Abstract
BackgroundThe Asthma Control Test (ACT) is widely used to assess asthma control, yet the validity and reliability of the test have not been specifically evaluated in adolescents or African-Americans. We conducted a prospective psychometric study of the ACT in African-American (AA) and non-African-American (nAA) adolescents with persistent asthma, with emphasis on the clinical utility of the test for medical decision making.MethodsParticipants completed the ACT and performed spirometry. A physician conducted a guidelines-based assessment of asthma control, blinded to the ACT score. Study procedures were repeated 6–8 weeks later. The ACT-based asthma control assessment was compared to physician assessment.ResultsFor baseline and follow-up visits, internal consistency, as measured using Cronbach’s alpha, was 0.80 and 0.81 in AA teens and 0.80 and 0.83 in nAA teens. Intraclass correlation coefficients were 0.59 and 0.76 in AA and nAA teens, respectively, with stable asthma control over time. Agreement between ACT and physician assessment was moderate in AA teens and fair in nAA teens. An ACT score of ≤19 showed reduced sensitivity for not well controlled asthma in both groups, while a score of ≤21 had the greatest area under the ROC curve. ACT scores were marginally responsive to change in control status.ConclusionsConcerns for the ACT’s ability to detect uncontrolled asthma in adolescents emphasizes the need for a more comprehensive evaluation of asthma control in clinical settings. A higher threshold ACT score to define not well controlled asthma may be needed if the ACT is to be used for medical decision making.Trial registrationClinicalTrials.gov: NCT02671643, NCT02662413.
Highlights
The Asthma Control Test (ACT) is widely used to assess asthma control, yet the validity and reliability of the test have not been evaluated in adolescents or African-Americans
We found no significant correlation between change in ACT scores and change in asthma control status among nAA teens, with a small yet statistically significant correlation in AA teens
We found some evidence for the validity of the ACT but not ideal levels of reliability for individual level assessment along with reduced sensitivity for detection of not well controlled asthma in adolescents with persistent asthma, independent of race
Summary
The Asthma Control Test (ACT) is widely used to assess asthma control, yet the validity and reliability of the test have not been evaluated in adolescents or African-Americans. Studies examining the use of the ACT in adolescents of European and Mexican ancestry have reported higher optimal cut points to distinguish well controlled from uncontrolled asthma [11,12,13] This divergence may be in part due to cultural and developmental or age-related differences in the way symptoms are perceived and reported, as well as differences in health literacy when compared to Caucasian adults. While questionnaires like the ACT were initially developed to serve as one component of the asthma control assessment, many busy practices have embraced the ACT as essentially a replacement for the recommended multidimensional assessment This is especially concerning given the questions surrounding the performance of the ACT in teens and minorities who may already be more likely to have their asthma severity underestimated by healthcare providers [14,15,16,17]. To avoid inappropriate medical management, it is imperative that tools like the ACT, which rely solely on patient-reported data, be validated in the populations in which they are frequently used [18]
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