General discussion 179 The focus of the protocol for follow-up research is to evaluate the feasibility and effectiveness of increased self-management and the validation of the PATCH tool. If more self-management proves to be feasible and effective and if the PATCH tool is valid (has a good discriminatory ability), further research can focus on patients who are non-adherent: can psychosocial interventions, in combination with the current biomedical intervention [3], ensure that adherence increases and that this patient group also eventually will need less clinical supervision? The protocol provides guidance for multiple studies, all of which should contribute to making healthcare more effective and efficient and ensure that patients receive the care and support they need. The protocol, like the rest of this thesis, focuses on patients with COPD. However, most healthcare demands and healthcare costs come from long-term care in general [37]. Since non-adherence is inherent to the duration of treatment [3], non-adherence is a major problem throughout long-term care. So, to design healthcare as effectively and efficiently as possible, follow-up research should also study other chronic diseases, such as cardiovascular disease or cancer. One of the research questions in the protocol should provide insight into the characteristics of patients with COPD who are capable of increased selfmanagement while maintaining stable health outcomes. Do these characteristics also apply to people with other chronic diseases? After validation of the PATCH tool, with possible calibration and adjustment of the cut-off value (for example no false positive classifications), follow-up studies should investigate whether the PATCH tool is also applicable in patients with other chronic diseases. Possibly the PATCH tool could be further developed if it turns out that other predictors better predict adherence to exercise in a different population. Further development of the PATCH tool is in particular interesting if the feasibility study, as described in the protocol, concludes that physiotherapists consider PATCH to be a useful tool to adjust treatment frequency to the degree of adherence. To further emphasize the importance of adherence on treatment outcomes, follow-up research focusing on the RAdMAT-NL and the PATCH tool could also focus on another setting, such as general practice and secondary and tertiary healthcare. Overall conclusions In this thesis, a valid and reliable measurement instrument was developed for the assessment of exercise adherence in patients with COPD following pulmonary rehabilitation in a primary physiotherapy practice. With a McDonalds omega of 0.92 and 0.68 for Participation and Communication subscales respectively, the RAdMATNL has good internal consistency reliability and the factor structure, Rasch analysis and Spearman’s correlations demonstrated good structural and construct (convergent) validity of the RAdMAT-NL. The participation items of the RAdMAT-NL
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