Lack of correlation of symptoms with specialist-assessed long-term asthma severity

Study objectives: To validate three indicators of asthma severity as defined in the National Asthma Education Program (NAEP) guidelines (ie, frequency of symptoms, degree of airflow obstruction, and frequency of use of oral glucocorticoids), alone and in combination, against severity as assessed by pulmonary specialists provided with 24-month medical chart data. Design: Cross-sectional comparison of questionnaire and clinical-based markers of asthma severity with physician-assessed severity based on chart review. The pulmonologists did not have access to the results of the baseline evaluations when making their severity assessments. Setting and participants: Study participants were 193 asthmatic members (age range, 6 to 55 years) of a large health maintenance organization who underwent a baseline evaluation as part of a separate longitudinal study. This evaluation consisted of spirometry, skin prick testing, and a survey that included questions on symptoms and medication use. The participants in the ancillary study were selected, based on their baseline evaluation, to reflect a broad range of asthma severity. Results: Based on the chart review, 86 of the study subjects (45%) had mild disease, 90 (45%) had moderate disease, and 17 (9%) had severe disease. This physician-assessed severity correlated highly (p ≤ 0.013) with NAEP-based indices of severity based on oral glucocorticoid use (never, infrequently for attacks, frequently for attacks, and daily use) and on spirometry (FEV₁ > 80% predicted, 60 to 80% predicted, and <60% predicted). It did not, however, correlate with current asthma symptoms (≤ once/week, 2 to 6 times/week, daily) (p = 0.87). A composite severity score based on spirometry and the glucocorticoid use data still provided an overall agreement of 63%, with a weighted kappa of 0.40. Conclusions: While current symptoms are the most important concern of patients with asthma, they reflect the current level of asthma control more than underlying disease severity. Investigators must therefore use caution when comparing groups of patients for whom severity categorization is based largely on symptomatology. This observation, that symptoms alone do not reflect disease severity, becomes even more important as health-care delivery moves closer to protocols/practice guidelines and 'best treatment' programs that rely heavily on symptoms to guide subsequent treatment decisions.