Feasibility, effectiveness and safety of self-management in pulmonary rehabilitation 159 significant differences in treatment outcomes (not only due to less exercise, but possibly also due to change in social aspect). The guideline is also followed in terms of follow-up moments. In practice, it turns out that it is not feasible for every physiotherapist to repeat all measurements at every evaluation moment. Possibly, if the discriminatory ability of the PATCH tool turns out to be good, the PATCH tool could be used to determine which patients should be evaluated every three months and which less frequently. Finally, patients are included who are in the maintenance phase of PR because they need to reduce the treatment frequency of the intensive treatment phase. So, the choice of participants of this study is also based on the KNGF Guideline COPD. In terms of risks and (unintended) effects, for participation in this study no severe or unexpected adverse events will be expected, because of the regular follow-ups. Nevertheless, it has to be kept in mind that patients could feel uncomfortable with the change in their supervision and the focus on self-management. Outcomes The outcomes of this multicenter study will add to the evidence on the effectiveness of partially replacing supervised exercise with unsupervised exercise in a PR program, and of initially using an adherence prediction tool to identify patients who are adherent and who are non-adherent. Because of the hybrid type 1 effectiveness-implementation design, it will give important insights in the acceptability of unsupervised exercise and the use of an exercise adherence prediction model in clinical practice from the perspective of patients and physiotherapists. If unsupervised exercise is feasible and acceptable, this study will inform the implementation of more self-management in clinical practice in other physiotherapy practices. So far, the optimal cut-off value for the PATCH tool is used. However, the PATCH tool applies a statistical prediction model and therefore does not take into account other individual factors, other than those of the prediction model, that may affect adherence, such as multimorbidity, for example. Hence, it is important to evaluate whether the cut-off value needs to be adjusted. With the results of this study, including clinical relevance, the cut-off value of the PATCH tool may be changed. For example, no patients should be classified as false positive (a patient is classified as adherent but he or she is not). In that case, a patient would incorrectly receive less clinical supervision. When the PATCH tool identifies patients effectively as adherent or non-adherent, the study will inform the implementation of the PATCH tool in other physiotherapy practices. The PATCH tool could then not only be used to determine treatment frequency, but could then potentially be used to reduce the registration burden (fewer evaluation moments).
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