3. Hypotheses
We hypothesise that over 12 months, compared to usual care, the intervention will lead to fewer COPD exacerbation days. In addition, it will lead to fewer hospitalisation days for COPD and comorbidities, a reduction of chronic heart failure exacerbation severity, anxiety or depression symptoms and
health care use, and a better general and COPD-specific health status. In addition, it will lead to increased self-efficacy, high adherence levels, patient's satisfaction and confidence, and a
direct saving in health care costs.