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No concordance on concordance
- Douglas E Ball (10 October 2003)
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Concordance and....NLP
- Lewis Walker (10 October 2003)
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concordance
- gordon cunliffe, west yorkshire bd212jh (13 October 2003)
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COMPLIANCE ENHANCED BY DRUG INDICATION ON EVERY REPEAT SCRIPT.
- Nigel J Masters, Highfield way ,hazlemere ,High Wycombe ,Buckinghamshire HP15 7UW (14 October 2003)
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Prescribing Concordance in Medicine?
- Daniel SW Tan (20 October 2003)
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Reviews on concordance
- Etienne Vermeire, Hilary M. Hearnshaw (27 October 2003)
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Concordance in surgical practice.
- Malcolm G Lucas (5 November 2003)
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Concordance and repeat prescriptions
- Jamie Coleman, Nigel J Langford, Robin E Ferner (10 November 2003)
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Douglas E Ball, Associate Professor Dept. of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, PO Box 24923 Safat 13110, Kuwait
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The recent editorials on concordance (1,2) imply that the concept has not been widely accepted by the healthcare community and identify important conflicts in the theory. From my experience, concordance appears to be little understood outside of the United Kingdom and frequently misunderstood within. It is often spoken of as if synonymous with the terms adherence and compliance when it is supposed to “define the process of successful prescribing and medicine taking, based on partnership”(3). Most of us can accept the transition from a paternalistic model for the health provider-patient relationship to one more of partnership, whether of equal or contractual partners. This shows respect for the patient’s rights, experiences and responsibility for their own health as well as recognizing changes in society and the availability of health information. However, concordance requires that a joint agreement is reached on the approach which is going to be followed (3,4). This raises legal and ethical issues, as intimated by Jones (1), should a suboptimal regimen be proposed as this requires redefinition or complete abrogation of professional responsibilities. Since concordance also has the ultimate aim of optimizing the potential of medical care essentially through improved treatment adherence (3) it also give the impression of trying to manipulate the patient to achieve 'a priori' health objectives. Is the emphasis on respect and responsibility of the individual or on what the public health system should be achieving? Partnership is not a new model – what is new in concordance is saying that it is the right approach to use for every patient and that the reason for it is to improve health outcomes. As health professionals we must act appropriately from within our knowledge base and the authority which society accords us, while recognizing the rights and views of our clients. Ultimately the patient takes responsibility for his/her own health and we must learn to accept that – this is the attitude which needs changing. References 1. Jones G. Prescribing and taking medicines BMJ 2003;327:819. 2. Ferner R. Is concordance the primrose path to health? BMJ 2003; 327: 821-822 3. Medicines Partnership. What is concordance? http://www.medicines- partnership.org/about-us/concordance [accessed 20 October 2003] 4. Concordance Co-ordinating Group. Concordance—partnership in medicine taking, information pack. London: Royal Pharmaceutical Society of Great Britain, 2000. Competing interests: None declared | |||
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Lewis Walker, GP Ardach Health Centre, Buckie, Scotland, AB56 1JE
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Dear Editor, The following is in my view the most significant quote from this article: "Patients need information that speaks in clear terms that reflect what matters to them, and prescribers need practical tools to use information in the consultation." This practical tool kit is already available in the form of Neuro- linguistic Programming (NLP). A more detailed and specific elaboration of the cognitive behavioural therapy model, NLP has been of immense help in my day to day general practice consultations....getting information across in a way that fits with the patients underlying beliefs, values and future expectations. Communication is both an art and a science, making meaningful research somewhat complex and arduous. Yet the communication principles in NLP give some straighforward "how to's" of the process involved in effectively getting your message across in a way that allows patients to make sense of it in their own way....and act on it accordingly. Academic research based on the NLP model is long overdue yet the referenced work below could well act as a framework for innovative investigation. Sincerely, Lewis Walker (FRCP). Ref. Walker, L. Consulting with NLP: neuro-linguistic programming in the medical consultation. (2002) Radcliffe Medical Press. Competing interests: I am the author of the quoted book | |||
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gordon cunliffe, gp ling house medical centre,49 scott street keighley, west yorkshire bd212jh
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Robert Ferner's editorial on concordance highlights most of the problems we face in getting patients to comply with their medication.In practice informed decision making on the part of the patient is in effect actively discouraged by the NHS as GPs are increasingly forced to meet targets that depend on the patients unquestioning aquiescence.If the individaul really knew and understood how small the chance was that they as individuals would benefit from ,for example, antihypertensives,then even fewer would choose to comply. The fact is that prevention is, in the main, about populations not individuals. Nothing wrong with that in principle but we should be honest about it. Competing interests: None declared |
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Nigel J Masters, general practitioner Highfield Surgery, Highfield way ,hazlemere ,High Wycombe ,Buckinghamshire HP15 7UW
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At my small general practice (5,600 patients) I have been endeavouring to enhance the compliance of drug medication by giving the reasons why a drug has been prescribed on all repeat prescriptions. For example the computerised prescription states the following : take one 75mg dispersible aspirin tablet daily to prevent heart attacks and strokes. This information is printed on both the green and white parts of the script and will occur every time the script is issued. My local pharmacist was impressed by this simple addition and said that now that she knew the real clinical indication she could be more effective in encouraging compliance with the script. I have been working on this for the last six months and I wish to share a few thoughts. Firstly it now seems unsafe to sign a repeat medication without an appropriate clinical indication on the printed script. Secondly it also serves a useful check on the completeness of the clinical summary- for example no mention of hypertension was coded despite frequent blood pressure lowering treatment! Thirdly it has been an educational experience as I am embarrassed to say that the exercise has required reading the British National Formulary on quite a few occasions to discover the clinical indication, in particular for renal, eye, and obscure nutritional agents. There is a downside –it remains extremely time consuming at present but perhaps now that patients, receptionists, carers, nurses, pharmacists and nursing home staff know why a particular drug is being taken there may have been unknown savings of my time! Competing interests: None declared |
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Daniel SW Tan, Head, Diving Medicine Branch Republic of Singapore Navy Medical Services, SAF Medical Corps, Singapore
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Sir–There are broader issues regarding concordance and compliance within the multi-faceted doctor-patient relationship. With the rapidly expanding menu of investigations and expensive wonder-drugs, there are more permutations available to escalate prescription and consultation fees. While such pursuits of self- interest might seem invidious, this scenario can be mutually beneficial in terms of convenience, and even preferred by both the patient and physician. Examples include, prescribing costly 4th generation antibiotics for blind treatment of a 2-week old dry cough (thought to be an atypical pneumonia) in primary care, obviates the need for more visits for chest radiographs and further consultations; or ordering a cardiac perfusion scan without the inconvenience of stress testing or the discomfort of cardiac catheterisation; and finally, to refrain from performing a compromising colonoscopy, in favour of a non-invasive CT scan. Such patient management might fall under the category of concordant medicine, while maintaining a reasonable standard of practice. Unfortunately, it has faltered in the purist view of the medical consultation, i.e. to do one’s best for the patients’ best interest: which includes curing the condition, as well as the psychological and financial health. Illness is unpleasant, and highly inconvenient. It follows that therapeutic measures may be equally unpleasant – physically and fiscally – albeit short-term, but ultimately instituted to resolve the inconvenience. It is unsurprising that the patient is naturally disinclined towards treatment. Thankfully, an abundance of research has been meticulously reported in the medical literature to provide a basis to facilitate our decision-making in justifying the treatment options. Issues of concordance and compliance must be taken in consideration in the decision-making process, but if over- valued, represents two steps backwards in medical progress. It is unreasonable to suggest that all differences in expectations between the doctor and patient can be resolved by mutual discussion. Therefore, it is important that physicians are objective in their doctoring role: consider the patient’s circumstances, communicate the management options based on facts, administer professional advice to patients, and decide what’s in the patient’s best interest. I am not advocating authoritarianism in the medical consultation, but if I suffered from a life-threatening disease, the last thing I want my doctor to be is to be flippant. Competing interests: None declared |
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Etienne Vermeire, GP Senior Researcher Department of General Practice, University of Antwerp, Wilrijk, Belgium 2160, Hilary M. Hearnshaw
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We welcome the airing of issues on concordance. However, we wish to expand the definition of concordance used in the articles. In our recent review of the literature on adherence to medication (1) we emphasised the need for shared, informed decision making as a necessary component of concordance. Thus, although we agree with Jones (2) that the health professional needs to give the patient information, and therefore needs to have skills in doing that, we fully endorse Heath (3) in saying that s/he also needs the skills to generate a shared decision. This requires exploration of the patient’s feelings and beliefs about their treatment options and choices, as well as negotiation. We therefore suggest that any skills training towards concordance in prescribing should also include these aspects. A further issue was raised in our minds, by the papers on concordance. The references cited in these papers do not appear to include any papers which appear listed in EmBase but not listed in Medline. In a current Cochrane review on adherence to treatment recommendation for type 2 diabetes, (4) we have found that more than 85% of the included studies were not found in Medline but were found in EmBase. It is possible this could have led to some bias in the interpretation of the literature. 1. Vermeire E, Hearnshaw H.M., Van Royen P, Denekens J, Patient adherence to treatment: three decades of research. A comprehensive review. J Clinical Pharmacy and Therapeutics, 2001;(5):331-342. 2. Jones G, Prescribing and taking medicines, BMJ 2003;327:819-20. 3. Heath I, A wolf in sheep’s clothing: a critical look at the ethics of drug taking, BMJ 2003;327:856-8. 4. Vermeire E, Wens J, Van Royen P, Hearnshaw H, Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus (protocol for a Cochrane review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software Competing interests: None declared |
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Malcolm G Lucas, Consultant Urologist Swansea NHS Trust, SA6 6NL
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Inspired by your recent issue on concordance, (BMJ, 11th October 2003), I find myself wondering how to apply these principles to my surgical practice. Allow me to illustrate the problem. I often treat patients who suffer from the severe incontinence of an overactive bladder. Usually they have tried every drug on the market and had pelvic muscle training to no avail. Their options vary hugely in their potential impact on the condition and also their potential for causing other adverse changes in the quality of life. I could recruit them to a number of trials (phase 2 and 3) of novel drugs such as potassium channel openers or more selective antimuscarinic agents, or of experimental interventions such as neuromagnetic stimulation. These may involve the possible use of placebo, a short treatment period with no subsequent open label, or else the use of a drug which one intrinsically doubts will offer any greater chance of improvement than the drugs they’ve already used. Of course the patient could simply choose to remain untreated, in the hope that some effective low risk procedure will become available before long. For some years I have offered surgical solutions. These include Clam enterocystoplasty, a major reconstructive procedure with a 20% serious perioperative complication rate in my hands, but a 90% chance of curing the incontinence. The procedure carries long term risks that include metabolic problems, infection, the need for intermittent catheterisation, bowel disturbance and the risk of malignant transformation. I have done over 100 of these and can describe my results with confidence. Detrusor Myectomy is an alternative – a lesser operation which avoids the use of bowel but is less reliable as a cure in my hands – less than 50% are improved at 12 months. And there is always a urinary diversion, another major procedure with short and long term complications, usually regarded by surgeons as an admission of defeat, but sometimes favoured by patients who are fed up with repeated fruitless attempts at “bladder preservation”. An onward referral is possible, for consideration of a spinal root neuromodulator – a new technique with promising short term results in the 50% who respond to test stimulation, but a high cost to the referring organisation (£8500 for the device alone). Only two centres are offering this solution in the UK, the waiting time is likely to be long, travelling will be involved and this may seem threatening in itself. Now there is also Botulinum toxin injection. This involves receiving about twenty injections into the bladder wall under anaesthetic. We have started a multi centre trial of this simple, new, day case technique which may offer a very high possibility of symptom relief, but with as yet undocumented results and a small risk of temporary muscle weakness. We will probably need to repeat these injections every 8 months or so. Although highly toxic, Botulinum toxin has been widely used in neurological practice and cosmetic surgery. This discussion takes at least 45 minutes. I am good at drawing and find this an effective way to communicate the meaning of surgery, so every patient emerges from consultation with a page of original art work, heavily annotated, as well as a written list of the options, and a simple risk / benefit summary. I will give leaflets describing stomas, cystoplasties and Botulinum treatment. I may ask the research nurse to see them if they seem eligible for a trial and will also arrange a separate visit to our Continence Advisor who will usually go through it all again. Usually at least one further appointment is needed when I will try to explore with them their perceptions, fears and expectations of treatment. So how do patients make these choices? Often this will involve their careful analysis of all the information, sometimes reinforced by speaking to other patients who have had similar experiences, and judicious use of the internet. However, despite my efforts to achieve equipoise, patients’ preferences sometimes seem highly emotive, even irrational. “I’ll have one of those conduits because my friend had one and it was good for her” is a familiar refrain. I confess to having shown such an individual a tabloid article claiming “How Botox changed my life!”, resulting in an instant change of mind. Was that concordance or was it coercion? Would it be ethical to perform major surgery, which I personally felt was inappropriate or carried disproportionate risk, when a simpler albeit unproven and experimental alternative existed. I readily accept that I may need training in the art of achieving concordance that 20 years of surgical practice have not equipped me with, and welcome the structured approach suggested by Elwyn et al (BMJ 2003. 327. p864). But surgery is a more complicated business than prescribing antihypertensive medication, whether its objective is to prolong or to enhance life. Uncertain natural disease histories, high short term and long term risks and the sometimes huge variation in local outcomes as well as multiple therapeutic options, with a limited evidence base, confound the discussion. How often are decisions made in this context truly informed – on either side? Are we deluded when we think we have reached concordance simply because the choice matches our own opinion? How do we prevent our own prejudices, enthusiasms and disparate experience from influencing the decisions that are made? We surgeons would like to know how to do it too. Competing interests: None declared |
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Jamie Coleman, SpR Clinical Pharmacology and Therapeutics City Hospital, Birmingham. B18 7QH, Nigel J Langford, Robin E Ferner
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One measure of adherence to chronic therapy is the frequency of requests for repeat prescriptions (1). Just after the issue on concordance was published (2) we admitted a patient treated for cardiac disease and diabetes who produced a collection of boxes of medications (fig 1). There were at least four generations of prescription medicines, of which only a small number had actually been taken. This case shows that patients can make regular requests for repeat prescriptions, but still not take their medicine. Title Figure 1. Concordance in question.
Reference List 1. British Thoracic Society and Scottish Intercollegiate Guidelines Network. Concordance and compliance. British guideline on the management of asthma. Thorax 2003;58(Suppl I):i59. 2. Jones G. Prescribing and taking medicines. Brit Med J 2003;327:819. Competing interests: None declared Editorial note
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