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Arslan et al. BMC Primary Care (2025) 26:278
https://doi.org/10.1186/s12875-025-02941-8 BMC Primary Care
*Correspondence:
I. G. Arslan
i.arslan@nivel.nl
L. van Eikenhorst
l.vaneikenhorst@nivel.nl
Full list of author information is available at the end of the article
Abstract
Background Pressurised metered-dose inhalers (pMDIs), often prescribed for the treatment of COPD and asthma
have a high global warming potential (GWP) compared to dry powder inhalers (DPIs) and soft-mist inhalers.
Despite calls to switch from high to DPIs or soft-mist inhalers, prescriptions of pMDIs have increased in recent years.
Understanding healthcare providers' preferences can help develop strategies to promote prescribing low GWP
inhalers. This study aimed to determine healthcare providers' preferences when prescribing inhalers for asthma and
COPD, including its GWP (i.e. environmental impact).
Methods A survey containing a discrete choice experiment was conducted. Primary care providers were repetitively
asked to choose between scenarios of inhalers that diered in ve attributes: multidose or unidose system (i.e. ease of
use), reduction in number of exacerbations, side eects, out of pocket costs and GWP. A multinomial logit model was
used to determine the relative importance of the attributes.
Results A total of 76 healthcare providers (general practitioners (GPs), nurse specialists and nurse practitioners)
completed the survey. On average, the attribute ‘reduction in number of exacerbations’ was most important in their
choice for inhalers, followed by, ‘side eects’, ‘GWP’, ‘out of pocket costs’, and ‘multidose or unidose system’. Healthcare
providers were willing to accept a high GWP inhaler instead of a low GWP inhaler when the inhaler reduced the
number of exacerbations and were willing to opt for low GWP inhaler with higher out of pocket costs instead of a
high GWP inhaler with lower out of pocket costs.
Conclusions Healthcare providers valued clinical factors (i.e. reduction in number of exacerbations and low side
eects) as most important when choosing inhalers for their patients with COPD or asthma, however GWP was
also an important driver of choice. Understanding these preferences can support strategies to support sustainable
inhalers for COPD and asthma, contributing to climate change mitigation. For example by enhancing the provision of
information regarding inhaler GWP, while ensuring that clinical eectiveness remains the primary focus.
The role of environmental impact
in healthcare providers’ choices of inhalers
for treatment of asthma and COPD: a discrete
choice experiment
I. G.Arslan1*, M.Vervloet1, E. W.deBekker-Grob2,3,4, K.Hek1, B. J.Knottnerus1, C.Wagner1,5 and L.vanEikenhorst1*
Page 2 of 9Arslan et al. BMC Primary Care (2025) 26:278
Introduction
Climate change is an important threat to global health of
our times, with the healthcare sector being a major con-
tributor [1, 2]. Globally, the healthcare sector accounts
for 4.4% of net CO₂ emissions, primarily driven by phar-
maceuticals [3]. In the Netherlands, healthcare accounts
for 8% of net CO₂ emissions [4]. Pressurised metered-
dose inhalers (pMDIs), often prescribed for the treatment
of Chronic Obstructive Pulmonary Disease (COPD)
and asthma [5], contribute for 0.03% to the net global
CO₂ emissions, mainly due to their propellants (HFA-
134a/227) [6]. ese inhalers have a higher global warm-
ing potential (GWP) compared to dry powder inhalers
(DPIs) and soft-mist inhalers; the CO₂ equivalent foot-
print of a pMDI is up to 25 times greater [7, 8].
e British oracic Society recommends choosing
a DPI when prescribing inhalers for newly diagnosed
patients with COPD or asthma and when patients use
multiple types of inhalers and can safely use a DPI, if the
required medicine for the patient is available in a DPI
[9]. Currently, 8.5% of the Dutch population uses inhal-
ers of which more than half (55%) pMDIs [10]. Prescrib-
ing DPIs or soft-mist inhalers instead of pMDIs has the
potential to reduce the CO₂ emissions, contributing to
climate change mitigation [11–13]. e transition of 20
patients from pMDIs to DPIs or soft-mist inhalers can
lead to emission reduction equivalent to replacing a con-
ventional car with an electric vehicle [14]. Another ben-
et of prescribing DPIs or soft-mist inhalers instead of
pMDIs is the indirect reduction of health risks for COPD
and asthma patients as it helps mitigate the rise in sum-
mer smog and the increased exposure to pollen caused
by climate change [14]. Important patient related condi-
tions for switching to DPIs or soft-mist inhalers are suf-
cient inspiratory force generated by the patient and an
adequate hand-lung coordination [15, 16]. Current user
proles reveal an opportunity for switching, given that
approximately 180,000 patients in the Netherlands use
both a DPIs or soft-mist inhalers and a pMDI [10]. In
Sweden, only 13% of inhalers are pMDIs [17], compared
to 55% in the Dutch population [10]. is demonstrates
the possibility for safe and durable switching to DPIs or
soft-mist inhalers, when patients receive adequate guid-
ance from healthcare providers and the switch aligns
with their needs and preferences.
In countries such as the Netherlands, the UK, and
Scandinavian countries, prescribers in general practice
play a crucial role in switching from pMDIs to DPIs or
soft-mist inhalers, which primarily include general prac-
titioners (GPs), but more recently also encompass nurse
practitioners, physician assistants, nurse specialists and
respiratory nurses [18, 19]. As they are often the rst
point of contact for patients, they typically make the
initial decision regarding treatment and type of inhalers
for COPD and asthma [20]. Recent guidelines from the
Dutch College of General Practitioners recommend con-
sidering environmental impact when prescribing inhalers
for asthma and COPD [14, 15]. Nevertheless, the num-
ber of pMDI prescriptions have increased in recent years
[14].
Although various studies has been conducted inter-
nationally on the preferences and perspectives on inhal-
ers [21–28], no study to date has examined the role of
environmental impact of inhalers in the trade-os that
healthcare providers make when choosing a type of
inhaler in COPD and asthma treatment. Understanding
of this process can support strategies to promote envi-
ronmentally friendly treatment for COPD and asthma.
erefore, our study aims to determine the preferences
of healthcare providers for characteristics of inhalers
for COPD and asthma, including environmental impact.
is study focused on maintenance inhalers (taken on
a regular daily basis) and not on short-acting inhalers
(taken during acute symptoms) as this is an import part
of long term treatment according to the guidelines of the
Dutch College of General Practitioners for treatment of
patients newly diagnosed with asthma or COPD [15, 16].
Methods
Discrete choice experiment
We used a discrete choice experiment (DCE) to deter-
mine the preferences of healthcare providers when pre-
scribing maintenance inhalers for patients with asthma
or COPD. A DCE is a technique used to quantify pref-
erences for health goods, products and services [29]. In
a DCE, it is assumed that preferences are based on the
underlying characteristics of healthcare services, so-
called attributes (e.g., out of pocket costs) [30]. ose
attributes are specied by their attribute levels that refer
to possible values (e.g., for out of pocket costs: €50,- or
€100,-). We presented healthcare providers several alter-
natives of ctitious inhalers with dierent combinations
of attribute levels, so-called choice tasks, in an online
questionnaire. Healthcare providers were repeatedly
asked to make a choice between two hypothetical alter-
natives. In this way, what matters to healthcare providers,
how much it matters (i.e., relative importance) to health-
care providers, and how willing they are to give up on
one attribute to gain something on another attribute (i.e.
trade-os) could be determined.
Keywords Asthma, COPD, Climate change, Carbon footprint, Inhaler, General practice, Discrete choice experiment,
Preferences
Page 3 of 9Arslan et al. BMC Primary Care (2025) 26:278
Attributes and levels
We composed a list of potential attributes based on the
results of our previous qualitative study on patients'and
healthcare providers’ willingness to choose for low GWP
inhalers [31] and from national guidelines for COPD
and asthma [15, 16]. A literature review was conducted
to complement this list. A search was conducted in
PubMed database to identify qualitative studies, DCEs
and literature reviews focusing on patients’ and health-
care providers’ experiences, preferences and perspectives
on inhalers (Supplementary File 1 for the search strat-
egy). e list covered the following domains: ease of use,
hygiene, dose conrmation, reusable/disposable/recy-
clable, appearance and design, ecacy, side eects, costs,
GWP, and patient satisfaction. In a DCE, the number of
attributes to include is limited, as a higher number of
attributes relates to a rising cognitive burden of the par-
ticipant [32]. erefore, we reduced the number of attri-
butes by presenting the list of potential attributes to three
GPs and asked them to rank the attributes from most to
least important. We then selected the ve attributes that
were deemed most relevant by these GPs (Table 1), as
attributes ranked sixth or higher were deemed substan-
tially less important. Attribute levels were specied by
publications of national sources [33], discussed within
the research team and veried by the same GPs.
Experimental design
A D-ecient experimental design [34] with 18 choice
tasks was designed using Ngene built within Survey
Engine software [35] to maximize the statistical eciency
in measuring the main eects. In DCEs, the higher the
number of choice tasks, the higher the cognitive burden
for participants, which might impact the reliability of the
results [32]. erefore, we divided the design into two
blocks of 9 choice tasks and randomly presented one of
the two blocks to the participants [36]. One additional
repeated choice task was included as a consistency check
(i.e. internal validity) [37, 38]. We repeatedly asked the
participants in each choice task what alternative they
preferred for the hypothetical case presented in the DCE.
Table 2 shows an example of a presented choice task
included in the questionnaire.
To exclude contextual and patient-related factors that
may inuence the choice responses, such as insucient
Table 1 Attributes and levels used in the discrete choice
experiment
Attribute Denition given to the partici-
pants in the survey
Levels
Multidose
or unidose
system (ease
of use)
A'multidose'inhaler contains
multiple doses within the inhaler.
A'unidose'inhaler uses individual
capsules and needs to be relled
before each inhalation. Therefore,
a'unidose'inhaler always requires
more steps before inhalation com-
pared to a multidose system
• Unidose system
• Multidose
system
Reduction
in number
of exacerba-
tions (are-
ups) per year
(ecacy)
The use of inhaler can reduce the
likelihood of exacerbations in the
next year. This reduction varies
depending on the type of inhaler
and serves as an indicator of the
eectiveness of the inhaler
• Likely to reduce
one exacerbation
in the upcoming
year
• Likely to reduce
two exacerba-
tions in the
upcoming year
• Likely to reduce
three exacerba-
tions in the
upcoming year
Likelihood of
side eects
(safety)
The use of inhaler can cause side
eects, such as dry mouth or palpi-
tations. These side eects may lead
to non-adherence to the agreed
regimen
• Likely to experi-
ence no side
eects
• Likely to experi-
ence mild side
eects, but they
do not interfere
with taking the
medicine
• Likely to experi-
ence moderate to
severe side eects
that may stop you
from taking the
medicine
Out of pocket
costs
Annual costs the patient has to pay
for using inhalers, not reimbursed
by the health insurer
• €50,- per year
• €150,- per year
• €250,- per year
Global warm-
ing potential
(GWP)
pMDIs contain greenhouse gases.
The environmental impact of
one inhalation from a pMDI, is 25
times higher than that of a low
GWP inhaler (i.e. DPI or soft-mist
inhaler). With average use of a pMDI
(5.5 packages per year), the CO₂
equivalent emissions per year are
equivalent to a round-trip ight
from Amsterdam to Paris
• High GWP
inhaler
• Low GWP inhaler
Table 2 Example of a choice task
Imagine that you can choose between two dierent types of
inhalers to prescribe to your patient, which of the following would
you choose, Option A or Option B?
Option A Option B
Multidose or unidose Multidose Unidose
Reduction in number of exacer-
bations (are-ups) per year
Reduction of two
exacerbations in the
upcoming year
Reduction
of two exac-
erbations in
the upcom-
ing year
Risk of side eects Mild side eects but
these do not aect the
intake of medication
No side
eects
Out of pocket costs per year €150,- €250,-
Global warming potential High Low
I would choose:
Page 4 of 9Arslan et al. BMC Primary Care (2025) 26:278
lung capacity as a barrier for using any type of inhaler,
participants were presented with a hypothetical patient
case to base their choices on (Table3).
Development of the questionnaire
e questionnaire also contained demographic ques-
tions, work-related questions and attitudinal questions
about environmental impact after the choice tasks, based
on the eory of Planned Behaviour [39]. Participants
were also asked if they were member of a professional
organisation or network for environmentally friendly
healthcare, such as ‘De Groene Huisarts’ (in English: ‘e
Green GP’) [40]. e questionnaire was designed to take
no longer than 10 min and included an explanation of the
attributes and levels and a warm-up choice task before
starting the choice tasks.
A draft version of the questionnaire was pre-tested
with three GPs using cognitive interviews in which they
were asked to read and think aloud while completing the
questionnaire [41]. As a result, minor textual alterations
to the questionnaire were made to improve the readabil-
ity and face validity. Prior estimates of the attribute-levels
were updated after a pilot run following good practices
[34, 41]. e nal version of the questionnaire translated
from Dutch to English is presented in Supplementary File
2.
Study population
Healthcare providers were approached through various
channels: the individual network of the authors, general
practices participating in the Nivel Primary Care Data-
base [42] and general practices making use of the ser-
vices of Calculus (a national company providing support
to GPs with their declarations and administration). GPs,
nurse practitioners, physician assistants, nurse specialists
and respiratory nurses treating at least one COPD and/
or asthma patient per week in general practice and gave
informed consent were included. Ten gift vouchers worth
€50,- each were raed among participants who com-
pleted the survey.
Statistical analyses
Descriptive characteristics were reported as means and
standard deviations (SDs), medians and interquartile
ranges (IQRs), and counts (n) and percentages (%), as
appropriate.
Choice data were analysed using a multinomial logit
model (Model A; multinomial logit model). e propor-
tion of participants consistently answering the repeated
choice task correctly was 89.5%, which suggest that
respondents were largely providing stable answers, indi-
cating high reliability. None of the participants always
chose option A or B (i.e. at-liners), which suggests a
sucient level of data quality. To avoid selection bias,
no participants were a priori excluded from the analysis
based on their answers to internal validity assessments
[43]. We tested for linearity of the attributes. Out-of-
pocket costs and number of exacerbations were coded as
continuous variables, and multidose or unidose system,
risk of side eects and GWP were treated as categorical
variables, with the “worst” level (i.e. least desirable level)
used as reference level.
In the second model, we included several interaction
terms based on background characteristics with su-
cient sample size within the subgroups to perform these
analyses to assess whether the preferences for low GWP
diered between: 1) GPs, and nurse practitioners and
nurse specialists, 2) healthcare providers with over 10
years of experience in general practice and those with 10
or fewer years of experience, and 3) healthcare providers
who were member of a professional organisation or net-
work for environmentally friendly healthcare and those
not (Model B; multinomial logit model plus systematic
preference heterogeneity). e utility function used in
the model is presented in Supplementary File 3.
Additional analyses were conducted to calculate the
relative importance of each attribute in percentages by
computing the dierence between the minimum and
maximum utility of each attribute divided by the sum of
the dierences between all utilities of all attributes (the
higher the greater the importance relative to other attri-
butes). We calculated the marginal rate of substitution
(MRS), i.e. the willingness to pay for a low GWP inhaler
and willingness to accept in number of reduction of exac-
erbation per year for a high GWP inhaler. Further infor-
mation is provided in Supplementary File 4.
Statistical analyses were performed using R-Studio
software version 4.3.1. For the analysis of choice data,
Apollo package in R-Studio software was used [44].
Results
Characteristics of participants
A total of 76 participants completed the DCE question-
naire. Most of the participants were between 40–49 years
old (28.9%) and female (75.0%) (Table 4). A total of 60.5%
was working as a GP and the remaining 39.5% as a nurse
practitioner/specialist in general practice. Most of the
participants (68.4%) had over 10 years of working experi-
ence and almost half (48.7%) worked in a general practice
located in an urban area. In addition, 10.5% was member
Table 3 Hypothetical patient case presented in the
questionnaire
“A patient with asthma or COPD for whom you are going to prescribe
maintenance medication for the rst time. This patient has sucient
lung capacity and coordination to use any type of inhaler no concomi-
tant medications and an average socioeconomic status.”
Page 5 of 9Arslan et al. BMC Primary Care (2025) 26:278
of a professional organisation or network for environ-
mentally friendly healthcare.
A total of 59.3% of the participants (strongly) agreed
that sustainability is a priority in their work, with an
even higher percentage (78.9%) expressing this senti-
ment about their private lives (Fig. 1). e majority
(77.6%) (strongly) agreed that inhalers containing green-
house gases contribute to climate change. However, a
smaller percentage (strongly) agreed in being encour-
aged by their profession colleagues (40.8%) or profession
(39.5%) in sustainability and believed they had sucient
resources to make sustainable choices (35.5%) in general
practice (i.e. external factors). ere were dierences in
the attitude towards climate change between GPs and
nurse practitioners/nurse specialists (see Supplementary
File 5). In general, a higher percentage of GPs (strongly)
agreed with all attitudinal questions (not statistically
tested due to low sample size), especially in the sentiment
that sustainability is a priority in their private lives (84.2%
versus 73.7% respectively) and in being encouraged by
their profession colleagues in sustainability (52.6% versus
29.0% respectively).
Discrete choice experiment
Table 5 presents the preferences of healthcare providers
(for utilities see Supplementary File 6). In general, all ORs
were statistically signicant, suggesting that all attributes
played a role in their decision for inhalers, except for out
of pocket costs. Healthcare providers preferred inhalers
reducing the number of exacerbations with multidose
system, no side eects and low GWP. GPs were more
likely to choose low GWP inhalers compared to nurse
practitioners/specialists (OR = 2.48; 95%CI = 1.50–4.09).
Finally, we found no statistically signicant interaction
between preferences for a low GWP inhaler and years
working in general practice or being member of a pro-
fessional organisation or a network for environmentally
friendly healthcare.
Figure 2 shows the relative importance of the attri-
butes. e reduction in number of exacerbations and
the risk of side eects were most important relative to
all other attributes. is was followed by impact on CO₂
emissions, and out of pocket costs and multidose/uni-
dose system were least important.
Marginal rates of substitution
Healthcare providers were willing to accept a high GWP
inhaler instead of a low GWP inhaler when the inhaler
reduced the number of exacerbations. In addition, they
were willing to opt for an inhaler with higher out of
pocket costs in exchange for a low GWP instead of a high
GWP inhaler.
Discussion
Main ndings
is study demonstrates that while healthcare provid-
ers valued clinical factors (i.e. reduction in number of
Table 4 Characteristics of participants
n = 76
n (%)
Female 57 (75.0)
Age
- 20–29years 3 (3.9)
- 30–39years 19 (25.0)
- 40–49years 19 (25.0)
- 50–59years 22 (28.9)
- ≥ 60years 13 (17.1)
Profession
- GP 46 (60.5)
- Of which specialised in asthma/COPD 9 (11.8)
- Nurse practitioner/nurse specialist 30 (39.5)
Working in general practice for
- < 5years 11 (14.5)
- 5–10years 13 (17.1)
- > 10years 52 (68.4)
Working in urban area 37 (48.7)
Member of a professional organisation or network for envi-
ronmentally friendly healthcare
8 (10.5)
Fig.1 Attitudinal questions towards climate change’
Page 6 of 9Arslan et al. BMC Primary Care (2025) 26:278
exacerbations and low side eects) as most important
when choosing inhalers for their patients with COPD or
asthma, low global warming potential (GWP) was also an
important driver of choice. Out of pocket costs for the
patient and multidose/unidose system of the inhaler were
also found to be drivers of choice, but they were deemed
less important. Our ndings further indicate that health-
care providers are willing to choose for high GWP inhal-
ers over low GWP alternatives if the inhaler reduced the
number of exacerbations even with higher out of pocket
costs.
Comparison with previous research
Findings from previous DCEs on preferences for inhal-
ers for COPD and asthma, which included both clinical
and system characteristics of inhalers, correspond to our
result that healthcare providers attach more importance
to clinical characteristics (e.g. eectiveness) than system
characteristics (e.g. cost attributes) [24]. However, no
DCE to date has investigated the role of environmental
impact of inhalers relative to these clinical and system
characteristics in healthcare providers’ choices. A recent
qualitative study reported that healthcare providers pri-
oritize clinical ecacy over the environmental impact of
inhalers, which is supported by the ndings of the cur-
rent study [45]. Furthermore, this study showed that
while most healthcare providers value environmentally
sustainable practices both in their work and private lives,
only a minority feels encouraged or adequately resourced
to make sustainable choices in general practice. Resource
limitations are frequently reported as barriers to imple-
menting sustainable practices in healthcare [46] and
should be addressed in future initiatives for facilitating
sustainable practices (e.g. stock and accessibility of low
GWP inhalers).
Implications for practice and policy
e introduction of novel pMDIs with greener propel-
lants expected in 2025 may reduce the environmental
impact of inhalers, but continued eorts to promote pre-
scribing low GWP inhalers will remain essential as high
GWP inhalers continue to be available on the market.
is study shows that healthcare providers are willing to
consider the GWP of inhalers when prescribing inhal-
ers. Prescribing low GWP inhalers to newly diagnosed
patients and switching current high GWP inhaler users
to low GWP alternatives in patients with sucient inspi-
ratory force and an adequate hand-lung coordination
could contribute to meet this target. Previous research
shows that healthcare providers with adequate knowl-
edge of sustainable prescribing are more likely to pre-
scribe sustainable medications [47]. Displaying the GWP
or integrating low-GWP options as the default choice
in electronic prescribing systems used in general prac-
tice may encourage the adoption of low GWP inhalers.
Recent research indicated that patients are willing to
choose more sustainable healthcare options, even when
these may be less eective [48]. However, they often
feel inadequately informed by their healthcare provid-
ers. Educating and informing healthcare providers and
Table 5 Results of the multinomial logit model
Attribute levels Model A** Model B***
OR (95%CI) OR (95%CI)
ASC* 1.33 (1.10;
1.62)
1.32 (1.12;
1.55)
Out of pocket costs per year
(per €100,-)
0.74 (0.62;
0.88)
0.72 (0.60;
0.87)
Reduction in number of ex-
acerbations per year (per one
exacerbation)
2.48 (2.08;
2.96)
2.51 (2.09;
3.02)
Multidose/unidose system
Unidose system (reference
level)
1.00 - 1.00
Multidose system 1.34 (1.02;
1.74)
1.37 (1.02;
1.85)
Risk of side eects
No side eects (reference
level)
1.00 - 1.00
Mild side eects 0.64 (0.43;
0.96)
0.66 (0.43;
0.99)
Moderate to severe side
eects
0.10 (0.07;
0.14)
0.09 (0.06;
0.15)
Impact on CO₂ emissions
High GWP (reference level) 1.00 - 1.00
Low GWP 3.39 (2.56;
4.49)
1.15 (0.96;
1.37)
Systemic preference heterogeneity
> 10years working in general
practice x low GWP
- 1.58 (0.72;
3.45)
GP (excl. nurse practitioner/
specialist) x low GWP
-2.48 (1.15;
5.36)
Member of organisation or
network for environmentally
friendly healthcare x low GWP
- 0.87 (0.35;
2.18)
AIC 672.79 616.58
Bold: Statistically signicance at 5% level
Abbreviations: OR odds ratio, CI condence interval, ASC alternative specic
constant, GP general practitioner, AIC Akaike Information Criterion
*The alternative specic constant (ASC) took the left–right bias of the choice
processes of the participants (i.e. participants always choosing option A or B)
into account
**Model A includes the results of the multinomial logit model
***Model B includes the results of the multinomial logit model plus systematic
preference heterogeneity with interaction terms
The coecients from the models represent marginal utilities for dierent
attribute levels and were converted from utilities to odds ratios (OR). A
statistically signicant OR (p-value < 0.05) indicates that the attribute level
had an impact on the choice process of the participants. If the OR for an
attribute level is higher than one, this indicates that this level is preferred over
the reference level of the same attribute. The higher the OR, the greater the
preference. For a correct interpretation of the results, it is important to notice
the dierent units of measurement, e.g. out of pocket costs is a continuous
variable that is measured per euro, whereas multidose system is a categorical
variable that are compared to their reference level
Page 7 of 9Arslan et al. BMC Primary Care (2025) 26:278
patients about medication switching, communication
to patients throughout this process and shared-decision
making between the healthcare provider and patient can
support the choice for low GWP inhalers. Also, address-
ing patient knowledge on sustainability is essential, as
patient awareness of sustainable medication appears to
be low [46, 49]. Another strategy to promote low GWP
inhalers can be providing feedback to healthcare provid-
ers on their prescribing behaviour based on electronic
health record data, as this approach has been proven to
be eective for appropriate prescribing behaviour [50].
Regardless of the treatment decision, the selected treat-
ment should adequately meet patients’ needs and prefer-
ences in terms of eectiveness and usability, while also
balancing environmental considerations [51].
Strengths and limitations of this study
e use of a DCE design is a strength of this study, as it is
a robust and well-established method for capturing and
quantifying preferences in decision-making [32, 34] Fur-
thermore, our sample is generally representative of the
age and sex distribution of GPs in the Netherlands [52].
Another strength of this study is included a diverse range
of primary care inhaler prescribers, which enhances the
representativeness of the ndings. However, due to the
low sample size, we were not able to perform more com-
plex analyses that could reveal additional information on
preference heterogeneity. Also, for attribute selection,
we used ndings from our previous qualitative study on
preferences for low-GWP inhalers, national COPD and
asthma guidelines, and conducted a literature review of
qualitative studies and DCEs. We then asked three GPs
to rank the attributes by importance and selected the ve
most relevant for inclusion in the DCE. A limitation of
this process is that nurses—who made up 39.5% of the
respondents—were not involved in the ranking process.
Including their input might have improved the represen-
tativeness and practical relevance of the attribute selec-
tion. Lastly, ndings of this study represent choices in
hypothetical settings that may not fully correspond to
choices in real life, although recent research has shown
that DCEs are able to predict choices [53]. Preferences
may vary depending on context, such as country-specic
dierences in healthcare systems. Preferences may dier
for more complex patients than presented in the current
hypothetical scenario, where for example the attribute
multidose versus unidose systems (i.e. ease of use) could
be more important.
Further research
is study showed that GPs were more likely to choose
low GWP inhalers compared to nurse practitioners and
specialists. Future research exploring dierences in pref-
erences among healthcare provider groups is needed
to help tailor strategies to promote low GWP-inhalers.
Additionally, this study demonstrated that out-of-pocket
costs are a relatively less important drivers of choice for
healthcare providers compared to other attributes, which
may dier for patients. Investigating patient preferences
for inhalers including its GWP would provide valuable
insights into potential dierences between patient and
provider priorities, supporting shared decision-making
in prescribing low GWP inhalers.
Conclusions
In conclusion, healthcare providers valued clinical fac-
tors (i.e. reduction in number of exacerbations and low
side eects) as most important when choosing inhalers
for their patients with COPD or asthma, however GWP
was also an important driver of choice. ey appear will-
ing to make more sustainable choices, despite feeling
constrained by external factors such as limited resources.
Fig.2 Relative importance of the attributes’
Page 8 of 9Arslan et al. BMC Primary Care (2025) 26:278
ese insights can support strategies to promote the
use of low GWP inhalers for the treatment of COPD
and asthma, contributing to climate change mitigation.
For example by enhancing the provision of information
regarding inhaler GWP, while ensuring that clinical eec-
tiveness remains the primary focus.
Supplementary Information
The online version contains supplementary material available at h t t p s : / / d o i . o r
g / 1 0 . 1 1 8 6 / s 1 2 8 7 5 - 0 2 5 - 0 2 9 4 1 - 8.
Supplementary Material 1.
Supplementary Material 2.
Supplementary Material 3.
Supplementary Material 4.
Supplementary Material 5.
Supplementary Material 6.
Acknowledgements
The authors would like to thank all participants for their contribution and prof.
dr.ir. Liset van Dijk for her valuable advice during the study.
Authors’ contributions
IGA, MV, KH, BJK, CW and LvE developed the rst idea for the DCE. IGA, LvE
and MV carried out the participants’ recruitment and data-collection. IGA and
LvE carried out the statistical analysis, reviewed by EWdBG. IGA wrote the
original draft of the manuscript. MV, EWdBG, KH, BJK, CW and LvE gave their
comments on the rst and nal version of this manuscript.
Funding
This work was partly supported by the Ministry of Health, Welfare and Sport.
The funder had no role in the study design, data collection and data analysis
and interpretation and reporting of results. Ten gift vouchers worth €50 each
were raed among participants who completed the survey.
Data availability
The aggregated data are available on request from the corresponding author.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines in the Declaration of
Helsinki and has been assessed by the Medical Ethics Review Committee of
Amsterdam University Medical Centers. This committee has conrmed that
the current Dutch Medical Research Involving Human Subject Act (WMO)
does not apply to the undertaken study (registration number 2023.0986). The
research has been conducted in accordance with applicable guidelines and
legislation.
Consent for publication
All participants gave informed consent.
Competing interests
The authors declare no competing interests.
Author details
1Netherlands Institute for Health Services Research (Nivel), Utrecht, the
Netherlands
2Erasmus School of Health Policy & Management, Erasmus University
Rotterdam, Rotterdam, The Netherlands
3Erasmus Choice Modelling Centre, Erasmus University Rotterdam,
Rotterdam, The Netherlands
4Erasmus Centre for Health Economics Rotterdam, Erasmus University
Rotterdam, Rotterdam, The Netherlands
5 Department of Public and Occupational Health, Amsterdam UMC, Vrije
Universiteit Amsterdam, Amsterdam, the Netherlands
Received: 10 February 2025 / Accepted: 2 July 2025
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