Abstract
Purpose
To develop a consensus document on how to follow-up patients with COPD in clinical practice in Spain.
Methods
A qualitative, three-round Delphi survey was conducted in the framework of Spanish pneumologists attending COPD patients in routine daily practice. Participants completed a 35-item questionnaire on how to follow-up COPD patients, according to four sections: 1) assessment of the patient’s clinical conditions, 2) therapeutical interventions, 3) frequency of follow-up visits, and 4) healthcare pathways. Consensus was defined if more than 70% of participants agree.
Results
A total of 155 specialists in respiratory medicine (53% men; mean age 47 years) participated in the study (69% with more than 10 years of professional practice). More than 80% of participants agreed on the use of clinical practice guidelines but 81.9% considered that recommendations on follow-up should be more explicit. Assessment of lung function (FEV1), dyspnea, and exacerbations were the clinical variables that reached a higher level of consensus. Dyspnea values were reported as the main indicator to assess increased bronchodilation, and exacerbations were the most important to assess the use of inhaled corticosteroids. Follow-up of low-risk patients should be performed in the primary care setting, and patients should be visited every 12 months, whereas high‑risk patients should be monitored by pneumologists and including nursing visits.
Conclusion
The participants agree that the guidelines should include more specific indications to define the follow-up of the COPD patient, and there is lack of evidence in many aspects. There is consensus on the importance of care to coordinate with nursing and primary care, but the protocols to follow and the working tasks for each healthcare setting remain unclear.
Keywords: chronic obstructive pulmonary disease, patient monitoring, pneumologists, primary care, expert consensus
Introduction
Chronic obstructive pulmonary disease (COPD) is a major public health problem and will remain a challenge for clinicians within the 21st century.1 In addition to impose a substantial impact on individuals with the disease due to a wide range of symptoms in terms of exacerbations, disability and impaired quality of life, COPD severity and its comorbidities are associated with a huge burden on direct and indirect costs.2,3 In a systematic review and meta-analysis to quantify the global prevalence of COPD, the pooled prevalence in adults aged ≥ 40 years was about 9–10%,4 which is consistent with data reported in other epidemiological studies in Spain.5–7
The quality of care for patients with COPD can be improved by adequate implementation of evidence-based treatment guidelines. However, a review of national guidelines for management of COPD in Europe showed good agreement on treatment goals, criteria for diagnosis of COPD, and use of long-acting bronchodilators, but there were differences in the definitions of patient subgroups and other recommended treatments.8 In relation to stratification of disease severity and prediction of future risk, patients are usually stratified based on the degree of airflow limitation into the four stages proposed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD),9 symptom severity, dyspnea, quality of life, and exacerbations. Also, clinical practice guidelines8,10 recognize that routine follow-up of COPD patients is essential as lung function and clinical status may worsen over time even with the best available care. Follow-up routines recommended regularly include evaluation of decline in FEV1 tracked by spirometry, symptoms assessment using the COPD Assessment Test (CAT),11 dyspnea using the modified Medical Research Council (mMRC) score,12 frequency, severity and likely causes of exacerbation, exercise tolerance, comorbidity, and smoking habits.8–10 Assessment of adherence to inhalers using specific questionnaires, such as the Test of Adherence to Inhalers (TAI),13 is also recommended. However, an analysis of 18 current guidelines’ recommendations for the follow-up of patients with COPD concluded that in none of the guidelines follow-up routines were evidence based.14 Likewise, a national clinical audit conducted in Spain, in 2017, revealed considerable variability and insufficient implementation of clinical guidelines, particularly the lack of a multidimensional disease evaluation to establish prognosis in more than 75% of COPD patients undergoing long-term follow-up in respiratory clinics.15
Despite awareness of the crucial role of routine follow-up of COPD patients to reduce the impact of exacerbations on outcomes, the risk of hospitalization, impairment of quality of life, and deterioration of health status, there are still uncertainties about the follow-up of patients with COPD in the real-world setting. Therefore, a survey study was designed to reach a consensus on the characteristics of the follow-up of patients with COPD in routine daily practice in Spain.
Materials and Methods
Design and Setting
Between May and December 2019, a qualitative, three-round Delphi study (“The SEGUIPOC Study”, acronym for SEGUImiento del paciente con ePOC [Follow-up of the Patients with COPD]) was conducted in the framework of Spanish pneumologists from public and private medical centers attending COPD patients in routine daily practice. The Delphi method is a valid procedure to reach consensus in which participants’ aggregated responses and adjustment of answers in subsequent rounds according to the group response, and the ultimate result represents to be a true consensus of what the group thinks.16,17
Participants and Procedures
The expert scientific committee was composed of four specialists in respiratory medicine with particular experience in the care of patients with COPD. The content and topics to be included in the study questionnaire were designed by the scientific committee based on their experience and a comprehensive search of the literature to identify previously conducted studies with high level of evidence and key primary studies focused on the management and follow-up of patients with COPD. The four members of the scientific committee participated in the development of the protocol and supervised the progression of the study, including recruitment of participants and results of data analysis.
Candidates to participate in the study were specialists in respiratory medicine involved in the care of patients with COPD visited in public or private consultations throughout Spain, who attended about 100 patients with COPD on a monthly basis and participated actively in the area of COPD of Spanish Society of Pneumology and Thoracic Surgery (SEPAR). Participants were recruited through invitations sent by e-mail, and participation in the study was anonymous and voluntary. The study questionnaire was lodged in an Internet microsite to which participants accessed via a weblink included in the e-mail. Physicians who accepted to participate in the study were provided with the microsite URL and the user’s password.
The study questionnaire included 35 items, divided into six sections, which included data of the participants and their centres (8 items); clinical assessment of the patient (8 items), assessment of pharmacological treatment (7 items), assessment of non-pharmacological interventions (2 items), frequency of follow-up visits (4 items), and healthcare pathway (4 items). The study questionnaire is described in the Supplementary material.
In relation to the follow-up, the Spanish COPD guideline (GesEPOC) 201718 was used for the classification of risk (low or high risk) on the basis of lung function, dyspnea grade, and history of exacerbations, as well as for the definition of the clinical phenotypes of non-exacerbator, asthma-COPD overlap (ACO), exacerbator with emphysema, and exacerbator with bronchitis. Briefly, non-exacerbators are characterized by presenting a maximum of one episode of exacerbation in the previous year; ACO is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD; exacerbator with emphysema presents two or more moderate exacerbations (that require at least outpatient treatment with systemic corticosteroids and/or antibiotics) in the previous year, or at least one severe exacerbation that requires hospital admission; and exacerbator with bronchitis is distinguished by the presence of cough and sputum production for at least 3 months per year in 2 consecutive years.
Briefly, those questions in which consensus was not achieved on the first round were included in the questionnaire of the second round. For those questions in which consensus was not obtained neither in the first and second rounds, solution to these uncertainties was sought in the third round.
The level of agreement was assessed using a 9-point Likert scale, categorized as 1 = “strongly disagree”, 2 = “somewhat disagree”, 3 = “disagree”, 4 = “slightly neutral (indifferent)”, 5 = “somewhat neutral (indifferent)”, 6 = “neutral (indifferent)”, 7 = “somewhat agree”, 8 = “agree”, and 9 = “strongly agree”. Consensus in favor or against each statement was defined if more than 70% of participants rated the item between 7 and 9 (agreement) or between 1 and 3 (disagreement).
Statistical Analysis
This was a qualitative study, the objective of which was to reach consensus among professionals involved in the care of COPD patients. Because it was a qualitative rather than a quantitative study, the number of selected participants according to a probability error was not fixed. However, the participation of 160 specialists in respiratory medicine was expected; a sample size would allow to analyze the questions raised in the objectives of the study with an error of 8% for a confidence level of 95% and maximal variability (p=q=0.5). Changes in responses between the two rounds were analyzed with the paired Student’s t test for continuous data and the McNemar-Bowker test for categorical variables. Descriptive statistics included frequencies and percentages for categorical variables and mean and standard deviation (SD) for continuous variables. Agreement was also expressed as the mean value and the standard deviation (SD) of the categories 7, 8, and 9 of the Likert scale. Data were analyzed using the SAS statistical program (Statistical Analysis Systems, SAS Institute, Cary, NC, USA) version 9.1.3 for Windows.
Results
A total of 155 specialists in respiratory medicine from all autonomous communities in the country participated in the study. There were 82 men and 73 women, with a mean (SD) age of 47 (10) years. Most participants (89.7%) worked in public hospitals and 69% had more than 10 years of professional practice. A total of 121 participants (78.1%) worked in general pneumology services and 17 (11%) in monographic COPD units. Overall, 63.2% of participants reported that between 25 and 75 patients they had attended in the previous week presented with COPD. A large number of pneumologists (71%) had participated in a training program on COPD and 40.6% in a research project of the disease in the previous 12 months.
Patients’ Clinical Assessment
Results of this section of the questionnaire are shown in Table 1. Overall, there was a high level of agreement (> 95%) in the 10 items related to clinical aspects that should be evaluated at follow-up visits. Consensus was also obtained regarding the use of CAT, mMRC, TAI and assessment of physical activity level at follow-up visits, although consensus was not reached for the use of the Clinical COPD Questionnaire (CCQ). More than 80% of participants agreed on the use of guidelines (GOLD9 and GesEPOC10) for the follow-up of COPD patients, but 81.9% considered that recommendations in these guidelines should be more explicit, 96.8% that follow-up should be different according to the risk level stratification. Although 98.1% agree that the risk should be periodically evaluated, only 36.8% selected performing evaluation at each medical visit. There was consensus regarding the need to identify frequent and non-frequent exacerbators (97.4%) and to differentiate follow-up strategies according to these categories (87.8%). In the follow-up of low-risk patients, exacerbations in the last year was the variable with the highest percentage of agreement (95.5%), whereas in high-risk patients, hospitalizations in the last year was the most frequently cited (98.7%) (Figure 1).
Table 1.
Resources Used and Characteristics of Follow-Up of COPD Patients
| Clinical Assessment of the Patient (Items of the Questionnaire) | Mean (SD) | Agreement No. (%) |
Disagreement No. (%) |
|---|---|---|---|
| Clinical history | |||
| Overall assessment (subjective) of the patient’s status | 8.1 (1.1) | 148 (95.5) | 1 (0.6) |
| Symptoms (dyspnea, cough, expectoration, sputum, etc) | 8.7 (0.8) | 153 (98.7) | 1 (0.6) |
| Previous exacerbations (number, type and severity) | 8.7 (0.8) | 154 (99.3) | 1 (0.6) |
| Use of rescue medication | 8.3 (1.0) | 149 (96.1) | 1 (0.6) |
| Patient’s physical activity | 8.4 (0.9) | 149 (96.1) | 1 (0.6) |
| Control of risk factors (e.g smoking) | 8.5 (0.9) | 153 (98.7) | 1 (0.6) |
| Review of comorbidities | 8.2 (1.0) | 145 (93.5) | 0 (0) |
| Vaccinations | 8.1 (1.1) | 149 (96.1) | 1 (0.6) |
| Correct use (technique) inhalers | 8.6 (0.9) | 152 (98.1) | 1 (0.6) |
| Adherence to routine inhalation therapy | 8.7 (0.8) | 153 (98.7) | 1 (0.6) |
| Use of questionnaires | |||
| COPD Assessment Test (CAT) | 7.6 (1.4) | 133 (85.8) | 3 (1.9) |
| Clinical COPD Questionnaire (CCQ) | 5.6 (1.7) | 57 (36.8) | 22 (14.2) |
| Assessment of physical activity level | 7.7 (1.5) | 134 (86.4) | 3 (1.9) |
| Dyspnea scale (mMRC) | 8.5 (1.1) | 152 (98.1) | 2 (1.3) |
| Test of Adherence to Inhalers (TAI) | 7.0 (1.5) | 122 (78.7) | 7 (4.5) |
| Clinical practice guidelines | |||
| GesEPOC recommendations | 7.7 (1.4) | 129 (83.2) | 1 (0.6) |
| GOLD recommendations | 7.6 (1.2) | 128 (82.6) | 0 |
| How follow-up should be performed is undefined | 5.1 (2.3) | 61 (39.3) | 56 (36.1) |
| Follow-up recommendations should be more explicit | 7.2 (1.5) | 127 (81.9) | 9 (5.8) |
| Follow-up should be different according to the patient’s level of risk | 0 (0) | 150 (96.8) | 5 (3.2) |
| The risk level of COPD patients should be periodically evaluated | 8.1 (0.9) | 152 (98.1) | 0 (0) |
| At each medical visit | 0 (0) | 57 (36.8) | 0 (0) |
| Every 3 moths | 0 (0) | 12 (7.7) | 0 (0) |
| Every 6 months | 0 (0) | 43 (27.7) | 0 (0) |
| Every year | 0 (0) | 40 (25.8) | 0 (0) |
| Missing | 0 (0) | 3 (1.9) | 0 (0) |
| It is necessary to identify frequent and non-frequent exacerbators | 8.6 (0.9) | 151 (97.4) | 1 (0.6) |
| Follow-up should be different for frequent and non-frequent exacerbators | 7.1 (7.7) | 136 (87.8) | 11 (7.1) |
Notes: Agreement (Likert 7–9) and disagreement (1–3) only; neutral (4–6) not shown.
Abbreviations: GesEPOC, the Spanish COPD Guideline; GOLD, Global Initiative for Chronic Obstructive Lung Disease; mMRC, modified Medical Research Council; SD, standard deviation.
Figure 1.
Consensus reached in the variables to assess the level of risk in the follow-up of low-risk and high-risk patients.
Abbreviations: FEV1, forced expiratory volume in one second; mMRC, modified Medical Research Council score; CAT, COPD Assessment Test; CCQ, Clinical COPD Questionnaire; SGRD, Saint George Respiratory Questionnaire; mo, months.
Assessment of Pharmacological Treatment
As shown in Table 2, participants considered that clinical practice guidelines provided clear recommendations on pharmacological treatment and escalating strategies, but consensus was not reached for clear recommendations of clinical practice guidelines regarding the use of mucolytic agents, reasons for de-escalating pharmacological treatment, and a change of molecules of the same class. Agreement was reached regarding reasons for changing treatment included exacerbations, in-hospital/emergency care, rescue medication (salbutamol ≥ 2 puffs/day), eosinophil count, and worsening of lung function. As shown in Table 3, exacerbation episodes and dyspnea were the variables with the higher percentages of agreement at the time of considering different medication regimens in escalating, de-escalating, and change of medication strategies.
Table 2.
Assessment of Pharmacological Treatment in the Follow-Up of COPD Patients
| Items of the Questionnaire | Mean (SD) | Agreement No. (%) |
Disagreement No. (%) |
|---|---|---|---|
| Clinical practice guidelines include clear recommendations regarding the use of pharmacological treatment of COPD for each of the therapeutic families | |||
| Monotherapy (LAMA) | 7.7 (1.5) | 137 (88.4) | 6 (3.9) |
| Fixed dose combinations of LABA/ICS | 7.4 (1.6) | 127 (81.9) | 5 (3.2) |
| Double bronchodilation (LAMA/LABA) | 8.2 (0.9) | 151 (97.4) | 1 (0.6) |
| Triple therapy (LABA/LAMA/ICS) | 7.8 (1.3) | 139 (89.7) | 3 (1.9) |
| Phosphodiesterase IV inhibitors | 7.3 (1.4) | 126 (81.3) | 4 (2.6) |
| Macrolides | 7.1 (1.3) | 132 (85.2) | 8 (5.2) |
| Mucolytics | 6.2 (1.4) | 84 (54.2) | 12 (7.7) |
| The reasons for recommending escalating pharmacological treatment in COPD are well defined in clinical practice guidelines | 7.2 (1.4) | 132 (85.2) | 7 (4.5) |
| The reasons for recommending de-escalating pharmacological treatment in COPD are well defined in clinical practice guidelines | 5.9 (1.8) | 79 (51.0) | 27 (17.4) |
| The reasons for recommending a change of molecules of the same therapeutic class are well defined in clinical practice guidelines | 4.8 (2.1) | 50 (32.2) | 67 (43.2) |
| There is an agreement between recommendations of clinical practice guidelines and actual clinical practice | 5.3 (1.8) | 55 (35.5) | 39 (25.2) |
| Decision regarding a change of pharmacological treatment are based on: | |||
| Moderate exacerbations (outpatient antibiotics and/or oral steroids) | 7.9 (1.3) | 140 (90.3) | 2 (1.3) |
| Severe exacerbations (hospital admission and/or stay in the emergency room > 24 h) | 8.5 (0.9) | 153 (98.7) | 1 (0.6) |
| Persistence of dyspnea ≥ 2 mMRC | 7.9 (1.3) | 142 (91.6) | 2 (1.3) |
| Persistence of CAT score ≥ 10 points | 6.2 (1.9) | 95 (61.3) | 23 (14.8) |
| Changes in the colour of sputum during the stable phase | 6.2 (1.9) | 104 (67.1) | 25 (16.1) |
| Need to use rescue medication (salbutamol ≥ 2 puffs/day) | 7.3 (1.4) | 123 (79.3) | 4 (2.6) |
| Peripheral blood eosinophil count | 6.6 (1.6) | 110 (71.0) | 13 (8.4) |
| Lung function deterioration | 7.8 (1.3) | 138 (89.0) | 3 (1.9) |
| The appearance of a side effect of mild intensity (xerostomia, oropharyngeal candidiasis, ecchymosis) is a reason for considering withdrawal of a pharmacological treatment | 5.0 (2.2) | 58 (37.4) | 62 (40) |
| The appearance of a side effect of moderate or severe intensity (cardiac arrhythmia, pneumonia or acute urinary retention) is a reason for considering withdrawal of a pharmacological treatment | 7.9 (1.3) | 145 (93.6) | 2 (1.3) |
| Adherence to pharmacological treatment | |||
| I monitor the level of adherence to the pharmacological treatment | 7.9 (1.3) | 146 (94.2) | 4 (2.6) |
| I monitor the level of adherence to the pharmacological treatment at each visit | 7.5 (1.8) | 129 (83.2) | 9 (5.8) |
| I use questionnaires to measure adherence to treatment | 4.8 (2.2) | 50 (32.2) | 60 (38.7) |
| The Test of Adherence to Inhalers (TAI) is a good method for assessing adherence to pharmacological treatment in daily practice | 6.4 (1.7) | 100 (64.5) | 13 (8.4) |
| I use the TAI questionnaire in my routine practice | 4.3 (2.3) | 41 (26.4) | 82 (52.9) |
| I monitor the inhalation technique | 8.1 (1.3) | 146 (94.2) | 3 (1.9) |
| I monitor the inhalation technique for each patient | 7.9 (1.4) | 135 (87.1) | 3 (1.9) |
Notes: Agreement (Likert 7–9) and disagreement (1–3) only; neutral (4–6) not shown.
Abbreviations: ICS, inhaled corticosteroids; LABA, long-acting beta-agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council; SD, standard deviation.
Table 3.
Variables to Be Consider in Changing Pharmacological Treatment in the Follow-Up of COPD Patients
| Therapeutic Change | Dyspnea No. (%) |
Exacerbations No. (%) |
Rescue Medication No. (%) |
Eosinophil Count No. (%) |
Inhaler Device No. (%) |
|---|---|---|---|---|---|
| Escalating treatment | |||||
| Monotherapy to LAMA/LABA | 152 (98.1) | 108 (69.7) | 122 (78.7) | 11 (7.1) | 72 (46.4) |
| Monotherapy to LABA/ICS | 49 (31.6) | 140 (90.3) | 64 (41.3) | 140 (90.3) | 53 (34.2) |
| LAMA/LABA combination to triple therapy | 100 (64.5) | 151 (97.2) | 81 (52.3) | 128 (82.6) | 71 (45.8) |
| LABA/ICS combination to triple therapy | 138 (89.0) | 132 (85.2) | 105 (67.7) | 50 (32.3) | 68 (43.9) |
| De-escalating treatment | |||||
| LABA/LAMA combination to monotherapy | 146 (94.2) | 103 (66.4) | 81 (52.3) | 6 (3.9) | 40 (25.8) |
| LABA/ICS combination to monotherapy | 85 (54.8) | 136 (87.7) | 62 (40.0) | 99 (63.9) | 39 (25.2) |
| Triple therapy to a LAMA/LABA combination | 90 (58.1) | 144 (92.9) | 62 (40.0) | 102 (65.8) | 37 (23.9) |
| Triple therapy to a LABA/ICS combination | 126 (81.3) | 114 (73.5) | 77 (49.7) | 65 (41.9) | 43 (27.7) |
| To change medication | |||||
| LABA/ICS combination to a double bronchodilation | 120 (77.4) | 120 (77.4) | 61 (39.3) | 105 (67.7) | 52 (33.5) |
| Double bronchodilation to a LABA/ICS combination | 70 (45.2) | 134 (86.4) | 53 (34.2) | 136 (87.7) | 42 (27.1) |
| Two molecules of the same class (e.g LAMA/LABA combinations) | 85 (54.8) | 38 (24.5) | 54 (34.8) | 13 (8.4) | 140 (90.3) |
Abbreviations: ICS, inhaled corticosteroids; LABA, long-acting beta-agonist; LAMA, long-acting muscarinic antagonist.
However, 90.3% of participants considered that the inhaler device should be taken into account at the time of changing two molecules of the same class. Most participants (93.6%) agreed that the presence of an adverse event of moderate or severe intensity (cardiac arrhythmia, pneumonia, acute urinary retention) was a reason to consider withdrawal of a pharmacological treatment. There was agreement in the need to assess adherence to treatment at follow-up (94.2%) and at each follow-up visit (83.3%), as well as to evaluate the inhalation technique at follow-up (94.2%) and at each follow-up visit (87.1%). Although the TAI questionnaire was considered to be a reliable tool to assess adherence (64.5%), only 26.4% used this questionnaire in daily practice (Table 2). A high percentage of participants (84.5%) asked about adverse events at each visit.
Assessment of Non-Pharmacological Interventions
There was consensus regarding assessment of tobacco smoking (87.1%) and nutrition (78%), recommendation of influenza and pneumococcal vaccination (98.7%) as well as physical exercise (84.6%), and respiratory rehabilitation (82.6%). Also, 85.2% of participants included non-pharmacological interventions in the follow-up of COPD patients and 75.5% considered that more information and scientific evidence of these interventions are required.
Frequency of Follow-Up Visits
There was consensus (85.2%) regarding that the follow-up of low-risk patients should be performed in the Primary Care setting and that patients should be visited every 12 months (71.6%) (Figure 2). In high‑risk non-exacerbator COPD patients, consensus was obtained only for the statement that a nursing visit (healthcare education) should be included in their follow-up (87.7%). In these patients, 65.2% of participants selected every 6 months as the frequency of visits (Figure 2). However, in high‑risk exacerbator COPD patients, participants agreed that these patients should be monitored by pneumologists (98.7%), including nursing visits (healthcare education) (92.9%), and that visits should be face-to-face (81.9%). The frequency of visits every 3 months was reported by 56% of participants (Figure 2). Table 4 shows the studies that should be performed at follow-up visits in low‑risk and high-risk patients (non-exacerbators and exacerbators) together with the frequency of indication and whether consensus was achieved. In all studies in which consensus was obtained, participants considered that studies, such as arterial blood gases, chest computerized tomography (CT) scan, echocardiography, and biomarkers should be performed if there was a medical reason.
Figure 2.
Percentages of responses regarding the frequency of follow-up visits in COPD patients based on the level of risk and non-exacerbator and exacerbator phenotypes.
Table 4.
Recommended Studies to Be Performed in COPD Patients at Follow-Up
| Studies | Low Risk | High Risk | |
|---|---|---|---|
| Non-Exacerbator | Exacerbator | ||
| Blood tests | 63.9% (medical reason) | 43.2% (every year) | 47.1% (every year) |
| Eosinophil count | 52.3% (medical reason) | 45.8% (every year) | 54.2% (every year) |
| Spirometry | 66.5% (every year) | 56.8% (every year) | 49.0% (every 6 months) |
| Bronchodilation test | 38.7% (every year) | 45.2% (every year) | 34.8% (every year) |
| Pulse oximetry | 53.5% (every year) | 40.6% (every year) | 39.4% (every 6 months) |
| Lung volumes | 69.7% (medical reason) | 36.1% (medical reason) | 41.9% (every year) |
| DLCO | 64.5% (medical reason) | 41.3% (every year) | 45.8% (every year) |
| 6-min walk test | 74.2% (medical reason) | 37.4% (medical reason) | 41.9% (every year) |
| Arterial blood gases | 90.3% (medical reason) | 78.1% (medical reason) | 61.9% (medical reason) |
| CAT questionnaire | 59.4% (every year) | 45.2% (every year) | 41.9% (every 6 months) |
| Chest radiography | 41.9% (medical reason) | 49.0% (every year) | 56.1% (every year) |
| Chest CT scan | 41.9% (medical reason) | 90.3% (medical reason) | 80.6% (medical reasons) |
| Echocardiography | 96.8% (medical reason) | 83.9% (medical reason) | 71.6% (medical reasons) |
| Biomarkers | 91.6% (medical reason) | 85.8% (medical reason) | 72.3% (medical reasons) |
| Treatment | 61.3% (every year) | 57.4% (every 6 months) | 47.7% (every 6 months) |
| Adherence inhalation technique | 61.9% (every year) | 55.5% (every 6 months) | 47.7% (every 6 months) |
Note: Items in which consensus was achieved are highlighted in green.
Abbreviations: CAT, COPD Assessment Test; CT, computed tomography; DLCO, diffusing capacity of the lungs for carbon monoxide.
Healthcare Pathway
Although 99.4% of participants agreed that close collaboration between Pneumology and Primary Care is an essential aspect in the follow-up of COPD patients, 61.3% recognized that collaboration was non-existent because of lack of common protocols (31.6%) and communication between the two levels of care (30.3%), lack of time (38.7%), and the fact that a coordinated follow-up strategy remained undefined (47.1%). Among criteria for discharge a COPD patient from the follow-up by Pneumology, there was consensus in case of low-risk patients (90.4%) and slightly symptomatic patients (71%). Also, 94.2% of participants recognized that nursing care programs in the Primary Care setting should be developed to guarantee a correct follow-up of COPD patients. All components of a primary care nursing program obtained consensus (promoting physical exercise/physical activity 99.3%, revision of the inhalation technique 100%, knowledge of the disease 94.8%, promoting adherence to inhalation technique 99.3%, vaccination program 99.3%, use of assessment questionnaires for follow-up control 84.5%, and non-face-to-face visits 73%). Moreover, there was consensus regarding the involvement of case management nursing (90.9%) and social workers (81.9%) in the follow-up high risk, complex COPD patients.
Discussion
This is the first Delphi study focused on the follow-up of patients with COPD conducted among pneumologists from public and private centers with representation from all the Spanish geography.
Results of the study indicate that clinical practice guidelines are insufficient for providing explicit recommendations on the follow-up of patients with COPD. Assessment of lung function (FEV1), dyspnea, and exacerbations were the variables that reached a higher level of consensus in the follow-up of COPD patients. Although decline in FEV1 function can be tracked by spirometry, consensus regarding the frequency of the indication of spirometry was not reached as 66.5% and 56.8% of participants recommended to perform spirometry studies every year in low‑risk and high‑risk non-exacerbator patients, respectively, and 49% recommended spirometry every 6 months in high‑risk exacerbators. Spirometry, however, is underused in the follow-up of patients with COPD. In a multicenter, cross-sectional study carried out in 801 patients with COPD attended in 21 primary care centers in Catalonia (Spain) during 2004–2005, only 50.8% had undergone a follow-up spirometry in the previous 2 years.19 In this study, however, the presence of follow-up spirometry in the previous 2 years did not modify the therapeutic approach of the professionals at the primary care level, which suggests that there is a tendency towards homogenizing the treatment regardless of the presence or absence of spirometry, or rather the spirometry results and their therapeutic implications have not been correctly understood.19
Participants also agreed on the importance of assessing acute exacerbation episodes and hospitalizations during the patients’ follow-up. In high-risk patients, 99% of participants agreed on the relevance of hospitalizations in the last year. It is well known that exacerbations represent an important event in the natural history of COPD patients and are associated with significant morbidity, mortality, and socioeconomic impact.20 The need to assess dyspnea was also recognized by 98% of specialists, as dyspnea is a cardinal symptom of COPD and its severity and magnitude increase as the disease progresses.21
Another remarkable finding of the study was the consensus reached regarding the control of adherence to routine inhalation treatment and appropriate use (technique) of inhalers. Assessment of patient’s satisfaction with the inhalation treatment (eg using a visual analogue scale) is clinically relevant in daily practice, given that dosage of inhalation therapy is positively associated with a better adherence. It is recommendable to include training of inhalation technique at each follow-up visit, as well as to assess adherence to inhaler device before changing pharmacological treatment. Non-adherence to medication and incorrect use of inhalers represent significant barriers to optimal disease management in COPD patients in daily practice.22 In this context, real-world evidence from Spain supports the magnitude of this problem. In a recent study conducted in a primary care setting, adherence assessed using the Test of Adherence to Inhalers (TAI) was poor in 46.3% of the 988 cases analysed, and this was significantly associated with poorer clinical control of the Disease.23
Although written personalized action plans and training on inhaler technique as part of education programs for COPD are effective in improving symptom control, exacerbation risk, and quality of life,24,25 different studies have shown that healthcare professionals had inadequate knowledge of the proper use of inhalers, which prevents them to being able to adequately assess and teach proper inhalation techniques to their patients.26–28
In relation to step-up treatments at follow-up, there was consensus on the role of dyspnea and the need of rescue medication to increase bronchodilators, and exacerbations to use inhaled corticosteroids (ICS) for escalating. In relation to variables to be considered for step-down treatment, consensus was obtained regarding the use of level of dyspnea to guide the change from LABA/LAMA combination to monotherapy or from triple therapy to LABA/ICS combination, and the absence of acute exacerbations to change from LABA/ICS combination to monotherapy or triple therapy to LAMA/LABA combination. However, in order to adjust therapy appropriately as disease progresses, discussion of the current therapeutic regimen should be included at each follow-up visit. Clinical practice guidelines (CPGs) provide clear recommendations for pharmacological treatment during follow-up, and a high level of agreement was observed among participants. However, adherence to these recommendations remains suboptimal. In a Spanish clinical audit, triple therapy was widely used across all GOLD groups, including GOLD A patients, while incorrect inhaled therapy prescriptions occurred in 5.9% of cases, mainly due to duplicate therapies (5.2%), with absence of long‑acting bronchodilators in GOLD B–D (0.6%) and use of ICS alone (0.1%) also observed.29 These findings suggest that more precise guidance for treatment adjustment during follow-up may be needed. In this regard, the latest update of the Spanish COPD guidelines recommends the use of clinical control to monitor disease progression over time.10
The concept of control of COPD includes achievement of a low level of symptoms, stable disease without exacerbations and without significant worsening in lung function over prolonged periods of time. This status of low level of symptoms (or low impact) and stability is what has been defined as control in COPD.30,31 On the other hand, 98% of participants agreed on assessment of the level of risk, but consensus regarding the periodicity of this evaluation was not reached, with percentages of 37% at each medical visit and 25.8% on an annual basis.
In relation to the level of care, there was consensus that low‑risk COPD patients should be managed early and with annual follow-up visits in the primary care setting, whereas the follow-up of patients at risk of being exacerbators should be performed by pneumologists in specialized healthcare setting. Models of effective healthcare management for COPD patients propose integrated multidisciplinary interventions at different levels of the healthcare system through coordinated routine clinical practice, and care pathways defined in terms of individual patient characteristics, level of disease severity, and presence or absence of exacerbation.32 Benefits of expanding the role of nurses in the integrated management of COPD have been recognized,33,34 and we also found consensus on the need of developing nursing care programs in primary care. Participants agreed on the need for better coordination, definition of common protocols, and effective communication among professionals involved in the care of COPD patients (primary care physicians, specialized nurses, pneumologists) as essential aspects for improving the care of COPD patients. No agreement was reached on the recommended frequency of follow-up for complementary studies. This was particularly evident for serial spirometry. GOLD recommends “at least” annual spirometry in patients with COPD9 although no formal grading of the level of evidence or strength of recommendation is provided to support this statement. The absence of disease-modifying treatments proven to slow lung function decline, the requirement for multiple serial measurements to reliably assess progression, and the associated healthcare burden may represent important barriers to its routine implementation in clinical practice.35 These findings underscore the need for more robust evidence and clearer guidance to support decision-making regarding the frequency of monitoring tests in COPD follow-up.
The present results should be interpreted in light of several limitations. These include the relatively small number of participants and the fact that the questionnaire was developed in Spanish and distributed exclusively to specialists in respiratory medicine involved in the routine care of patients with COPD. It would also have been desirable to include primary care physicians in the target population to allow comparisons between different levels of care. In addition, the study was conducted between May and December 2019, and therefore there has been a substantial time interval between data collection and publication. During this period, important advances have occurred in the management of COPD, including updates in international and national clinical practice guidelines (eg GOLD and GesEPOC), as well as evolving concepts such as disease control and more individualized treatment approaches. As a result, some of the perspectives captured in this Delphi process may not fully reflect current clinical practice. However, we believe that the findings remain relevant, as they highlight persistent areas of uncertainty and variability in the follow-up of COPD patients, many of which continue to be insufficiently addressed in current recommendations. Moreover, after the development of the survey, new proposals for the conceptualization and control of COPD were incorporated into the Spanish guidelines,10,20 which consequently were not integrated into the questionnaire. As far as we are aware, no previous survey studies addressing integral aspects of the follow-up of patients with COPD have been reported, and the evolving conceptual framework of disease control underscores the need for periodic re-evaluation of consensus recommendations as clinical practice and guidelines continue to advance.
Conclusion
This Delphi survey study of pneumologists with expertise in COPD provides a reference framework for patient management in clinical practice. The study shows that clinicians would benefit from more specific guideline recommendations regarding patient follow-up, as evidence remains limited in several areas. Overall, a high level of agreement was observed regarding recommendations for pharmacological treatment. There was also consensus on the need to strengthen coordination with nursing and primary care, although protocols and roles across levels of care remain insufficiently defined. Dyspnoea was identified as the main indicator for bronchodilator escalation, and exacerbations for the use of ICS.
Acknowledgments
The authors would like to thank all COPD experts in the SEGUIPOC Study Group who independently participated in the Delphi questionnaire, as well as Natalia Bartolomé and Alfonso Martínez for their project management support.
Funding Statement
This study was sponsored by GSK, which funded Grupo Saned S. L. to design and conduct the survey following the Delphi methodology, Marta Pulido, MD, PhD, to provide medical writing support for drafting the publication and Adelphi Targis S.L. for editorial support. The publication is also derived from a consensus initiative funded by GSK. GSK reviewed a draft of the publication for data accuracy only. The sponsor had no role in the identification of experts, development of the questionnaire, data analysis, interpretation of results, formulation of conclusions, or decisions related to manuscript content. The scientific committee made all scientific decisions independently. The study was conducted in accordance with the Farmaindustria Code of Good Practices.
Contributor Information
The SEGUIPOC Study Group (members by alphabetical order)::
S. Aguado Ibáñez, L. Alemany Frances, J. Allende González, W. Almonte Batista, E. Alonso Mallo, M. Alwakil Olbah, C. A. Amado Diago, E. I. Amara Elori, R. Amaro Rodriguez, M. Amatriain Arrozpide, I. S. Arroyo Fernández, M. J. Aviles Ingles, R. Ayerbe Garcia, M. Ballester Canelles, D. Barros Casas, J. B. Bauza Deroulede, J. Belda Ramírez, M. Bengoa Dolon, M. Bentabol Manzanares, C. Berastegui García, M. C. Bermejo Navas, N. Blanco Cid, D. Bravo Blanco, R. Bravo Fernández, A. Bustamante Ruiz, M. C. Cabrera Lacalzada, M. J. Cadenas De Llano Conde, M. Calderón Alcalá, J. C. Calderón López, S. Campos Téllez, F. Canales Cid, M. B. Cartón Sánchez, L. F. Cassini Gómez De Cádiz, R. Català Pérez, J. A. Ceballos Gutiérrez, J. Cegoñino De Sus, N. Celorrio Jiménez, A. Cobas Paz, M. Contreras González, P. Cordero Montero, J. Costan Galicia, V. Cresencio Pérez, A. J. Cruz Medina, J. M. Cruz Molina, E. De Casimiro Calabuig, E. B. De Higes Martinez, I. De Los Santos Ventura, N. Díaz Alfaro, C. Díaz Chantar, Y. Dobarganes Sanson, A. Doménech Del Rio, L. Domínguez Juncal, Z. El Molaka El Qulii, C. Esteban González, A. Falces Sierra, R. Fernández Mellado, D. Ferrando García, A. Fuster Gomila, M. Gallego Díaz, E. García Castillo, J. A. García Romero De Tejada, J. Garcia De Pedro, P. I. García Flores, M. C. García García, A. García Hidalgo, P. García López, J. P. García Múñoz, C. García Quero, J. L. García Rivero, P. García Sidro, R. Golpe Gómez, H. Gómez Márquez, M. T. González García, A. González López, F. González Vargas, M. A. Gotor Lázaro, J. Grau Delgado, I. Hamad Chaaban, J. Hernández Borge, C. Hinojosa Astudillo, B. Hortal Reina, M. D. Ibáñez Cuerda, I. Inchaurraga Alvarez, D. Jorge García, A. Juanes Olite, E. Juárez Moreno, S. A. Juarros Martínez, A. Lahuerta Castro, R. Lama Martínez, L. Lamrini Hamido Laarbi, J. Lázaro Polo, M. Lobo Gallardo, C. López Represa, C. López Riolobos, M. Lumbierres Burgues, E. Macías Fernández, R. Magarolas Jordà, D. Malia Alvarado, F. Marín Sánchez, C. Martín Ontiyuelo, A. Martín Medina, M. A. Martín Pérez, E. Martín Zapatero, J. A. Martínez Carbonell, C. Martínez González, A. Martínez Sanchís, J. A. Martos Velasco, C. Matesanz Ruiz, M. Merino Sánchez, R. Mirambeaux Villalona, A. Molina Cano, G. Mora Ortega, A. Múñoz Montiel, A. Ortega González, A. M. Pérez Fernández, F. Pérez Grimaldi, J. G. Pérez Mendoza, A. M. Pérez Rodríguez, J. Pérez Ronchel, J. A. Pinto Blázquez, C. Puchaes Manchón, N. Quilez Ruiz-Rico, C. Represas Represas, N. Reyes Núñez, J. P. Rivas López, J. L. Rodríguez Hermosa, F. Rodríguez García, P. Rodríguez Rodríguez, F. J. Roig Vázquez, V. Roig Figuero, A. Romero Ortíz, D. Romero Ribate, V. F. Romero Sanz, J. A. Royo Prats, C. Rueda Rios Rios, C. Ruiz Martínez, D. Sánchez Berenguer, M. Sánchez Bommatty, I. M. Sánchez Hernández, I. Sánchez Rodríguez, R. Sandoval Contreras, P. Sanz Sanz, A. Saura Vinuesa, J. Sellares Torres, P. Sobradillo Ecenarro, C. Soto Fernández, J. Tabara Rodríguez, F. Tatay Soler, M. Torres González, A. Valido Morales, M. Valle Falcones, R. Vázquez Oliva, A. I. Velázquez Benítez, I. Véliz Flores, F. J. Verdú Rivera, M. Vilaplana Vilaplana, Marc Vilaplana, and L. Zamora Molina
Use of Artificial Intelligence
No artificial intelligence tools were used to generate, analyse, or draft the scientific content of this manuscript.
Abbreviations
ACO, asthma-COPD overlap; CAT, COPD Assessment Test; CCQ, Clinical COPD Questionnaire; COPD, Chronic Obstructive Lung Disease; CT, Computerized Tomography; DLCO, Diffusing Capacity of the Lungs for Carbon Monoxide; FEV1, Forced Expiratory Volume in one second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, Inhaled Corticosteroids; LABA, Long-Acting Beta-Agonist; LAMA, Long-Acting Muscarinic Antagonist; mMRC, modified Medical Research Council; SAS, Statistical Analysis Systems; SD, Standard Deviation; TAI, Test of Adherence to Inhalers; SEGUIPOC, SEGUImiento del paciente con ePOC [Follow-up of the COPD patient]); SEPAR, Spanish Society of Pneumology and Thoracic Surgery.
Data Sharing Statement
For requests for access to anonymised subject level data, please contact corresponding author.
Ethical Considerations and Informed Consent
This study is a Delphi expert consensus survey and does not constitute a clinical trial. The participants were healthcare professionals recognized as experts in the management of Chronic Obstructive Pulmonary Disease (COPD), who were asked to provide their opinions on specific issues related to treatment adherence and disease control. No patients were involved in the study, and the experts did not undergo any interventions or biological sample collection. In accordance with the ISPOR Good Practices for Outcomes Research (2017), specifically sections 9.2 and 9.3 from Appendix 9, and the EPHMRA Code of Conduct (2023), specifically sections 1.2 and 1.3, as well as examples from similar published studies, ethical review is not required for this type of non-interventional research. Only experts who provided consent to participate through the online platform were included in the Delphi survey. Data were analysed anonymously, ensuring confidentiality and privacy. Additionally, the questionnaire content does not pertain to clinical trials or scientific research involving patient data, nor does it compromise the physical or psychological integrity of any subject.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
B. Alcázar-Navarrete reports grants and personal fees from GSK; personal fees and non-financial support from Novartis AG, Boehringer Ingelheim, Chiesi, Laboratorios Menarini; payments to institution from Sanofi, GSK, AstraZeneca; personal fees from AstraZeneca, Gilead, Bial, PulmonX, outside the submitted work. M. Miravitlles has received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols and Novartis; consulting fees from AstraZeneca, Atriva Therapeutics, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, Spin Therapeutics, ONO Pharma, pH Pharma, Palobiofarma SL, Takeda, Novartis, Sanofi and Grifols and research grants to institution from Grifols. J.A. Riesco reports grants and personal fees from GSK, grants, speaker fees from Astra-Zeneca, Pfizer, Novartis AG, Menarini, personal fees and non-financial support from Boehringer Ingelheim, Chiesi, Gebro, personal fees from Laboratorios Rovi, outside the submitted work. J.J. Soler-Cataluña has received grants for GlaxoSmithKline, speaker fees from AstraZeneca, Bial, Boehringer Ingelheim, Chiesi, Faes, GlaxoSmithKline, Grifols, Menarini and Sanofi, and consulting fees from AstraZeneca, Bial, Chiesi, GlaxoSmithKline, Grifols and Sanofi.
References
- 1.López-Campos JL, Tan W, Soriano JB. Global burden of COPD. Respirology. 2016;21(1):14–14. doi: 10.1111/resp.12660 [DOI] [PubMed] [Google Scholar]
- 2.Quaderi SA, Hurst JR. The unmet global burden of COPD. Glob Health Epidemiol Genom. 2018;3:e4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Miravitlles M, Ribera A. Understanding the impact of symptoms on the burden of COPD. Respir Res. 2017;18(1):67. doi: 10.1186/s12931-017-0548-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Halbert RJ, Natoli JL, Gano A, Badamgarav E, Buist AS, Mannino DM. Global burden of COPD: systematic review and meta-analysis. Eur Respir J. 2006;28(3):523–532. doi: 10.1183/09031936.06.00124605 [DOI] [PubMed] [Google Scholar]
- 5.Sobradillo-Peña V, Miravitlles M, Gabriel R, et al. Geographic variation in prevalence and underdiagnosis of COPD: results of the IBERPOC multicentre epidemiologic study. Chest. 2000;118(4):981–989. doi: 10.1378/chest.118.4.981 [DOI] [PubMed] [Google Scholar]
- 6.Miravitlles M, Soriano JB, García-Río F, et al. Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities. Thorax. 2009;64(10):863. doi: 10.1136/thx.2009.115725 [DOI] [PubMed] [Google Scholar]
- 7.Soriano JB, Alfageme I, Miravitlles M, et al. Prevalence and determinants of COPD in Spain: EPISCAN II. Arch Bronconeumol. 2021;57:61–69. doi: 10.1016/j.arbres.2020.07.024 [DOI] [PubMed] [Google Scholar]
- 8.Miravitlles M, Vogelmeier C, Roche N, et al. A review of national guidelines for management of COPD in Europe. Eur Respir J. 2016;47(2):625–637. doi: 10.1183/13993003.01170-2015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Global Initiative for Chronic Obstructive Lung Disease. 2026 GOLD Report [Internet]. 2026. Available from: https://goldcopd.org/2026-gold-report-and-pocket-guide/. Accessed August 07, 2026.
- 10.Miravitlles M, Calle M, Molina J, et al. Update 2025 of the Spanish COPD guidelines (GesEPOC): pharmacological treatment of stable COPD. Arch Bronconeumol. 2025;61(12):766–782. doi: 10.1016/j.arbres.2025.10.008 [DOI] [PubMed] [Google Scholar]
- 11.Jones PW, Harding G, Berry P, et al. Development and first validation of the COPD Assessment Test. Eur Respir J. 2009;34(3):648–654. doi: 10.1183/09031936.00102509 [DOI] [PubMed] [Google Scholar]
- 12.Bestall JC, Paul EA, Garrod R, et al. Usefulness of the medical research council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax. 1999;54:581–586. doi: 10.1136/thx.54.7.581 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Plaza V, Fernández-Rodríguez C, Melero C, et al. Validation of the ‘Test of the Adherence to Inhalers’ (TAI) for asthma and COPD patients. J Aerosol Med Pulm Drug Deliv. 2016;29(2):142–152. doi: 10.1089/jamp.2015.1212 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.van den Bemt L, Schermer T, Smeele I, et al. Monitoring of patients with COPD: a review of current guidelines’ recommendations. Respir Med. 2008;102(5):633–641. doi: 10.1016/j.rmed.2007.12.014 [DOI] [PubMed] [Google Scholar]
- 15.Calle Rubio M, López-Campos JL, Miravitlles M, et al. Variations in chronic obstructive pulmonary disease outpatient care in respiratory clinics: results from the 2021 EPOCONSUL audit. Arch Bronconeumol. 2023;59(5):295–304. doi: 10.1016/j.arbres.2023.02.004 [DOI] [PubMed] [Google Scholar]
- 16.Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008–1015. doi: 10.1046/j.1365-2648.2000.t01-1-01567.x [DOI] [PubMed] [Google Scholar]
- 17.Williams PL, Webb C. The Delphi technique: a methodological discussion. J Adv Nurs. 1994;19(1):180–186. doi: 10.1111/j.1365-2648.1994.tb01066.x [DOI] [PubMed] [Google Scholar]
- 18.Miravitlles M, Soler-Cataluña JJ, Calle M, et al. Spanish COPD guidelines (GesEPOC) 2017. Pharmacological treatment of stable chronic obstructive pulmonary disease. Arch Bronconeumol. 2017;53:324–335. doi: 10.1016/j.arbres.2017.03.018 [DOI] [PubMed] [Google Scholar]
- 19.Monteagudo M, Rodriguez-Blanco T, Parcet J, et al. Variability in the performing of spirometry and its consequences in the treatment of COPD in primary care. Arch Bronconeumol. 2011;47(5):226–233. doi: 10.1016/j.arbres.2010.10.009 [DOI] [PubMed] [Google Scholar]
- 20.Soler-Cataluña JJ, Piñera P, Trigueros JA, et al. en representación del grupo de trabajo de GesEPOC 2021. Spanish COPD Guidelines (GesEPOC) 2021 Update Diagnosis and Treatment af COPD Exacerbation Syndrome. Arch Bronconeumol. 2022;58:159–170. doi: 10.1016/j.arbres.2021.05.011 [DOI] [PubMed] [Google Scholar]
- 21.Marciniuk DD, Goodridge D, Hernandez P, et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. Can Respir J. 2011;18(2):69–78. doi: 10.1155/2011/745047 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Price D, Keininger DL, Viswanad B, et al. Factors associated with appropriate inhaler use in patients with COPD – lessons from the REAL survey [Erratum]. Int J Chron Obstruct Pulmon Dis. 2018;13:2253–2254. doi: 10.2147/COPD.S178410 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Calle Rubio M, Esmaili S, Rodríguez Hermosa JL, et al. Determinants and phenotypes of poorly controlled COPD using the RADAR score: a cohort in real-world primary care. J Clin Med. 2026;15:1283. doi: 10.3390/jcm15031283 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Kim YM, Yu M, Moon HR, et al. Effects of a tailored inhaler use education program for chronic obstructive pulmonary disease patients. Patient Educ Couns. 2020;103(4):717–723. doi: 10.1016/j.pec.2020.02.005 [DOI] [PubMed] [Google Scholar]
- 25.Press VG, Arora VM, Trela KC, et al. Effectiveness of interventions to teach metered-dose and diskus inhaler techniques. A randomized trial. Ann Am Thorac Soc. 2016;13(6):816–824. doi: 10.1513/AnnalsATS.201509-603OC [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Plaza V, Giner J, Rodrigo GJ, et al. Errors in the use of inhalers by health care professionals: a systematic review. J Allergy Clin Immunol Pract. 2018;6(3):987–995. doi: 10.1016/j.jaip.2017.12.032 [DOI] [PubMed] [Google Scholar]
- 27.Plaza V, Sanchis J. Medical personnel and patient skill in the use of metered dose inhalers: a multicentric study. CESEA Group. Respiration. 1998;65(3):195–198. doi: 10.1159/000029259 [DOI] [PubMed] [Google Scholar]
- 28.Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respir Care. 2005;50(10):1360–1375. doi: 10.4187/respcare.05501360 [DOI] [PubMed] [Google Scholar]
- 29.Lopez-Campos JL, Alcázar Navarrete B, Soriano JB, et al. Determinants of medical prescriptions for COPD care: an analysis of the EPOCONSUL clinical audit. Int J Chron Obstruct Pulmon Dis. 2018;13:2279–2288. doi: 10.2147/COPD.S160842 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Soler-Cataluña JJ, Alcázar B, Miravitlles M. Clinical Control in COPD: a new therapeutic objective? Arch Bronconeumol. 2020;56(2):68–69. doi: 10.1016/j.arbres.2019.06.004 [DOI] [PubMed] [Google Scholar]
- 31.Miravitlles M, Sliwinski P, Rhee CK, et al. Changes in control status of COPD over time and their consequences: a prospective international study. Arch Bronconeumol. 2021;57(2):122–129. doi: 10.1016/j.arbres.2020.06.003 [DOI] [PubMed] [Google Scholar]
- 32.Bolíbar I, Plaza V, Llauger M, et al. Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease. BMC Public Health. 2009;9:68. doi: 10.1186/1471-2458-9-68 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Fletcher MJ, Dahl BH. Expanding nurse practice in COPD: is it key to providing high quality, effective and safe patient care? Prim Care Respir Med. 2013;22(2):230–233. doi: 10.4104/pcrj.2013.00044 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Baker E, Fatoye F. Clinical and cost effectiveness of nurse-led self-management interventions for patients with COPD in primary care: a systematic review. Int J Nurs Stud. 2017;71:125–138. doi: 10.1016/j.ijnurstu.2017.03.010 [DOI] [PubMed] [Google Scholar]
- 35.Khan J, McCarthy C, Franciosi AN. Questioning the purpose of annual follow-up spirometry for all patients with COPD. Eur Respir J. 2023;61:2300292. doi: 10.1183/13993003.00292-2023 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
For requests for access to anonymised subject level data, please contact corresponding author.