Concordance Monica Arora © Swindon/Bath GPR Day Release Course 2006

What is concordance?  The process of prescribing and medicine taking based on partnership.  It is an agreement reached after negotiation between a patient and a healthcare professional that respects the beliefs and wishes of the patient in determining whether, when and how medicines are to be taken.  Differs from compliance, as compliance suggests the patient should simply follow the doctor’s orders.  Patient concordance is a major challenge in general practice.

Does concordance matter?  Concordance sufficient to attain therapeutic objectives occurs approx 50% of the time.  1 in 6 patients take medication exactly as directed.  20% of prescriptions are never cashed.

Consequences of non-concordance  May affect patient’s own immediate health or have implications for the wider society.  Failure to prevent complications from chronic diseases, formation of resistant infections or untreated psychiatric illness.  There are also important implications when assessing reports from research into treatment efficacy rates, given that concordance rates during closely monitored studies are usually far higher than real world situations (eg 97% concordance in some studies on statins but only about 50% of patients continue at 6 months).

Consequences of non-concordance  Financial- approximately £230 million worth of medicines are returned to pharmacies each year for disposal- the actually quantity wasted is likely to be much more.

Causes of non-concordance  Patients beliefs strongest factor-how natural the medicine is seen to be, the dangers of addiction and dependence, the belief that constant use may lead to decreased efficacy have all been shown to influence patient concordance.

Causes of non-concordance  Lifestyle choices –  Unpleasant side-effects ( especially if not pre-warned).  Inconvenience (e.g. multiple daily dosing regimes- though little difference between od and bd dosage).  No perceived benefit.

Causes of non-concordance  Information – instructions not understood or poor understanding of the condition/treatment.

Causes of non-concordance  Practical –  Forgetfulness  Inability to open the containers

Causes of non-compliance  Professional –  Doctor- patient relationship ( link between patient satisfaction with consultation and subsequent concordance ).  Inappropriate prescribing- mistakes in administration/ dispensing.

Improving Concordance  Approx 70% of patients want to be more involved in decisions about treatment.  Doctors underestimate the degree to which they instruct and overestimate the degree to which they consult and elicit their patients’ views.  The doctors task is, by negotiation, to help patients choose the best way to manage their problem.  Patients are more likely to be motivated to take medicines as prescribed when they – understand and accept the diagnosis; agree with the treatment proposed; have their concerns about the medicines specifically and seriously addressed.

How do we improve concordance?  Use simple language and avoid medical terms.  Discuss reasons for treatment and consequences of not treating the condition- ensuring information is tailored, clear, accurate, accessible and sufficiently detailed.  Seek the patient’s view on their condition.  Agree on a course of action before prescribing.

How do we improve concordance?  Explain what the drug is, its function, and ( if known and not too complex ) its mechanism of action.  Keep the drug regime as simple as possible- od or bd dosing preferable, especially long-term.  Seek the patient’s views on how they will manage the regime within their daily schedule and try to tie in with daily routine ( e.g. take one in the morning when you get up ).

How do we improve concordance?  Discuss possible side-effects- especially common or unpleasant ones

How do we improve concordance?  Give clear verbal instructions and reinforce with written instructions if it is complex regime, the patient is elderly or understanding of the patient is in doubt.  Deal with any questions the patient has.  Repeat information yourself and also ask the patient to repeat the information back to you to reinforce.

How do we improve concordance?  If necessary, arrange review within a short time of starting medicine to discuss progress or queries, or arrange follow-up by another member of the primary healthcare team ( e.g. asthma nurse to check inhaler technique 2-3 weeks after starting an inhaler ).  Address further patient questions and practical difficulties at follow-up.  Monitor repeat prescritions.

References  NICE-Medicines concordance  Crome P,Pollock K, Age discrimination in prescribing: accounting for concordance. Reviews in Clinical Gerontology 2005:14:1-4  J Avorn et al. Persistance of use of lipid-lowering drugs. A cross-sectional study. JAMA :  J Westbury, K Pollock and A Blenkinsopp, A study of concordance issues for older people. The International Journal of Pharmacy Practice 2003: 11:R41  Achieving Concordance Primary Care Pharmacy September 2000 Vol 1 No  C Simon, H Everitt, T Kendrick Oxford Handbook of General Practice