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Adherance and concordance (Improving adherence (Practical problems …
Adherance and concordance
Introduction
Patients don't always agree or
adhere to medications correctly
May adversely affect health of others
e.g. vaccination schedules
Reasons for non-adherance include SEC factors,
therapy-related factors, condition-related factors,
patient factors and healthcare system factors
Implications - poor health for patient and healthcare resource burden (waste of resources and use of more care)
Shared decision making increases adherance
Adherance difficult to assess in clinical practice
Definitions
Concordance
A harmonious agreement (a concord) regarding therapeutic decisions that incorporate their respective views
Compliance
Compliance is the old term for adherence
The extent to which the patient's behaviour matches the prescriber's recommendations
Adherance
The extent to which the patient's behaviour matches agreed recommendations from the prescriber
Shared decision
making
Can affect adherance to medications
Meds may be prescribed and not dispensed,
or dispensed and then not taken
Health professional and patient agreed plan
Non-adherance
The problem
Results in few patients getting
optimal therapy for their condition
Particular problem for long-term conditions
e.g. asthma, COPD, diabetes, hypertension,
hyperlipidemia, HIV, epilepsy
Common - may be >50%
Patients often believe costs>benefits
Implications
Deterioration in health and its cost to NHS
Primary and secondary prevention
of poor health outcomes
Cost of unused drugs to the NHS
Reasons
Health system
Poor quality of instructions
Patient factors
Self esteem
Low motivation
Concerns about SEs
Fear of denepdence
Disagree about need for treatment
SEC
Age (low in adolescents and elderly),
gender, inability to pay for meds
Condition
Hard to take meds e.g. dysphagia
Rate of progression, prognosis, severity of symptoms
and illness, level of disability
Dosing regimen
Complex dosing/regimen
NICE Guidance
Intentional non-adherence
The patient makes a conscious decision
not to follow treatment recommendations.
Unintentional non-adherence
The patient wants to follow the treatment instructions
but is prevented from doing so by certain factors.
Medicines Adherence: Involving patients in decisions about prescribed medicines and supporting adherence (2009)
Improving shared
decision making
Patient involvement
Explain condition
Advantages and disadvantages
Check patient preferences and concerns
Check any misconceptions
Improve communication
Adapt consultation style to their needs
Any factors affecting communcation
Open ended questions
Encourage to ask questions
Use infromation aids
(pics, large print, interpreter, braille)
Understanding the patient perspective
Address any concerns
Knowledge and beliefs about medicines
Consequences of not taking meds
Health professional interventions
Target specific groups
Adequate patient profiling
Sympathetic approach to patient ICE
Appropriate resources available
Auditable and relevant outcomes
Provide information
What med is and how to use
Likely benefits
Any SEs and how likely
What to do if SEs happen
What to do if a dose is missed
Expected duration of tx
Improving adherence
Practical problems
Encourage monitoring of condition e.g. BP
Simplify dosing regimen e.g. OD modified release
Change formulation e.g. orodispersible tablets
Change device e.g. inhalers
Monitored Dosage Systems
Addressing AEs
OUtline benefits of tx
Likely/potential SEs
How to deal with SEs
Dose adjustment/timing/change drug
Inform them about Yellow Cards
Interventions
Simplify the regimen
Counselling
Reminders
Follow up
Self monitoring e.g BP
Rewards for success
Therapy (family, couples, psych)
Crisis intervention
Telephone FU
Consultation assessment
Ask if missed any doses recently
Ask in a non-judgemental, blame free way
Explain why you are asking
Give a timeframe (e.g. last week/month)
Check habits e.g. with AM coffee
Prescription records/pharmacy to identify unused meds
Religious beliefs
Can affect adherance e.g. fasting
Adjust regimen or suggest avoid fasting
Assessing adherance
Subjective - patient reported
Objective - serum levels
Prescription costs
Prescription pre-payment certificate
(spreads prescriptions across 3/12 months)
NHS Low Income Scheme (HC1 form)
New medicines service
Pharmacy based intervention to support
people with long-term conditions prescribed a new med
(asthma, COPD, T2DM, HTN, antiplatelet/anticoagulation)