Week 7: Concordance/ Adolescent self management Flashcards
Define concordance
A negotiated, shared agreement between clinician and patient concerning treatment regime (s), outcomes and behaviours; a more cooperative relationship than those based on issues of compliance and non compliance.
Define compliance
The fufilment by the patient of the healthcare professional’s recommended course of treatment.
Define adherence
The extent to which a person’s behaviour - taking medication, following a diet, and or executing lifestyle changes corresponds with agreed recommendations from a health care provider.
How is concordance reached?
- Concordance is reached through a therapeutic alliance and negotiation between the prescriber and patient.
- The patient is encouraged to dicuss concernsa bout medications that have been prescribed and preference for tx, and participation in decision making
- the health professional gives evidence based information to the patient and shares his or her clinical experience.
Give examples of therapeutic behaviours to be negotiated
- seeking medical attention
- taking medication app.
- filling prescriptions
- obtaining immunizations
- attending follow up appt.
- behavioural modification of personal hygiene
- self management of asthma or diabetes
- smoking
- contraception
- risky sexual behaviours
- unhealthy diet
- insufficient level of physical activity
What are the main effects of poor concordance?
- Problems for treatment outcomes and direct clinical consequences
- increases financial burden on society
How can poor concordance affect treatment outcomes?
- poor concordance is directly associated with poor treatment outcomes in patients with diabetes, epilepsy, AIDS, asthma, tuberculosis, hypertension, and organ transplants
- Poor concordance has an effect on long term conditions –> e.g. diabetes has many potential long term complications, it is vital concordance is embraced
describe the financial burden caused by poor concordance?
- excess urgent care visits, hospitilisation and higher tx costs
- poor concordance linked to 33-69% medication related hospital admissions in US and 25% hosp admissions in australia
- Annual burden to U.S. = 100 billion
- Annual burder to U.K of unplanned pregnancies = 135.5 million
What are the factors affecting concordance?
- Patient centred
- Therapy related
- Social and economic
- healthcare system
- disease
Factors affecting concordance:
Patient centred aspects?
- Demographic (age/ income etc)
- psychological
- patient prescriber relationship
- health literacy (degree to which individuals have capacity to retain, process and understand medical advice).
- patient knowledge
How does demographics influence concordance?
- Age –>
- better concordance as pts get older until disabilities occur
- younger patients work commitments hamper concordance
- adolescents have poor concordance –> rebellious behaviour and disagreement w parents/ authorities
- Ethnicity, Gender and education –>
- Equivocal results
- except in adolescents with diabetes
- Marriage –>
- increases concordance (may be due to support from the spouse)
How can the psychological state of the pt affect concordance?
-
Psychological state of pt affects both:
-
patient attitude towards therapy
- negative attitude towards therapy –> depression, anxiety, anger towards illness.
- adolescents feel stigmatised and different to their peers.
-
patient beliefs and motivation
- ideally patient is motivated to take the treatment if they believe it to be effective and patient believes illness poses threat
- other end of spectrum; pt believes disease uncontrollable, fear dependence on treatment and fear tx will become ineffective.
- may be religious beliefs and cultural beliefs –> e.g. malaysians fearing western medicine, supernatural beliefs in pakistan, tongans think illness is God’s will.
-
patient attitude towards therapy
What aspects affect the patient prescriber relationship?
What aspects can go wrong?
How can we improve pt prescriber relationship?
- Communication
- Patient’s trust in prescriber
- Empathy of prescriber towards patient
What goes wrong –> pts feel drs lack compassion for their problems, and multiple physicians involved in care
Improving care –> patients help design treatment plan, detailed explanation re disease and treatment, pts need to understand illness and therapy.
What aspects of health literacy are there?
- being able to read
- understanding what is read
- remembering what is read
- acting on information
How does knowledge affect concordance?
patients need knowledge of:
therapy and its role
lifestyle changes
clinics and their role
long term complications
However in adolescent compliance more knowledge is not always best –> there is an optimal level of knowledge.
What therapy related factors affect concordance?
- route of administration –> oral best
- treatment complexity –> dosing frequency not quantity
- side effects
- degree of behavioural change needed –> type ii diabetes
- duration of treatment –> compliance high during acute illness, lowest during medium term illness and becomes higher with chronic illness
- With medium term illness compliance declines from 3 months (87 % compliance) to 12 months (68% compliance).
What social and economic factors affect concordance?
- Time commitment for appointments
- 1:10 US seniors cannot afford medication
- Social support from family and friends
How does the healthcare system affect concordance?
1) accessibility and availability –> waiting times, problems getting referred, quality of consultation
How does disease affect concordance?
- Concordance reduces with:
- fluctuating / absent symptoms –> hypertension
- severity –> adolescents better with mild asthma
- Concordance improves with:
- marked improvement of sx
- percieved poor health status
How can concordance be achieved in practice?
- Doctors and pt are equals in partnership
- Dr explains illness and explores patient beliefs
- Dr describes treatment options so understandable
- Pt and dr discuss beliefs about tx
- pt makes informed decisions
- pt controls choice and takes responsibility
Challenges for the health service and concordance?
when multiple tx’s required
need to promote self management
depression is prevalent
identify main health challenges in adolescence
- Adolescence –> ranges from 10 -19 yrs of age
- higher morbidity and mortality rates in adolescence than earlier childhood
- during adolescence pts learn to manage onset of new conditions
- long term self management of existing chronic conditions
identify link between brain development and risk taking
- Biological basis of adolescent risk taking behaviour:
- observed behaviour e.g. risk taking
- risk behaviours = those that potentially expose people to harm, or significant risk of harm which are associated with poor health or psychosocial outcomes
- risk taking = normal part of adolescent behaviour
- disparity in maturation between the limbic sx and prefrontal cortex during early to mid- adolescence
- brain maturing at 25 yrs
- developmentally app. exploratory behaviour
when is long term self management initiated and why?
what tends to be a problem during the intro of long term self management?
- long term self management is initiated during adolescence
- there is a period of transition to self management with ups and downs along the way
- self management behaviours initiatives at this time remain for life and therefore succesfful negotation of transition is essential
- lack of concordance is notably a problem –> part of learning to self manage and fit in rather than deliberately destructive behaviour
Why do young people find self management and concordance challenging?
self management requires:
1) working towards independence and autonomy
2) new relationships with peers, family and clinicians
3) new environments and activities
how can different conditions affect the degree to which young people manage that condition in line with medical advice?
degree to which young people manage their condition in line with clinical advice varies by:
1) age
2) gender
3) family context
4) socioeconomic position
some barriers are similar across conditions
some barriers are condition or treatment specific
•Explain why self-managing Type 1 diabetes can be challenging in adolescence
- diabetic control often deteriorates in adolescence
- mean HbA1C levels increase w age, at all ages mean levels slightly higher in females than in males
- diabetic control among young people w type 1 diabetes is poorer than in other high income countries
- management regimes can be difficult and demanding
•State reasons given by children and young people with diabetes for poorer concordance with treatment
self monitoring can be inconvenient and disruptive (social activities take priority)
feeling of being “controlled” by parents, school staff, clinicians
management regimens can make it difficult to “fit in” –> use of normalisation strategies, social relationships are a key factor in self management.
•Explain the how gender can affect self management
Girls
- gender refers to the social/ cultural meanings assigned to being male or female
- gender impacts on meanings and management of diabetes in adolescne
- Girls:
- may be more likely to incorporate diabetes into their identity
- more open about their condition with friends
- expectation that able to self care assocaited with less parental monitoring
- more freq reported “secret” non adherence –> associated with less monitoring
- consequential feelings of guilt and self blame
- can feel pressures of taking over self care
•Explain the how gender can affect self management : Boys
- Boys may perceive diabetes to be more of a threat to their gender identity (masculine status) than girls
- less open about condition or managed condition in public – > passing strategy (not disclosing hidden stigma felt about having DB).
- may be less independent in management –> mothers more likely to be invovled in management of diabetes
What do young people w chronic conditions want?
- treated as a person, not differently
- encouragement, support, understanding
- no enforcement, options given
- expertise given
