ReviewMotivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials
Introduction
Unhealthy eating, smoking, excessive drinking, and lack of exercise are among the most important modifiable causes of health care problems in the developed world [1], [2]. As medical care increasingly focuses on managing long-term conditions, clinicians have a growing need to motivate patients to make lifestyle changes that modify risk factors and optimize adherence to medical advice [3].
One counseling approach for promoting behavior change in medical care is MI, defined as “a person-centered counseling style for addressing the common problem of ambivalence about change.” [4] MI arose from efforts to start difficult conversations with patients about risky alcohol intake [5]. The inclination to confront or persuade patients was replaced by evoking clients’ own reasons to change, which minimized resistance [6]. Later innovations focused on people's natural use of language about change and how listening skills might evoke such language [7]. MI is both flexible and robust, producing desirable outcomes across many problem areas in different formats [4]. That is, MI can focus on a variety of problem behaviors—typically one at a time—and can be delivered in a single session or through multiple sessions, including as a prelude to other treatments (e.g., inpatient care), integrated with other treatments (e.g., cognitive behavior therapy), or as a stand-alone intervention.
The relevance of MI to health care settings emerged in studies on providing feedback of medical test results [8], [9]. Whereas MI is patient-centered, it is also directional in its focus on change targets, including health behaviors. Refinements to suit health care consultation therefore emerged along with outcome studies [10], [11], [12]. MI has now been learned and implemented by practitioners of diverse professions, including medical providers [13], [14], [15], and appears durable up to 1-year post treatment [16].
Reviews of MI cover mostly mental health outcomes; when medical outcomes have been targeted, outcomes generally result from studies outside of primary care settings [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]. Taken together, these reviews yield odds ratios for MI treatments in the 1.5 range (a 50% benefit) versus patients who do not receive MI. A systematic review of MI delivered in physical health care settings has been conducted [25], though no known meta-analysis has been conducted on MI within medical settings. Our study seeks to fill this gap, as a meta-analysis uniquely provides a broad perspective and bird's eye view of the value of a specific treatment, which can then be used to focus future individual-level research.
Our study investigated whether MI holds true potential as a treatment option alongside or within the delivery of routine medical care. This review is the first to focus explicitly on the effects of MI delivered in general medical care settings across a range of problem behaviors. Accordingly, the aims of this study are threefold: (1) clarify the general efficacy of MI in medical care settings; (2) ascertain whether MI effects in medical care are moderated by medical problem type, delivery (e.g., treatment setting, dose of MI, provider MI training), patient characteristics (e.g., ethnicity, gender, or age), or study design characteristics (e.g., methodological rigor); and (3) provide guidance for future research of MI in medical care settings.
Section snippets
Study eligibility criteria
We followed PRISMA guidelines in conducting this study. Studies were included if they: used MI or motivational enhancement therapy (MET; MI plus feedback); employed a randomized trial that isolated MI's unique effect by comparing it to another group of patients who did not receive MI; and was conducted in a medical care setting such as a hospital, physician clinic, emergency department, medically-guided weight loss or diabetes center, dentist office, or physical therapy office. A study was
Results
Our selection criteria yielded 48 unique studies with 51 comparisons and 332 effect sizes. This occurred because some studies had more than one comparison group and many studies reported multiple effect sizes by measuring multiple outcomes or the same outcome with multiple instruments and/or by repeatedly assessing outcomes across time. Across all studies, there were 9618 participants. To control for outlier effects [29], approximately 8% of the highest and lowest effect sizes were winsorized,
Discussion
This is the first systematic review and meta-analysis of the efficacy of MI across medical care settings. Overall, MI showed beneficial effects, with 63% of main outcome comparisons in these studies yielding statistically significant advantages favoring MI. The omnibus OR suggests a 55% increased chance of MI producing a positive outcome relative to comparison interventions, which were mostly treatment-as-usual groups (55%) or waitlist (14%) or information-only controls (31%).
MI produced a
Declaration of competing interest
All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and we declare that (1) none of the authors has support from an external source to produce this systematic review; (2) none of the authors have relationships with those that might have an interest in the submitted work in the previous 3 years; (3) their spouses, partners, or children do not have financial relationships that may be relevant to
Authors’ contributions
All authors contributed to study design, analysis, and writing. Teena Moleni, MSW, took care of data base management and with Brad Lundahl PhD searched and coded studies.
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