Incentives and enablers to improve adherence in tuberculosis.
Incentives and enablers to improve adherence in tuberculosis.
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DOI：
10.1002/14651858.cd007952.pub3
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发表时间：
2015-09-03
期刊：
影响因子：
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通讯作者：
Volmink J
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文献类型：
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作者：
Lutge EE;Wiysonge CS;Knight SE;Sinclair D;Volmink J
患者对药物的依从性，特别是对于需要长期治疗的疾病，如结核病，往往不太理想，并可能导致治疗结果不佳。有时会以现金、代金券或食物的形式给予物质奖励，以奖励良好行为和消除获得医疗服务的经济障碍。评估物质激励和促进因素对接受结核病诊断检测或接受预防性或治愈性治疗的患者的影响。我们对Cochrane传染病组专业登记进行了全面的搜索；Cochrane中央对照试验登记册；MEDLINE;EMBASE;紫丁香;科学引文索引；及截至2015年6月5日的相关刊物参考书目。正在接受结核病调查的患者的物质激励或对潜伏或活动性结核病的治疗的随机对照试验。至少有两位综述作者独立筛选和选择研究，提取数据，并评估纳入试验的偏倚风险。我们使用风险比（RR）比较了干预措施的效果，并给出了95%置信区间（CI）的风险比。使用GRADE评估证据的质量。我们确定了12项符合条件的试验。其中10项在美国进行：青少年（1项试验）、注射毒品或可卡因使用者（4项试验）、无家可归的成年人（3项试验）和囚犯（2项试验）。其余两项试验在东帝汶和南非进行，均为一般成年人群。只有两项试验评估了物质激励和使能因素是否可以改善活动性结核病的长期依从性和完成治疗，但都没有显示出明显的益处（RR 1.04, 95% CI 0.97至1.14；两项试验，4356名参与者；低质量证据）。在一项试验中，每天提供热餐作为奖励，由于中午去诊所不方便，人们不太接受；而在另一项试验中，分发代金券的护士选择在符合条件的患者中“定量”分配代金券，只给那些她们认为最贫困的患者。三项试验评估了物质激励和推动因素对完成结核病预防的影响，结果好坏参半（证据质量低）。在治疗完成率极低的对照组中，在每次就诊时给予吸毒者定期现金奖励，效果显著(干预组治疗完成率为52.8%，对照组为3.6%；RR为14.53,95% CI为3.64 ~ 57.98；一项试验，108名参与者)，但在一项评估最近释放的囚犯的现金激励的试验（373名参与者），或另一项评估父母向青少年提供的物质激励的试验（388名参与者）中，没有看到效果。然而，在特定人群中，如新近释放的囚犯、吸毒者和无家可归者，试验表明，物质激励可能确实提高了开始或继续抗结核预防的一次性诊所复诊率（RR 1.58, 95% CI 1.27至1.96；3项试验，595名参与者；中等质量证据），并可能提高结核菌素皮肤试验结果阅读的回复率(RR 2.16, 95% CI 1.41至3.29；2项试验，1371名参与者；证据质量低)。在特定亚人群中进行的单一试验表明，即时现金奖励可能比延迟奖励直到治疗完成更有效（RR 1.11, 95% CI 0.98至1.24；一项试验，300名受试者；低质量证据），现金奖励可能比非现金奖励更有效(完成结核病预防：RR 1.26, 95% CI 1.02至1.56；一项试验，141名受试者，低质量证据；皮肤试验读数返回：RR 1.13, 95% CI 1.07 ~ 1.19；一项试验，652名参与者；证据质量低)；较高的现金奖励可能比较低的现金奖励更有效（RR 1.08, 95% CI 1.01至1.16；一项试验，404名受试者；低质量证据）。物质激励和促进因素可能会对诊所就诊人数产生一些积极的短期影响，特别是对吸毒者、新近获释的囚犯和无家可归者等边缘人群，但目前没有足够的证据表明它们是否能够改善结核病治疗的长期依从性。CIDG目前正在审查一项截至2018年7月19日的新搜索，以寻找可能相关的研究。这些研究尚未被纳入Cochrane综述。提高患者对结核病诊断、预防和治疗依从性的激励和促进因素Cochrane研究人员对物质（经济）激励或促进因素对接受潜伏性或活动性结核病（TB）检测或治疗的患者依从性和结果的影响进行了综述。在检索到2015年6月5日的相关试验后，他们在Cochrane综述中纳入了12项随机对照试验。什么是物质激励和推动因素，它们如何改善病人的护理？物质激励和使能因素是指可以给予患者的经济干预措施，以奖励健康行为（激励）或消除获得医疗保健的经济障碍（使能因素）。可以直接以现金或代金券的形式给予奖励和支持，也可以间接提供病人可能需要付费的服务（如前往医疗机构的交通）。物质激励和促进因素可能对改善活动性结核病患者治疗结果的影响很小或没有影响（低质量证据），但是需要对替代激励和促进因素进行进一步的试验。在某些情况下，物质激励和推动因素可能对完成潜伏性结核病预防有一定影响，但试验结果好坏参半，一项试验显示效果很大，两项试验显示没有效果（低质量证据）。一次性的物质激励和促成因素可能会提高开始或继续结核病预防的患者单次门诊预约的回复率（中等质量证据），并可能提高结核病诊断测试读数的回复率（低质量证据）。因此，尽管物质激励和使能因素可能在短期内提高一些患者的就诊率，但需要更多的研究来确定它们是否对结核病患者的长期治疗有重要的积极作用。
Patient adherence to medications, particularly for conditions requiring prolonged treatment such as tuberculosis (TB), is frequently less than ideal and can result in poor treatment outcomes. Material incentives to reward good behaviour and enablers to remove economic barriers to accessing care are sometimes given in the form of cash, vouchers, or food to improve adherence. To evaluate the effects of material incentives and enablers in patients undergoing diagnostic testing, or receiving prophylactic or curative therapy, for TB. We undertook a comprehensive search of the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; Science Citation Index; and reference lists of relevant publications up to 5 June 2015. Randomized controlled trials of material incentives in patients being investigated for TB, or on treatment for latent or active TB. At least two review authors independently screened and selected studies, extracted data, and assessed the risk of bias in the included trials. We compared the effects of interventions using risk ratios (RR), and presented RRs with 95% confidence intervals (CI). The quality of the evidence was assessed using GRADE. We identified 12 eligible trials. Ten were conducted in the USA: in adolescents (one trial), in injection drug or cocaine users (four trials), in homeless adults (three trials), and in prisoners (two trials). The remaining two trials, in general adult populations, were conducted in Timor‐Leste and South Africa. Sustained incentive programmes Only two trials have assessed whether material incentives and enablers can improve long‐term adherence and completion of treatment for active TB, and neither demonstrated a clear benefit (RR 1.04, 95% CI 0.97 to 1.14; two trials, 4356 participants; low quality evidence). In one trial, the incentive, given as a daily hot meal, was not well received by the population due to the inconvenience of attending the clinic at midday, whilst in the other trial, nurses distributing the vouchers chose to "ration" their distribution among eligible patients, giving only to those whom they felt were most deprived. Three trials assessed the effects of material incentives and enablers on completion of TB prophylaxis with mixed results (low quality evidence). A large effect was seen with regular cash incentives given to drug users at each clinic visit in a setting with extremely low treatment completion in the control group (treatment completion 52.8% intervention versus 3.6% control; RR 14.53, 95% CI 3.64 to 57.98; one trial, 108 participants), but no effects were seen in one trial assessing a cash incentive for recently released prisoners (373 participants), or another trial assessing material incentives offered by parents to teenagers (388 participants). Single once‐only incentives However in specific populations, such as recently released prisoners, drug users, and the homeless, trials show that material incentives probably do improve one‐off clinic re‐attendance for initiation or continuation of anti‐TB prophylaxis (RR 1.58, 95% CI 1.27 to 1.96; three trials, 595 participants; moderate quality evidence), and may increase the return rate for reading of tuberculin skin test results (RR 2.16, 95% CI 1.41 to 3.29; two trials, 1371 participants; low quality evidence). Comparison of different types of incentives Single trials in specific sub‐populations suggest that an immediate cash incentive may be more effective than delaying the incentive until completion of treatment (RR 1.11, 95% CI 0.98 to 1.24; one trial, 300 participants; low quality evidence), cash incentives may be more effective than non‐cash incentives (completion of TB prophylaxis: RR 1.26, 95% CI 1.02 to 1.56; one trial, 141 participants; low quality evidence; return for skin test reading: RR 1.13, 95% CI 1.07 to 1.19; one trial, 652 participants; low quality evidence); and higher cash incentives may be more effective than lower cash incentives (RR 1.08, 95% CI 1.01 to 1.16; one trial, 404 participants; low quality evidence). Material incentives and enablers may have some positive short term effects on clinic attendance, particularly for marginal populations such as drug users, recently released prisoners, and the homeless, but there is currently insufficient evidence to know if they can improve long term adherence to TB treatment. 8 May 2019 Update pending Studies awaiting assessment The CIDG is currently examining a new search conducted up to 19 Jul, 2018 for potentially relevant studies. These studies have not yet been incorporated into this Cochrane Review. Incentives and enablers for improving patient adherence to tuberculosis diagnosis, prophylaxis, and treatment Cochrane researchers conducted a review of the effects of material (economic) incentives or enablers on the adherence and outcomes of patients being tested or treated for latent or active tuberculosis (TB). After searching up to 5 June 2015 for relevant trials, they included 12 randomized controlled trials in this Cochrane review. What are material incentives and enablers and how might they improve patient care? Material incentives and enablers are economic interventions which may be given to patients to reward healthy behaviour (incentives) or remove economic barriers to accessing healthcare (enablers). Incentives and enablers may be given directly as cash or vouchers, or indirectly in the provision of a service for which the patient might otherwise have to pay (like transport to a health facility). What the research says Material incentives and enablers may have little or no effect in improving the outcomes of patients on treatment for active TB (low quality evidence), but further trials of alternative incentives and enablers are needed. Material incentives and enablers may have some effects on completion of prophylaxis for latent TB in some circumstances but trial results were mixed, with one trial showing a large effect, and two trials showing no effect (low quality evidence). One‐off material incentives and enablers probably improve rates of return to a single clinic appointment for patients starting or continuing prophylaxis for TB (moderate quality evidence) and may improve the rate of return to the clinic for the reading of diagnostic tests for TB (low quality evidence). Thus although material incentives and enablers may improve some patients' attendance at the clinic in the short term, more research is needed to determine if they have an important positive effect in patients on long term treatment for TB.