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

1 Citation (Scopus)


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
JournalInternational journal of chronic obstructive pulmonary disease
Issue number17
Publication statusPublished - 25 Sep 2022


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


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