Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 5

Validation of Rules of TwoTM as a paradigm for assessing
asthma control
Mark Millard, MD, Mary Hart, MS, RRT, AE-C, and Sunni Barnes, PhD

Assessing asthma control at each patient encounter is an essential
task to determine pharmacologic requirements. Rules of Two (Ro2) was
created from the original 1991 National Asthma Education Program
guidelines to determine the need for controller therapy. This study determined the degree of agreement between Ro2 and the Expert Panel
Report (EPR-3) definition of “in control” asthma and compared that
value with the Asthma Control Test (ACT) in a group of asthmatics for
the purpose of validating this tool. Patients with documented asthma
were randomized to complete Ro2 or ACT prior to being assessed for
asthma control by certified asthma educators using an EPR-3 template.
Assessments occurred in either a specialty asthma clinic or at a local
health fair. Patients were also queried for their personal assessment
of asthma control. The primary statistical methodology employed was
the degree of agreement (kappa) between each survey tool and the
EPR-3 template. Of 150 patients, 72% did not have their asthma in
control, based on the EPR-3 template. Ro2 identified 58% of patients
not in control of their asthma, whereas ACT identified 36%, with kappa
scores of 0.41 for Ro2 and 0.37 for ACT compared with the EPR-3
template. These were not significantly different. Of the 150 patients,
75% considered their asthma in control based on self-assessments,
with a kappa of 0.23. In 14 of 73 ACT questionnaires, scores were not
added or were misadded. Eliminating evaluation of static lung function
significantly improved both kappa scores of Ro2 and ACT. In conclusion, Ro2 identifies patients with uncontrolled asthma as well as ACT
and may be useful to the primary assessing clinician in determining
asthma control.

he assessment of asthma control drives therapeutic decisions in patients with asthma, as articulated in the
2007 edition of the National Asthma Education and
Prevention Program (NAEPP) (1), also referred to as
the Expert Panel Report (EPR-3). That assessment reflects the
contributions of two related domains, impairment and risk, and
consists of patient-reported symptoms and symptom frequency,
documentation of health care encounters, medication use, and
objective measurement of lung function. The decision to step
up, step down, or maintain any specific therapy rests upon the
determination of asthma control.
Rules of TwoTM (Ro2) was created in 1992 as a tool to signal
the need for controller therapy according to the first National

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Proc (Bayl Univ Med Cent) 2014;27(2):79–82

Asthma Education Program (NAEP) guidelines published in
1991. At that time, the use of controller therapy for patients
with persistent asthma had not been generally accepted within
the primary care community, and there was a need to develop
an easily remembered synopsis of the NAEP criteria for mild
persistent asthma, which was the point at which antiinflammatory therapy for asthma was first recommended. While abstracts demonstrating the impact of Ro2 educational efforts we