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Drug round

From compliance to concordance

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Concordance involves a shared approach to medication

5 key points

  1. The reasons for non-compliance with medicines are complex and should be explored with the patient
  2. Using the concept of concordance facilitates a shared agreement between the patient and prescriber about the overall aims of any drug treatment and how these are achieved  
  3. Medicines should be regularly reviewed with the patient to ensure they are appropriate, safe and effective
  4. Compliance aids such as Dosette boxes should only be used after a full assessment
  5. Research shows information leaflets provided with medicines fail to increase patients’ knowledge about treatment. Patients must have an opportunity to discuss their prescription with an appropriately qualified practitioner

When medicines are administered in hospital there is a high degree of certainty that they are given to, or taken by the correct patient. However, in the community such certainties do not exist, and a high proportion of patients do not take or use their medicines in the way they are prescribed – whether intentionally or unintentionally.

The concept of “compliance” or “adherence” is difficult to measure. However, it is estimated between a third and a half of all medicines for long-term conditions are not taken as intended (National Institute for Health and Clinical Excellence, 2009).

Non-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). The causes of non-compliance are complex, particularly when it is intentional, and contributory factors include: polypharmacy (multiple drug therapy), complicated dose regimens (for example, several medicines all with differing dose intervals), unpleasant side-effects, and cognitive problems or physical disability preventing the patient taking the medicines.

Managing non-compliance

Patients who are known to be at risk of non-compliance should have each medicine reviewed to assess:

  • 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 patients’ weekly medicines to be dispensed into a single container and give some patients and carers valuable help in complying with prescribed regimens. However, compliance aids should not be seen as a solution for all patients with compliance problems. The decision to issue medicines in them should only be made after a full assessment has taken place to explore whether:

  • The patient is able to open the device and get the medicines;
  • The patient understands how the medicines are organised in the device;
  • Arrangements are in place for the device to be refilled on a weekly basis.

Patient-practitioner partnership

Research on medicines compliance has demonstrated the importance of the relationship between the patient and the healthcare provider in determining the level of compliance with prescribed treatment (Horne et al, 2005).

The concept of concordance describes a shared process leading to an agreement between the patient and prescriber about the overall aims of any drug treatment and how these are achieved. The process enables the patient to participate fully and ultimately to influence the outcome.

A significant part of such agreements depends on what information patients are given to inform their decisions. The European Union requires patient information leaflets to be given with every medicine supplied to patients. However, research has suggested that patients believe the written medicines information they receive is of little value (Raynor et al, 2007). It is essential that whenever patients are given information they have an opportunity to discuss it with an appropriately qualified practitioner. Medicine self-administration schemes have become an increasingly popular way of addressing this by encouraging patients to manage their own medicines during hospital stays.

Martin Shepherd is head of medicines management at Chesterfield Royal Hospital Foundation Trust 

Points to consider

  • Is it unintentional, where the patient simply forgot to take a prescribed medicine?
  • Is it intentional, where the patient consciously decides not to take medicines?
  • Does the patient understand what the medicine is for?
  • Is the patient prescribed multiple drugs?
  • Are the dose regimens complicated?
  • Is the patient experiencing unpleasant side-effects?
  • Is the patient unable to take medicines him or herself due to cognitive problems or physical disability? 
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