Chapter 6 116 Discussion We developed and validated a model to predict exercise adherence in patients with COPD following PR in a primary physiotherapy practice in the Netherlands and Belgium. The final model integrates four easily available predictors (intention, depression, MRC-score, alliance), and is intended for use in the population of COPD patients following PR for at least one month. Internal validation showed good discrimination, calibration, and net benefit. The calculator provides a probability output that indicates the chance that the patient under evaluation is adherent. These predictions will enable healthcare providers to objectively determine which patients are adherent and might be able to exercise more by themselves. Patients who are non-adherent might need more support than patients who are adherent. As a result, healthcare capacity might be better distributed, potentially reducing pressure on healthcare without compromising the effectiveness of PR for the individual patient. One of the predictors in the final prediction model is not yet available at the time a patient first comes for PR: alliance. Therefore, this prediction model can only be used for patients following PR for at least one month. It is important for healthcare providers to realize, however, that alliance is an important predictor of adherence. So, when a patient follows PR for the first time, there should immediately be invested in alliance (the larger the alliance, the better the adherence). Literature shows that it is widely accepted that the treatment regimen alone cannot fully account for patient outcome [20]. The relationship between patient and therapist has been viewed as an important determinant of treatment outcome and is considered central to the therapeutic process [21]. The construct of alliance in therapeutic situations refers to the sense of collaboration, warmth, and support between the client and therapist [21]. The study of Peiris et al. showed that the patient-therapist interaction was more important to the patient than the amount or content of their physiotherapy [34]. In relation with the TPB model it is shown that patients who experience a positive alliance are more likely to have a stronger selfefficacy and outcome expectations. And self-efficacy and outcome expectations are highly correlated with patient adherence to treatment [35]. Strengths and limitations The strengths of this study are inclusion of patients from different physiotherapy practices and from patient organizations in the Netherlands and Belgium. In this way, a representative sample of COPD patients attending PR participated in this study, which enhances the generalizability of the study results regarding other COPD patients already attending PR. The final variables are easy to obtain and can be entered into the adherence calculator to obtain prognostic estimates. A manual for using the calculator is available, including advise for the healthcare provider how to deal with the probability score. Another strength is the use of a prespecified
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