de Bruin Marijn, Viechtbauer Wolfgang, Schaalma Herman P, Kok Gerjo, Abraham Charles, Hospers Harm J
Department of Work and Social Psychology, Maastricht University, the Netherlands.
Arch Intern Med. 2010 Feb 8;170(3):240-50. doi: 10.1001/archinternmed.2009.536.
Poor adherence to medication limits the effectiveness of treatment for human immunodeficiency virus. Systematic reviews can identify practical and effective interventions. Meta-analyses that control for variability in standard care provided to control groups may produce more accurate estimates of intervention effects.
To examine whether viral load and adherence success rates could be accurately explained by the active content of highly active antiretroviral therapy (HAART) adherence interventions when controlling for variability in care delivered to controls, databases were searched for randomized controlled trials of HAART adherence interventions published from 1996 to January 2009. A total of 1342 records were retrieved, and 52 articles were examined in detail. Directly observed therapy and interventions targeting specific patient groups (ie, psychiatric or addicted patients, patients <18 years) were excluded, yielding a final sample of 31 trials. Two coders independently retrieved study details. Authors were contacted to complete missing data.
Twenty studies were included in the analyses. The content of adherence care provided to control and intervention groups predicted viral load and adherence success rates in both conditions (P < .001 for all comparisons), with an estimated impact of optimal adherence care of 55 percentage points. After controlling for variability in care provided to controls, the capacity of the interventions accurately predicted viral load and adherence effect sizes (R(2) = 0.78, P = .02; R(2) = 0.28, P < .01). Although interventions were generally beneficial, their effectiveness reduced noticeably with increasing levels of standard care.
Intervention and control patients were exposed to effective adherence care. Future meta-analyses of (behavior change) interventions should control for variability in care delivered to active controls. Clinical practice may be best served by implementing current best practice.
药物依从性差会限制人类免疫缺陷病毒治疗的效果。系统评价可以识别切实有效的干预措施。对对照组提供的标准护理的变异性进行控制的荟萃分析可能会更准确地估计干预效果。
为了检验在控制给予对照组的护理变异性时，高效抗逆转录病毒治疗（HAART）依从性干预措施的活性成分是否能准确解释病毒载量和依从成功率，检索了1996年至2009年1月发表的HAART依从性干预措施的随机对照试验数据库。共检索到1342条记录，并对52篇文章进行了详细审查。排除直接观察治疗和针对特定患者群体（即精神病患者或成瘾患者、18岁以下患者）的干预措施，最终样本为31项试验。两名编码员独立检索研究细节。联系作者以补充缺失数据。
20项研究纳入分析。给予对照组和干预组的依从性护理内容在两种情况下均能预测病毒载量和依从成功率（所有比较P<0.001），最佳依从性护理的估计影响为55个百分点。在控制了给予对照组的护理变异性后，干预措施的能力准确预测了病毒载量和依从效应大小（R²=0.78，P=0.02；R²=0.28，P<0.01）。虽然干预措施总体上是有益的，但随着标准护理水平的提高，其有效性显著降低。
干预组和对照组患者均接受了有效的依从性护理。未来对（行为改变）干预措施的荟萃分析应控制给予积极对照组的护理变异性。实施当前最佳实践可能最有利于临床实践。
