Compliance or concordance: is there a difference? Noncompliance with prescribed medication regimens is thought to be a major cause of treatment failure. Although many methods have been tried in an attempt to improve patient compliance, only about one-third of patients are estimated to completely comply with clinicians' recommendations. However, it is being recognised that unless the patient is involved in the decision-making process, it is unlikely that the percentage of patients who comply with treatment recommendations will increase. To achieve this, clinicians and patients need to be able to discuss concerns about treatment regimens openly and honestly, so that there is concordance between them as to the nature of the illness, the treatment required and the risks and benefits associated with any such treatment. [I]

What is patient compliance? Patient compliance has been defined as the extent to which a person's behaviour coincides with health-related advice and includes the ability of the patient to do the following: [2] • attend clinic appointments as scheduled • take medication as prescribed • make recommended lifestyle changes • complete recommended investigations. Compliance with medication regimens is considered the area in which most noncompliance occurs and this will be the main focus of the article.

Clinicians have one point of view . .. Noncompliance can be seen as a problem of the patient not following instructions, often because it is thought they do not understand the importance of what the clinician is telling them.l 6] Therefore, clinicians try to improve compliance by looking for ways to increase the chance of patients doing what they are told.l 6] Many strategies have been put forward to improve patient compliance (see table 1). Some of these strategies may well increase the probability of improved compliance, such as simple regimens and those that minimise the risk of adverse effects.l 2 ,6] However, other non-medication related issues may well affect compliance, such as the clinician/patient relationship.[6] If the clinician is seen as being approachable, to give serious consideration to the patient's concerns, and can communicate well with the patient, then it has been shown that better patient compliance is likely.l6] Table 1. Strategies used by clinicians to improve compliance[2] Factor required to be enhanced

Strategy

Commitment of patient

Ask patients to:

Noncompliance is high Many patients do not comply with the clinician's recommendations for taking their medication.l l ,2] About one-third of patients are said to comply with recommended treatment, one-third sometimes comply and about one-third never comply.[3] Moreover, one-third of patients with chronic illness have strong reservations about the medications they are prescribed.[I] Overall, it has been estimated that rates of compliance with long-term therapy are about 50% regardless of the illness or setting.l4 ] Although compliance with short-term therapy is generally considered to be higher than with long-term therapy, rapid declines in compliance occur even in the first 10 days of short-term treatment.[S]

II 72-0360!991()() 1-00 11/$01.00 ©Adis International Limited. All rights reserved

monitor their condition, e.g. daily bodyweight measurements

•

explain consequences of missed medication

•

verbally agree to take medication

Patient appreciation of cost

I nform patient of cost of treatment

Patient recall

Use schedule card listing medication dose, indication and time Link medication dosage times with daily events/habits Ask patient to record details of medication taken Involve other family members Phone to remind patient of scheduled visit to clinician

Patient education opportunities

Make available audiovisual aids, written materials and access to drug information services

Optimise treatment

Use single rather than multiple dose regimens where possible

A common cause of treatment failure? Poor compliance has been reported as the most common cause of nonresponse to medication.l21 Moreover, there is evidence which suggests that patients who adhere to treatment have better health outcomes than nonadherers, even when taking placebo.l 2 ]

•

Change contingencies, e.g. pay attention to adverse effects, use special reinforcement General

Increase motivation by persuasion, providing evidence of treatment benefits and practical help(7)

Vol. 13, No.1; January 18, 1999

~Drugs 12 \:f I/rtnq'Y I'Cr.i!Hfll'/?!> Table 2. Some of the reasons why patients do not comply with clinicians' instructions[1 .6.9] Fear about taking a 'drug' Unwillingness to accept the label of an illness

issue and feel that it is necessary to repeatedly coerce the patient into taking the medication as prescribed.[2,6) They may not understand a patient's reluctance to take the medication.

Perceived stigma attached to an illness Risks perceived as outweighing the benefits of treatment Fear of loss of control to their illness or clinician Adverse effects from the medication Inconvenient regimen Inability to pay for the medication Lack of confidence in clinician's decision

... but patients may have another There are many reasons why patients do not take their medication according to the clinician's directions.l 6,81 Some of the reasons are shown in table 2. Often the reasons for noncompliance are not related to a lack of understanding regarding their medication, but a conscious decision by the patient not to take the medication as directed.(8) Sometimes patients self-regulate their medication as a means of feeling in control of their disease, rather than permitting the illness (or the clinician) to control them.l IO) Moreover, regular medication can act as a daily reminder to the patient that they have a particular illness.(8)

Ultimately, it is the patient who decides on a daily basis whether or not to take any medication as prescribed Many patients do their own risk-benefit analysis of necessity vs concern. [II Often the final decision as to whether or not a patient takes a medication is an assessment of the importance of 4 factors. These factors are:[6] • how high a personal priority it is to take the medication • the perceived seriousness of the illness • the patient's faith in the efficacy of the medication • whether the changes required are personally acceptable.

... or can clinicians and patients agree? Ultimately, it is the patient who decides on a daily basis whether or not to take any medication as prescribed.[2,8) Therefore, clinicians have no option but to take the patient's opinion into account.(8) Thus, it is becoming recognised that clinicians and patients must take joint responsibility in agreeing to a treatment regimen.l l ,2,6,91 In order for this to occur the patient must be actively involved in the negotiation and feel ownership of the decision-making process.(9)

Concordance the way forward? Patient noncompliance is a major issue, therefore, it has been suggested that a new approach be tried in an attempt to improve patient outcomes; this has been termed 'concordance' .[91 Concordance requires open and honest discussion between the clinician and patient, so that they come to an agreement about the nature of the illness and the most appropriate treatment regimen.(9) The concept of concordance suggests that clinician and patient find areas of health belief that are shared and then build on these rather than the clinician trying to impose his/her views on the patient.[61 The final agreement by this method will probably require concessions on both sides: with the patient having to take more medication than they initially wanted to and the clinician having to accept that the patient is taking, at least initially, less than may be considered medically ideal.[91

References I. Practice research a potent force for change, says President. Pharm J 1998 May 30; 260: 791-4 2. Murphy J, Coster G. Issues in patient compliance. Drugs 1997 Dec;

54 (6): 797-800

Is it war . .. Medicine-taking has been described as a battleground where patients and clinicians are engaged in an unacknowledged war.l 91 The patient may be unwilling to discuss their fear and anxieties about taking the medication prescribed ·in case it jeopardises the relationship between themselves and their clinician.l 9) Moreover, the patient may be afraid that the clinician will not understand or accept their point of view. By comparison, the clinicians, having prescribed medication they consider essential for treating the patient's condition, believe that noncompliance is a major health

Vol. 13, No. I; January 18, 1999

3. Fedder DO. Managing medication and compliance: physicianpharmacist-patient interaction. J Am Geriatr Soc 1982; 30: S 113-7 4. Sackett DL, Snow Je. The magnitude of compliance and non compliance. In: Haynes RB , Taylor OW, Sackett DL, editors. Compliance in health care. Baltimore: John Hopkins University Press, 1979: 11-22 5. Horowitz RI, Horowitz SM. Adherence to treatment and health outcomes. Arch Int Med 1993; 153: 1863-8 6. Misselbrook D. Managing the change from compliance to concordance. Prescriber 1998 Apr 19; 9 (8): 23, 26, 28, 33 7. Wright We. Non compliance - or how many aunts has Matilda? Lancet 1993;342: 909-13 8. Misselbrook D. Why do patients decide to take their medicines? Prescriber 1998 Apr 5; 9 (7): 41-4 9. Britten N. Communication: the key to improved compliance. Prescriber 1998 May 19; 9 (10): 27-31 10. Conrad P. The meaning of medications: another look at compliance. Soc Sci Med 1985; 20: 29-37

1172-0360/99/001 -0012/$01.00 'DAdis International Limited. All rights reseT'l'ed