Xiaohang Wu and Haotian Lin*
State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
Received: 23 October, 2015; Accepted: 21 November, 2015; Published: 23 November, 2015
Haotian Lin, Zhongshan Ophthalmic Center, Xian Lie Nan South Road #54, Guangzhou, Guangdong Province, China, 510060; E-mail:
Wu X, Lin H (2015) Patient Adherence to Follow-Up in Clinical Research: A Systematic Review of Measurements, Associated Factors and Intervention Strategies. J Clin Res Ophthalmol 2(4): 058-64.. 10.17352/2455-1414.000023
© 2015 Wu X, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Adherence to follow-up; Measurement; Associated factors; Intervention strategies; Clinical research
Objectives: A patient's adherence to follow-up (AFU) plays a key role in the implementation of clinical research with respect to cost and validity. Most present studies focus exclusively on some specific steps during clinical research implementation, regardless of the synthetic action of patient-society-medicine system. The objective of the study is to provide a comprehensive systematic review of the measurements, associated factors and intervention strategies of AFU across a broad spectrum.
Methods: A search was performed for studies that reported AFU in English in Medline, EMBASE, PubMed or the Cochrane Library from January 1995 to February 2014. Given the huge variety in study design and multifold complexity, a qualitative systematic review instead of meta-analysis was performed for the measurements, associated factors and intervention strategies of AFU according to Cochrane methodology.
Results: A total of 125 included studies identified six measurements of AFU according to different definitions and calculations; the majority of studies used follow-up rate, with calculation methods varying in numerators but with the same denominator. The factors associated with AFU were assigned to 5 major categories, of which “individual patient characteristics” and “research design and practice setting” were most studied, with respect to having the most subcategories (12) and most related studies (76/125) respectively. The most studied type of the 3 major interventions used to improve AFU was information system and interaction improvement (56/99).
Conclusions: The number of published studies regarding the measurements, associated factors and intervention strategies of AFU is increasing, which contributes to improving the final quality of clinical research. Individual patient-centered information system and interaction improvement have been gaining most attention, and would be the most important direction of development to improve patient AFU. While, the function of multiaspect environment factors and research design enhancement remain to be noticed.
The term follow-up refers to the timely surveillance of health status and guidance on a medication regimen for patients who have been treated by medical staff through a variety of methods . It is now well accepted that follow-up plays an irreplaceable role in chronic disease management, detecting complications associated with a surgery, collection outcome data and diagnosis of recurrent disease [2-5]. Increasing numbers of studies have reported that the treatment effect and prognosis of disease are significantly related to adherence to follow-up (AFU), including studies of coronary artery diseases , cerebral infarction . Diabetes , asthma , chronic kidney disease , obesity , chronic sinusitis , cataract , and amblyopia . In addition to the treatment effect . AFU can seriously affect clinical research, such as by undermining the internal and external validity of the findings and causing bias, increasing the cost or duration of the trial or delaying important results . However, the measurement of AFU varies in different studies, and there is still a lack of research focusing on standardizing methods for calculating AFU. Moreover, various influencing factors of AFU have been reported in different studies, in which different intervention strategies for AFU were used. The increasing variety of measurement, associated factors and intervention strategies of AFU existing in published studies reflect an increasing awareness of the importance of AFU by clinical investigators. Gaining a systematic understanding of these considerations will be an important step in improving the quality of clinical research. As we previously reported, mobile information technology, short message service (SMS) and telephone included could significantly improve FUR . However, to our knowledge, there is still no systematic review addressing this goal. In the present study, we aimed to systematically assess the meaning of AFU, evaluate the measurement methods used in previous studies, identify influencing factors associated with AFU and explore effective intervention improvements, which would offer guidance in development directions to improve patient AFU.
A comprehensive search of databases from January 1995 to February 2014, including Medline, EMBASE, PubMed, and the Cochrane Library, was conducted using the combined following key words searched in the title or abstract: “follow-up”; “adherence” or “compliance”; “clinical research”; “measurement”, “follow-up rate” “factors” or “intervention”. These databases were selected because they were considered to contain a high proportion of widely read and practice-changing clinical studies covering a broad range of medical aspects. We also searched conference abstracts and the reference lists of the studies identified by the search. Only English-language journal articles or those with English abstracts containing adequate information to be extracted were included. Two authors independently screened titles and abstracts to determine potential eligibility for this systematic review. When screening discrepancies occurred, consensus was achieved after further discussion.
Inclusion and exclusion criteria
We carefully reviewed all potentially relevant articles that included studies of measurement, associated factors and intervention strategies of AFU. The inclusion of the studies was not restricted to study design ranging from observational study (retrospective and prospective included) to randomized controlled study, relevant comments and reviews are also included to achieve a better coverage. The studied patients or population size were not restricted. For the studies relevant to measurement to AFU, specific AFU calculation formula or measurement strategy should be mentioned to be included; The eligible articles concerning associated factors and intervention strategies of AFU should have collected or statistical data to indicate direction and magnitude of associated factors or intervention strategies to AFU, so as to guarantee methodological rigor and validity of this study. Studies with duplicate data were excluded, and the newest and most informative article was selected when multiple studies were conducted by the same authors.
Date extraction and outcome measure
Adhering to the international systematic review guidance of the Cochrane Collaboration, the data from each eligible study were extracted independently by two reviewers to rule out subjectivity in the data gathering and entry processes. The extracted data were independently recorded into separate databases by both investigators. The two completed databases were compared and discussed between the two investigators until a consensus was reached. We did not contact the authors of the eligible studies for additional data. AFU (or a related term) was a primary outcome of our study. Previously designed data abstraction forms and data manuals were used to capture information regarding study methodology, measurements, associated factors and intervention strategies of AFU. We identified all definitions, measurements and calculations of AFU. The factors associated with AFU were classified into major categories and subcategories. Intervention strategies to promote AFU were also recorded, classified and sub-classified.
Trends in published AFU studies were compared across study periods (2005–2014 versus 1995–2004). The studies were also classified by study design. Studies that focused on measurements, associated factors and intervention strategies of AFU were classified, calculated and analyzed. Diversity in category and sub-category strategies for each part can mostly be explained by the differences in the collected information from included studies, and the innate nature for each item. 6 methods for measurement of AFU are derived according to definition of follow-up, ranging from a consultation with a physician to completion of all recommended testing or diagnostic resolution. Category method for intervention strategies was consistent with the major aspects of associated factors, however less items were listed than the latter, for the included study appeared in smaller number and more focused research objectives. Associated study number for each sub-category was counted respectively. Total numbers for the major categories were calculated considering the overlap for the subcategories among the studies, for instance, a study which talked of age as an associated factor will possibly mention sex, or education, meanwhile. All statistical analyses were performed using the software SPSS version 17 (SPSS Inc., Chicago, IL, USA).
Of the 12359 articles initially identified, 18 articles were excluded because they were duplicate publications. After screening the titles and abstracts, an additional 11974 articles were excluded. The remaining 367 articles were reviewed in full text. After the full text review, 242 articles were excluded because they did not involve AFU. At the end of this culling process, 125 articles were selected for the systemic review. Figure 1 shows a flow diagram of the selection process for the relevant studies.
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