Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 7

individuals were judged “in control” by ACT but “not in control”
by EPR-3 (false-negative), yielding
Score
In the past 4 weeks, how much of the time did your asthma keep you from
1.
an overall agreement rate of 64%.
getting as much done at work, school or at home?
In comparison, the false-positive
1. All of the time 2. Most of the time 3. Some of the time
rate for “not in control” asthma for
4. A little of the time 5. None of the time
the Ro2 instrument was 5 out of
During the past 4 weeks, how often have you had shortness of breath?
2.
77 patients, and the false-negative
rate was 16 out of 77 patients. The
1. More than once a day 2. Once a day 3. 3 to 6 times a week
4. Once or twice a week 5. Not at all
overall agreement between Ro2 and
EPR-3 was 73%.
During the past 4 weeks, how often did your asthma symptoms (wheezing,
3.
coughing, shortness of breath, chest tightness or pain) wake you up at night or
Disagreements in the determiearlier than usual in the morning?
nation of asthma control by Ro2
1. 4 or more nights a week 2. 2 or 3 nights a week 3. Once a week
and ACT when compared with the
4. Once or twice 5. Not at all
EPR-3 template occurred primarDuring the past 4 weeks, how often have you used your rescue inhaler or
4.
ily in patients with lung function
nebulizer medication (such as albuterol)?
(forced expiratory volume in 1 sec1. 3 or more times per day 2. 1 or 2 times per day 3. 2 or 3 times per week
ond [FEV1] or FEV1/forced vital
4. Once a week or less 5. Not at all
capacity [FVC]) that was abnorHow would you rate your asthma control during the past 4 weeks?
5.
mal. Ten of the 16 patients judged
“in control” by Ro2 but not EPR-3
1. Not controlled at all 2. Poorly controlled 3. Somewhat controlled
4. Well controlled 5. Completely controlled
had abnormal lung function. Seventeen of 26 patients erroneously
Total
considered “in control” by ACT
likewise had abnormal pulmonary
Figure 2. Asthma Control Test.
function tests, although 7 of those
of 42 years; 33% were male and 67% female, which reflects the
17 patients had other positive responses to EPR-3 questions
increased adult female incidence of asthma in addition to incluthat would have resulted in a “not in control” determination,
sion of participants in the women’s health fair. In addition, 74%
despite an ACT score of >20. If resting lung function was not
were Caucasian, 17% African American, and 9% Hispanic.
used to determine asthma control in the EPR-3 tool, then the
As shown in Table 2, 109 of the entire group of 150 patients
kappa for both Ro2 and ACT would have been much higher
(72%) assessed using a template taken directly from EPR-3 were
(0.63 and 0.49, respectively). While not the primary endpoint
identified as having uncontrolled asthma, compared with 45 of
of this study, 14 of 73 ACT questionnaires failed to add up or
77 patients (58%) assessed with the Ro2 and 26 of 73 patients
misadded scores. For determination of kappa, additions were
(36%) assessed with the ACT. The degree of agreement, as ascompleted or corrected prior to analysis.
sessed using a kappa statistic, was 0.41 for Ro2 and EPR-3 and
0.37 for ACT and EPR-3. There was no statistical difference in
DISCUSSION
the agreement with EPR-3 between the Ro2 and ACT tools.
The fundamental concept of asthma “control” has been a
By contrast but as expected, agreement with patient perception
consistent element in the series of reports issued by the NAEP(P),
of self-control when compared to the EPR-3 assessment was
first in 1991, revised in 1997, and most recently in 2007 with
poor, with only 25% of patients feeling their asthma was “not
EPR-3. Delineation of impairment and risk domains is articuin control” (kappa 0.23).
lated in EPR-3, but the need for a comprehensive evaluation of
There were no false-positive ACT questionnaires when
specific aspects of asthma symptomatology and physiology is
compared to the EPR-3 template. However, 26 out of 73
longstanding and has been widely accepted as the standard for
asthma assessment. In this study, we used
the specific elements of control articulatTable 2. Determinations of in-control asthma based on different tests
ed in EPR-3 as the basis of comparison
for both Ro2 and ACT and overall deterAsthma in Asthma not in Agreement with
Agreement
mined “fair” agreement (8).
Test
control (%)
control (%)
EPR-3 (kappa) with EPR-3 (%)
A consistent finding of multiple paEPR-3 (n = 150)
28
72
–
–
tient surveys is the discordance between
Ro2 (n = 77)
42
58
0.41
73
self-assessment of asthma control and the
ACT (n = 73)
64
36
0.37
64
assessment derived from asthma-specific
Patient self-assessment (n = 151)
75
25
0.23
37
questionnaires. The Asthma in America
EPR-3 indicates Expert Panel Report-3; Ro2, Rules of Two; ACT, Asthma Control Test.
Survey (1998) (9) quantified the discrepancy between patient perception of asthma
Please complete the following form about your asthma and add up your scores.

April 2014

Validation of Rules of TwoTM as a paradigm for assessing asthma control

81