Adherence to Treatment, Compliance & Concordance

Question 1

People required to take over 2 medications only do so 67% of the time, why?

Answer 1

-Education - understanding
-Cognition
-Social - Dr-patient relationship
-Not feeling the effects
-Money
-Forgetfulness
-Ability to get a refill

Question 2

Why has there been a shift away from doctor centred to patient-centred care?

Answer 2

Due to long term conditions, chronic condition, mental health conditions - pushed away from doctor-centred to pat-centred (more self-management)

Question 3

What was a doctor-centred consultation style like?

Answer 3

-Paternalistic (make decisions for others manner)
-Tightly controlled interviewing style - to reach an organic diagnosis (observable & measurable) based on biomedical model

Question 4

What is a patient-centred consultation style like?

Answer 4

-Less authoritarian – encourages pat to discuss feelings & concerns
-Open Qs - interest in psychosocial aspects of illness
-Shared decision making, self-management (long-term conditions)

Question 5

What is medication compliance?

Answer 5

Degree/extent of conformity to the recommendations about day-to-day treatment by the provider in terms of timing, dosage, & freq
-‘extent to which pat’s beh matches prescriber’s recommendations’

Question 6

Which type of centred approach to consultation does compliance fit into & why?

Answer 6

Doctor-centred
–> suggests Dr is experts & responsibility is on patient to ‘do as they are told’

Question 7

What is medical adherence?

Answer 7

-‘Extent the pat’s bah matches agreed recommendations from prescriber’

Question 8

Which type of centred approach to consultation does adherence fit into & why?

Answer 8

-Neutral term - between dr-centred & pat-centred
–> as emphasises need for agreement (shared-decision making but on the basis that the Dr is the expert & so pat is expected to follow this, but they are free to decide whether to adhere to treatment or not (follow recommendations?)

Question 9

Where might adherence be shown & not compliance (i.e., there is some leeway/choice in it for the patient)?

Answer 9

-Keeping med appts (e.g., screenings, follow-up appts)
-Following self-care advice (e.g., wound care after surgery)
-Taking meds as directed (e.g., taking =correct dos @ prescribed intervals, completing course)

Question 10

What are some problems with measuring adherence?

Answer 10

-Patient estimation - over-estimate (socially desirable)
-Practitioner estimation -How reliable (under report?)
-Pill/quantity accounting - (counting pills left - but patients may throw away)
-Biomedical (blood or urine) tests - expensive, intrusive
-Mechanical methods - calc diff between no. prescriptions issued & no. presented @ chemist

Question 11

Problems associated with patients not adhering to medical advice?

Answer 11

-Puts their health @ risk
-Cost implications - wasted drugs, education/health prom moneys, need more expensive treatment (as didn’t adhere), days off work

Question 12

Roughly, what % of people do not take their meds as intended?

Answer 12

50%

Question 13

% of patients not adhering to these roughly?

Answer 13

Question 14

Why do some patients not follow treatment advice (not adhere)?

Answer 14

-Social factors - low education levels, low soc support, young women
-Psych factors - inc anx & depress, can’t accept illness - avoidance as coping mech (denial), stigma of some illnesses, -ve beliefs about some meds (addiction)
-Treatment factors - misunderstand treatment, complex to take (lots, regular time intervals), poor Dr communication, match/mis-match w/ desired level of control
–> drug may have severe -ve side-effects - may affect quality of life (e.g., chemo drugs)

Question 15

What are the WHOs 5 dimensions of adherence?

Answer 15

Question 16

What are some factors that WHO suggests as potential reasons for a lack of medical adherence?

Answer 16

-Soc & econ factors - age, race, economic status, meds cost
-Cultural values health system & healthcare team-related factors
-Therapy-related factors - e.g., length of treatment, complexity of treatment, unwanted side effects
-Condition-related factors e.g., comorbidities, level of disability, acuity & condition severity
-Pat-related factors e.g., forgetfulness, treatment anxiety, misunderstood instructions, beliefs about medicines -fear of med dependence

Question 17

What is distrust & aversion in terms of medical adherence?

Answer 17

-Desire to finish meds quickly - to ‘get back to normal’ ASAP (sick role link) - don’t really want to take
-Worry of side-effects of meds that are still unknown

Question 18

What are some lay evaluations of medications?

Answer 18

-Weigh up costs & benefits of taking - worry of any adverse effects & whether taking pills fits into their daily routine - social
(side effects worse than outcomes of not taking
-‘If stop meds can see what happens’ - if nothing = must be working

Question 19

What are behavioural solutions to target non-adherence - what do they aim to do?

Answer 19

Intervene on lack of adherence, reasons why don’t adhere - stop prevent poorer clinical outcomes
-Target - beh actions of adherence

Question 20

What are some behavioural solutions to non-adherence?

Answer 20

-Health coaching,
-Motivational interviewing,
-Cognitive behavioural therapy - targets reasons for not adhering, deals w/ anxiety of illness

Question 21

What do behavioural interventions to increase medical adherence involve?

Answer 21

4Es
Explore –> what pat wants to know about meds (follows their agenda)
Educate –> on what they want to know & also check understanding
Empower –> take ongoing responsibility to take meds
Enable –> beh changes - discuss practical implications on taking meds

Question 22

What does Ley say are the 3 factors that influence adherence?

Answer 22

-Understanding - info given by Dr
-Memory - ability to recall the info (i.e., med instructions)
-Satisfaction - w/ consultation process (need confidence in Dr)

Question 23

What is meant by understanding (adherence)?

Answer 23

-Explain causes of illness &/or processes involved in treatment (give understanding)
-Use language that lay individuals will understand (simplified versions of medical words)

Question 24

What is meant by memory (adherence)?

Answer 24

-Unlikely to remember all info given
-Early information is remembered best (primacy & recency effects)
-↑anxiety affects recall
-Subjective definition of important info to remember (pat’s vs Dr)

Question 25

What is meant by satisfaction (adherence)?

Answer 25

-Affected by level of emotional support & understanding shown by Drs
-Will have satis - if perceive explanations & competence of practitioners, & level of emotional support = adequate
-Dr must be present - not just ticking off checklist

DR MUST MOTIVATE ADHERENCE

Question 26

What is the problem with having patient-centred care (i.e., shared decision making) & maximal adherence?

Answer 26

Ability to communicate expertise & competence without it being Dr driven (i.e., not patient-centred) - as still want there to be some patient input but not too much that Dr’s skills are questioned

Question 27

How can adherence be increased?

Answer 27

Printing out summary letter or getting audiotape of consultation relevant info at end of appt
-Pats feel level of care = improved
-Enhanced Dr-pat relationships
–> inc satisfaction (motivated adherence)
(but making electronic records could shit Dr’s focus)

Question 28

What do both compliance & adherence focus on?

Answer 28

Patient-behaviour during medication taking

Question 29

What is concordance?

Answer 29

Involves agreement between the patient and doctor about whether, how and when medical treatment will be used
-Patient centred (as pat involved) - shared therapeutic relationship = effective
–> pat’s = experts in their own health conditions - Drs need their input
-Follows pat’s treatment journey

(may explore alternative options if pat not keen on one idea)

Question 30

How are concordance levels made highest?

Answer 30

-Dr fully informs pat - decision making & monitoring = inclusive

Question 31

How is concordance different from both compliance & adherence?

Answer 31

-Conc = focus on processes involved in med taking
-Comp & Ad = focus on pat beh during med taking

Question 32

What is the key factor that influences adherence?

Answer 32

Dr-pat interactions (relationship) - understandable lang - so not to confuse pat & reduce satisfaction & confidence
–> so pat returns
-Relationship influences how much a pat feels they can share

Question 33

What does shared decision making within the patient-centred approach, involve?

Answer 33

-Drs form partnership w/ pat
-Ind neds, preferences considered
-Allows pat to make informed decision on their own care/treatment
-Open discussion
-Dr provides info & support along course of any long-term treatments

Question 34

Summarise what the patient-centred approach involves.

Answer 34

-Pat’s main problem explored
-Gets insight into pat’s world (many factors)
-Common ground found - allows for mutually agreed management plans
-Enhances prevention & health promotion
-Enhanced Dr-pat relationship (more likely to return)

Question 35

Compliance vs concordance

Answer 35

*Compliance:
-‘Dr knows best’
-Dr centred approach
-Paternalistic - pat has less power (authoritarian)
-Responsibility on pat ‘to do as they are told’ -as Dr is expert
-Aims for biomed diagnosis - observable & manageable
-Controlled interview style consultation

*Concordance:
-Pat-dr partnership
-Shared decision making
-Pat has more control over their care
-Agreement
-Empowers pat
-Pats decide whether to follow ADVICE
-Pat satisfaction
-Pat understanding
-Drs strive to achieve this
-More holistic - attempts to gain insight into pat’s world (integrated understanding of pat’s world)

Adherence = neutral term (in middle)

Question 36

What do Drs aim for - concordance or compliance?

Answer 36

Concordance