Roter D L, Hall J A, Merisca R, Nordstrom B, Cretin D, Svarstad B
Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205, USA.
Med Care. 1998 Aug;36(8):1138-61. doi: 10.1097/00005650-199808000-00004.
This article summarizes the results of 153 studies published between 1977 and 1994 that evaluated the effectiveness of interventions to improve patient compliance with medical regimens.
The compliance interventions were classified by theoretical focus into educational, behavioral, and affective categories within which specific intervention strategies were further distinguished. The compliance indicators broadly represent five classes of compliance-related assessments: (1) health outcomes (eg, blood pressure and hospitalization), (2) direct indicators (eg, urine and blood tracers and weight change), (3) indirect indicators (eg, pill count and refill records), (4) subjective report (eg, patients' or others' reports), and (5) utilization (appointment making and keeping and use of preventive services). An effect size (ES) r, defined as Fisher's Z transformation of the Pearson correlation coefficient, representing the association between each intervention (intervention versus control) and compliance measure was calculated. Both an unweighted and weighted r were calculated because of large sample size variation, and a combined probability across studies was calculated.
The interventions produced significant effects for all the compliance indicators (combined Z values more than 5 and less than 32), with the magnitude of effects ranging from small to large. The largest effects (unweighted) were evident for refill records and pill counts and in blood/urine and weight change studies. Although smaller in magnitude, compliance effects were evident for improved health outcomes and utilization. Chronic disease patients, including those with diabetes and hypertension, as well as cancer patients and those with mental health problems especially benefited from interventions.
No single strategy or programmatic focus showed any clear advantage compared with another. Comprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions.
本文总结了1977年至1994年间发表的153项研究的结果，这些研究评估了旨在提高患者对医疗方案依从性的干预措施的有效性。
依从性干预措施按理论重点分为教育、行为和情感三类，其中进一步区分了具体的干预策略。依从性指标大致代表五类与依从性相关的评估：（1）健康结果（如血压和住院情况），（2）直接指标（如尿液和血液追踪剂以及体重变化），（3）间接指标（如药丸计数和续方记录），（4）主观报告（如患者或他人的报告），以及（5）利用率（预约和就诊以及预防服务的使用）。计算效应量（ES）r，定义为皮尔逊相关系数的费舍尔Z变换，代表每种干预措施（干预组与对照组）与依从性测量之间的关联。由于样本量差异较大，计算了未加权和加权的r，并计算了各研究的综合概率。
干预措施对所有依从性指标均产生了显著影响（综合Z值大于5且小于32），影响程度从小到大都有。续方记录和药丸计数以及血液/尿液和体重变化研究中（未加权）的影响最大。虽然影响程度较小，但依从性对改善健康结果和利用率也有明显影响。慢性病患者，包括糖尿病和高血压患者，以及癌症患者和有心理健康问题的患者尤其从干预措施中受益。
与其他策略或方案重点相比，没有单一策略或方案重点显示出明显优势。结合认知、行为和情感成分的综合干预措施比单一重点干预措施更有效。
