Overestimation of Impairment-Related Asthma Control by Adolescents

Maria T. Britto, MD, MPH, Terri L. Byczkowski, PhD, Elizabeth A. Hesse, BS, Jennifer Knopf Munafo, MA,
Anna-Liisa B. Vockell, MSN, CNP, and Michael S. Yi, MD, MSc
We investigated the concordance between adolescents perceived and impairment-related asthma control. Based
on self-reported medication use, symptoms, and activity limitations, most overestimated their impairment-related
control (73.8%). Providers should ask detailed, structured questions to get the most comprehensive picture of a patients impairment-related control so they can ultimately improve disease outcomes. (J Pediatr 2011;158:1028-30)

sthma affects 6.7 million American youth and causes

more than 100 deaths per year among adolescents.1,2
The 2007 National Asthma Education and Prevention
Program guidelines emphasize asthma control, specifically as
it relates to symptoms, rescue medication use, activity limitations, and exacerbations.3 However, population-based studies indicate low levels of asthma control are being achieved
and that adults tend to overestimate their control.4-9 Given
the high asthma morbidity among adolescents, we investigated perception as a reason for suboptimal control in this
vulnerable population. We tested the hypothesis that, similar
to adults, adolescents would overestimate control and that
severity would impact the likelihood of accurate perception.

Methods
Participants were 12 to 22 years old and receiving primary
care at an urban teen clinic that trains students, residents,
and fellows and where providers rather than asthma educators provide nonprotocolized education. Eligible adolescents
had a diagnosis of asthma and spoke English. The institutional review board approved the study.
After consent/assent was given, participants completed
self-administered questionnaires regarding motivation to
control asthma and impairment-related asthma control. Providers determined patients disease severity (intermittent,
mild persistent, moderate persistent, or severe persistent) using clinical judgment.
Perceived control was based on the adolescents response
to the question How would you rate your asthma control
during the past month? Impairment-related control was
based on the adolescents reports of day and night symptoms,
rescue inhaler use, and activity limitations. Questions were
based on the Asthma Control Test but modified slightly to reflect clinical practice.10,11
The elements determining level of impairment-related
control are outlined in Table I (available at www.jpeds.
com).3 The new 2007 National Asthma Education and
Prevention Program guidelines consider impairment and
risk separately. We focused on impairment because it
(symptoms, activity limitations, etc) would be observable
by adolescents, whereas risk may not. Our primary purpose
was to determine correlation between impairment-related
control, as defined by the National Heart, Lung, and Blood
1028

Institute, and perceived control. Additionally, we measured

self-efficacy to manage asthma with a previously validated
item: How confident are you in your ability to manage
your asthma, rated on a scale of 1 to 10?12
Statistical Analysis
Descriptive analyses were calculated for demographic characteristics, disease and symptom-related variables, medication
use, and clinic visits. We used a k statistic to test for significant agreement between perceived and impairment-related
control. We compared each patients impairment-related
control and perceived control and categorized patients as accurate estimators, overestimators, or underestimators of control. We used bivariate analyses to test differences between
groups and logistic regression to test significant predictors
of whether or not perceived control was concordant with
impairment-related control. ORs were developed for each
predictor.

Results
Two-hundred-one adolescents participated, and 98.0% had
complete data for analysis. Participant and asthma characteristic data are in Table II (available at www.jpeds.com). Only
16 (8.0%) participants were well controlled, 92 (46.0%)
were not well controlled, and 92 (46.0%) were very poorly
controlled. More than half (57.4%) had intermittent
asthma, and most of them were not well controlled (45.1%)
or were very poorly controlled (46.9%). In addition, 191
(97.0%) of participants were prescribed Albuterol and 93
(47.2%) were prescribed controller medications, including
90.5% of those with persistent asthma. Fluticasone was the
controller most frequently prescribed. The mean number of
clinic visits in the year prior was 3.1 (
3.22).

From the Center for Innovation in Chronic Disease Care (M.B., E.H., J.M., A.-L.V.);
Division of Emergency Medicine (T.B.); Division of General Internal Medicine,
Department of Pediatrics (M.Y.), Cincinnati Childrens Hospital Medical Center,
Cincinnati, OH
Supported by Cincinnati Childrens Hospital Medical Center. The authors declare no
conflicts of interest.
0022-3476/$ - see front matter. Copyright 2011 Mosby Inc.
All rights reserved. 10.1016/j.jpeds.2011.01.034

Vol. 158, No. 6  June 2011

Table III. Concordance between impairment-related and perceived asthma control

Impairment-related control
Patients perceived control
Well controlled
Not well controlled
Very poorly controlled

Well controlled

Not well controlled

Very poorly controlled

8.0%*
0.0%
0.0%

29.1%z
15.6%*
1.0%

26.6%z
18.1%z
1.5%*

*Accurate.
Underestimate.
zOverestimate.

The most common reason adolescents were not well controlled was activity limitations, with 84.8% of not wellcontrolled adolescents and 73.8% of very poorly controlled
adolescents reporting limitations. Table III summarizes the
concordance between patient perceived and impairmentrelated asthma control. Agreement was very low (k = 0.04).
Only 25.1% accurately perceived their impairmentrelated control. Most overestimated (73.8%), and only
1.0% underestimated. Because only two patients (1.0%)
underestimated control, only overestimators and accurate
estimators were included in subsequent analyses.
Even though bivariate analyses (Table IV) showed higher
confidence in ability to manage asthma and race were
associated with overestimation of control, only confidence
was independently associated with control in the logistic
regression models (OR, 1.19; 95% CI, 1.04 to 1.36). A onepoint increase in confidence was associated with a 19%
Table IV. Percentage of patients who overestimate their
control level by patient characteristics
Patient characteristics
Severity
Intermittent
Mild persistent
Moderate persistent
Severe persistent
Prescription for Albuterol
Yes
No
Prescription for controller medication
Yes
No
Sex
Male
Female
Race*
White
African American
Other
Ethnicity
Non-Hispanic
Hispanic
Health insurance
Private
Public
None
Maternal education
College graduate or higher
Some college
High school diploma/GED
Did not finish high school
*P value <.05.

% Patients overestimating control

78.8
65.2
77.1
33.3
75.4
50.0
68.8
79.8
74.4
74.8
84.6
74.8
45.5
75.1
80.0
79.4
74.6
66.7
78.8
75.9
80.6
61.0

increase in the odds that an adolescent will overestimate his

or her level of control.

Discussion
Adolescents who know less about asthma and/or have lower
expectations may have higher confidence than those who
perceive a gap between current control and what is possible.
The relationship between confidence and overestimation of
control is a novel finding of our study. However, the overestimation of control demonstrated by our participants is similar to most past studies in adults.6,8,9
Overestimation of control may be multifactorial. Adolescents may assume better control is not possible and accept
lower levels of control than recommended. We suspect improper severity classification and subsequent undertreatment
occurred with some patients, as 57.4% were classified as intermittent and many of them were not controlled. Provider
underestimation of asthma severity has been reported9 and
may partly account for our patients overestimation of control. Further, these patients may be dependent on their rescue
inhaler to reduce symptoms immediately, when what they
might need is a controller medication that would regulate
symptoms daily.
Not only are adolescents overestimating their impairmentrelated asthma control, they also fail to recognize that
symptoms and activity limitations contribute to their lack
of control and that better control is possible. Providers
should counsel adolescents on what well-controlled asthma
means and that it is possible to reach that goal. Providers
should question adolescents more comprehensively about
the elements of control, especially activity limitations, and
use structured questions to elicit multicomponent aspects
of asthma control. Tools like the Asthma Control Test, especially if it is updated to reflect the 2007 guidelines, can be easily administered and have been shown to be reliable
indicators of asthma control.10,11 In addition, implementation of standardized algorithms for asthma diagnosis, management, and education/home management probably
would improve both adolescents control and their understanding of how much they could improve their lives with
asthma. n

Submitted for publication Jun 3, 2010; last revision received Jan 12, 2011;
accepted Jan 19, 2011.

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THE JOURNAL OF PEDIATRICS

www.jpeds.com

Reprint requests: Dr Maria T. Britto, MD, MPH, Cincinnati Childrens Hospital

Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio,
3333 Burnet Avenue MLC 7027, Cincinnati, OH 45229. E-mail: maria.britto@
cchmc.org

References
1. Centers for Disease Control and Prevention. Summary Health Statistics
for US Children: National Health Interview Survey, 2007. National Center for Health Statistics, National Vital Statistics Report 2009; 10. Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_239.pdf; 2009.
2. Centers for Disease Control and Prevention. Deaths: Final Data for 2006.
National Center for Health Statistics, National Vital Statistics Report
2009; 14. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr57/
nvsr57_14.pdf; 2009.
3. National Heart Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report 2007.
National Institutes of Health, 2007. Available at: http://www.nhlbi.nih.
gov/guidelines/asthma/asthgdln.pdf; 2007.
4. Sawyer SM, Fardy HJ. Bridging the gap between doctors and patients
expectations of asthma management. J Asthma 2003;40:131-8.
5. Rakusic N, Krmpotic D, Samarzija M, Richter D, Krmpotic P. Physician/patient differences in the perception of asthma: impact on every-

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day life and level of the asthma control in Croatia. Coll Antropol 2001;
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Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of
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Ponte EV, Petroni J, Ramos DC, Pimentel L, Freitas DN, Cruz AA. [Perception of asthma control in asthma patients]. J Bras Pneumol 2007;33:
635-40.
Laforest L, Van Ganse E, Devouassoux G, Osman LM, Brice K, Massol J,
et al. Asthmatic patients poor awareness of inadequate disease control:
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Chapman KR, Ernst P, Grenville A, Dewland P, Zimmerman S. Control
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2001;8(Suppl A):35A-40.
Nathan RA, Sorkness CA, Kosinski M, Schatz M, Li JT, Marcus P, et al.
Development of the asthma control test: a survey for assessing asthma
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Britto et al

CLINICAL AND LABORATORY OBSERVATIONS

June 2011

Table I. Determination of impairment-related asthma control

Classification of asthma control

Components of control
Impairment
Symptoms*
Nighttime awakenings
Interference with normal activityz
Short-acting b2 agnostic use for symptom
control (not prevention of EIB)x

Well controlled

Not well controlled

#2 days/week
#2/month
None
#2 days/week

>2 days/week
1-3/week
Some limitation
>2 days/week

Very poorly controlled

Throughout the day
$4/week
Extremely limited
Several times per day

EIB, exercise-induced bronchospasm.

Table I modified from National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report 2007. National Institutes of Health 2007.
Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf; 2007.
*During the past 2 weeks, how frequently have you experienced episodes of cough, shortness of breath, wheezing or reduced activity due to asthma during the DAY?
During the past 2 weeks, how frequently have you experienced episodes of cough, shortness of breath, wheezing due to asthma during the NIGHT?
zHow often does asthma limit your activities?
xDuring the past 2 weeks, how often did you use a fast acting or quick relief medication, at times other than before exercise? (includes Albuterol, Ventolin, Proventil, Xepenex).

Table II. Participant and asthma characteristics

Characteristics

Male
Race
White
African American
Other
Ethnicity
Hispanic
Non-Hispanic
Maternal education
Did not finish HS
HS diploma or GED
Some college
College grad or more
Health insurance
Commercial
Public
None
Mean (
SD), age, y
Self-reported time since diagnosis, mean (
SD)
Frequency of nighttime symptoms
7 nights per week
5-6 nights per week
3-4 nights per week
0-2 nights per week
Frequency of daytime symptoms
More than once a day
Once per day
3-6 days per week
0-2 days per week
Frequency of rescue inhaler use
4 or more times per day
1-3 times per day
Less than 1 time per day
Not at all
Not sure
Activity limitation
All or most of the time
Some or a little of the time
Not at all
Confidence in ability to manage asthma, mean
(
SD)

80

39.8

27
162
11

13.5
81.0
5.5

5
189

2.6
97.4

41
69
30
53

21.2
35.8
15.5
27.5

34
16.9
145
72.1
22
10.9
16.2 (
2.26)
6 (
5)
10
15
31
144

5.0
7.5
15.5
72.0

64
36
43
57

32.0
18.0
21.5
28.5

7
39
27
79
47

3.5
19.6
13.6
39.7
23.6

15
7.5
131
65.5
54
27.0
7.64 (
2.44)

Overestimation of Impairment-Related Asthma Control by Adolescents

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