Concordance Karen Ford - December 2011. Learning Objectives At the end of the session students will have explored the concept of concordance and increased

ConcordanceConcordance

Karen Ford - December 2011

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Learning Objectives

• At the end of the session students will have explored the concept of concordance and increased their understanding of how the concept can be applied to future prescribing practice.

Karen Ford, De Montfort University


Concordance

• Jargon or reality?• Medicines Adherence

NICE 2009


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Definitions

• Compliance:• ‘a willingness to follow or consent to the wishes

of another person’ Buckman 1997

What are your views on a compliant consultation?• Refers to taking medicines in the right way and does not

regard patients rights Lahdenpera and Kynagas 2000

• Non-compliance suggests the patient has not done what they were told by a doctor or nurse Gray et al 2002


Concordance

• The process of prescribing and medicine-taking based on partnership

• Medicines Partnership


Adherence

• Definition use by NICE 2009:

• ‘The extent to which the patient’s action matches the agreed recommendations’

• What are you views on this definition?


Cost of wasteful prescribing each year

• The annual cost of loss to the NHS is £7–9bn, or between 16 and 20 per cent of the total NHS budget

Bellingham 2001

• Returned medicines represent some of the cost- £230 million in 2000

Stoat 2000


Wasteful prescribing details:• Adverse patient events (leading to

prolonged stays in hospital):

• £2bn sickness and absence

• Crime: £1–3bn

• Hospital acquired infection: £1bn

• Medication errors: £300–600m


Wasteful prescribing details:

• Clinical negligence: £400m (with potential liabilities of between £2bn and £4bn)

• Malnutrition: £230m

• Occupational health and safety: £150m

• Avoidable management and legal costs: £100m

Bellingham (2002)


Cost of wasted medicines and dressings

• Around £100 million per year in the UK (NPC 2002).

• 617 million items dispensed in 2001.

• In England 2002 net NHS community cost of prescriptions = £6847 million

• In England 1999/2000 medicines accounted for £1.5 billion spent by NHS hospitals

Granby 2005


Consequences of wasted medicines and dressings

• Ill-health

• Reduced quality of life

• Reduced life expectancy• An estimated 50% of medicines prescribed

for chronic conditions are not taken as prescribed Stoat 2000

• Economic loss to society


Concordance

• Suggests an equal partnership needs to exist between professionals and patients before patients will buy into the need to comply with medication

• (RPSG & Merck Sharpe and Dohme 1997)


Patient/health care professional partnership is not a new concept

• Griffiths report 1984• Working for patients

1989• The patients charter

1991• New NHS Modern

and dependable 1998


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Facts from Medicines Partnership

• At any one time 70% of the UK population is taking medicines to treat or prevent ill health or to enhance well-being NPC Plus 2006

• Many long term illnesses are tackled by means of prescribed drugs


Concept of the non-compliant patient

• Deviant?• You or me?• The Expert Patient?• 30% - 60% of patients

who fail to comply with medication

• 90% with some medications -Humphries 2002

• NICE 2009 ‘non-adherence should not be considered the patient’s problem. Rather, it usually results form a failure to fully agree the prescription with the patient ‘


Risks associated with non-compliance

• Medication mismanagement accounts for 6% of unplanned admissions to hospital Tierney & North 1995

• Non-concordance leads to mismanagement of medical conditions, readmission to hospital, development of adverse effects and sometimes death Henderson et al 1989, Cline et al 1999


Psychological theories behind non-concordant behaviour

• The patients perception of the reason for being prescribed the medication

• The rationale for treatment not accepted by the patient therefore non- acceptance of prescribed medication

• Patients receiving conflicting advice• Patients alter regime according to how they feel• Poor coping strategies, anxiety, attitudes and

beliefs


Socio-economic factors and therapy related factors

• Complicated regimes -strong correlation between polypharmacy and non-compliance Rudd 1993

• Side effects and long term treatment • Cost Robertson 1992, Nystanga 1997,Cheesman 2006

• Socio-economic-unstable living conditions, unemployment, lack of adequate social networks Cheesman 2006


Dancing not WrestlingRollnick (2000)


Yes

No

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Healthcare and condition related factors

• Health care system factors- lack of follow up; poor capacity in the system to provide patient education and patient-provider relationship De Geest 2005

• Condition related- difficulty accepting diagnosis and patient & prescriber having poor knowledge


Non-compliance and the elderly

• Over 65s constitute 20% of the population

• 45% of medications prescribed are for this age group

• Over 75s 3 out of 4 people are taking prescribed medication

• 36% of older people take 4 or more different medications on a regular basis


Causes of medication mismanagement in the elderly

• Social vulnerability

• Physical vulnerability

• POLYPHARMACY ( 5 or more medications taken concurrently)

• Dementia, confusion, impaired memory

• Impaired vision, and dexterity related problems


Barriers to optimal use of medicine

• What can you think of?


Karen Ford August 2010

Patients haveenough

knowledge to participateas partners

Prescribingconsultations

involve patients

as partners

Partnersare supported

in takingmedicines

Adapted from: Bond C (2004) Concordance a partnership in medicines-taking. Pharmaceutical Press, pp 149 (Figure 8.1)

CONCORDANCE


Patients have enough knowledge to participate as partners

• Information provided is:-tailored, clear & accurate -on treatment options-on the risks v benefits-accessible where patient feels confident to ask questions and discuss issues-sufficiently detailed

• Education empowers patients to manage their own health

• Health professional needs to be skilled to engage and regard this as important


Prescribing consultation involves patients as partners

• Patients invited to talk about medicine-taking

• Professionals explain proposed treatment fully

• Agreement reached jointly

• Understanding and ability to follow treatment checked


Patients are supported in taking medicines

• All opportunities used to discuss medicines

• Information effectively shared between professionals

• Medications reviewed regularly with patients

• Practical difficulties addressed


Findings from a studyby Royal Pharmceutical Society &

Merck & Dohme (1997)

• Most influential factor is the belief patients have about their treatment

• These beliefs are often at variance with the best evidence from medical science and consequently received scant- if any attention from the prescriber

• To ignore the beliefs of the patient is to fail to prescribe effectively


How might we achieve concordance?

• Patient choice

• Negotiation

• Patient involvement in decision making process

• Achieving a therapeutic alliance

• An ‘open’ relationship

• Key principles outlined by NICE 2009


Key Principles NICE 2009

• Adapt your consultation style to the individual’s needs

• Tailored communication and how information can be made more accessible

• Offer for patient to be involved in decision making process about their medicines

• Remember increased involvement may result in refusal to take drugs or stop taking drugs – record keeping


Key Principles cont..

• Accept patient has the right to not take medicines – even if you do not agree

• Be aware of patient beliefs and how they perceive the need or not for a drug

• Provide additional patient information relating to condition

• Recognise non-adherence is common, most will not adhere at some time


Key principles cont…

• Adherence can be improved but no specific intervention is recommended for all patients i.e. tailor your intervention

• Review patient knowledge, understanding and concerns about medicines.

• Review patient understanding of their condition and need to take medicines at agreed intervals with patient

• Offer repeat information and reviews- especially for long-term conditions


Medication reviews

• 3 types:

• Prescription review

• Concordance & Compliance review

• Clinical medication review

• Clyne et al 2008 NPC


Prescription Review

• Addresses technical issues such as anomalies, changed items, cost effectiveness with script. May not need patient present.

• May include all or some of medicines prescribed but does not include OTC or complementary drugs, mapped to professional activities e.g. QOF or basic medication reconciliation in hospitals

Concordance & Compliance review

• Addresses issues relating to patient’s medication taking behaviour. Usually requires patient to be present and must involve patient or carer if changes are to be made

• Includes all prescription drugs, OTC & complementary meds. Review medicines use. Map to QOF, MUR, DRUM, Single assessment process etc.

Clinical Medication Review

• Addresses issues relating to patients medication taking behaviour but in relation to their clinical condition. Patient/carer must be present.

• Includes all types of medication – a review of medicines and condition

• Links to QOF, enhanced service in community pharmacyKaren Ford - December 2011

Case study- concordance element

• Take care not to confuse compliance and concordance

• What is the difference?


References and Further reading• Banning M. (2004) Enhancing older people’s

concordance with taking their medication British Journal of Nursing Vo. 13, No.11.

• Bellingham C. (2001) The Pharmaceutical Journal Vol 267 No 7175 pp741-74224 November 2001

• Cheesman S. (2006) Promoting Concordance: the implications for prescribers. Nurse Prescribing Vol.4 No.5 pp205-208

• Clyne W Blenkinsopp & Seal R (2008) A Guide to Medication Review NPC Available on line @ http://www.npci.org.uk/medicines_management/review/medireview/library/mr_library_agtmr08.php


Further reading cont….• Granby T (2005) Evidence based prescribing www.nurse-

prescriber.co.uk Accessed 9/10/06• Gray R., Wykes T., & Gournay K. (2002) from compliance to

concordance: a review of the literature on interventions to enhance compliance with anti-psychotic medication Journal of Psychiatric and Mental Health Nursing 9 pp277-284

• NICE 2009 Medicines Adherence January 2009 No. 76 www.nice.org.uk

• National Prescribing Centre Plus 2006 Available @ http://www.keele.ac.uk/pharmacy/npcplus/medicinespartnershipprogramme/ (Accessed 20.12.11)

• Shuttleworth A. (2004) improving drug concordance in patients with chronic conditions Nursing Times vol.100 November.


Further reading……• Rollnick S Mason P Butler C (2000) Health

behaviour change a guide for practitioners London: Churchill Livingstone

• Stoate H (2000) Concordance and wasted medicines. House of Commons All Party Pharmacy Group. London: House of Commons

• Taylor B. (2002) nurse-patient partnership: rhetoric or reality Journal of Community Nursing vol.16, issue 3 march.

• Weiss M & Britten N. (2003) what is concordance? The Pharmaceutical Journal vol.271


This work was produced as part of the TIGER project and funded by JISC and the HEA in 2011. For further information see: http://www.northampton.ac.uk/tiger.

This work by TIGER Project is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. Based on a work at tiger.library.dmu.ac.uk.

The TIGER project has sought to ensure content of the materials comply with a CC BY NC SA licence. Some material links to third party sites and may use a different licence, please check before using. The TIGER project nor any of its partners endorse these sites and cannot be held responsible for their content. Any logos or trademarks in the resource are exclusive property of their owners and their appearance is not an endorsement by the TIGER project.Karen Ford - December 2011

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Concordance Karen Ford - December 2011. Learning Objectives At the end of the session students will have explored the concept of concordance and increased