Compliance and concordance
When medicines are administered in hospital there is a high degree of certainty that medicines are given to or taken by the patient for whom they are intended. In the community, however, such certainties do not exist, and one of the major drawbacks of our reliance on pharmacotherapy in treating ill health is that, either intentionally or unintentionally, a high proportion of patients do not take or use their medicines in the way that is intended.
The concept of ‘compliance’ is notoriously difficult to measure. However it is estimated that up to 80% of patients may be ‘non-compliant’ in taking their medicines, although there is significant variation between patient groups and types of illness (Carter and Taylor, 2003).
Compliance can be described as unintentional (where the patient simply forgot to take a prescribed medicine) or intentional (where the patient consciously decides not to). In the latter case in particular, causes of non-compliance are complex.
However, such factors as polypharmacy (multiple drug therapy), complicated dose regimens (for example several different medicines all with differing dose intervals), and unpleasant side-effects are all known to be significant contributory factors.
Patients who are known to be at risk of non-compliance should:
Have their medicines reviewed in order to minimise polypharmacy, side-effects and complicated regimens, for example any unnecessary medicines should be stopped. Clarification should be sought as to which medicines the patient may or may not be taking. Each medicine should be reviewed in terms of:
-Appropriateness– Is it still required?
-Safety – Is it likely to interact with any other medicines?
-Effectiveness – Is the patient taking it?
Medicines that are required should be given in the smallest appropriate dose and in a form that reduces the number of daily doses to one or two.
Compliance aids, such as Dosette boxes, can be used. These enable a patient’s weekly medication requirement to be dispensed into a single container and offers some patients and carers valuable help in complying with prescribed regimens. Compliance aids should not, however, be seen as a solution for all patients with compliance problems. The decision to issue medicines in such a device should only be made after a full assessment has taken place. This should explore whether:
-The patient has sufficient dexterity to open the device and access the relevant medicines
-The patient understands how the medicines are organised in the device
-Arrangements are in place for the device to refilled on a weekly basis.
A patient-practitioner partnership:
Research on medicines compliance has demonstrated the importance of the relationship between the patient and the health care provider in determining the level of compliance with prescribed treatment (Royal Pharmaceutical Society of Great Britain, 1997).
Older ‘paternalistic’ models that have been used to describe the interaction between the prescriber, the patient, and their medicines are now seen to inadequately describe the complexity of these relationships. In the light of such findings the concept of concordance has been proposed. This describes a shared process leading to the agreement of the overall aims of any prescribed drug treatment and how they are to be achieved.
Throughout this process the patient is able to participate and is ultimately able to influence the outcome. It is suggested that achieving concordance between prescriber and patient is more likely to lead to higher rates of compliance (RPSGB, 1997).
For patients, a significant part of such agreements depends on what information they have available to inform their decisions. A statutory framework across the European Union requires the provision of a statutory patient information leaflet (PILs) with every medicine supplied to a patient at any time. These leaflets describe in detail what the medicine is for, its dose and dose interval, its interactions with food and other medicines, and possible side-effects.
While the widespread availability of such information is to be welcomed, it is also problematic. Not only are the leaflets densely typed and difficult to read, but also the information contained in them may raise concerns on the part of patients (and their carers) that could reduce rather than increase compliance. However, recent research has suggested that patients believe the written medicines information they receive is of little value and fails to increase their knowledge (Raynor, 2007).
Patients also think that the main purpose of PILs that accompany medicines is to highlight side-effects rather than to promote concordance (Raynor 2007). This is an argument for ensuring that whenever patients are given information they have an opportunity to discuss it with an appropriately qualified practitioner, who can offer a realistic assessment of the treatment, and its risks and benefits.
It is unfortunately in most situations where patients receive medicines, whether on the ward at discharge, via an outpatient attendance or the GP, such counselling is rarely achievable. The development of medicine self-administration schemes within the hospital setting has become an increasingly popular way of attempting to offset such shortcomings by encouraging patients to manage their own medicines during a hospital stay.
For information about self administration of medicines click here.
Covert administration of medicines
The NMC regularly receives enquiries about the covert administration of medicines in food and drink. The council recognises that this is a complex issue and distinguishes between covert administration and administration against a person’s will, which may not be deceptive but may be unlawful.
When medicine is disguised in food and drink the patient is being led to believe that they are not receiving medication. Nurses involved in this activity need to be sure that they are acting in the best interest if their patient and are accountable for their decision.
The NMC notes that disguising medicine in order to save life, prevent a deterioration or ensure an improvement in the person’s physical and mental health cannot be taken in isolation from the recognition of the rights of the person to give consent.
Before attempting to administer medicines in this way a nurse must have the support of the multidisciplinary team and the risk assessment and the decision to administer medicines in this way should be supported by good record-keeping.
Decisions should be supported by local policies and procedures on covert administration, and staff involved in making such a decision should have access to legal advice if necessary. The NMC (2004) recommends a number of considerations before covert administration is attempted.
Considerations for covert drug administration:
The patient’s best interests are considered at all times
The medication is essential for the patient’s health and well-being or for the safety of others
The decision to administer a drug covertly should be a contingency measure used after an individual assessment of the patient
Carers, relatives and the multidisciplinary team (especially the pharmacist) should be involved in the decision
The method of administration should be agreed with the pharmacist
The decision, action taken and all parties concerned should be documented in the plan of care and reviewed at appropriate intervals.
Carter S, Taylor D (2003) A question of choice- Compliance in Medicine Taking. Medicine Partnership.
Nursing and Midwifery Council (2004) Guidelines for the administration of medicines. NMC London
Raynor DK (2007) A systematic review of quantative and qualitative research on the role and effectiveness of written information available to patients about individual medicines. Health Technology Assessment 11 (5)
Royal Pharmaceutical Society of Great Britain (1997) From compliance to concordance (1997) Royal Pharmaceutical Society of Great Britain. London
Medicine Guides are designed for members of the public who are looking for information about individual medicines. The guides are developed as part of the Medicines Information Project.