Optimizing ACQ Cutoffs in Chinese Asthma Patients: Stratified Validation Against GINA Criteria_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

WANG Qinqin ^1,2 , ZHANG Qiao ³ , LI Hong ^1,2 , LIU Lingjun ^1,2 , LAN Yi ^1,2 ,  MA Qianli ^1,2,3

1. Department of Allergy and Immunology, Chongqing Songshan Hospital, Chongqing 401120, P.R. China;
2. Chronic Respiratory Disease Management and Rehabilitation Center, Chongqing Songshan Hospital, Chongqing 401120, P.R.China;
3. Department of Respiratory and Critical Care Medicine, Chongqing Songshan Hospital, Chongqing 401120, P.R.China;

Corresponding?author：

MA Qianli, Email: cqmql@163.com

Keywords：

Asthma; Asthma control; Symptom control; Asthma Control Questionnaire

DOI：

10.7507/1671-6205.202412130

Video：

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Objective To evaluate the applicability of the cut-off points of different versions of the Asthma Control Questionnaire (ACQ) in the Chinese population and their consistency with the symptom control criteria of the Global Initiative for Asthma (GINA), so as to provide strategies for cut-off point selection in clinical practice. Methods Based on baseline data from a multicenter prospective cohort study, asthma patients who completed pulmonary function tests, GINA symptom control assessments, and the ACQ-7 questionnaire were included. Taking the GINA symptom control level as the gold standard, the Receiver Operating Characteristic Curve (ROC) was used to determine the optimal cut-off points of the ACQ for discriminating the GINA symptom control levels, and the consistency was analyzed by kappa statistics. Results Among 399 patients (58.9% female; mean age 44.5 ± 12.8 years), asthma symptom control, partial control, and uncontrolled rates were 61.7%, 27.6%, and 10.8%, respectively. ROC analysis revealed the following optimal cutoffs for identifying symptom control: ACQ-5 (0.5), ACQ-6Res (0.42), ACQ-6PFT (0.92), and ACQ-7 (0.93); for identifying uncontrolled symptoms: ACQ-5 (0.9), ACQ-6Res (1.08), ACQ-6PFT (1.42), and ACQ-7 (1.36). All corresponding areas under the ROC curve (AUC) exceeded 0.9. Consistency between ACQ and GINA symptom control levels was moderate (Fleiss’ κ = 0.453–0.531). Performance characteristics varied between traditional (0.75/1.5) and optimized cutoffs. After optimization, ACQ-5 emerged as the only version achieving balanced sensitivity-specificity (Youden index = 0.75) in dual tasks: ACQ-5 ≤ 0.5 demonstrated sensitivity (91%) and specificity (84%) for symptom control, while ACQ-5 ≥ 0.9 showed sensitivity (95%) and specificity (80%) for uncontrolled status. Conclusions Region-specific calibration of ACQ cutoffs enhances clinical utility in the Chinese population. A stratified application strategy is recommended: high-sensitivity cutoffs for initial screening to reduce underdiagnosis, high-specificity cutoffs for resource-constrained settings to minimize overtreatment, and optimized ACQ-5 cutoffs (≤0.5/≥0.9) for comprehensive management to balance sensitivity and specificity. Flexible combination of cutoff protocols tailored to screening objectives may optimize hierarchical asthma management.

Citation： WANG Qinqin, ZHANG Qiao, LI Hong, LIU Lingjun, LAN Yi, MA Qianli. Optimizing ACQ Cutoffs in Chinese Asthma Patients: Stratified Validation Against GINA Criteria. Chinese Journal of Respiratory and Critical Care Medicine, 2025, 24(8): 542-547. doi: 10.7507/1671-6205.202412130 Copy

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10.	Korn S, Both J, Jung M, et al. Prospective evaluation of current asthma control using ACQ and ACT compared with GINA criteria. Ann Allergy Asthma Immunol, 2011, 107(6): 474-479.
11.	Huang K, Yang T, Xu J, et al. China Pulmonary Health (CPH) Study Group. Prevalence, risk factors, and management of asthma in China: a national cross-sectional study. Lancet, 2019, 394(10196): 407-418.
12.	Chen X, Sun W, Li S, et al. Current status of prevention and treatment of respiratory diseases in primary care in China: a cross-sectional study. BMC Pulm Med, 2022, 22(1): 156.
13.	中華醫學會呼吸病學分會哮喘學組. 支氣管哮喘防治指南(2020年版). 中華結核和呼吸雜志, 2020, 43(12): 1023-1048.
14.	中華醫學會呼吸病學分會肺功能專業組. 肺功能檢查指南(第二部分)--肺量計檢查. 中華結核和呼吸雜志, 2014, 37(7): 481-486.
15.	Juniper EF, O'Byrne PM, Roberts JN. Measuring asthma control in group studies: do we need airway calibre and rescue beta2-agonist use?. Respir Med, 2001, 95(5): 319-323.
16.	Juniper EF, Svensson K, M?rk AC, et al. Measurement properties and interpretation of three shortened versions of the asthma control questionnaire. Respir Med, 2005, 99(5): 553-558.
17.	彭博, 張小娟, 姜驍桐, 等. 基層醫療衛生機構慢性阻塞性肺疾病基本藥物與診斷設備可獲得性調查研究. 中國全科醫學, 2022, 25(7): 771-781.
18.	Juniper EF, Bousquet J, Abetz L, et al; GOAL Committee. Identifying 'well-controlled' and 'not well-controlled' asthma using the Asthma Control Questionnaire. Respir Med, 2006, 100(4): 616-621.
19.	Sastre J, Olaguibel J, Vega JM, et al. Cut-off points for defining asthma control in three versions of the Asthma Control Questionnaire. J Asthma, 2010, 47(8): 865-870.

1. Papi A, Brightling C, Pedersen SE, et al. Asthma. Lancet, 2018, 391(10122): 783-800.
2. Rees PJ. Guidelines for the management of asthma in adults. BMJ, 1990, 301(6755): 771-772.
3. 中華醫學會呼吸病學分會哮喘學組. 支氣管哮喘患者自我管理中國專家共識. 中華結核和呼吸雜志, 2018, 41(3): 171-178.
4. Global Initiative for Asthma. Global strategy for asthma management and prevention: update 2006[EB/OL]. [2023-07-13]. http://www.ginaasthma.org/.
5. Global Initiative for Asthma. Global strategy for asthma management and prevention: update 2021[EB/OL]. [2023-07-13]. http://www.ginaasthma.org/.
6. Juniper EF, O'Byrne PM, Guyatt GH, et al. Development and validation of a questionnaire to measure asthma control. Eur Respir J, 1999, 14(4): 902-907.
7. Bateman ED, Boushey HA, Bousquet J, et al. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med, 2004, 170(8): 836-844.
8. Global Initiative for Asthma. Global strategy for asthma management and prevention: update 2014[EB/OL]. [2023-07-13]. http://www.ginaasthma.org/.
9. Wyrwich KW, Khan SA, Navaratnam P, et al. Validation and agreement across four versions of the asthma control questionnaire in patients with persistent asthma. Respir Med, 2011, 105(5): 698-712.
10. Korn S, Both J, Jung M, et al. Prospective evaluation of current asthma control using ACQ and ACT compared with GINA criteria. Ann Allergy Asthma Immunol, 2011, 107(6): 474-479.
11. Huang K, Yang T, Xu J, et al. China Pulmonary Health (CPH) Study Group. Prevalence, risk factors, and management of asthma in China: a national cross-sectional study. Lancet, 2019, 394(10196): 407-418.
12. Chen X, Sun W, Li S, et al. Current status of prevention and treatment of respiratory diseases in primary care in China: a cross-sectional study. BMC Pulm Med, 2022, 22(1): 156.
13. 中華醫學會呼吸病學分會哮喘學組. 支氣管哮喘防治指南(2020年版). 中華結核和呼吸雜志, 2020, 43(12): 1023-1048.
14. 中華醫學會呼吸病學分會肺功能專業組. 肺功能檢查指南(第二部分)--肺量計檢查. 中華結核和呼吸雜志, 2014, 37(7): 481-486.
15. Juniper EF, O'Byrne PM, Roberts JN. Measuring asthma control in group studies: do we need airway calibre and rescue beta2-agonist use?. Respir Med, 2001, 95(5): 319-323.
16. Juniper EF, Svensson K, M?rk AC, et al. Measurement properties and interpretation of three shortened versions of the asthma control questionnaire. Respir Med, 2005, 99(5): 553-558.
17. 彭博, 張小娟, 姜驍桐, 等. 基層醫療衛生機構慢性阻塞性肺疾病基本藥物與診斷設備可獲得性調查研究. 中國全科醫學, 2022, 25(7): 771-781.
18. Juniper EF, Bousquet J, Abetz L, et al; GOAL Committee. Identifying 'well-controlled' and 'not well-controlled' asthma using the Asthma Control Questionnaire. Respir Med, 2006, 100(4): 616-621.
19. Sastre J, Olaguibel J, Vega JM, et al. Cut-off points for defining asthma control in three versions of the Asthma Control Questionnaire. J Asthma, 2010, 47(8): 865-870.

Chinese Journal of Respiratory and Critical Care Medicine

Optimizing ACQ Cutoffs in Chinese Asthma Patients: Stratified Validation Against GINA Criteria

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