Feasibility, effectiveness and safety of self-management in pulmonary rehabilitation 143 Introduction As population ageing accelerates worldwide, chronic diseases will place an increasing burden on society and healthcare systems [1]. Chronic diseases affect over 80% of people aged over 65 years in Europe, account for an estimated 77% of disease burden [2] and contribute to 70-80% of healthcare costs [3]. One of the chronic diseases with the highest burden of disease and cost is Chronic Obstructive Pulmonary Disease (COPD) [4]. COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction [5]. Self-management interventions may become a key strategy for addressing chronic disease burden, contributing to the paradigm shift from a paternalistic model where patients are viewed as passive recipients of care, towards more equitable and collaborative models of healthcare provider-patient interaction [6]. In doing so, selfmanagement is seen as a possible solution to keep healthcare affordable. Selfmanagement is defined as the partnering of healthcare providers with patients to support patients’ independent efforts to undertake long-term adherence to a preventive or therapeutic regimen that can improve functional status and health outcomes [7]. There is evidence that COPD self-management interventions can improve quality of life at generally acceptable societal costs [8], and in some cases even result in short-term healthcare savings [9]. A core component of the management of COPD is pulmonary rehabilitation (PR) [10]. It is often stated that PR is a cost-effective method of reducing dyspnea, increasing exercise capacity, and improving health-related quality of life in patients with COPD [8], and is recommended in national guidelines [10]. According to the Dutch Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF) [Royal Dutch Society for Physiotherapy] Guideline COPD, self-management interventions should be implemented in PR treatment; physiotherapists should reduce the number of supervised treatments after the maintenance phase and support self-management [11]. In practice, this does not (always) happen. One reason for this is that it appears that patients do not always adhere to recommendations, which negatively affects health outcomes [12, 13]. From a rehabilitation context, adherence has been defined as an ‘active, voluntary collaborative involvement of the patient in a mutually acceptable course of behavior to produce a desired preventive or therapeutic result’ [14]. Patients with COPD who are adherent to PR have better treatment outcomes [12, 15]. However, in every situation in which patients have to take responsibility for their own treatment and supervised support is lowered, there is a substantial chance of non-adherence [12]. This non-adherence could potentially reduce the effectiveness of PR, leading to
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