Sometimes patients do not complete a course of treatment or they do not follow recommended changes in diet or personal habits. This poor adherence may be because treatments take a long time, have side effects or involve changing patients' habits, which is often difficult. Several interventions aim to change the relationship between patients and healthcare practitioners in order to improve the patients' adherence to treatments. One of these interventions is in the form of contracts between healthcare practitioners and patients, by which one or both parties commit to a set of behaviours related to the care of the patient. Contracts may be written or verbal. Most contracts are between healthcare practitioners and patients, but they may also occur between practitioners and carers, carers and patients or by a patient with him/herself. In this review we assessed whether contracts between practitioners and patients really improve the patients' adherence to treatment or their health status. We also assessed the effects of contracts on other outcomes, including patient participation and satisfaction, health practitioner behaviour and views, health status, harms, costs, and ethical issues. We found 30 trials involving 4691 participants, examining several types of contracts. The main health problems targeted were substance addictions, hypertension and overweight. Many of the trials were of poor quality and involved small numbers of people. Most were conducted in the USA. In 15 of the trials there was at least one outcome showing statistically significant differences in favour of the contracts group (although some of the improvements in adherence did not remain when measured after a longer period). In six trials at least one outcome showed such differences in favour of the control group. In 26 trials there was at least one outcome for which there was no difference between the contract and control groups. There is not enough reliable evidence available to recommend the routine use of contracts in health services to improve patients' adherence to healthcare activities or other outcomes.
Bosch-Capblanch, X.; Abba, K.; Prictor, M.; Garner, P. Contracts between patients and healthcare practitioners for improving patients’ adherence to treatment, prevention and health promotion activities. Cochrane Database of Systematic Reviews (2007) (Issue 2) Art. No.: CD004808. [DOI: 10.1002/14651858.CD004808.pub3]