Suboptimal peak inspiratory flow and critical inhalation errors are associated with higher COPD-related healthcare costs

Marika Leving, Job F.M. van Boven, Sinthia Bosnic-Anticevich, Joyce van Cooten, Jaime Correia de Sousa, Biljana Cvetkovski, Richard Dekhuijzen, Lars Dijk, Marina Garcia Pardo, Asparuh Gardev, Radosław Gawlik, Iris van der Ham, Elisabeth Sophia Hartgers-Gubbels, Ymke Janse, Federico Lavorini, Tiago Maricoto, Jiska Meijer, Boyd Metz, David Price, Miguel Roman-RodriguezKirsten Schuttel, Nilouq Stoker, Ioanna Tsiligianni, Omar Usmani, Janwillem WH Kocks* (Corresponding Author)

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

5 Citations (Scopus)
4 Downloads (Pure)


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 1,434 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.
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 inhalation (<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.
1sPIF and inhalation technique errors were associated with higher COPD-related
healthcare utilisation and costs in COPD patients on DPI maintenance therapy.
Original languageEnglish
Pages (from-to)2401-2415
Number of pages15
JournalInternational journal of chronic obstructive pulmonary disease
Issue number17
Publication statusPublished - 25 Sept 2022

Bibliographical note

The members of the PIFotal study group would like to acknowledge Dr. Judith Cohen and Dr. Wilma Zijlema for their assistance with the review, drafting, and editing of the paper, and Dr. Hans Wouters for his contribution to the project administration in the initial phase of the project. They would also like to thank all contributing researchers: Maria João Barbosa, Ana Margarida Cruz, Liliana Silva, Duarte Araújo, Eurico Silva, Daniel Castro, João Ramires, Ana Fernandes, Catarina Carvalho, Raquel Castro, Jerzy Zientek, Ewa Pasko, Witold Drzastwa, Tomasz Kachel, Kornelia Ciekalska, Krzysztof Wytrychowski, Bernard Panaszek, Krzysztof Kowal, Ebian Brill, Willemien Feenstra, Geert Struik, Hans Schuurman, Mariette van Oostrum, Hennie Holwerda Meekma, Boudewijn Dierick, George Amofa, Esther Kuipers, Lennard Ringnalda, Boris Tyndall, Mark Drenth, Peter Mast, Hilbert Talsma, Raoul Wolfs, Cobie Hoogeboom, Hanneke van Andel, Paul Stoutenberg, Nancy van de Laak, Tessa Hillaert, Laura Holtzer, Natascha Fehrmann, Anniek Makkinga – Maassen van den Brink, Annemarie Hilbink, Erik Feenstra, Murat Tek, Sabrina Burer, Jan van Ginkel, Rinze Boersma, Alyssa Bonger, Miguel Roman Rodriguez, Marina García Pardo, Alejandra Valero Suau, Laura López Velasco, Cecilia Amato, Francisco Palmer Simó, Alberto Abenza, Rosa Llull Vila, Bartolomé Llompart Van Belzen, Silvia Jimeno Martínez, Francesc Moranta Ribas, Margarita Perelló Oliver, Yolanda Gómez López, Patricia Ibañez Gómez, María Nieves Mendieta Lagos, Laura Bueno López, Virginia María Mirabal Sánchez, Ana Delia Rodríguez Delgado, Nils Fischer, Alicia González Sansó, Nayra Ramírez Mendoza, Valeria Gazzaneo, Paula Merced Guillama Rodríguez, Virginia Naranjo Guerrero, Jose Angel Suarez Caballero, Isidoro Souto Bethencourt, Juan R. Dominguez Beatell, Elena Vanesa Rojas Manrique, Maria Jose Sanz Orejas, Cary Perez Lorenzo, Jesús Antonio Pérez Jiménez, Silvia Lara Afonso Trujillo, Bartolomé Dominguez Del Río Boada, Stavroula Papageorgakopoulou, Eleytheria Vakouti, Claire Gkatzoudi, Thodoris Krasanakis, Dimitris Kounalakis , Izoldi Bouloukaki, Nikolaos Tsakountakis, Emmanouela Chronaki, Katherine Mary Borg and Kamila Abutalieva for their time and efforts to perform the study measurements and complete patient inclusion, even in the challenging times of the pandemic. Finally, they would like to thank the participants who generously gave their time to participate in the study.
The study sponsor is the General Practitioners Research Institute; data collection and analysis were performed by the
General Practitioners Research Institute. Boehringer Ingelheim is the funding and scientific partner

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author J.K


  • Chronic Obstructive Pulmonary Disease
  • Dry Powder Inhaler
  • health economics
  • Cost Analysis
  • Healthcare Resource Utilisation


Dive into the research topics of 'Suboptimal peak inspiratory flow and critical inhalation errors are associated with higher COPD-related healthcare costs'. Together they form a unique fingerprint.

Cite this