Adherence to pulmonary rehabilitation during a 12-month period 85 Introduction The prevalence of chronic diseases is rising across Europe, triggered by increasing life expectancy and changing lifestyles [1]. The resulting pressures on health systems to address chronic diseases, including chronic obstructive pulmonary disease (COPD), have become a concern for policymakers and -providers [2]. For example, in the Netherlands, in 2015, 50% of the population had at least one chronic disease. By 2040, it is expected that one in three Dutch people will have two or more chronic diseases, and almost one in five will have three or more chronic diseases [3]. In the medium term the cost of care is rising and a shortage of personnel is looming. In 2022-2025, healthcare costs increase by an average of 2.7% per year and annual healthcare employment growth over the same period is 2.1% [4]. COPD is one highly prevalent chronic disease that demands increasing care; it is already the third leading cause of death worldwide [5]. Thus, the challenge is to keep good quality, accessible, and affordable care [6]. One of the possible solutions to keep care affordable is ‘self-management’. Selfmanagement is defined as the partnering of health care providers with patients to support efforts to undertake long-term adherence to a preventive or therapeutic regimen that can improve functional status and health outcomes [7]. Selfmanagement programs in primary care may improve health behaviors, health outcomes, and quality of life and, in some cases, have demonstrated effectiveness for reducing health care utilization and the societal cost burden of chronic diseases [8]. One of the biggest challenges here is long-term adherence [9]. Long-term adherence in self-management can be conceptualized by three components: 1. Initiation: When the patient starts a lifestyle behavior change in accordance with his health care provider; 2. Implementation: The extent to which a patient’s behavior corresponds with agreed recommendations from his health care provider; 3. Persistence: The time from initiation to discontinuation [10]. Non-adherence can occur in any of these phases, and may change over time in patients. So, appropriate attention should be paid to patients’ level of adherence, as reduced adherence attenuates the benefits of the behavior change, and may worsen health outcomes [3]. In supporting patients staying adherent, available resources should be used in ways that are both effective (desired outcomes) and efficient (that do so with the least amount of effort and cost) [6]. If, for example, it can be predicted who is at risk of non-adherence, then care maybe tailored. For this purpose, a prediction model could be helpful. Such a model is currently being developed. But to predict adherence over time, it is important to have an understanding of how this variable might change over time. Presently, it is unclear whether adherence is a constant factor over time, or rather increases or decreases or fluctuates. Understanding this
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