Journal of Asthma

ISSN: 0277-0903 (Print) 1532-4303 (Online) Journal homepage: http://www.tandfonline.com/loi/ijas20

Asthma-specific health related quality of life of

people in Great Britain: A national survey

Jane Upton, Carine Lewis, Emily Humphreys, David Price & Samantha Walker

To cite this article: Jane Upton, Carine Lewis, Emily Humphreys, David Price & Samantha
Walker (2016): Asthma-specific health related quality of life of people in Great Britain: A
national survey, Journal of Asthma, DOI: 10.3109/02770903.2016.1166383

To link to this article: http://dx.doi.org/10.3109/02770903.2016.1166383

Accepted author version posted online: 26

Apr 2016.
Published online: 26 Apr 2016.

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Asthma-specific health related quality of life of people in Great Britain: A national survey

Running title: HRQOL and asthma

Authors: Jane Upton (Asthma UK), Carine Lewis (Asthma UK), Emily Humphreys

(Asthma UK), David Price (University of Aberdeen), Samantha Walker (Asthma UK)
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Corresponding author: Dr Samantha Walker, Asthma UK 18 Mansell Street, London, E1

8AA - swalker@asthma.org.uk

Keywords: Asthma, quality of life, cross-sectional survey

Abstract

Introduction: Although the ultimate goal of asthma treatment is to improve asthma-

specific health-related quality-of-life (HRQOL), in the UK population this is insufficiently

studied. National asthma-specific HRQOL data is needed to inform strategies to

address this condition.

Aims and objectives: To benchmark asthma-specific HRQOL in a national survey of

adults with asthma, and explore differences in this measure within subsections of the

population

Methods: We analysed answers to the Marks Asthma Quality-of-Life Questionnaire

(AQLQ-M) from a representative sample of 658 adults with asthma. Respondents

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answered asthma-specific questions to assess control, previous hospital admissions,

asthma attacks and an indicator of severity. Higher scores indicate poorer HRQOL

(maximum=60). The highest quintile formed a subgroup ‘Poor HRQOL’. Data were

weighted to correct for any biases caused by differential non-response. Chi square

analyses were used to determine differences between good and poor quality of life and

regression analyses performed to determine what factors are associated with poor
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HRQOL.

Results: The response rate was 49%. AQLQ-M median (IQR) scores were 5 (2-13) for

the total sample, (poor HRQOL = 21, good HRQOL = 3). Significant differences

between good and poor HRQOL were observed in smoking status, SES, employment

status and comorbidities, but no differences were found between age groups. Those

with poorly controlled asthma were significantly more likely to have poor HRQOL, ≥1

breathing related hospital admission or ≥1 asthma attack.

Conclusions: This paper provides benchmarking data on asthma-specific HRQOL.

Improved strategies are needed to target interventions towards people experiencing

poor HRQOL.

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Introduction

The UK has one of the highest prevalence rates of asthma in the world (1), estimated to

be 9-10% in England (2), 11% in Wales (3) and 14% in Scotland (4). UK outcomes for

asthma, such as mortality and hospital admission rates are among the highest in

Western Europe (5). The National Review of Asthma Deaths (6), a high-profile report
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coordinated by the Royal College of Physicians emphasised the need to improve

asthma outcomes, as nearly two thirds of deaths were associated with a potentially

avoidable factor.

There is excellent evidence that supported self-management is particularly effective in

asthma care (7), yet despite efforts to maximise patient activation, outcomes remain

poor (8). It has been consistently reported that many patients overestimate their asthma

as being well controlled, even if they have experienced frequent exacerbations and

persistant symptoms (9, 10).

Health Related Quality Of Life (HRQOL) refers to an individual’s physical and mental

wellbeing in relation to their health. It differs from general quality of life by focusing on

factors related to specific health conditions, in this case asthma. HRQOL is now

considered to be an important outcome measure for interventions and trials and a

number of studies have looked at the specific relationship between poor HRQOL and

asthma (11). Much of this research stems from outside the UK and has focused on the

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impact of quality of life on children. Research in the US has indicated that people with

asthma tend to experience persistent burden of asthma symptoms (12), in particular

when they have poor levels of control (13). Good asthma control refers to patients

leading physically active lives, with few troublesome symptoms and therefore little need

to use asthma rescue medication or seek emergency help (14). With inadequate

asthma control being found to be positively correlated to poor scores on quality of life, it
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is therefore feasible that asthma is having an adverse affect on HRQOL (15).

Considerable research evidence, however, suggests that patient perceptions of the

impact of asthma vary to an extent that is not solely explained by differences in asthma

control (16). In addition to the correlation between levels of control, associations have

also been found with quality of life and asthma severity (17), comorbidities (18) and

respiratory symptoms (19), with tightness in the chest and lung function performance

being able to predict HRQOL scores (9, 17).

In order to put research to best practice and provide targeted interventions at the

national level, analysis of population based data for the national level of asthma-specific

HRQOL of people in the UK is needed. The UK National Health Service (NHS) is

seeking to narrow the gap between the focus of clinicians and issues that matter most

to patients by promoting a more patient-centred approach to care (20), including the

addition of patient-reported outcome measures in consultations (21). Improving our

understanding of patients’ perceptions of asthma and its impact on their daily lives and

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the outcomes they prioritise will be vital to help healthcare professionals engage with

patients to help them self-manage more effectively.

We therefore set out to address this evidence gap by conducting a national survey,

using an asthma-specific measure of HRQOL. The aim of this was to benchmark

asthma-specific quality of life collectively across the UK; however, it was not possible to
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collect data from respondents living in Northern Ireland due to access with the Northern

Ireland Health Survey. The purpose of this study was to benchmark the quality of life of

individuals with asthma across England, Scotland and Wales. The provision of this data

will aid decision-makers to target interventions to improve the asthma-specific HRQOL

of patients and evaluate the effect of future policies.

Method

Survey design and population

The sample was selected from a database of people held by the National Centre for Social

Research (NatCen). Respondents had previously participated in one of three national health

Surveys in 2010: the Health Survey for England (HSE), commissioned by the National Health

Service Information Centre for Health and Social Care, the Welsh Health Survey (WHS) or the

Scottish Health Survey (SHeS), commissioned by their respective governments. In England, the

core sample included 8,736 adults, randomly selected from 672 representative postcode sectors

(22). In Scotland the core sample was randomly selected from a Royal Mail list of private

residential addresses (n=4776), from which 7245 adults were interviewed (23). In Wales the core

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sample included 10,341 interviews obtained from a random sample of 14,775 private households

in Wales selected at random from the Post Office’s Postcode Address File (24).

Eligible respondents were aged between 18 and 74 years, had a working telephone

number, and reported a diagnosis of asthma and no other chronic lung condition in

2010 (see Fig. 1). The 1350 people that met these criteria were sent an advance letter
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and contacted by a NatCen telephone interviewer between June and August 2013. All

respondents had given permission to be contacted, and provided stable addresses of

someone who could give updated contact details if necessary. The field work period of

three months was sufficient for appointments to be booked if the respondent was initially

unavailable. An attempt to contact all potential respondents was made on at least 14

occasions, on various times and days of the week. Respondents were screened by

asking if they had ever been told by a health professional that they had asthma, had a

current prescription for asthma medication and no diagnosis of chronic obstructive

pulmonary disease. This resulted in 216 exclusions.

NHS ethical approval was not required since respondents were not identified through

health service records or recruited on health service sites. Respondents had previously

given their consent in the original health surveys to be invited to take part in follow-up

studies. Participants were recruited and data collected and stored according to the

Market Research Society Code of Conduct, and in accordance with the Data Protection

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Act, 2003, meaning additional ethical approval was not required. Informed, written

consent was obtained for this study, with assurances that all data would be kept

confidential and adhere to the code of conduct.

Survey questionnaire
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A number of measures were collected from respondents including demographic

characteristics, two validated measures to assess asthma control and a validated

measure to assess HRQOL.

Respondents reported the number of times in the last year they had been admitted to

hospital for breathing or chest problems. The number of asthma attacks over the last

year were also recorded (defined as the initiation of a course of systemic steroids for

worsening asthma) (25).

Marks Asthma Quality of Life Questionnaire (AQLQ-M)

The AQLQ-M (26) is an asthma-specific measure of HRQOL and was chosen because

of its validated use with adult British respondents (27) and telephone administration

(28). Made up of 20-items, it is scored on a 4-point likert scale, [0=Not at all; 1=A little;

2=Somewhat; 3=A great deal], and asks adults questions regarding how their asthma

has had an impact on their life over the past four weeks, across four domains: physical

impact (5 items), emotional impact (5 items), social impact (7 items), and health

concerns (3 items). The total score is the sum of all items and ranges from 0 to 60, with

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higher scores indicating poorer HRQOL. Internal consistency of the AQLQ-M is high,

ranging from .94 - .97 across the US and Portugal (28, 29). Internal consistency based

on Cronbach’s alpha was .94 and remained reliable across subdomains; physical

impact (α = .86), emotional impact (α = .86), social impact (α = .91) and health concerns

(α = .7).

Asthma Control Test (ACT)

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The ACT (30) is a clinically validated 5-item scale asking about asthma symptoms in the

last four weeks. It uses a 5-point ordinal scale, with answers ranging from poorly

controlled to well controlled asthma. Scores are totaled with a cut-off point for well-

controlled asthma of ≥ 20. Internal consistency based on Cronbach’s alpha for the

current sample was .79.

Royal College of Physicians 3-Questions (RCP3Q)

The RCP3Q (31) measures asthma control over the last week and consists of three

questions:

- Have you had difficulty sleeping because of your asthma symptoms (including

cough)?

- Have you had your usual asthma symptoms during the day (cough, wheeze,

chest tightness or breathlessness?

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- Has your asthma interfered with your usual activities (e.g. housework,

work/school etc)?

Each question is answered ‘yes’ or ‘no’; responding ‘no’ to all three questions indicates

well-controlled asthma). The RCP3Q have been demonstrated to reliably quantify

asthma control (31) and are recommended as a simple measure in the BTS/SIGN

guidelines (32). Internal consistency in the present sample based on Kuder-Richardson

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was .65.

Demographic and additional clinical characteristics

Respondents listed all currently prescribed asthma medications, although dose could

not be reliably collected and was therefore not recorded. We used these data to

approximate the treatment step according to the BTS/SIGN guidelines (32); treatment

step is a way to identify approximate severity of asthma. Age, gender, smoking status

(smoker, ex-smoker, never smoked) and comorbid long-term conditions were recorded.

Long-term conditions were subsequently categorized as none or ≥1 comorbid condition.

The level of highest educational qualification and employment status was also taken as

an indication of Socio-Economic Status (SES). These data, along with ethnicity, were

obtained from the datasets of the original health surveys.

Data analysis

Data were analysed using SPSS Version 19. The target sample size was 666, based on

a 5% error level and 99% confidence level and the number of adults in the UK with a

diagnosis of asthma being approximately 4.3million (33). In order to correct for any

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biases caused by differential non-response, a set of weights were applied using a

calibration technique. For HSE and WHS we calibrated according to age, sex, home

ownership and the number of children per household. For SHeS the small sample size

necessitated we only calibrated for age and sex. The distribution of the samples by

calibration variables are shown in supplementary table 1. Weights were adjusted so the

sample size was proportionate to the population estimates of each country. All results
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reported are for weighted data unless explicitly stated otherwise.

The clinical cut-off points for the ACT (≥20) and RCP3Q (>0) were used to calculate

binary variables to categorise respondents as ‘Poorly Controlled’ or ‘Well Controlled’.

Descriptive statistics are presented for the total values of each variable. Post-hoc

subgroup analysis was conducted to explore the impact of demographic and clinical

variables on respondents’ HRQOL. The distribution of HRQOL scores were skewed

such that respondents had either low scores and therefore a good quality of life or very

high scores, indicating a very poor quality of life. Due to this skewed distribution of

HRQOL scores, AQLQ-M scores were categorized, as suggested by the authors of the

measure, where the lowest four quintiles identified respondents with good HRQOL and

the quintile with the highest scores identified those with poor HRQOL (Blanc, P. Oral

communication, 17/10/2013).

Statistical differences between poor and good HRQOL and the associated demographic

variables were then analysed using the Chi-Square test. In addition, a block-wise linear

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regression analysis was used to examine what variables were associated HRQOL. This

was carried out with two models, to determine the relationship between HRQOL scores

and asthma-specific outcomes in model 1 (control, asthma attack, hospitalisation and

BTS step as a measure of severity) and how the additional demographic and clinical

variables in model 2 (smoking status, SES and presence of comorbidity) affected the

model. The ACT was used as the measure of control due to the higher internal
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consistency achieved. Variables that had more than two categories were dummy coded

and those that were not statistically significant at p < .05 were subsequently dropped

from the final model.

Results

Respondent population

The purpose of this research was to benchmark quality of life in asthma across

England, Scotland and Wales, so comparisons between the three countries were made

to determine whether scores were consistent in order to allow aggregation of data. No

significant differences were found in both a one-way ANOVA on the total AQLQ-M

scores (F (2,655) = .74, p = .476) and a Chi square test between good and poor

HRQOL (χ2 (2, N =657) =.25, p = 0.881). Results were therefore aggregated in order to

benchmark HRQOL scores across England, Scotland and Wales.

The response rate was 49% (see Fig. 1).Respondents’ characteristics by age group,

gender, smoking status, BTS step, comorbidities, qualification level, employment status,

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ethnic origin, and country of residence are presented in Table 1. Respondents ranged in

age from 18 to 74 years (Median = 43) with an interquartile range of 31 – 56. Forty-three

percent had one or more co-morbidities. The most common were hypertension (8.9%),

arthritis/rheumatism (7.4%), and diabetes (7.4%). AQLQ-M median (IQR) scores were 5

(2-13) for the total sample, indicating good overall HRQOL (Table 1).

The cut-off score between good and poor HRQOL groups in this sample was 15 on the
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AQLQ-M. Scores between poor and good HRQOL were 21 (17-25) for the poor HRQOL

group and 3 (0-6) for the good HRQOL. Of the total sample, 22.7% had poor HRQOL.

HRQOL in relation to asthma control, hospital admissions and asthma attacks

Distribution of AQLQ-M scores by asthma control and treatment are presented in Table

2. A significantly larger percentage of people with poor HRQOL had poorly controlled

asthma compared to well controlled asthma: ACT (χ2 (1, N =657) =134.34, p<0.001),

RCP-3Q (χ2 (1, N =658) =66.46, p<0.001). A larger percentage of people reporting at

least one hospital admission or at least one asthma attack in the last year had poor

HRQOL compared with respondents who had not experienced an admission (χ2 (1, N

=658) =75.87, p<0.001) or asthma attack (χ2 (1, N =658) =44.43, p<0.001) in the past

year.

HRQOL in relation to demographic and additional clinical characteristics

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Table 1 also shows the median AQLQ-M scores by each demographic characteristic.

Significant differences in the percentage of people in the poor HRQOL group were

found between people with different smoking status (χ2 (1, N =658) =30.56, p<0.001)

with poorer quality of life reported in smokers, and between socioeconomic groups

(educational level (χ2 (1, N =653) =8.85, p=0.012); employment (χ2 (1, N =643) =13.52,

p<0.001)), and people with ≥1 comorbidities were more likely to have poorer quality of
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life compared with no comorbidities (χ2 (1, N =658) =22.82, p<0.001). There was no

difference in the percentage of people in the poor HRQOL group between the different

age groups (χ2 (1, N =658) = 7.692, p=0.174), or sex (χ2 (1, N =658) = 2.98, p=0.051).

Relationship between HRQOL and asthma-specific and demographic outcomes

Multiple regression analyses looking at the asthma-specific outcomes showed a

significant association with HRQOL scores, F(4, 638) = 330.29, p < .001, explaining

67% of the variance. This association remained significant when also accounting for

demographic factors, F(6, 636) = 225.04, p < .001, also explaining 67% of the variance.

However, the only significant associations of poor HRQOL found here were with

comorbidities and employment. The significant associations for poor quality of life in the

final model are presented in Table 3, showing that ACT control accounted for the most

variance, followed by a hospital admission in the previous 12 months and being on BTS

Steps 4-5 (indicating severe asthma). Poorer control, a hospital admission and more

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severe asthma were also significantly associated with poorer HRQOL scores. Smoking

and education were not significant factors in the model.

Multiple regression analyses looking at the RCP as an alternative measure of control

also found a significant association with HRQOL scores, F(7, 644) = 107.96, p < .001,

with the final model accounting for 54% of the variance.

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Discussion

Summary of main findings

To the best of our knowledge this is the first study to use a validated measure to

benchmark the asthma- specific HRQOL of the collective population across England,

Scotland and Wales. Overall HRQOL was relatively good. However, in contrast to the

majority of respondents, a substantial minority had extremely poor responses, indicating

poor quality of life. Subgroup analysis on demographic characteristics revealed that

people with poor HRQOL were significantly more likely to be in an older age band, have

higher rates of smoking and/or be of lower socio-economic status (SES). In addition, a

higher proportion of people with poor HRQOL had poorly controlled asthma and were

more likely to have had an asthma attack or been admitted to hospital more than once

in the previous 12 months. Further regression analyses revealed asthma control,

previous hospital admissions and stage of severity to have the biggest associations with

poor HRQOL. This is hardly surprising, especially in regards to the association with

control in particular, which is in line with previous research. Only the presence of

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comorbidities and employed respondents vs unemployed/economically active

respondents remained as significant associations of the model, suggesting that clinical

factors explain a larger degree of variance than demographic factors.

Strengths and limitations

The study design ensured this was a representative survey. As the aim was to
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benchmark asthma HRQOL across England, Scotland and Wales, it was based on the

population rather than a clinical sample, and data were weighted to ensure the

characteristics of the sample closely matched those of the originally issued sample.

While this resulted in a strong weighting towards the data from England, this was to be

expected as it is reflective of the larger population in England in comparison to the rest

of the UK. Moreover, the standard error of the mean was small relative to the mean for

all variables, indicating that this sample is likely to be an accurate reflection of the

population. However, the survey did not include non-English speakers and the authors

were unable to collect data from respondents living in Northern Ireland. The multicultural

character of the included countries is therefore not reflected in these findings. In

addition, while high quality methods of data collection were used, the dose of asthma

medication was self-reported and could not therefore be consistently collected in this

survey, and some respondents on Step 4 may therefore have been misclassified as

Step 3.

A major strength of this survey is that it utilised a number of standardised measures,

including a disease-specific measure of HRQOL validated for telephone administration,

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the Marks AQLQ. Disease specific measures of HRQOL provide data of more clinical

relevance to patients than a generic measure. For example, they are better able than

generic measures to identify patients who will seek physician care for asthma (34).

These data are therefore likely to be applicable to clinical practice. A weakness

however, is that the AQLQ-M does not have a published cut-off point for poor HRQOL.

As a result, there is the potential that results could change with future samples and this
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hinders comparison with studies not using the AQLQ-M, yet was unavoidable as it is the

only such measure validated for telephone administration. Rather, this survey identifies

the characteristics of the quintile of respondents with the poorest asthma-specific

HRQOL, providing benchmarking data on which future strategies for improving the

health of the asthma population can be developed. Cronbach’s alpha confirmed high

internal consistency for the AQLQ-M and asthma control test in the current sample.

However, this was just below the optimum threshold of .7 for the RCP3Q at .66. Further

analyses were therefore conducted using the results from the asthma control test.

Interpretation of findings in relation to previously published work

The overall asthma-specific HRQOL of this representative sample was good and this is

reflective of some published work, including large-scale population studies, showing

asthma to have a moderate impact on HRQOL (35). The median value of 5

demonstrates that the majority of respondents currently perceived little impact of

asthma on their lives. This should not lead to complacency though; asthma is a variable

disease, the asthma-specific HRQOL of individual patients is therefore likely to fluctuate

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over time. Future research, exploring a three level variable could provide more

information and reliability to this method.

In this sample the relatively good overall HRQOL scores masked very much poorer

HRQOL among those in the upper quintile of AQLQ-M scores. While, by definition, this

group must have poorer HRQOL than others, the size of the difference between the
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median HRQOL for the overall sample and for the top quintile is striking. In order to

attain an AQLQ-M score of 21, the median in the poor HRQOL group, a patient would

need to be affected by the equivalent of “a great deal” in seven of the twenty items

covered by the scale, each one of which in itself reflects an important detriment to daily

life. This suggests that a substantial minority (23%) of people with asthma experience

very poor HRQOL because of their asthma, and that this problem is even more common

in certain demographic groups. In accordance with previous studies we found poorer

outcomes reported by smokers (36). Guidelines advise that smokers are offered support

to quit (37), yet low cessation rates indicate that improved strategies are needed (38).

Poor HRQOL was also reported by people with low socio-economic status (SES) (39,

40). However, this was not significant in the regression, suggesting inequalities between

people with low and high SES does not relate to asthma-specific quality of life. It is

widely recognised that the number of comorbidities is associated with HRQOL (41). Our

study reinforces the message that asthma is often one of a number of long-term

conditions experienced by patients. In order to improve HRQOL a more generalist

approach needs to be taken where the breadth of conditions are considered

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simultaneously (42). The subgroup analyses presented here are exploratory and future

research should specifically compare isolated cases of asthma-related quality of life with

comorbidities.

As expected, a higher percentage of people with poor HRQOL had poor asthma control

(37.1 – 47.2%) compared to well controlled asthma (8 – 10.4%), as did people reporting
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asthma attacks compared with no attacks. This is partly because the AQLQ-M

measures symptoms, and therefore overlaps with items included in the ACT and

RCP3Q. It is noteworthy that the majority of people with poorly controlled asthma were

categorised as having good HRQOL. This highlights the need for HRQOL to be

measured independently from asthma control.

The findings also indicate that for the majority of people with a breathing related hospital

admission in the last year, their HRQOL in the last four weeks was poor. This study was

not designed to analyse the factors that may confound this relationship (such as

BTS/SIGN step and age), yet this exploratory analysis indicates that more needs to be

done to improve the HRQOL of patients with asthma after they have been discharged

from hospital care.

As expected, this survey found that those on higher treatment steps were more like to

have poor quality of life, indicating that improving HRQOL should be a very important

consideration for people with severe asthma. Of equal concern, but perhaps more

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surprising, is the poor HRQOL reported by a large number of respondents prescribed

medication at BTS/SIGN steps 1 and 2, indicative of mild/moderate asthma. This may

partly be due to the high levels of poorly controlled asthma at these medication steps. A

recent UK report found excessive prescribing of reliever medication and under-

prescribing of preventer medication for patients who had died due to asthma between

February 2012 and January 2013 (6). Our findings suggest that this kind of prescribing
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is also detrimental to HRQOL.

Implications for future research, policy and practice

Further research is needed to investigate the findings of the exploratory subgroup

analysis presented here, and strategies developed to improve the HRQOL of the

sections of society reporting the poorest asthma-specific HRQOL. This is important

given the very high prevalence of asthma in the UK. It is estimated that there are

approximately 4.3 million adults with asthma in the UK (35). Based on our data, 29% of

respondents were economically inactive, and 32% of these have poor asthma-specific

HRQOL. This equates to more than 395,000 people with asthma who are economically

inactive and experiencing poor asthma-specific HROQL. Using the same method of

calculation we estimate that 235,296 smokers (48%), 204,336 people with no

qualifications (35%), and 582,044 people (32%) with one or more comorbidities have

poor asthma-specific HRQOL.

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The relationship between HRQOL and clinical outcomes is imperfect (43) and some

results have suggested that pharmacological treatment aimed at asthma control may

not improve HRQOL (44). The current results suggest that the relationship with clinical

symptoms may be a bigger factor to explain quality of life than demographic factors.

Future research may therefore focus on the relationship between managing risk and

quality of life. In addition, interventions to improve HRQOL for people with asthma may
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want to stratify those who present with particularly poor scores of quality of life.

The recent publication of respiratory strategies for each of the four UK health systems

presents a landmark opportunity to make changes that will improve the HRQOL of

patients with asthma. It is now vital for decision-makers to match other European

countries by putting the recommendations of those documents into practice to reduce

the number of people experiencing poor HRQOL, asthma attacks and hospital

admissions.

Conclusions

These data provide a benchmark from which to evaluate the extent of strategies aimed

at improving asthma care over the coming years, particularly for subsections of society

for whom asthma-specific HRQOL is poor. For, although asthma control is essential, the

effect of these strategies on patient’s quality of life is equally as important when

evaluating their impact.

Acknowledgements: We thank the respondents for giving their time to be interviewed.

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Conflicts of interest: The authors declare that they have no competing financial

interests in relation to the work described and no conflicts of interest in relation to this

article.

Contributorship: JU, CL, EH, SW, and DP contributed to the conception of the article.

The article was drafted by JU, EH, and SW. All authors contributed to the critical

appraisal and revision of the article.

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Funding: This study was financially supported by GlaxoSmithKline, Pharmacy2U and

Boston Scientific.

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References

1. Masoli M, Di Marco F, Holt S, Beasley R. The global burden of asthma: executive

summary of the GINA Dissemination Committee report. Allergy. 2004;59:469–78.

http://dx.doi.org/10.1111/j.1398-9995.2004.00526.x

2. The Information Centre for Health and Social. Health Survey for England 2010:

Respiratory Health. 2010. Available from:

Downloaded by [University of Nebraska, Lincoln] at 19:04 18 May 2016

http://www.hscic.gov.uk/pubs/hse10report (accessed 4 Nov 2014)

3. The Welsh Government. The Welsh Health Survey. 2011. Available from:

http://www.bhfactive.org.uk/userfiles/Documents/welshhealthsurvey20111.pdf

(accessed 4 Nov 2014)

4. Scottish Government. The Scottish Health Survey 2010: Main Report.2010.

Available from: http://scotland.gov.uk/Resource/Doc/358842/0121284.pdf

(accessed 4 Nov 2014)

5. Gibson GJ, Loddenkemper R, Lundbäck B, Sibille Y. Respiratory health and

disease in Europe: the new European Lung White Book. Eur Respir J. 2013;

42(3):559-63. http://dx.doi.org/10.1183/09031936.00105513.

6. Levy M, Andrews R, Buckingham R, Evans H, Francis C et al 2014. Why asthma

still kills: The national review of asthma deaths (NRAD). Project Report. Royal

College of Physicians, London- Royal College of Physicians.

https://www.rcplondon.ac.uk/projects/national-review-asthma-deaths (accessed 4

Nov 2014)

22
ACCEPTED MANUSCRIPT
 ACCEPTED MANUSCRIPT

7. Taylor S, Pinnock H, Epiphanou E, Pearce G, Parke H, et al. A rapid synthesis of

the evidence on interventions supporting self-management for people with long-

term conditions: PRISMS - Practical systematic Review of Self-Management

Support for long-term conditions. Health Serv Deliv Res 2014; 2:53.

http://dx.doi.org/10.3310/hsdr02530

8. Price D, Fletcher M, van der Molen T. Asthma control and management in 8000
Downloaded by [University of Nebraska, Lincoln] at 19:04 18 May 2016

European patients: the REcognise Asthma and LInk to Symptoms and Experience

(Realise) Survey. Prim Care Respir Med. 2014; 24. Article number:14009.

http://dx.doi.org/10.1038/npjpcrm.2014.9

9. Maspero JF, Jardim JR, Aranda A, Tassinari P, Gonzalez-Diaz SN, Sansores RH

et al. Insights, attitudes, and perceptions about asthma and its treatment: findings

from a multinational survey of patients from Latin America. World Allergy Organ. J

2013; 6(19): 1 – 7. http://www.waojournal.org/content/6/1/19

10. Thompson PJ , Salvi S, Lin J, Cho YJ, Eng P, Abdul Manap R et al. Insights,

attitudes and perceptions about asthma and its treatment: Findings from a

multinational survey of patients from 8 Asia-Pacific countries and Hong Kong.

Respirology. 2013; 18: 957 – 967. DOI: 10.1111/resp.12137

11. Chapman KR. Impact of ‘mild’ asthma on health outcomes: findings of a

systematic search of the literature. Resp. Med. 2005; 99(11): 1350 – 1362.

DOI: http://dx.doi.org/10.1016/j.rmed.2005.03.020

23
ACCEPTED MANUSCRIPT
 ACCEPTED MANUSCRIPT

12. Fuhlbrigge AL, Adams RJ, Guilbert TW, Grant E, Lozano P, Janson SL et al. The

Burden of Asthma in the United States Am. J. Respir. Crit. Care Med 2002; 166:

1044 – 1049. DOI: 10.1164/rccm.2107057

13. Sullivan PW, Smith KL, Ghushchyan VH, Globe DR, Lin SL, Globe G. Asthma in

USA: its impact on health-related quality of life/ Asthma 2013;50(8): 891-899. doi:

10.3109/02770903.2013.813035
Downloaded by [University of Nebraska, Lincoln] at 19:04 18 May 2016

14. Global Initiative for Asthma (GINA) Pocket guide for asthma management and

prevention. 2011.

http://www.ginasthma.org/local/uploads/files/GINA_Pocket_April20_1.pdf (Last

accessed 21/1/16)

15. Wilson, SR. Rand, CS, Cabana MD, Foggs MB Halterman JS et al. Asthma

outcomes: Quality of life. J Allergy Clin Immunol. 2012; 129:S88-123.

http://dx.doi.org/doi.org/10.1016/j.jaci.2011.12.988

16. Mroczek B, Kurpas D, Urban M, Sitko Z, Grodzki T. The Influence of Asthma

Exacerbations on Health-Related Quality of Life. Ventilatory Disorders. 2015;16:

65-77

17. Siroux V, Boudier A, Anto JM, Cazzoletti L, Accordini S et al. Quality-of-Life and

asthma severity in general population asthmatics: results of the ECRHS II study.

Allergy 2008; 63: 547 – 554. DOI: 10.1111/j.1398-9995.2008.01638.x

18. Chen W, Lynd LD, FitzGerald JM, Marra CA, Rousseau R, Sadatsafavi M. The

added effect of comorbidity on health-related quality of life in patients with asthma.

Quality of Life Research. 2015; 24(10): 2507-2517.

24
ACCEPTED MANUSCRIPT
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19. Voll-Aanerud M, Eagan TM, Plana E, Omenaas ER, Bakke PS, Svanes C, et al.

Respiratory symptoms in adults are related to impaired quality of life, regardless of

asthma and COPD: results from the European community respiratory health

survey. Health Qual Life Outcomes. 2010 Sep 27;8(107):10-186.

20. Primary Care Commissioning. Designing and commissioning services for adults

with asthma: A good practice guide. 2012. http://www.pcc-

Downloaded by [University of Nebraska, Lincoln] at 19:04 18 May 2016

cic.org.uk/article/designing-and-commissioning-services-adults-asthma-good-

practice-guide. (accessed 30 Dec 2014).

21. Worth A, Hammersley V, Knibb R, Flokstra-de-Blok B, DunnGalvin A et al. Patient-

reported outcome measures for asthma: a systematic review. Prim Care Respir J.

2014;24:14020. http://dx.doi.org/10.1038/npjpcrm.2014.20

22. The NHS Information Centre for Health and Social Care. Health Survey for

England - 2010, Respiratory Health. http://www.hscic.gov.uk/pubs/hse10report Last

accessed 3/1/15

23. The Scottish Government. The Scottish Health Survey: Volume 1: Main Report.

2011. http://www.scotland.gov.uk/Publications/2011/09/27084018/3 Last

accessed 3/1/15

24. Sadler K, Doyle M, Hussey D, Stafford R. Welsh Health Survey -2010 -Technical

Report. 2010.

http://doc.ukdataservice.ac.uk/doc/6895/mrdoc/pdf/6895technical_report.pdf Last

accessed 3/1/15

25
ACCEPTED MANUSCRIPT
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25. Fuhlbrigge A, Peden D, Apter A, Boushey H, Camargo CJ, et al. Asthma

outcomes: exacerbations. J Allergy Clin Immunol. 2012;129:S34-S48.

http://dx.doi.org/10.1016/j.jaci.2011.12.983

26. Marks GB, Dunn SM, Woolcock AJ. A scale for the measurement of quality of life

in adults with asthma. J Clin Epidemiol. 1992;45(5):461-72.

http://dx.doi.org/10.1016/0895-4356(92)90095-5.
Downloaded by [University of Nebraska, Lincoln] at 19:04 18 May 2016

27. Apfelbacher CJ, Jones C, Hankins M, Smith H. Validity of two common asthma-

specific quality of life questionnaires: Juniper mini asthma quality of life

questionnaire and Sydney asthma quality of life questionnaire Health Qual Life

Outcomes. 2012;10:97. http://dx.doi.org/10.1186/1477-7525-10-97.

28. Katz PP, Eisner MD, Henke J, Shiboski S, Yelin EH, Blanc PD. The Marks Asthma

Quality of Life Questionnaire: further validation and examination of responsiveness

to change. J Clin Epidemiol. 1999;52(7):667-675. http://dx.doi.org/10.1016/S0895-

4356(99)00026-8

29. Ferreira J, Silveira P, Figueiredo MM, Andrade C, Joȁo F, et al. Validation of the

Portugese version of the Asthma Quality of Life Questionnaire [AQLQ-M] by

Marks. Rev Port Pneumol. 2005;11(4):351-66

30. 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 control. J.

Allergy Clin. Immunol. 2004;113(1):59–65.

http://dx.doi.org/10.1016/j.jaci.2003.09.008

26
ACCEPTED MANUSCRIPT
 ACCEPTED MANUSCRIPT

31. Thomas M, Gruffydd-Jones K, Stonham C, Ward S, Macfarlane TV. Assessing

asthma control in routine clinical practice: use of the Royal College of Physicians

“3 questions”. Prim Care Respir J. 2009;18(2):83–8.

http://dx.doi.org/10.3132/pcrj.2008.00045

32. SIGN/BTS British guideline on the management of asthma. 2014. https://www.brit-

thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/ (accessed 4
Downloaded by [University of Nebraska, Lincoln] at 19:04 18 May 2016

Nov 2014).

33. Asthma UK. Facts and Statistics. 2014 . Available from:

http://www.asthma.org.uk/asthma-facts-and-statistics (accessed 5 Nov 2014)

34. Osman LM, Calder C, Robertson R, Friend JAR, Legge JS, Douglas JG.

Symptoms, quality of life, and health service contact among young adults with mild

asthma. Am J Respir Crit Care Med 2000;161:498–503.

http://dx.doi.org/10.1164/ajrccm.161.2.9904063.

35. Nishiyama O, Taniguchi H, Kondoh Y, Kimura T. Evaluating Health-Related

Quality of Life in Asthma. Allergology Intnl, 2005;54:181 - 186

36. Tan NC, Ngoh SHA, Teo SSH, Swah TS, Chen Z. et al Impact of cigarette

smoking on symptoms and quality of life of adults with asthma managed in public

primary care clinics in Singapore: a questionnaire study,” Prim Care Respir J.

2012;21(1): 90–93. http://dx.doi.org/10.4104/pcrj.2012.00003

37. Department of Health. An Outcomes Strategy for Chronic Obstructive Pulmonary

Disease (COPD) and Asthma in England. 2011:1–56.

27
ACCEPTED MANUSCRIPT
 ACCEPTED MANUSCRIPT

https://www.gov.uk/government/publications/an-outcomes-strategy-for-people-

with-chronic-obstructive-pulmonary-disease-copd-and-asthma-in-

(accessed 4 Nov 2014)

38. Polosa R, Thomson NC. Smoking and asthma: dangerous liaisons. Eur Respir J.

2013;41(3):716-26. http://dx.doi.org/10.1183/09031936.00073312.33.

39. Blanc PD, Yen IH, Chen H, et al. Area-level socio-economic status and health
Downloaded by [University of Nebraska, Lincoln] at 19:04 18 May 2016

status among adults with asthma and rhinitis. Eur Resp J 2006;27:85-94.

http://dx.doi.org/10.1183/09031936.06.00061205

40. Mielck A, VogelmannM, Leidl R. Health-related quality of life and socioeconomic

status: inequalities among adults with a chronic disease. Health and Quality of Life

Outcomes 2014;12:58. http://dx.doi.org/10.1186/1477-7525-12-58

41. Alonso J, Ferrer M, Gandek B, et al. IQOLA Project Group. Health-related quality

of life associated with chronic conditions in eight countries: results from the

International Quality of Life Assessment (IQOLA) Project. Qual Life Res.

2004;13:283–298. http://dx.doi.org/10.1023/b:qure.0000018472.46236.05

42. Mercer SW. Comorbidity in asthma is important and requires a generalist

approach [letter] Prim Care Respir J 2014;23(1):4.

http://dx.doi.org/10.4104/pcrj.2014.00012

43. Juniper EF, Wisniewski ME, Cox FM, et al. Relationship between quality of life and

clinical status in asthma: a factor analysis. Eur Respir J. 2004;23(2):287-291

http://dx.doi.org/10.1183/09031936.04.00064204

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44. Yorgancioglu A, et al. Asthma control test and asthma quality of life questionnaire

association in adults. Iran J Allergy Asthma Immunol. 2012;11: 301–307.

http://dx.doi.org/011.04/ijaai.301307
Downloaded by [University of Nebraska, Lincoln] at 19:04 18 May 2016

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Table 1: Sample characteristics

Characteristics Weighted Unweighte Mean SE 95% Media IQR % with

* sample d base** AQLQ (M) CI n Poor

size -M HRQO

N (%) L

Age
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7.18 0.8 5.56 20.0

18-24 75 (11.3) 33 1 – 6 2-7

8.80

6.16 0.7 4.74 20.2

130
25-34 63 2 – 4 0-8
(19.7)
7.58

7.81 0.8 6.16 17.4

149
35-44 136 4 – 4 1-11
(22.7)
9.46

11.23 1.0 9.11 24.0

128 7 –
45-54 156 6 2-14
(19.5) 13.3

14.57 1.7 11.1 30.9

55-64 97 (14.7) 127 1 9– 7 3-17

17.9

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8.21 0.9 6.31 26.6

6 –
65-74 79 (12.0) 138 4 2-15
10.1

Gender
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8.59 0.7 7.19 19.5

282
Male 231 1 – 4 1-13
(42.8)
9.99

9.53 0.5 8.43 25.2

376 6 –
Female 427 6 2-15
(57.2) 10.6

Smoking status

9.69 0.8 7.98 19.8

187 7 –
Ex-smoker 169 6 2-14
(28.4) 11.4

7.88 0.5 6.90 19.4

396
Non-smoker 405 0 – 4 1-11
(60.2)
8.87

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14.31 1.7 10.9 48.0

1 1– 2-
Smoker 75 (11.4) 84 8.7
17.7 20.9

BTS/SIGN Step

1 Short- 23.5
5.99
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acting 133 0.8 0-

126 7.63 – 4
bronchodilato (20.2) 3 11.9
9.27
rs

2 Short- 21.7

acting

bronchodilato 6.85
258 0.5
rs and 225 7.99 – 5 2-14
(39.2) 8
inhaled 9.12

corticosteroid

inhalers

3 Long-acting 6.92 16.1

236 0.5
bronchodilato 257 8.05 – 5 2-11
(35.9) 8
r inhaler 9.19

4 The 23.8 68.2

4.6 4.36
addition of 23 (3.5) 33 33.54 5– 45
7 -52
leukotriene 43.2

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receptor 3

antagonists

or

theophylline

tablet

preparations
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19.8 100

5 Systemic 5.5 2– 24 –
8 (1.2) 17 32.96 25
steroids. 6 46.1 53.8

Comorbidities

377 0.4 6.1- 15.9

None 348 7.05 4 1-9
(57.3) 8 8.0

281 0.7 10.4- 31.7

≥ 310 11.93 7 3-17
(42.7) 8 13.5

Qualification

level

Degree and 157 7.98 0.7 6.44- 19.7

166 5 2-8
above (24.1) 8 9.52 (31)

8.67 0.5 7.58 21.6

407
Sub-degree 376 6 – 5 1-13 (88)
(62.5)
9.77

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13.43 1.4 10.6 35.2

No formal 2 0– 2.6- (31)

88 (13.5) 101 11
qualifications 16.2 24

Employment

status
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7.48 0.4 6.64 19.1

429
Employed 400 3 – 5 1-11
(66.8)
8.32

7.01 1.3 4.30 11.5

Unemployed 26 (4.1) 13 1 – 6 4-6

9.71

12.33 1.0 10.2 31.6

Economically 187 7 2– 2-
237 7
Inactive (29.1) 14.4 19.6

Ethnic Origin

7.77 0.3 7.02 19.8

597
White 638 8 – 5 1-11
(90.8)
8.52

13.81 0.5 12.0 14- 0

Mixed 4 (0.6) 3 14
7 2– 14

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15.6

17.20 2.7 11.5 55.6

Asian/British 7 2–
28 (4.2) 7 16 8-25
Asian 22.8

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20.02 4.2 10.9 40.0

Black/British 3 9–
16 (2.4) 6 11 7-32
Black 29.0

39.27 5.7 26.7 69.2

Other 5 6–
13 (2.0) 2 52 8-52
ethnicity 51.7

Country of

residence

6.91 1.3 4.25 15.8

0.6-
Scotland 56 (8.6) 140 3 – 3
8.7
9.58

9.30 2.0 5.17 21.2

2-
Wales 33 (5.0) 335 3 – 5
12.7
13.4

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9.34 0.4 8.40 15.8

569 8 –
England 183 6 2-14
(86.5) 10.2

ALQL-M: Asthma Quality of Life Questionnaire Marks, SE (M) Standard Error of the
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Mean; CI Confidence Interval; IQR Interquartile Range. * Weighted numbers reflect the

relative size of each group in the population. ** Unweighted base indicates the numbers

of interviews made.

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Table 2: Distribution of AQLQ-M scores by asthma control and treatment

Clinical Weighte Unweighte Mean SE 95% Media % in

characteristic d sample d Base ** AQLQ (M) CI n IQ Poor

s size N -M R HRQO

(%)* L group
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AQLQ-M 658 657 0.4 8.26- 2- -

9.13 5
Total score (100) 4 9.99 13

Poor HRQOL 149 133 24.18 -

0.9 17-
‡ (22.7) 26.10 - 21.44
7 32
28.02

Good 509 524 0.1 3.81- -

4.15 3.00 0-6
HRQOL (77.3) 7 4.49

ACT

15.75 47.2
Not well 246 0.8 7-
253 17.47 – 14
controlled (37.4) 8 24
19.20

Well 412 0.2 3.65 – 8

405 4.14 2.77 0-6
controlled (62.6) 5 4.62

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RCP-3Q

13.33 37.1
Not well 302 0.7 5-
340 14.84 – 11
controlled (45.9) 7 19
16.34

356 0.3 3.66 – 10.4

Controlled 316 4.29 2 0-6
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(54.1) 2 4.92

Hospital

Admissions in

last year

24.30 79.5
2.8 15-
≥1 39 (5.9) 27 29.96 – 22
0 52
35.62

619 0.3 7.08 – 1- 19.2

None 631 7.83 5
(94.1) 8 8.57 11

Asthma

attacks in last

year

≥1 96 (14.6) 110 17.70 1.7 14.31 13 5- 49

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1 - 24

21.09

562 0.4 6.88 – 1- 18.1

None 548 7.66 5
(85.4) 0 8.44 11

Abbreviations: AQLQ-M: Asthma Quality of Life Questionnaire Marks, SE (M) Standard

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Error of the Mean; CI Confidence Interval; IQR Interquartile Range, BTS/SIGN, British

Thoracic Society and Scottish Intercollegiate Guideline Network.

* Weighted numbers reflect the relative size of each group in the population. **

Unweighted base indicates the numbers of interviews made.

‡ The quintile of respondents with the highest AQLQ-M scores, indicating poorer

HRQOL

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Table 3: Predictors of asthma-specific quality of life

Predictor b SE B β t

Asthma control -1.52 .06 -.63 -

25.66**
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Asthma attack 2.52 .74 .08 3.35**

Hospital 11.19 1.17 .24 9.59**

admission

BTS step 4/5 7.17 1.39 .13 5.18**

Comorbidity -1.28 .52 -.06 -2.29*

Employment 1.27 .55 .05 2.31*

status

*p <.05

**p ≤.001

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