临床医生对患者联合抗逆转录病毒治疗依从性的评估有多准确？
How well do clinicians estimate patients' adherence to combination antiretroviral therapy?
作者信息
Miller Loren G, Liu Honghu, Hays Ron D, Golin Carol E, Beck C Keith, Asch Steven M, Ma Yingying, Kaplan Andrew H, Wenger Neil S
机构信息
Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance Calif., 90509 USA.
出版信息
J Gen Intern Med. 2002 Jan;17(1):1-11. doi: 10.1046/j.1525-1497.2002.09004.x.
OBJECTIVE
Adherence to combination antiretroviral therapy is critical for clinical and virologic success in HIV-infected patients. To combat poor adherence, clinicians must identify nonadherent patients so they can implement interventions. However, little is known about the accuracy of these assessments. We sought to describe the accuracy of clinicians' estimates of patients' adherence to combination antiretroviral therapy.
SETTING
Public HIV clinic.
DESIGN
Prospective cohort study. During visits, we asked clinicians (nurse practitioners, residents and fellows, and their supervising attending physicians) to estimate the percentage of antiretroviral medication taken by patients over the last 4 weeks and predicted adherence over the next 4 weeks. Adherence was measured using electronic monitoring devices, pill counts, and self-reports, which were combined into a composite adherence measure.
PATIENTS AND PARTICIPANTS
Clinicians estimated 464 episodes of adherence in 82 patients.
RESULTS
Among the 464 adherence estimates, 264 (57%) were made by principal care providers (31% by nurse practitioners, 15% by fellows, 6% by residents, and 5% by staff physicians) and 200 (43%) by supervising attending physicians. Clinicians' overestimated measured adherence by 8.9% on average (86.2% vs 77.3%). Greater clinician inaccuracy in adherence prediction was independently associated with higher CD4 count nadir (1.8% greater inaccuracy for every 100 CD4 cells, P=.005), younger patient age (3.7% greater inaccuracy for each decade of age, P=.02), and visit number (P=.02). Sensitivity of detecting nonadherent patients was poor (24% to 62%, depending on nonadherence cutoff). The positive predictive value of identifying a patient as nonadherent was 76% to 83%.
CONCLUSIONS
Clinicians tend to overestimate medication adherence, inadequately detect poor adherence, and may therefore miss important opportunities to intervene to improve antiretroviral adherence.
目的
坚持联合抗逆转录病毒疗法对于HIV感染患者的临床和病毒学治疗成功至关重要。为应对依从性差的问题，临床医生必须识别出不依从的患者，以便实施干预措施。然而，对于这些评估的准确性知之甚少。我们试图描述临床医生对患者联合抗逆转录病毒疗法依从性估计的准确性。
设置
公共HIV诊所。
设计
前瞻性队列研究。在就诊期间，我们要求临床医生（执业护士、住院医师和研究员以及他们的指导主治医师）估计患者在过去4周内服用抗逆转录病毒药物的百分比，并预测未来4周的依从性。使用电子监测设备、药丸计数和自我报告来测量依从性，并将其合并为一个综合依从性指标。
患者和参与者
临床医生估计了82名患者的464次依从性情况。
结果
在464次依从性估计中，264次（57%）由初级护理提供者做出（执业护士占31%，研究员占15%，住院医师占6%，主治医师占5%），200次（43%）由指导主治医师做出。临床医生平均高估了测量的依从性8.9%（86.2%对77.3%）。依从性预测中临床医生更大的不准确与更低的CD4细胞计数最低点独立相关（每100个CD4细胞不准确程度高1.8%，P = 0.005）、患者年龄更小（每增加十岁不准确程度高3.7%，P = 0.02）以及就诊次数（P = 0.02）。检测不依从患者的敏感性较差（24%至62%，取决于不依从的临界值）。将患者识别为不依从的阳性预测值为76%至83%。
结论
临床医生往往高估药物依从性，不能充分检测出依从性差的情况，因此可能错过改善抗逆转录病毒疗法依从性的重要干预机会。
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