Kravitz R L, Hays R D, Sherbourne C D, DiMatteo M R, Rogers W H, Ordway L, Greenfield S
RAND, Santa Monica, Calif.
Arch Intern Med. 1993 Aug 23;153(16):1869-78.
Patient adherence to treatment regimens may be a critical mediator between physician recommendations and patient outcomes, but levels of adherence have not been compared across disease groups, and patient self-reports have not been well validated.
To determine recall of and adherence to physicians' recommendations among patients with chronic medical conditions and to measure the correspondence between self-reported adherence and disease activity, we analyzed data from the Medical Outcomes Study. A total of 1751 patients with diabetes mellitus, hypertension, and heart disease were identified among 20,223 patients visiting family physicians, general internists, cardiologists, and endocrinologists in 1986. Main outcome measures included recall of 15 disease-specific recommendations, self-reported general and specific adherence, and correlations between adherence and clinical measures of disease activity and control.
Among patients in all three disease groups, the proportion recalling recommendations to take prescribed medications (> or = 90%) exceeded the fraction recalling recommendations to follow a restricted diet, exercise regularly, and perform various self-care activities (22% to 84%). Adherence to recalled recommendations was similar across conditions but varied markedly according to the nature of the recommendations; for example, 91% of diabetics took prescribed medications but 69% followed a diabetics diet and 19% engaged in regular exercise. Adherence to recommendations was correlated with reduced serum glucose (r = -.33) and glycohemoglobin (r = -.25) levels among insulin-dependent diabetics and with reduced diastolic blood pressure among patients with hypertension (r = -.15).
The majority of chronically ill patients failed to recall elements of potentially important medical advice and did not always adhere to advice that was recalled. Self-reported adherence was correlated with clinical measures of disease activity and control. Additional research is needed not only to improve adherence to medical advice in patients with chronic illnesses but also to determine which life-style changes are truly beneficial for these patients.
患者对治疗方案的依从性可能是医生建议与患者治疗结果之间的关键调节因素，但不同疾病组之间的依从性水平尚未得到比较，且患者的自我报告也未得到充分验证。
为了确定慢性病患者对医生建议的记忆和依从性，并衡量自我报告的依从性与疾病活动之间的对应关系，我们分析了医疗结果研究的数据。1986年，在20223名就诊于家庭医生、普通内科医生、心脏病专家和内分泌专家的患者中，共识别出1751名患有糖尿病、高血压和心脏病的患者。主要结局指标包括对15项特定疾病建议的记忆、自我报告的总体和特定依从性，以及依从性与疾病活动和控制的临床指标之间的相关性。
在所有三个疾病组的患者中，记得服用处方药建议的比例（≥90%）超过了记得遵循限制饮食、定期锻炼和进行各种自我护理活动建议的比例（22%至84%）。不同疾病的患者对记得的建议的依从性相似，但根据建议的性质有显著差异；例如，91%的糖尿病患者服用处方药，但69%遵循糖尿病饮食，19%进行定期锻炼。在胰岛素依赖型糖尿病患者中，对建议的依从性与血糖水平降低（r = -0.33）和糖化血红蛋白水平降低（r = -0.25）相关，在高血压患者中与舒张压降低相关（r = -0.15）。
大多数慢性病患者未能记住潜在重要医疗建议的内容，并且并不总是遵守所记住的建议。自我报告的依从性与疾病活动和控制的临床指标相关。不仅需要进一步研究以提高慢性病患者对医疗建议的依从性，还需要确定哪些生活方式的改变对这些患者真正有益。
