been reported.

In comparison to composite asthma-control questionnaires, when a single global question about control is asked, both children and parents have been found to overestimate the level of control.69,70 One study also showed that selection of asthma-control criteria among physicians varies and is not always compatible with asthma guidelines.70 In each of these studies, inclusion of the components of the asthma-control composite questionnaires provided a better estimate of actual control. A summary of the content of currently available instruments for assessment of asthma control in children and adolescents is provided in Table 2.


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  		TABLE 2 Summary of Asthma-Control Measures for Use With Children

 
At the time of this writing, several new instruments in this area were noted, although no formal validation work has been published.71–73

Limitations and Gaps in Assessing Control
The primary means of assessing asthma control is through patient self-report of symptom severity and frequency, functional limitations, and use of rescue medication. Similar to the symptom assessment in classification of severity, it is necessary to decide who should be the primary source of information (parent, child, or caregiver) about disease status, impact of disease on daily life, current use of medications, and existence or concerns about treatment adverse effects.

In contrast to severity assessment, which is designed to be conducted in the office and usually by the physician, asthma-control assessments can be done by patients, parents, or guardians in the office or at home. Regular office visits are infrequent for many children with asthma, resulting in a lack of information on symptoms and asthma-burden variability. Self-completed asthma-control measures offer the potential to use the assessment of control outside the office setting, with certain results triggering additional clinical follow-up. Protocols for how to incorporate control assessment in this manner have yet to be established.

Although asthma control provides a different method to view a patient with asthma, it fails to incorporate patient-specific goals of treatment or desired level of control. The significance of the control assessment to the child is not known. Children may be most interested in playing soccer without breathing problems or keeping their pets in the bedroom with them at night. The clinician may still need to translate the control assessment into terms that are meaningful to children and their caregivers. Assessment of control should lead to action, and few control measures suggest specific actions other than increasing the medication dose or adding another class of medication. They fail to incorporate measures of adherence, appropriate medication use, and trigger identification and avoidance. All national and international asthma guidelines include these issues, in addition to pharmacologic measures, as required components of optimal asthma management. Unfortunately, current control measures do not provide specific direction to clinicians on how to link the control scores to the patients' educational, pharmacologic, or nonpharmacologic needs.


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 ABSTRACT
 MEASUREMENT OF ASTHMA SEVERITY
 MEASUREMENT OF ASTHMA CONTROL
 IMPLICATIONS FOR TREATING...
CONCLUSIONS
 REFERENCES
 
Approaches for assessments that guide the management of childhood asthma have been in constant evolution. The 1991 development of the empirically based asthma-severity assessment was the first step in translating asthma research into guidelines and patient care. Although the empirically based severity assessment continued to be the basis for the 2002 US guideline update,2,3,74 other available guidelines have chosen alternative approaches that acknowledge the impact and burden of asthma.4–6,8 Yet, even with asthma control as an integral part of asthma-burden assessment, many of the same issues remain: how and when to use and evaluate the meaning of lung function parameters in children, the best approach to symptom assessment, and the determination of appropriate levels of both initial and subsequent treatment.

Our review of the literature shows that the assessment of severity continues to be important for the initial diagnosis, assessment of the disease process, and treatment decisions. However, once treatment is initiated, the goal is asthma control, including both disease activity and symptom manifestation. Although only a few of the currently available instruments to measure control have been tested for use in children, the incorporation of a control measure within clinical practice has distinct advantages. First, the use of such a tool ensures regular assessment of the elements of control. Second, completion of the control measure can be facilitated by health care personnel other than physicians, thereby ensuring that the data are collected and relieving the physician-specific burden while facilitating a physician-patient partnership.75 Third, consistent questioning of control elements at each office visit will train the child and/or the parent to anticipate what symptoms and experiences are important for the management of their asthma. Fourth, the instruments can be completed periodically between office visits so that the variability and changing nature of asthma can be captured.

Finally, the concept of control is "patient focused." Patient self-management decisions as well as the patients' beliefs regarding diagnosis, prognosis, and the efficacy, necessity, and safety of therapy affect asthma control. It is not clear that any of the available asthma-control assessment tools capture all of this information effectively and efficiently. To develop patient-centered goals and treatment plans, physicians and patients must have additional interactions beyond simple completion of a control measure. However, an asthma-control assessment provides a good starting point for these conversations.76

Currently, there is a gap in the ability of primary care practices to translate the asthma care evidence and guidelines into practice. Therefore, in addition to determining the clinical validity of both asthma severity for initial assessment and asthma-control measures for longitudinal care of children, it will also be necessary to develop tools, systems, and clinical imperatives to collect the information required. Guideline developers should offer specific tools or methods to assess control, removing the burden of development and risk of nonuniformity from the individual practices.


   CONCLUSIONS
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 MEASUREMENT OF ASTHMA SEVERITY
 MEASUREMENT OF ASTHMA CONTROL
 IMPLICATIONS FOR TREATING...
 CONCLUSIONS
REFERENCES
 
The choice of medications and recommendations for further care reflected in guidelines is typically based on the assessed and documented frequency and impact of asthma symptoms, the modification of functional status, and the use of current medications.30,61,65–66,76,77 A plan of asthma care that includes the use of severity assessment initially and thereafter a patient-focused approach of control assessment is likely to lead to better assessment of the impact of asthma, better patient adherence, and a tailored asthma-management plan appropriate to individualized clinical assessment.


   FOOTNOTES
 
Accepted Jan 19, 2006.

Address correspondence to Barbara P. Yawn, MD, MSc, 210 Ninth St SE, Olmsted Medical Center, Rochester, MN 55904. E-mail: yawnx002{at}umn.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 REFERENCES
 

  1. Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma: United States, 1980–1999. MMWR Surveill Summ. 2002;51 (1):1–13
  2. National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma Bethesda, MD: National Institutes of Health; 1997. NIH Publication 97-4051
  3. National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program. Expert Panel Report 2 Update: Guidelines for the Diagnosis and Management of Asthma Bethesda, MD: National Institutes of Health; 2002. NIH Publication 02-5074
  4. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention Bethesda, MD: National Institutes of Health; 2004. NIH Publication 02-3659
  5. Becker A, Lemiere C, Berube D, et al. Summary of recommendations from the Canadian Asthma Consensus guidelines, 2003. CMAJ. 2005;173 (6 suppl):S3–S11
  6. Boulet LP, Becker A, Berube D, Beveridge R, Ernst P. Canadian asthma consensus report, 1999. Canadian Asthma Consensus Group. CMAJ. 1999;161 (11 suppl):S1–S62
  7. Boulet LP, Bai TR, Becker A, et al. What is new since the last (1999) Canadian Asthma Consensus guidelines? Can Respir J. 2001;8 (suppl A):5A–27A
  8. British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Thorax. 2003;58 (suppl 1):i1–i94
  9. Doerschug KC, Peterson MW, Dayton CS, Kline JN. Asthma guidelines: an assessment of physician understanding and practice. Am J Respir Crit Care Med. 1999;159 :1735 –1741[Abstract/Free Full Text]
  10. Cabana MD, Bruckman D, Meister K, Bradley JF, Clark N. Documentation of asthma severity in pediatric outpatient clinics. Clin Pediatr (Phila). 2003;42 :121 –125[Abstract/Free Full Text]
  11. Diette GB, Skinner EA, Markson LE, et al. Consistency of care with national guidelines for children with asthma in managed care. J Pediatr. 2001;138 :59 –64[CrossRef][ISI][Medline]
  12. Senturia YD, Rosenstreich D, Bauman L. Pediatric primary care for asthma: how does the content of the office visit relate to NIH guidelines? Am J Respir Crit Care Med. 1998;157 :A540
  13. Homer CJ. Asthma disease management. N Engl J Med. 1997;337 :1461 –1463[Free Full Text]
  14. Wu AW, Young Y, Skinner EA, et al. Quality of care and outcomes of adults with asthma treated by specialists and generalists in managed care. Arch Intern Med. 2001;161 :2554 –2560[Abstract/Free Full Text]
  15. Legorreta AP, Christian-Herman J, O'Connor RD, Hasan MM, Evans R, Leung KM. Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience. Arch Intern Med. 1998;158 :457 –464[Abstract/Free Full Text]
  16. Cabana MD, Ebel BE, Cooper-Patrick L, Powe NR, Rubin HR, Rand CS. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med. 2000;154 :685 –693[Abstract/Free Full Text]
  17. Cabana MD, Rand CS, Becher OJ, Rubin HR. Reasons for pediatrician nonadherence to asthma guidelines. Arch Pediatr Adolesc Med. 2001;155 :1057 –1062[Abstract/Free Full Text]
  18. Calhoun WJ, Sutton LB, Emmett A, Dorinsky PM. Asthma variability in patients previously treated with beta2-agonists alone. J Allergy Clin Immunol. 2003;112 :1088 –1094[CrossRef][ISI][Medline]
  19. Yawn BP. The impact of childhood asthma on daily life of the family. Prim Care Respir J. 2003;12 :82 –85
  20. Baker KM, Brand DA, Hen J Jr. Classifying asthma: disagreement among specialists. Chest. 2003;124 :2156 –2163[Abstract/Free Full Text]
  21. Halterman JS, Yoos HL, Kaczorowski JM, et al. Providers underestimate symptom severity among urban children with asthma. Arch Pediatr Adolesc Med. 2002;156 :141 –146[Abstract/Free Full Text]
  22. Yawn BP, Yawn RA. Measuring asthma quality in primary care: can we develop better measures? Respir Med. 2006;100 :26 –33[CrossRef][ISI][Medline]
  23. Cabana MD, Slish KK, Nan B, Lin X, Clark NM. Asking the correct questions to assess asthma symptoms. Clin Pediatr (Phila). 2005;44 :319 –325[Abstract/Free Full Text]
  24. Fritz GK, McQuaid EL, Spirito A, Klein RB. Symptom perception in pediatric asthma: relationship to functional morbidity and psychological factors. J Am Acad Child Adolesc Psychiatry. 1996;35 :1033 –1041[CrossRef][ISI][Medline]
  25. Beausoleil JL, Weldon DP, McGeady SJ. Beta 2-agonist metered dose inhaler overuse: psychological and demographic profiles. Pediatrics. 1997;99 :40 –43[Abstract/Free Full Text]
  26. Christie MJ, French D, Sowden A, West A. Development of child-centered disease- specific questionnaires for living with asthma. Psychosom Med. 1993;55 :541 –548[Abstract/Free Full Text]
  27. Kuehni CE, Frey U. Age-related differences in perceived asthma control in childhood: guidelines and reality. Eur Respir J. 2002;20 :880 –889[Abstract/Free Full Text]
  28. Fritz GK, Yeung A, Wamboldt MZ, et al. Conceptual and methodologic issues in quantifying perceptual accuracy in childhood asthma. J Pediatr Psychol. 1996;21 :153 –173[Abstract/Free Full Text]
  29. Guyatt GH, Juniper EF, Griffith LE, Feeny DH, Ferrie PJ. Children and adult perceptions of childhood asthma. Pediatrics. 1997;99 :165 –168[Abstract/Free Full Text]
  30. Yawn BP, Wollan P, Scanlon PD, Kurland M. Outcome results of a school-based screening program for undertreated asthma. Ann Allergy Asthma Immunol. 2003;90 :508 –515[ISI][Medline]
  31. Lara M, Duan N, Sherbourne C, et al. Differences between child and parent reports of symptoms among Latino children with asthma. Pediatrics. 1998;102 (6). Available at: www.pediatrics.org/cgi/content/full/102/6/e68
  32. Beydon N, Pin I, Matran R, et al. Pulmonary function tests in preschool children with asthma. Am J Respir Crit Care Med. 2003;168 :640 –644[Abstract/Free Full Text]
  33. Gorelick MH, Stevens MW, Schultz T, Scribano PV. Difficulty in obtaining peak expiratory flow measurements in children with acute asthma. Pediatr Emerg Care. 2004;20 :22 –26[CrossRef][ISI][Medline]
  34. Paull K, Covar R, Jain N, Gelfand EW, Spahn JD. Do NHLBI lung function criteria apply to children? A cross-sectional evaluation of childhood asthma at National Jewish Medical and Research Center, 1999–2002. Pediatr Pulmonol. 2005;39 :311 –317[CrossRef][ISI][Medline]
  35. Fuhlbrigge AL, Kitch BT, Paltiel AD, et al. FEV(1) is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol. 2001;107 :61 –67[CrossRef][ISI][Medline]
  36. Eid N, Yandell B, Howell L, Eddy M, Sheikh S. Can peak expiratory flow predict airflow obstruction in children with asthma? Pediatrics. 2000;105 :354 –358[Abstract/Free Full Text]
  37. Bacharier LB, Strunk RC, Mauger D, White D, Lemanske RF Jr, Sorkness CA. Classifying asthma severity in children: mismatch between symptoms, medication use, and lung function. Am J Respir Crit Care Med. 2004;170 :426 –432[Abstract/Free Full Text]
  38. Horak E, Grassl G, Skladal D, Ulmer H. Lung function and symptom perception in children with asthma and their parents. Pediatr Pulmonol. 2003;35 :23 –28[CrossRef][ISI][Medline]
  39. Spahn JD, Cherniack R, Paull K, Gelfand EW. Is forced expiratory volume in one second the best measure of severity in childhood asthma? Am J Respir Crit Care Med. 4;169 :784 –786
  40. Klein RB, Fritz GK, Yeung A, McQuaid EL, Mansell A. Spirometric patterns in childhood asthma: peak flow compared with other indices. Pediatr Pulmonol. 1995;20 :372 –379[ISI][Medline]
  41. Colon-Semidey AJ, Marshik P, Crowley M, Katz R, Kelly HW. Correlation between reversibility of airway obstruction and exhaled nitric oxide levels in children with stable bronchial asthma. Pediatr Pulmonol. 2000;30 :385 –392[CrossRef][ISI][Medline]
  42. Covar RA, Szefler SJ, Martin RJ, et al. Relations between exhaled nitric oxide and measures of disease activity among children with mild-to-moderate asthma. J Pediatr. 2003;142 :469 –475[CrossRef][ISI][Medline]
  43. Rosias PP, Dompeling E, Dentener MA, et al. Childhood asthma: exhaled markers of airway inflammation, asthma control score, and lung function tests. Pediatr Pulmonol. 2004;38 :107 –114[CrossRef][ISI][Medline]
  44. Napier E, Turner SW. Methodological issues related to exhaled nitric oxide measurement in children aged four to six years. Pediatr Pulmonol. 2005;40 :97 –104[CrossRef][ISI][Medline]
  45. Pijnenburg MW, Hofhuis W, Hop WC, de Jongste JC. Exhaled nitric oxide predicts asthma relapse in children with clinical asthma remission. Thorax. 2005;60 :215 –218[Abstract/Free Full Text]
  46. Cabana MD, Medzihradsky OF, Rubin HR, Freed GL. Applying clinical guidelines to pediatric practice. Pediatr Ann. 2001;30 :274 –282[ISI][Medline]
  47. Roghmann MC, Sexton M. Adherence to asthma guidelines in general practices. J Asthma. 1999;36 :381 –387[ISI][Medline]
  48. Cockcroft DW, Swystun VA. Asthma control versus asthma severity. J Allergy Clin Immunol. 1996;98 :1016 –1018[CrossRef][ISI][Medline]
  49. Vollmer WM. Assessment of asthma control and severity. Ann Allergy Asthma Immunol. 2004;93 :409 –413[ISI][Medline]
  50. Fuhlbrigge AL. Asthma severity and asthma control: symptoms, pulmonary function, and inflammatory markers. Curr Opin Pulm Med. 2004;10 :1 –6[CrossRef][ISI][Medline]
  51. Juniper EF, O'Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. 1999;14 :902 –907[Abstract/Free Full Text]
  52. Jones K, Cleary R, Hyland M. Predictive value of a simple asthma morbidity index in a general practice population. Br J Gen Pract. 1999;49 :23 –26[ISI][Medline]
  53. Boulet LP, Boulet V, Milot J. How should we quantify asthma control? A proposal. Chest. 2002;122 :2217 –2223[Abstract/Free Full Text]
  54. Revicki DA, Leidy NK, Brennan-Diemer F, Sorensen S, Togias A. Integrating patient preferences into health outcomes assessment: the multiattribute Asthma Symptom Utility Index. Chest. 1998;114 :998 –1007[Abstract/Free Full Text]
  55. Vollmer WM, Markson LE, O'Connor E, et al. Association of asthma control with health care utilization and quality of life. Am J Respir Crit Care Med. 1999;160 :1647 –1652[Abstract/Free Full Text]
  56. Vollmer WM, Markson LE, O'Connor E, Frazier EA, Berger M, Buist AS. Association of asthma control with health care utilization: a prospective evaluation. Am J Respir Crit Care Med. 2002;165 :195 –199[Abstract/Free Full Text]
  57. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113 :59 –65[CrossRef][ISI][Medline]
  58. Juniper EF, O'Byrne PM, Ferrie PJ, King DR, Roberts JN. Measuring asthma control: clinic questionnaire or daily diary? Am J Respir Crit Care Med. 2000;162 :1330 –1334[Abstract/Free Full Text]
  59. Bateman ED, Bousquet J, Braunstein GL. Is overall asthma control being achieved? A hypothesis-generating study. Eur Respir J. 2001;17 :589 –595[Abstract/Free Full Text]
  60. Skinner EA, Diette GB, Algatt-Bergstrom PJ, et al. The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents. Dis Manag. 2004;7 :305 –313[CrossRef][Medline]
  61. Diette GB, Markson L, Skinner EA, Nguyen TT, Algatt-Bergstrom P, Wu AW. Nocturnal asthma in children affects school attendance, school performance, and parents' work attendance. Arch Pediatr Adolesc Med. 2000;154 :923 –928[Abstract/Free Full Text]
  62. Bukstein DA, Luskin AT, Bernstein A. "Real-world" effectiveness of daily controller medicine in children with mild persistent asthma. Ann Allergy Asthma Immunol. 2003;90 :543 –549[ISI][Medline]
  63. Garcia Garcia ML, Wahn U, Gilles L, Swern A, Tozzi CA, Polos P. Montelukast, compared with fluticasone, for control of asthma among 6- to 14-year-old patients with mild asthma: the MOSAIC study. Pediatrics. 2005;116 :360 –369[Abstract/Free Full Text]
  64. Dolan CM, Fraher KE, Bleecker ER, et al. Design and baseline characteristics of the epidemiology and natural history of asthma: Outcomes and Treatment Regimens (TENOR) study—a large cohort of patients with severe or difficult-to-treat asthma. Ann Allergy Asthma Immunol. 2004;92 :32 –39[ISI][Medline]
  65. Patel PH, Welsh C, Foggs MB. Improved asthma outcomes using a coordinated care approach in a large medical group. Dis Manag. 2004;7 :102 –111[CrossRef][Medline]
  66. Algatt-Bergstrom PJ, Markson LE, Murray RK, Berger ML. A population-based approach to asthma disease management. Dis Manag Health Outcomes. 2000;7 :179 –186[CrossRef]
  67. Narayanan S, Edelman JM, Berger ML, Markson LE. Asthma control and patient satisfaction among early pediatric users of montelukast. J Asthma. 2002;39 :757 –765[CrossRef][ISI][Medline]
  68. Schatz M, Mosen D, Apter AJ, et al. Relationship of validated psychometric tools to subsequent medical utilization for asthma. J Allergy Clin Immunol. 2005;115 :564 –570[CrossRef][ISI][Medline]
  69. Schatz M, Kosinski M, Sorkness C. Comparison of two patient-based measures of asthma control: ACT and ACQ. Proc Am Thorac Soc Int Conf. hiladelphia, PA: American Thoracic Society; 2005:A255
  70. Boulet LP, Phillips R, O'Byrne P, Becker A. Evaluation of asthma control by physicians and patients: comparison with current guidelines. Can Respir J. 2002;9 :417 –423[Medline]
  71. Halterman JS, McConnochie KM, Conn KM, et al. A potential pitfall in provider assessments of the quality of asthma control. Ambul Pediatr. 2003;3 :102 –105[CrossRef][ISI][Medline]
  72. GlaxoSmithKline, Inc; QualityMetrics, Inc. Childhood Asthma Control Test for children with asthma 4 to 11 years old. 2005. Available at: www.asthmacontrol.com/AsthmaControlTestChild.html. Accessed December 5, 2005
  73. Asthma and Allergy Foundation of America. SleepLearnPlay Washington, DC: Asthma and Allergy Foundation of America; 2005
  74. Gibson P. Asthma guidelines and evidence-based medicine. Lancet. 1993;342 :1305[ISI][Medline]
  75. Griffiths C, Foster G, Barnes N, et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA). BMJ. 2004;328 :144[Abstract/Free Full Text]
  76. Wolfenden LL, Diette GB, Krishnan JA, Skinner EA, Steinwachs DM, Wu AW. Lower physician estimate of underlying asthma severity leads to undertreatment. Arch Intern Med. 2003;163 :231 –236[Abstract/Free Full Text]
  77. Joseph CL, Foxman B, Leickly FE, Peterson E, Ownby D. Prevalence of possible undiagnosed asthma and associated morbidity among urban schoolchildren. J Pediatr. 1996;129 :735 –742[CrossRef][ISI][Medline]
  78. Bai J, Peat JK, Berry G, Marks GB, Woolcock AJ. Questionnaire items that predict asthma and other respiratory conditions in adults. Chest. 1998;114 :1343 –1348[Abstract/Free Full Text]
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