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Kocks J, Bosnic-Anticevich S, van Cooten J, Correia de Sousa J, Cvetkovski B, Dekhuijzen R, Dijk L, Garcia Pardo M, Gardev A, Gawlik R, van der Ham I, Janse Y, Lavorini F, Maricoto T, Meijer J, Metz B, Price D, Roman Rodriguez M, Schuttel K, Stoker N, Tsiligianni I, Usmani O, Voorham J, Leving MT. Identifying critical inhalation technique errors in Dry Powder Inhaler use in patients with COPD based on the association with health status and exacerbations: findings from the multi-country cross-sectional observational PIFotal study. BMC Pulm Med 2023; 23:302. [PMID: 37592263 PMCID: PMC10433653 DOI: 10.1186/s12890-023-02566-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/16/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Correct inhaler use depends on a complex interplay of factors, including device preparation and generating sufficient inspiratory flow. It is currently unknown which inhalation technique errors can be considered critical in Chronic Obstructive Pulmonary Disease (COPD) patients on Dry Powder Inhaler (DPI) maintenance therapy. OBJECTIVE To investigate the association between inhalation technique errors and health status or exacerbations in patients with COPD. Additionally, the association between the number of errors and COPD outcomes was determined. METHODS The PIFotal study is a cross-sectional multi-country observational study in a primary care setting, including 1434 COPD patients aged ≥ 40 years (50.1% female; mean age 69.2 yrs) using a DPI for their maintenance therapy. Inhalation technique was video recorded and scored by two independent researchers using inhaler-specific checklists. Health status was assessed with two questionnaires; the Clinical COPD Questionnaire (CCQ) and the COPD Assessment Test (CAT). The number of moderate and severe exacerbations in the past 12 months was recorded. Critical errors were identified based on their association with health status or exacerbations through multi-level prediction models adjusted for identified confounding. RESULTS Errors in inhalation technique steps 'Breathe in', 'Hold breath', and 'Breathe out calmly after inhalation' were significantly associated with poorer CCQ and CAT outcomes and thus deemed critical. None of the errors were significantly associated with moderate exacerbations. Patients with errors 'Preparation', 'Hold inhaler in correct position during inhalation', and 'Breathe in' had significantly more severe exacerbations, and therefore these errors were also deemed critical. 81.3% of patients with COPD made at least one critical error. Specific combinations of errors were associated with worse outcomes. The more inhalation technique errors identified, the poorer the health status and the higher the exacerbation rate. CONCLUSION In this study, we identified multiple critical inhalation technique errors in COPD patients using DPIs each associated with poorer outcomes. Explorative analysis revealed that specific combinations of errors may be of clinical relevance, especially those related to the inhalation manoeuvre. COPD outcomes worsened with increasing error count. These results warrant further prospective longitudinal studies to establish the effect of correcting these errors on COPD control. TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT04532853 (31/08/2020).
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Affiliation(s)
- Janwillem Kocks
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands.
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands.
- Observational and Pragmatic Research Institute, Singapore, Singapore.
- Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Local Health District, Sydney, Australia
| | - Joyce van Cooten
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), PT Government Associate Laboratory, School of Medicine, University of Minho, Braga, Portugal
| | - Biljana Cvetkovski
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | - Lars Dijk
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Marina Garcia Pardo
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma, Spain
| | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim Am Rhein, Germany
| | - Radosław Gawlik
- Department of Internal Medicine, Allergology, Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | - Iris van der Ham
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Ymke Janse
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Federico Lavorini
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Tiago Maricoto
- Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
| | - Jiska Meijer
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Boyd Metz
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Miguel Roman Rodriguez
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma, Spain
| | - Kirsten Schuttel
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Nilouq Stoker
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Ioanna Tsiligianni
- Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Omar Usmani
- Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, London, UK
| | - Jaco Voorham
- Data to Insights Research Solutions, Lisbon, Portugal
| | - Marika T Leving
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
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Leving MT, Bosnic-Anticevich S, van Cooten J, de Sousa JC, Cvetkovski B, Dekhuijzen R, Dijk L, Pardo MG, Gardev A, Gawlik R, van der Ham I, Janse Y, Lavorini F, Maricoto T, Meijer J, Metz B, Price D, Roman-Rodriguez M, Schuttel K, Stoker N, Tsiligianni I, Usmani O, Emerson-Stadler R, Kocks JWH. Clinical recommendations for dry powder inhaler use in the management of COPD in primary care. NPJ Prim Care Respir Med 2022; 32:59. [PMID: 36575175 PMCID: PMC9794707 DOI: 10.1038/s41533-022-00318-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/11/2022] [Indexed: 12/28/2022] Open
Abstract
Over 1400 patients using dry powder inhalers (DPIs) to deliver COPD maintenance therapies were recruited across Europe and Australia. Their peak inspiratory flow (PIF) was measured, inhaler technique was observed, and adherence to treatment assessed. From relating the findings with patient health status, and thereby identifying critical errors, key clinical recommendations for primary care clinicians were determined, namely - measure PIF before prescribing a DPI to ensure inhalation manoeuvre ability is well-matched with the device. Some patients could benefit from inhalation training whereas others should have their DPI changed for one better suited to their inspiratory ability or alternatively be prescribed an active device (such as a soft mist inhaler or pressurized metered dose inhaler). Observing the inhalation technique was valuable however this misses suboptimal PIF (approaching one fourth of patients with a satisfactory observed manoeuvre had a suboptimal PIF for their DPI). Assess adherence as deliberate non-adherence can point to a mismatch between a patient and their inhaler (deliberate non-adherence was significantly associated with PIFs below the minimum for the DPI). In-person observation of inhalation technique was found to be inferior to video rating based on device-specific checklists. Where video assessments are not possible, observation training for healthcare professionals would therefore be valuable particularly to improve the ability to identify the critical errors associated with health status namely 'teeth and lips sealed around mouthpiece', 'breathe in' and 'breathing out calmly after inhalation'. However, it is recommended that observation alone should not replace PIF measurement in the DPI selection process.Trial registration: https://clinicaltrials.gov/ct2/show/NCT04532853 .
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Affiliation(s)
- Marika T. Leving
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Sinthia Bosnic-Anticevich
- grid.1013.30000 0004 1936 834XWoolcock Institute of Medical Research, University of Sydney, Sydney, Australia ,grid.410692.80000 0001 2105 7653Sydney Local Health District, Sydney, Australia
| | - Joyce van Cooten
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Jaime Correia de Sousa
- grid.10328.380000 0001 2159 175XLife and Health Sciences Research Institute (ICVS), PT Government Associate Laboratory, School of Medicine, University of Minho, Braga, Portugal
| | - Biljana Cvetkovski
- grid.1013.30000 0004 1936 834XWoolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Richard Dekhuijzen
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Nijmegen, Netherlands
| | - Lars Dijk
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Marina Garcia Pardo
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Asparuh Gardev
- grid.420061.10000 0001 2171 7500Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Radosław Gawlik
- grid.411728.90000 0001 2198 0923Department of Internal Medicine, Allergology, Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | - Iris van der Ham
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Ymke Janse
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Federico Lavorini
- grid.24704.350000 0004 1759 9494Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Tiago Maricoto
- grid.7427.60000 0001 2220 7094Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
| | - Jiska Meijer
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Boyd Metz
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - David Price
- grid.500407.6Observational and Pragmatic Research Institute, Singapore, Singapore ,grid.7107.10000 0004 1936 7291Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Miguel Roman-Rodriguez
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Kirsten Schuttel
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Nilouq Stoker
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Ioanna Tsiligianni
- grid.8127.c0000 0004 0576 3437Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Omar Usmani
- grid.7445.20000 0001 2113 8111Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, London, United Kingdom
| | - Rachel Emerson-Stadler
- grid.420061.10000 0001 2171 7500Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Janwillem W. H. Kocks
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands ,grid.500407.6Observational and Pragmatic Research Institute, Singapore, Singapore ,grid.4494.d0000 0000 9558 4598University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands ,grid.4494.d0000 0000 9558 4598Dept. of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Leving MT, van Boven JFM, Bosnic-Anticevich SZ, van Cooten J, Correia de Sousa J, Cvetkovski B, Dekhuijzen R, Dijk L, García Pardo M, Gardev A, Gawlik R, van der Ham I, Hartgers-Gubbels ES, Janse Y, Lavorini F, Maricoto T, Meijer J, Metz B, Price DB, Roman-Rodríguez M, Schuttel K, Stoker N, Tsiligianni I, Usmani OS, Kocks JH. Suboptimal Peak Inspiratory Flow and Critical Inhalation Errors are Associated with Higher COPD-Related Healthcare Costs. Int J Chron Obstruct Pulmon Dis 2022; 17:2401-2415. [PMID: 36185173 PMCID: PMC9521797 DOI: 10.2147/copd.s380736] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/12/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To assess the relationship between suboptimal Peak Inspiratory Flow (sPIF), inhalation technique errors, and non-adherence, with Healthcare Resource Utilisation (HCRU) in Chronic Obstructive Pulmonary Disease (COPD) patients receiving maintenance therapy via a Dry Powder Inhaler (DPI). Patients and methods The cross-sectional, multi-country PIFotal study included 1434 COPD patients (≥40 years) using a DPI for maintenance therapy. PIF was measured with the In-Check DIAL G16, and sPIF was defined as a typical PIF lower than required for the device. Inhalation technique was assessed by standardised evaluation of video recordings and grouped into 10 steps. Patients completed the “Test of Adherence to Inhalers” questionnaire. HCRU was operationalised as COPD-related costs for primary healthcare, secondary healthcare, medication, and total COPD-related costs in a 1-year period. Results Participants with sPIF had higher medication costs compared with those with optimal PIF (cost ratio [CR]: 1.07, 95% CI [1.01, 1.14]). Multiple inhalation technique errors were associated with increased HCRU. Specifically, “insufficient inspiratory effort” with higher secondary healthcare costs (CR: 2.20, 95% CI [1.37, 3.54]) and higher total COPD-related costs (CR: 1.16, 95% CI 1.03–1.31). “no breath-hold following the inhalation manoeuvre (<6 s)” with higher medication costs (CR: 1.08, 95% CI [1.02, 1.15]) and total COPD-related costs (CR 1.17, 95% CI [1.07, 1.28]), and “not breathing out calmly after inhalation” with higher medication costs (CR: 1.19, 95% CI [1.04, 1.37]). Non-adherence was not significantly associated with HCRU. Conclusion sPIF and inhalation technique errors were associated with higher COPD-related healthcare utilisation and costs in COPD patients on DPI maintenance therapy.
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Affiliation(s)
- Marika T Leving
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Job F M van Boven
- University Medical Centre Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, the Netherlands
- University Medical Centre Groningen, Department of Clinical Pharmacy & Pharmacology, University of Groningen, Groningen, the Netherlands
- Medication Adherence Expertise Centre of the Northern Netherlands (MAECON), Groningen, the Netherlands
| | - Sinthia Z Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Local Health District, Sydney, Australia
| | - Joyce van Cooten
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), PT Government Associate Laboratory, School of Medicine, University of Minho, Braga, Portugal
| | - Biljana Cvetkovski
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | - Lars Dijk
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Marina García Pardo
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Radosław Gawlik
- Department of Internal Medicine, Allergology, Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | - Iris van der Ham
- General Practitioners Research Institute, Groningen, the Netherlands
| | | | - Ymke Janse
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Tiago Maricoto
- Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
| | - Jiska Meijer
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Boyd Metz
- General Practitioners Research Institute, Groningen, the Netherlands
| | - David B Price
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore
| | - Miguel Roman-Rodríguez
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Kirsten Schuttel
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Nilouq Stoker
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Ioanna Tsiligianni
- Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Omar S Usmani
- Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, London, UK
| | - Janwillem H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands
- University Medical Centre Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, the Netherlands
- Observational and Pragmatic Research Institute, Singapore
- Department of Pulmonology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- Correspondence: Janwillem H Kocks, General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, Groningen, 9713 GH, the Netherlands, Tel +31 50 211 3898, Email
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W H Kocks J, Wouters H, Bosnic-Anticevich S, van Cooten J, Correia de Sousa J, Cvetkovski B, Dekhuijzen R, Dijk L, Dvortsin E, Garcia Pardo M, Gardev A, Gawlik R, van Geer-Postmus I, van der Ham I, Harbers M, de la Hoz A, Janse Y, Kerkhof M, Lavorini F, Maricoto T, Meijer J, Metz B, Price D, Roman-Rodriguez M, Schuttel K, Stoker N, Tsiligianni I, Usmani O, Leving MT. Factors associated with health status and exacerbations in COPD maintenance therapy with dry powder inhalers. NPJ Prim Care Respir Med 2022; 32:18. [PMID: 35618739 PMCID: PMC9135702 DOI: 10.1038/s41533-022-00282-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/10/2022] [Indexed: 01/25/2023] Open
Abstract
The study aimed to determine the associations of Peak Inspiratory Flow (PIF), inhalation technique and adherence with health status and exacerbations in participants with COPD using DPI maintenance therapy. This cross-sectional multi-country observational real-world study included COPD participants aged ≥40 years using a DPI for maintenance therapy. PIF was measured three times with the In-Check DIAL G16: (1) typical PIF at resistance of participant’s inhaler, (2) maximal PIF at resistance of participant’s inhaler, (3) maximal PIF at low resistance. Suboptimal PIF (sPIF) was defined as PIF lower than required for the device. Participants completed questionnaires on health status (Clinical COPD Questionnaire (CCQ)), adherence (Test of Adherence to Inhalers (TAI)) and exacerbations. Inhalation technique was assessed by standardised evaluation of video recordings. Complete data were available from 1434 participants (50.1% female, mean age 69.2 years). GOLD stage was available for 801 participants: GOLD stage I (23.6%), II (54.9%), III (17.4%) and IV (4.1%)). Of all participants, 29% had a sPIF, and 16% were shown able to generate an optimal PIF but failed to do so. sPIF was significantly associated with worse health status (0.226 (95% CI 0.107–0.346), worse units on CCQ; p = 0.001). The errors ‘teeth and lips sealed around mouthpiece’, ‘breathe in’, and ‘breathe out calmly after inhalation’ were related to health status. Adherence was not associated with health status. After correcting for multiple testing, no significant association was found with moderate or severe exacerbations in the last 12 months. To conclude, sPIF is associated with poorer health status. This study demonstrates the importance of PIF assessment in DPI inhalation therapy. Healthcare professionals should consider selecting appropriate inhalers in cases of sPIF.
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Affiliation(s)
- Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, The Netherlands. .,University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands. .,Observational and Pragmatic Research Institute, Singapore, Singapore. .,Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Hans Wouters
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Sydney Local Health District, Sydney, Australia
| | - Joyce van Cooten
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), PT Government Associate Laboratory, School of Medicine, University of Minho, Braga, Portugal
| | - Biljana Cvetkovski
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | - Lars Dijk
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Evgeni Dvortsin
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marina Garcia Pardo
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Radosław Gawlik
- Department of Internal Medicine, Allergology, Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | | | - Iris van der Ham
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marten Harbers
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Ymke Janse
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Marjan Kerkhof
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Federico Lavorini
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Tiago Maricoto
- Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
| | - Jiska Meijer
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Boyd Metz
- General Practitioners Research Institute, Groningen, The Netherlands
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Miguel Roman-Rodriguez
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Kirsten Schuttel
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Nilouq Stoker
- General Practitioners Research Institute, Groningen, The Netherlands
| | - Ioanna Tsiligianni
- Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Omar Usmani
- Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, London, UK
| | - Marika T Leving
- General Practitioners Research Institute, Groningen, The Netherlands
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