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Robert West has produced a good checklist for writing up research reports.




The UNLOCK validation study Primary Care COPD Patients Compared with Large Pharmaceutically-Sponsored COPD Studies has been published in PLOS ONE. The studyevaluated the external validity of six LPCS (ISOLDE, TRISTAN, TORCH, UPLIFT, ECLIPSE, POET-COPD) on which current guidelines are based. It found that primary care COPD patients stand out from patients enrolled in LPCS in terms of gender, lung function, quality of life and exacerbations. It concluded more research is needed to determine the effect of pharmacological treatment in mild to moderate patients and encourages future guideline makers to involve primary care populations in their recommendations.

The study authors are Annemarije L. Kruis, Björn Ställberg, Rupert C. M. Jones, Ioanna G. Tsiligianni, Karin Lisspers, Thys van der Molen, Janwillem H. Kocks, Niels H. Chavannes. View the study at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0090145

See here for first use of the Desktop Helper in a research project that concluded among Swiss GPs and patients, both our innovative communication tool and the IPCRG tool were well accepted and both merit further dissemination and application in research.

Acceptance and practicability of a visual communication tool in smoking cessation counselling: a randomised controlled trial
Stefan Neuner-JehleMarianne I KnechtClaudia Stey-Steurer,Oliver Senn.
To view click here 

Authors: Cave AJ, Atkinson L, Tsiligianni IG, Kaplan AG

Published Date July 2012 Volume 2012:7 Pages 447 - 456

DOI: http://dx.doi.org/10.2147/COPD.S29868

COPD is considered a complex disease and global problem that is predicted to be the third most common cause of death by 2030. While managing this chronic condition, primary health care practitioners are faced with the ongoing challenge of achieving good quality of life and overall "wellness" for those affected. As such, a practical tool for monitoring quality of life in a clinical setting is required. However, due to the wide variety of general and disease-specific tools from which to choose, primary health care practitioners are given minimal guidance as to which tool may be most appropriate. To address these challenges, the International Primary Care Respiratory Group (IPCRG) proposed the creation of a user's guide for primary health care practitioners to assess "wellness" in COPD patients in an everyday clinical setting. This short report outlines the process by which the IPCRG Users' Guide to COPD "Wellness" Tools was developed. It also describes why this guide has the potential to be of great value in guiding primary health care practitioners to improve patient wellness.

 To read the paper click here

Impact of chronic respiratory symptoms in a rural area of sub-Saharan Africa: an in-depth qualitative study in the Masindi district of Uganda by our Our FRESH-AIR Uganda team is now online:

F van Gemert et al. Prim Care Respir J 2013;22(X): XX-XX http://dx.doi.org/10.4104/pcrj.2013.00064


Chronic obstructive pulmonary disease (COPD), once regarded as a disease of developed countries, is now recognised as a common disease in low- and middle-income countries. No studies have been performed to examine how the community in resource- poor settings of a rural area in sub-Saharan Africa lives with chronic respiratory symptoms.
To explore beliefs and attitudes concerning health (particularly respiratory illnesses), use of biomass fuels, tobacco smoking, and the use of health services.
A qualitative study was undertaken in a rural area of Masindi district in Uganda, using focus group discussions with 10–15 members of the community in 10 randomly selected villages.
Respiratory symptoms were common among men, women, and children. In several communities respiratory symptoms were stigmatised and often associated with tuberculosis. Almost all the households used firewood for cooking and the majority cooked indoors without any ventilation. The extent of exposure to tobacco and biomass fuel smoke was largely determined by their cultural tradition and gender, tribal origin and socioeconomic factors. Many people were unaware of the damage to respiratory health caused by these risk factors, notably the disproportionate effect of biomass smoke in women and children.
The knowledge of chronic respiratory diseases, particularly COPD, is poor in the rural community in sub-Saharan Africa. The lack of knowledge has created different beliefs and attitudes concerning respiratory symptoms. Few people are aware of the relation between smoke and respiratory health, leading to extensive exposure to mostly biomass-related smoke.



Background: Pulmonary Rehabilitation for moderate Chronic Obstructive Pulmonary Disease in primary care could improve patients’ quality of life.


Methods: This study aimed to assess the efficacy of a 3-month Pulmonary Rehabilitation (PR) program with a
further 9 months of maintenance (RHBM group) compared with both PR for 3 months without further maintenance
(RHB group) and usual care in improving the quality of life of patients with moderate COPD.
We conducted a parallel-group, randomized clinical trial in Majorca primary health care in which 97 patients with
moderate COPD were assigned to the 3 groups. Health outcomes were quality of life, exercise capacity, pulmonary
function and exacerbations.

Results: We found statistically and clinically significant differences in the three groups at 3 months in the emotion
dimension (0.53; 95%CI0.06-1.01) in the usual care group, (0.72; 95%CI0.26-1.18) the RHB group (0.87; 95%CI 0.44-1.30)
and the RHBM group as well as in fatigue (0.47; 95%CI 0.17-0.78) in the RHBM group. After 1 year, these differences
favored the long-term rehabilitation group in the domains of fatigue (0.56; 95%CI 0.22-0.91), mastery (0.79; 95%CI 0.03-
1.55) and emotion (0.75; 95%CI 0.17-1.33). Between-group analysis only showed statistically and clinically significant
differences between the RHB group and control group in the dyspnea dimension (0.79 95%CI 0.05-1.52). No differences
were found for exacerbations, pulmonary function or exercise capacity.

Conclusions: We found that patients with moderate COPD and low level of impairment did not show meaningful
changes in QoL, exercise tolerance, pulmonary function or exacerbation after a one-year, community based
rehabilitation program. However, long-term improvements in the emotional, fatigue and mastery dimensions (within
intervention groups) were identified.

Trial registration: ISRCTN94514482
Keywords: Chronic obstructive pulmonary disease, Pulmonary rehabilitation, Quality of life, Clinical trial, Primary care


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To assess the long term effects of two different modes of disease management (comprehensive self management and routine monitoring) on quality of life (primary objective), frequency and patients' management of exacerbations, and self efficacy (secondary objectives) in patients with chronic obstructive pulmonary disease (COPD) in general practice.


24 month, multicentre, investigator blinded, three arm, pragmatic, randomised controlled trial.


15 general practices in the eastern part of the Netherlands.


Patients with COPD confirmed by spirometry and treated in general practice. Patients with very severe COPD or treated by a respiratory physician were excluded.


A comprehensive self management programme as an adjunct to usual care, consisting of four tailored sessions with ongoing telephone support by a practice nurse; routine monitoring as an adjunct to usual care, consisting of 2-4 structured consultations a year with a practice nurse; or usual care alone (contacts with the general practitioner at the patients' own initiative).


The primary outcome was the change in COPD specific quality of life at 24 months as measured with the chronic respiratory questionnaire total score. Secondary outcomes were chronic respiratory questionnaire domain scores, frequency and patients' management of exacerbations measured with the Nijmegen telephonic exacerbation assessment system, and self efficacy measured with the COPD self-efficacy scale.


165 patients were allocated to self management (n=55), routine monitoring (n=55), or usual care alone (n=55). At 24 months, adjusted treatment differences between the three groups in mean chronic respiratory questionnaire total score were not significant. Secondary outcomes did not differ, except for exacerbation management. Compared with usual care, more exacerbations in the self management group were managed with bronchodilators (odds ratio 2.81, 95% confidence interval 1.16 to 6.82) and with prednisolone, antibiotics, or both (3.98, 1.10 to 15.58).


Comprehensive self management or routine monitoring did not show long term benefits in terms of quality of life or self efficacy over usual care alone in COPD patients in general practice. Patients in the self management group seemed to be more capable of appropriately managing exacerbations than did those in the usual care group.



Juliet McDonnellSiân WilliamsNiels H ChavannesJaime Correia de Sousa, H John FardyMonica FletcherJames StoutRon TomlinsOsman M Yusuf, Hilary Pinnock

This discussion paper describes a scoping exercise and literature review commissioned by the International Primary Care Respiratory Group (IPCRG) to inform their E-Quality programme which seeks to support small-scale educational projects to improve respiratory management in primary care. Our narrative review synthesises information from three sources: publications concerning the global context and health systems development; a literature search of Medline, CINAHL and Cochrane databases; and a series of eight interviews conducted with members of the IPCRG faculty. Educational interventions sit within complex healthcare, economic, and policy contexts. It is essential that any development project considers the local circumstances in terms of economic resources, political circumstances, organisation and administrative capacities, as well as the specific quality issue to be addressed. There is limited evidence (in terms of changed clinician behaviour and/or improved health outcomes) regarding the merits of different educational and quality improvement approaches. Features of educational interventions that were most likely to show some evidence of effectiveness included being carefully designed, multifaceted, engaged health professionals in their learning, provided ongoing support, were sensitive to local circumstances, and delivered in combination with other quality improvement strategies. To be effective, educational interventions must consider the complex healthcare systems within which they operate. The criteria for the IPCRG E-Quality awards thus require applicants not only to describe their proposed educational initiative but also to consider the practical and local barriers to successful implementation, and to propose a robust evaluation in terms of changed clinician behaviour or improved health outcomes.

To see the full paper click here

Read the Education Strategy that resulted

Learn more about E-Quality rounds 1-4.


A paper created with the help of the IPCRG and the PCRS-UK via the UKRRF in the Primary Respiratory Care Journal 'Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study' the pdf can be downloaded here.


Background: Annual recording of the Royal College of Physicians three questions (RCP3Q) morbidity score is rewarded within the UK ‘pay-for-performance’ Quality and Outcomes Framework.

Aims: To investigate the performance of RCP3Qs for assessing control in real-life practice compared with the validated Asthma Control Questionnaire (ACQ) administered by self-completed questionnaire.

Methods: We compared the RCP3Q score extracted from a patient’s computerised medical record with the ACQ self-completed after the consultation. The anonymous data were paired by practice, age, sex, and dates of completion. We calculated the sensitivity and specificity of the RCP3Q scale compared with the threshold for good/poor asthma control (ACQ >1).

Results: Of 291 ACQ questionnaires returned from 12 participating practices, 129 could be paired with complete RCP3Q data. Twenty- five of 27 patients who scored zero on the RCP3Q were well controlled (ACQ <1). An RCP3Q score >1 predicted inadequate control (ACQ >1) with a sensitivity of 0.96 and specificity of 0.34. Comparable values for RCP3Q>2 were sensitivity 0.50 and specificity 0.94. The intraclass correlation coefficient of 0.13 indicated substantial variability between practices. Exacerbations and use of reliever inhalers were moderately correlated with ACQ (Spearman’s rho 0.3 and 0.35) and may reflect different aspects of control.

Conclusions: In routine practice, an RCP3Q score of zero indicates good asthma control and a score of 2 or 3 indicates poor control. An RCP3Q score of 1 has good sensitivity but poor specificity for suboptimal control and should provoke further enquiry and consideration of other aspects of control such as exacerbations and use of reliever inhalers.

To see more research projects the IPCRG are involved with please see the Research Projects Section

Using meta-analysis, the authors combined data from 13 randomized controlled trials in order to determine the impact of nutritional interventions on various improvements of anthropometric measures in COPD patients. The meta-analysis revealed that contrary to the results of published studies, nutritional support improved nutrition parameters for body weight and was associated with improved grip strength. An improved caloric and protein intake was also seen. The authors suggest that previous results were influenced by a bias between the groups.

Collins PF et al. Am J Clin Nutr. 2012 Apr 18. [Epub ahead of print]


AIM: To determine the feasibility of recruiting patients with early chronic obstructive pulmonary disease (COPD) to the Health Enhancing Activity in Lung THerapy (HEALTH) exercise and education programme. METHODS: Patients with early COPD were identified from general practices. Those meeting the study inclusion criteria were administered tiotropium throughout the study period. Participants were randomised to either an eight-week health enhancing and physical activity (HEPA) programme, or to a control group (usual care). Behavioural, physiological and psychosocial outcome measures were reported preand post-intervention. RESULTS: Out of 27 practices approached, 16 (59.3%) agreed to participate. Of 215 potentially eligible patients contacted, 60 (27.9%) replied. Twenty (33.3%) were randomised to either HEPA intervention (n=10) or usual care (n=10). Fourteen patients attended a postintervention assessment. CONCLUSION: This study provides valuable information on the feasibility of conducting such a trial involving a physical activity intervention.



Globally, asthma morbidity remains unacceptably high. If outcomes are to be improved, it is crucial that routine review consultations in primary care are performed to a high standard. Key components of a review include: • Assessment of control using specific morbidity questions to elucidate the presence of symptoms, in conjunction with the frequency of use of short-acting bronchodilators and any recent history of acute attacks • After consideration of the diagnosis, and an assessment of compliance, inhaler technique, smoking status, triggers, and rhinitis, identification of poor control should result in a step-up of treatment in accordance with evidence-based guideline recommendations • Discussion should address understanding of the condition, patient-centred management goals and attitudes to regular treatment, and should include personalised self-management education Regular review of people with asthma coupled with provision of self-management education improves outcomes. Underpinned by a theoretical framework integrating professional reviews and patient self-care we discuss the practical barriers to implementing guided selfmanagement in routine clinical practice.


Identifying the most current and practical research questions allows prioritization of research. The IPCRG (International Primary Care Respiratory Group) polled 23 experts from 21 countries and had them rate as important and feasible, on a scale from 1-5, 145 research questions involving asthma, rhinitis, chronic obstructive pulmonary disease, smoking and respiratory infections. Of these, there was strong agreement as to the importance and feasibility of 67 questions. Most of the questions involved basic management of the diseases in question and the creation of validated questionnaires for evaluating.



The Brussels Declaration, published in the European Respiratory Journal in 2008 1, recognises the high prevalence of patients with poorly controlled asthma and calls for changes in asthma management across Europe. Prescribing an appropriate inhaler device for asthma, a device that the patient accepts and can handle correctly, is one key element in this process. Inhaler mishandling is very common in real-world clinical practice and can contribute to poor asthma control 25.

The International Primary Care Respiratory Group (IPCRG) is committed to identifying reasons for poor asthma control and to promoting interventions to help patients achieve asthma control 69. An international panel of healthcare providers (HCPs), academics and a patient representative was convened under the auspices of IPCRG to discuss and challenge the science behind inhaler therapy, and to propose practical solutions to real-life problems related to inhaler choice and mishandling. The focus was on the problems confronting clinicians in prescribing a suitable inhaler for each individual and those confronting patients in using their inhalers.

Until recently, inhaler therapy and devices have been marginal topics of clinical investigation and research in the field of asthma, mainly confined to a limited circle of experts, and lacking evidence for practical application. Thus, we propose this call for action, given: 1) the importance of inhaler technique for effective inhaled therapy; 2) the critical gaps in knowledge that need still to be addressed; and 3) the lack of solid evidence supporting HCPs in making clinical decisions regarding inhalers for asthma treatment.



National and international asthma guidelines stress that before making changes to patients’ therapy their compliance and inhaler technique should be checked. This review addresses these issues and highlights the differences between inhalers in terms of inhaler technique, individual ability/competence, and ease of use. The advantages and disadvantages of metered-dose inhalers (MDIs) and dry powder inhalers (DPIs) are presented. The reformulation of beclometasone MDIs is discussed since there has been some confusion over prescribing and Regulatory Authorities have recommended that these should be prescribed by brand name and not generically. This review should provide prescribers with an update to help them appreciate the differences between inhalers thereby optimising each patient’s inhaled treatment.