Chapter 8 158 supervision is described in the KNGF Guideline COPD and can be considered as usual care (therefore no RCT); 2. patients will be followed in time to evaluate whether there are changes in treatment outcomes (therefore prospective); 3. only patients who receive clinical supervision, as opposed to patients who already exercise independently, will be included (therefore treatment cohort). A disadvantage of this design is that only the association between self-management and health outcomes, and not causation, can be inferred from the results of the study [40]. However, by following patients over time and measuring various variables, it can be determined which patients are at greater risk for poorer health outcomes. Furthermore, a mixed-method approach was chosen because experiences can vary from person to person. Therefore, qualitative measures are added to the quantitative measures; participants should be able to provide an explanation in their own words, e.g., why they think self-management is or is not effective. [41]. The function of this mixed-method approach is using the qualitative data to explain the results of the analysis of the quantitative data. Finally, this study does not focus only on outcomes. Instead, the whole process of implementation is taking into account. The study is based on a hybrid type 1 effectivenessimplementation design, focusing on testing the effects of a clinical intervention on relevant outcomes while observing and gathering information on implementation, in order to more rapidly move interventions from effectiveness testing through implementation to public health impact [19]. This design was chosen as the effectiveness of more self-management (more unsupervised exercise) regarding PR has not yet been demonstrated in primary physiotherapy settings in the Netherlands and little information exists on implementation of unsupervised exercise in primary care. An additional advantage of this design is that the predictive validity and implementation of the PATCH tool can be evaluated in the same cohort, which reduces the burden on physiotherapists and patients and saves time and money. Self-management and follow-up The KNGF Guideline COPD includes a section on supervision by the physiotherapist: "In the intensive treatment phase, strive to achieve the treatment goal. Strive in the phase-out phase to maintain the treatment goal and in the maintenance phase of the therapeutic treatment to transition to regular sports and exercise activities" [11]. For patients who are considered for maintenance treatment, a treatment frequency of once a week is advised until the patient is able to exercise independently [11]. Based on this guideline, it was chosen to halve clinical supervision. As an inclusion criterion, it was chosen to include only patients who receive PR once a week. This choice was made because training theory indicates that exercising once a week is considered a maintenance treatment [11]. When patients go from twice-weekly to once-weekly supervised exercise, it may not be possible to measure a difference in health outcomes due to maintenance treatment. However, supervised exercise every other week will be able to show
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