Development and validation of an exercise adherence prediction model 101 Introduction Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide with an economic and social burden that is both substantial and increasing [1]. The prevalence of COPD increased by almost 40% between 1990 and 2017, and by 2017 COPD had become the third leading cause of death globally [2]. In the European Union, the total costs of respiratory disease are estimated to be about 6% of the total annual healthcare budget, with COPD accounting for 56% (38.6 billion euros) [3]. In the United States the costs attributable to COPD are expected to increase over the next 20 years, with projected costs of 800.90 billion dollars [4]. COPD prevalence, morbidity and mortality vary across countries [5]. Based on demographic trends, the absolute number of patients with COPD is expected to increase by 31% between 2015 and 2040 in the Netherlands [6]. COPD is associated with an increase in disability-adjusted life years and years of life lost across the life course, and with substantial social and economic consequences for both individual patients and health systems [2]. Total healthcare costs for patients with COPD were 400 million euros in 2007 in the Netherlands, and will rise to nearly 1.4 billion euros in 2032, being more than three times what it was in 2007 (including a growth in healthcare spending of 2.3% per year) [7]. Pulmonary rehabilitation (PR) aims to reduce the levels of morbidity, to improve functioning, and is currently an integral component of managing COPD [8]. PR is a cost-effective method of improving health-related quality of life in patients with COPD, and is recommended in national guidelines [9]. Despite PR being costeffective, increasing demand by an aging population and increasing costs of supply demands for sustainable and affordable care [10]. In the medium term the cost of care is rising and a shortage of personnel is looming [11]. Due to the high number of consultations per patient per year (24.7), the cost of PR in primary care is relatively high: nearly 40 million euros in 2007 [7]. To keep healthcare affordable and to make PR less labor-intensive, there is a need for more focus on selfmanagement, without compromising on the effectiveness of PR [12]. Selfmanagement programs in primary care may improve health behaviors, health outcomes, and quality of life and, in some cases, have demonstrated effectiveness for reducing health care utilization and the societal cost burden of chronic diseases [13]. One of the biggest challenges here is long-term adherence [14]. Adherence is a multidimensional construct that is defined as the extent to which a person’s behavior in therapeutical interventions corresponds with agreed recommendations from a healthcare provider [15]. Adherence includes behaviors such as attendance at clinic appointments, the extent to which patients follow the prescribed treatment, and the communication with their healthcare provider about their recovery [16]. In supporting patients staying adherent, available resources
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