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Concordance in primary care: making the case

Julie Smith
SRN ONC
Specialist Nurse
General Practice Nursing
Chaddlewood Surgery
Devon

It is well documented that client adherence to prescribed treatments for a number of diseases is rarely more than 60%.(1) This includes HIV*, child and adult asthma, diabetes, hypertension and post­myocardial infarction care.(3-7)

*Taking medication exactly as prescribed is especially critical in HIV care. What is acceptable adherence (60-80%) for other chronic illnesses is absolutely unacceptable in HIV. Clients must take their antiretrovirals 95% of the time to achieve complete viral suppression.(2)

Around £230m worth of medicines are returned to pharmacies each year for disposal,(8) and it is estimated that clients dispose of a great deal more themselves, often in environmentally harmful ways. The cost of this problem is not only a financial one to the NHS; clients and their families often suffer serious health and lifestyle consequences as a result of noncompliance or inappropriate use of medicines.
The issue for policymakers and health professionals is how to best tackle this problem. Traditionally, achieving client compliance has been seen as the principal objective. Increasingly, health professionals are reviewing this notion, and in the process are recognising that a different relationship is required between the health professional and the client. It is from this that the concept of concordance has developed.
About eight years ago the Royal Pharmaceutical Society of Great Britain (RPSGB) set up a collaborative project with the Department of Health and the drug company Merck Sharp & Dohme with the aims of understanding why some clients did not take their medicines and to devise ways of changing this. A multidisciplinary group was formed to review the literature and develop an agenda for action. The resulting report, From Compliance to Concordance, published in 1997, is now regarded as a landmark in the move towards improving the client's involvement in their own treatment.(9)
To understand the issue, the terms commonly used in addressing clients and concordance need to be described.

Compliance
This term implies that the client follows the healthcare professional's orders, is less informed, and has little or no input.

Adherence
This word focuses more on client commitment to the regimen. It is based on reasonable negotiations and more client empowerment than compliance.

Concordance
This is a new approach to the prescribing and taking of medicines. It is based on a notion of client equality and respect for client autonomy. This allows for a relationship and therapeutic alliance between the care team and the client. The difference with concordance is that it is an agreement that is reached after negotiation between a client and a health professional that respects the beliefs and wishes of the client in determining whether, when and how medicines are to be taken. Although reciprocal, this is an alliance in which the health professionals recognise the primacy of the client's decisions about taking the recommended medications.
In other words, compliance is simply another way of saying that the client should follow doctor's orders, but concordance is about the client being empowered to manage their own life and being satisfied with a consultation.
The factors that influence concordance in medication with clients may be intentional or involuntary.(10) Many studies have listed various combinations of the following explanations:

  • Logistic issues - access to care, transportation.(11)
  • Perceptions of health benefit from the therapy, concern about side-effects.(12)
  • Social and cultural issues, including practical and ­emotional support and beliefs.(13)
  • Complexity of treatment regimens (eg, number of daily doses and dietary requirements).(14)
  • The client's condition (eg, whether they suffer from ­depression or are over 75 years of age).(15,16)

Communication can be a problem - when clients and healthcare professionals discuss treatment there is often what has been described as an unequal balance of power in favour of the healthcare professional. The client may fear that they won't be taken seriously, they may fear rejection or have anxieties about accepting the additional personal responsibility for the consequences of deciding to deviate from what medicine suggests is the appropriate treatment. (17,18)
From the healthcare professional's stance, it is probably important to stress that clinicians cannot always predict which client will concord with their treatment, because there is no definitive characteristic - gender, ethnicity, marital status, personality traits and educational level fail to predict concordance.(19)
Another major barrier for the health professional is the uncertainty about (and absence of training in) the skills required to conduct a concordant negotiation; how to reconcile the conflicts between continuing commitment to the best care of the client, serious respect for the client's beliefs and wishes, and the professional responsibility to remain faithful to the best evidence from clinical research.

How can we improve client concordance?
It is well established that communication and the clinician-client relationship are the major determinants as to whether the client will follow the advice and take the medication as prescribed. For example, one study looking at patients with asthma found that the health outcomes were dependent on the partnership/relationship with the doctor.(20) Moreover, clients only follow recommendations that they really believe in and that they actually have the ability to undertake.(21) Clinical therapies do not exist in isolation; they exist in a contextual environment that includes the client-clinician relationship, and this relationship modifies therapeutic effectiveness.(22)
The main lesson to be learnt is that healthcare professionals must listen to the client.
A change in the culture of the clinician-client encounter is needed. Concordance presents new challenges for clients, doctors, nurses, pharmacists, pharmaceutical companies, policymakers and others.
We must learn to create robust therapeutic alliances with mutual respect for both the client's personal decisions and the ­clinician's professional opinion.
In 2002 the Department of Health endorsed and adopted the principles of concordance and created the Medicines Partnership Task Force to carry this work forward. This comprises representatives from the medical, nursing and pharmacy professional bodies, client groups, the pharmaceutical industry and academia. Its two-year remit is to explore ways of implementing concordance in the NHS so as to improve health outcomes and satisfaction of care.

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References

  1. Sackett DL, Snow JC. The magnitude of compliance and non-compliance. In: Haynes RB, Taylor DW, Sackett DL, editors. Compliance in health care. Baltimore: Johns Hopkins University Press; 1979. p. 11-22.
  2. Paterson D, Swindells S, Mohr J. How much adherence is enough? A perspective study of adherence to protease inhibitor therapy using MEMSCaps (abstract). 6th Conference on Retroviruses and Opportunistic Infections. Chicago, USA; 31 Jan-4 Feb. Available on URL: http://www.thebody. com/confs/retro99/session15.html
  3. Wu A. Report from Buenos Aires: lessons in adherence. Hopkins HIV Rep 2001;13(5):9-11.
  4. Rand CA. Comprehensive review of the history, context, issues and ­measurement of adherence. In: Asthma adherence ­workshop report. Melbourne: National Asthma Campaign; 1997. p. 5-12.
  5. Sadur CN, Moline N, Costa M. Diabetes management in a health maintenance organisation. Efficacy of care management using cluster visits. Diabetes Care 1999;12:2007-11.
  6. Berlowitz DR, Ash AS, Hickey EC. Inadequate management of blood ­pressure in a hypertensive population. N Engl J Med 1998;339(27):1957-63.
  7. Horwitz RI, Viscoli CM, Berkman L. Treatment adherence and risk of death after a myocardial infarction. Lancet 1990;336(8714):542-5.
  8. Stoate H. Concordance and wasted medicines. London Health Rep July 2000.
  9. RPSGB and Merck Sharp & Dohme. From compliance to concordance. Achieving shared goals in medicine taking. London: RPSGB; 1997.
  10. Britten N. Concordance and ­compliance. In: Jones R, Britten N, Culpepper L, et al, editors. Oxford textbook of primary medical care. Oxford: Oxford University Press; 2003 (in press).
  11. Markson LE, Turner BJ, Cocroft J, Houchens R, Fanning TR. Clinic ­services for persons with AIDS. Experience in a high prevalence state. J Gen Int Med 1997;12(3):141-9.
  12. Lin EH, Von Koff M, Katon W. The role of the primary care physician in patients' adherence to antidepressant therapy. Med Care 1995;33(1):67-74.
  13. Stanton AL. Determinants of adherence to medical regimens by hypertensive patients. J Behav Med 1987;10(4):377-94.
  14. Gordis L. Conceptual and methodological problems in measuring patient compliance. In: Haynes RB, Taylor DW, Sackett DL, editors. Compliance in health care. Baltimore: Johns Hopkins University Press; 1979. p. 23-5.
  15. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for non-compliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160:2101-7.
  16. Shimp LA, Ascione FJ, Glazer HM, Atwood BF. Potential medication- related problems in noninstitutionalized elderly. Drug Intell Clin Pharm 1985;19(10):766-72.
  17. Bartlett EE, Grayson M, Barker R, et al. The effects of physician communications skills on patient satisfaction, recall and adherence. J Chronic Dis 1984;37:755-64.
  18. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient ­communication: a review of the ­literature. Soc Sci Med 1995;40:903-18.
  19. Meichenbaum D, Turk DC. Facilitating treatment adherence: a ­practitioner's handbook. New York: Plenum Press; 1987.
  20. Anderson J. Patient behaviour and attitudes to asthma. In: Asthma ­adherence workshop report. Melbourne: National Asthma Campaign; 1997. p. 51-3.
  21. DiMatteo MR. Enhancing patient adherence to medical recommendations. JAMA 1994;271:79,83.
  22. Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet 2001;357(9258):757-62.

Resources
Medicines Partnership Task Force A two-year ­initiative supported by the Department of Health, aimed at putting the ­principles of concordance into practice
W:www.concordance.org
or
W:www.medicines- partnership.org