{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T18:56:29Z","timestamp":1781204189450,"version":"3.54.1"},"reference-count":17,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T00:00:00Z","timestamp":1781136000000},"content-version":"unspecified","delay-in-days":10,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004325","name":"AstraZeneca","doi-asserted-by":"publisher","award":["Not applicable"],"award-info":[{"award-number":["Not applicable"]}],"id":[{"id":"10.13039\/100004325","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,4,30]]},"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To explore the impact of acute worsening events (AWEs), defined as clinically relevant deteriorations in peak expiratory flow, reliever use and\/or symptoms, on patients\u2019 daily lives and identify behaviours linked to their recognition and management.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A qualitative international substudy was conducted in the Netherlands, Spain, the USA, Canada and the UK (2023\u20132024).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>19 patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) from a randomised clinical trial participated. Interviews, triggered by AWEs and repeated 6\u2009weeks later, were audio-recorded, transcribed and analysed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Patients varied in identifying bad days, reporting inability to perform physical activities, symptom worsening or the need for add-on treatment. Recognition of AWEs depended on their duration: shorter events (&lt;2\u2009days) often went unnoticed, while longer events were typically recognised. Most patients indicated they would seek healthcare if needed. Barriers included difficulty obtaining timely appointments (external) and a reactive attitude to worsenings (internal).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>AWEs significantly impact daily life but vary widely in recognition and thresholds for seeking care. Limited awareness of daily disease variations may contribute to both under-reporting of worsening events to healthcare providers and suboptimal self-management in COPD.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT05492877\">NCT05492877<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-104245","type":"journal-article","created":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T18:00:25Z","timestamp":1781200825000},"page":"e104245","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["How do acute worsening events influence daily life and healthcare-seeking behaviour in patients with COPD: an international multicountry qualitative study"],"prefix":"10.1136","volume":"16","clinical-trial-number":[{"clinical-trial-number":"nct05492877","registry":"10.18810\/clinical-trials-gov"},{"clinical-trial-number":"nct05492877","registry":"10.18810\/clinical-trials-gov"},{"clinical-trial-number":"nct05492877","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9544-1487","authenticated-orcid":false,"given":"Lars","family":"Dijk","sequence":"first","affiliation":[{"name":"General Practitioners Research Institute, Groningen, Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Merijn M G","family":"Driessen","sequence":"additional","affiliation":[{"name":"General Practitioners Research Institute, Groningen, Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoran H","family":"Gerritsma","sequence":"additional","affiliation":[{"name":"General Practitioners Research Institute, Groningen, Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clare","family":"Bolton","sequence":"additional","affiliation":[{"name":"Global Medical Affairs, Respiratory and Immunology, AstraZeneca, Cambridge, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6993-0546","authenticated-orcid":false,"given":"Carla","family":"Da Silva","sequence":"additional","affiliation":[{"name":"Early Respiratory and Immunology Clinical Development, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janwillem W H","family":"Kocks","sequence":"additional","affiliation":[{"name":"General Practitioners Research Institute, Groningen, Netherlands"},{"name":"University of Groningen, Department of Pulmonary Diseases and Tuberculosis, University Medical Centre Groningen, Groningen, Netherlands"},{"name":"Observational and Pragmatic Research Institute, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,6,11]]},"reference":[{"key":"2026061111001285000_16.6.e104245.1","unstructured":"Global initiative for chronic obstructive lung disease - gold. GOLD Report. Available: https:\/\/goldcopd.org\/2024-gold-report\/ [Accessed 19 Jul 2024]."},{"key":"2026061111001285000_16.6.e104245.2","unstructured":"World Health Organization . Leading causes of deaths. Available: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/the-top-10-causes-of-death [Accessed 28 Aug 2024]."},{"key":"2026061111001285000_16.6.e104245.3","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(07)61382-8"},{"key":"2026061111001285000_16.6.e104245.4","doi-asserted-by":"publisher","DOI":"10.1183\/09031936.03.00078002"},{"key":"2026061111001285000_16.6.e104245.5","doi-asserted-by":"crossref","unstructured":"Mathioudakis AG , Moberg M , Janner J , et al . Outcomes reported on the management of COPD exacerbations: a systematic survey of randomised controlled trials. 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