Chapter 9 170 (PR), a protocol was developed in Chapter 8 detailing the evaluation of safety and effectiveness of COPD-patient self-management regarding pulmonary rehabilitation in primary physiotherapy practices in the Netherlands. This protocol is based on implementing guideline advice: clinical supervision will be halved but patients are stimulated to engage in self-management by exercising unsupervised, leading to no change in the total planned exercise frequency. During the supervised sessions physiotherapists will assess and stimulate self-management. With a follow-up of 12 months, the study will provide insight in the relationship between self-management and adherence, and the COPD-specific health outcomes exercise capacity, disease burden, health related quality of life, MRC dyspnea score, and lung attacks, on the long term. In addition, this study will also evaluate the predictive validity of the Predicting Adherence in paTients with CHronic diseases (PATCH) tool, and the implementation outcomes feasibility and adoption of self-management and the PATCH tool. Data collection Interpretation of the results A number of problems regarding data collection can be mentioned, which should be taken into account when interpreting the results of the studies. First, patients provided data by self-reports. They had to indicate by themselves whether they adhered to the agreements they made with their physiotherapist. The main limitation of retrospective self-reports is the possibility of inaccurate recall, and a bias towards an overestimation of doing the home-based activities [12]. This is reflected in the correlations calculated in chapter 3; a medium correlation was found between the RAdMAT-NL and self-reported adherence. While large correlations were found between the RAdMAT-NL and other measures associated with adherence. Thus, when adherence measures are used as an indication of a particular intervention, it is recommended that objective measurements are used instead of self-reports. Second, before the start of the study, all participating physiotherapists received an email about the implementation of the study. This information consisted of a manual on how to use and administer the RAdMAT-NL, the SIRAS and the Five Times Sit to Stand Test. By providing this information to the physiotherapists, it was assumed that the physiotherapists' assessment method was standardized. However, there was no further training for the physiotherapists in the use of the measurements, so consensus regarding the use of the measurements were not obtained. If physiotherapists applied the measurements slightly different from those described in the manual, measurement bias may have occurred. Although, the results are a reflection of practice (rather than an experimental setting), and thus can be generalized to other physiotherapy practices, this potential measurement bias should be taken into account when interpreting the results. To minimize measurement bias, more training could be
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