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Ellen Ricke,1 Eric W Bakker2 1Department of Social Psychology, University of Groningen, Groningen, the Netherlands; 2Department of Epidemiology and Data Science | Division EBM, Academic Medical Centre, Amsterdam, the NetherlandsCorrespondence: Ellen Ricke, Department of Social Psychology, University of Groningen, Grote Kruisstraat 2/1, Groningen, 9712 TS, the Netherlands, Tel +31 6 211 817 02, Email E.Ricke@rug.nlPurpose: Pulmonary rehabilitation (PR) is considered a cost-effective method of improving health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). However, increasing demand and increasing costs of supply demands for sustainable and affordable care. One of the possible solutions to keep care affordable is self-management. A challenge here is non-adherence. Understanding who are adherent and who are non-adherent could be helpful to differentiate between patients who need more or less support. Therefore, the aim of this study was to develop and validate a model to predict adherence to PR in patients with COPD.Patients and methods: A multivariable logistic regression model for exercise adherence was developed. Eight candidate predictors, that were prespecified, were obtained in a prospective cohort study from 196 patients with COPD following PR in 53 primary physiotherapy practices in the Netherlands and Belgium, between January 2021 and August 2022. To create a parsimonious model, variable selection using backward selection was performed with a p-value of > 0.05 for elimination. Model performance was assessed by discrimination, calibration and clinical utility. Internal validation was assessed by bootstrapping (n = 500).Results: The final model included four predictors: intention, depression, MRC-score and alliance. The optimism-corrected AUC after bootstrap internal validation was 0.79 (95% CI, 0.72– 0.85). Calibration plots suggested good calibration and decision curve analysis showed great net benefit in a wide range of risk thresholds.Conclusion: The exercise adherence prediction model has potential for clinical utility to predict adherence in patients with COPD. Information from such a model can be used to manage the patient instead of managing the disease, and thereby to determine the treatment frequency for each individual patient. As a result, healthcare capacity might be better distributed, potentially reducing pressure on healthcare without compromising the effectiveness of PR for the individual patient.Keywords: chronic obstructive pulmonary disease, sustainable healthcare, pulmonary rehabilitation, self-management

Introduction: Patients with a chronic disease may have an increased risk of non-adherence to prescribed home-based exercise therapy. We performed a systematic review with the aim to identify and grade the quality of variables associated with (non-)adherence to home-based exercise therapy in patients with chronic diseases. Methods: Cohort studies, cross-sectional studies and the experimental arm of randomized trials were identified using a search strategy applied to PubMed, Embase, PsychINFO and CINAHL from inception until August 1th 2022. We included studies with participants ³ 18 years with a chronic disease as an indication for home-based exercise therapy and providing data (quantitative and qualitative) on prognostic factors of (non)adherence to home-based exercise. Risk of bias was assessed using the Quality in Prognostic Studies (QUIPS) tool for observational studies, the Quality Assessment Tool for Observational Cohort and Cross- sectional studies of the National Institutes of Health (NIH) for cross-sectional studies and the Critical Appraisal Skills Program (CASP) qualitative checklist for the qualitative studies. Prognostic factors of adherence were identified and graded for quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for predictor studies. We performed a meta-analysis and best evidence synthesis of the obtained information. Results: A total of 68 studies (11 qualitative and 57 quantitative) were included. Within patient-related factors moderate- and high-quality evidence suggested that more self-efficacy, exercise history, motivation and perceived behavioral control predicted higher adherence. Within social-economic factors moderate-quality evidence suggested more education and physical health to be predictive of higher adherence and within condition-related factors moderate- and low-quality evidence suggested that less comorbidities, depression and fatigue predicted higher adherence. For the domains therapy-related and health-system factors there was not enough information to determine the quality evidence of the prognostic factors. Conclusion: These findings might aid the development of future home-based exercise programs as well as the identification of individuals who may require extra support to benefit from prescribed home-based exercise therapy. Registration: The protocol of this systematic review is registered in PROSPERO with registration number CRD42021277003.