Chater FortySix 46 Concordance Marjorie C. Weiss STUDY POINTS * What is meant and understood by the term concordance * How concordance differs from comliance and adherence * The concordance model and the relationshi with atients * The need for good communication skills in develoing a concordant relationshi * Concerns about using a concordance aroach with atients Introduction Mrs Jones is being a non n concordant atient (sigh) again. Or is she? Concordance offers a way forward when we, as harmacists, notice that atients are not taking their medicines as rescribed. Yet concordance can fundamentally challenge our assumtions about the role of atients in a rofessional atient interac tion. It states that atients have a legitimate and valu able ersective on taking their medicines and that healthcare rofessionals should encourage atients, should they wish it, to become involved in decisions about their treatment. For these reasons, concord ance is about a consultation rocess and not an individual atient behaviour. Mrs Jones cannot be non concordant on her own: it takes at least two, rofessional and atient, to have a non concordant (or successfully concordant) encounter. The consulta tion could have been non concordant but Mrs Jones, on her own, cannot have been. Mrs Jones can be non comliant or non adherent to her medicine but these have a distinctly different meaning from concordance. What is concordance? cor Concordance occurs when the atient and the healthcare e rofessional articiate as artners to reach an agreement on when, how and why to use medicines, drawing on the exertise of the healthcare rofessional as well as the exeriences, beliefs and wishes hē of the atient (Marinker et al 1997). It arose from the recognition that throughout the decades of research investigating interventions to hel atients follow rescritions for medications, there was still a high level of non adherence. In a review by Haynes et al (2001), interventions that used a combination of aroaches in heling atients take their medicines such as roviding more convenient care, giving atients more information, roviding reminders or offering medicine counselling, did not lead to large imrovements in adherence rates. From this synthesis of research findings, there was a call to investigate more innovative aroaches to assist atients with taking their medicines. Concordance is one such in novative aroach. This is not to say that terms like adherence and comliance can no longer be used. When referring to the extent to which atients take medicines as re scribed by their doctor or other healthcare rofession al, the words adherence and comliance are aroriate terms to be used. As a concet distinct from comliance or adherence, concordance may affect adherence although it is mainly concerned with imroving the quality of health care through a shared understanding between rofessional and atient on treatment choices. Yet there are difficulties with words like adherence and comliance which have PROPERTY OF ELSEVIE EVIER ge from ssiono
SECTION FIVE Pharmacy services and monitoring the medicinetaking atient overtones of the atient being disobedient or naugh ty in not following the doctor s instructions. Conce tually, terms like comliance and adherence reinforce a aternalistic doctor knows best model of health care and imlicitly devalue the views and exerience of atients as users of medicines. Concordance seeks to redress this balance by acknowledging that atients and customers have a key role in the decision making of whether or not to take their medicine. The term adherence has been usefully slit into those who are intentionally non adherent and those who are unintentionally non adherent. Uninten tionally non adherent atients are those who do not take their medicine because of a number of reasons, for examle because they are unable to read the label due to oor eyesight, or forgot to take a tablet because a medicine regimen is comlex and difficult to remember. Aroriate solutions to un intentional non adherence are big rint labels, im roved medicines information, simlified medicine regimens or adherence aids such as a Dosette box. Intentional non adherence is where concordance can lay a role; revious research has suggested that atients make reasoned decisions about whether or not to take their medicines. Patients may alter their medicine taking behaviour for a number of reasons; for examle: * They have exerienced side effects * Taking medicines interferes with their daily lives * They have beliefs about the medicines ines or illness which conflict with medicine taking * They are adjusting the medicine ine dose in resonse to symtoms. Concordance has been called a artnershi in med icine taking and has three imortant ingredients: (1) includes an exlicit agreement between two eole; (2) is based uon resect for each other s beliefs; and (3) gives the atient s view riority although they may choose to have the rofessional make all the decisions about treatment. This third ingredient recognizes that once the atient leaves the encoun ter with the healthcare rofessional, they will ulti mately have the casting vote to decide whether or not to take that medicine. Ethical considerations The need to involve atients in decisions about their care is enshrined in rincile 4 of the Code of Ethics for Pharmacists and Pharmacy Technicians, ublished by the Royal Pharmaceutical Society of Great Britain. This rincile draws uon healthcare rofessionals duty to obtain informed consent when initiating new medicines and the ethical rincile of resect for atient autonomy, which recognizes that atients should be allowed to have control over their own lives and make decisions that affect their lives. In common with the concordance initiative, this rinci le advocates working in artnershi with atients, to exlain the otions available and to hel atients make informed decisions about different treatment otions. The concordance model Concordance shares many characteristics with other models and themes currently revalent in health care, most imortantly those of shared decision making and atient centredness. There is a greater chance of a successfully ully concordant cord encounter when each artic iant knows what the other is thinking. For this rea son, concordance shares many characteristics with shared decision making: where both the doctor and atient share arē information with each other, when both take stes to articiate in the decision making ro cess by exressing treatment references and they jointly agree on the treatment to imlement. Shared decision making may be considered art of the wider concet of atient centredness. Patient centredness has three themes: eliciting the atient s ersectives and understanding them within a sychosocial context; reaching a shared understanding of the atient s roblem and treatment; and involving atients, to the extent they wish to be involved, in choices about their care. It is not a coincidence that the concet of concordance arose during the same time eriod that atient centred care be came dominant in healthcare olicy. Concordance can be seen as art of the wider atient centred olitical context but one which secifically focuses on medicine taking behaviour. Concordance also shares many features with the formative communication teaching guides, the Calgary Cambridge guides as discussed in Chater 13. Although designed as a formative aid in teaching medical students communication skills, the Calgary Cambridge guides have a consultation structure which is readily adatable to the harmacy setting. These guides assume a chronology to the consultation with distinct sections on initiating the consultation, gathering information, roviding structure to the PROPERT ERTY OF taelsevier nessco s 524
Concordance CHAPTER 46 consultation, building a relationshi, exlanation and lanning and closing the consultation. The Calgary Cambridge guide has been adated to reflect two common harmacy consultation situa tions of (1) handing out a new rescrition and (2) issuing a reeat rescrition, as shown in Box 46.1. Samle hrases or catchhrases useful in con ducting a concordant consultation in harmacy are shown in Box 46.2. The Medicines Partnershi at NPC Plus has devel oed a cometency framework for shared decision making with atients, describing the skills and beha viours rofessionals need to reach a shared agreement about treatment. In this document, shared decision making and concordance are used synonymously, highlighting the common aroach underinning these concets. These eight cometencies are shown in Box 46.3. Box 46.1 A concordance model for harmacy: Involving atients in decisions about their medicines New rescritions Reeat rescritions ritions Reinforces rescriber s instructions and rovides other imortant t information * Prioritizes key information: how to take the medicine, what it does,what it is for and imortant sideeffects * Gives information in manageable chunks so as not to overload atient Exlores atient s ideas, concerns and exectations Exlores atient s ideas, concerns and exectations * Exlores the atient s view on the ossibility of having to take a medicine * Exlores revious exerience with using the medicine * Exlores revious exerience e with medicines * Exlores atient concerns about taking * Exlores atient concerns about taking the medicine(s) the medicine(s) Develos raort Develos raort * Accets legitimacy of atient s views * Accets legitimacy of atient s views * Picks u on atient verbal and nonverbal cues * Picks u on atient verbal and nonverbal cues SA s * Facilitates atient s resonses * Facilitates atient s resonses ofproperty bilo OF ELSEVIER Provides additional information Provides additional information * Discusses the ros and cons of taking and not taking the medicine * Finds out if the atient wants any other information * Finds out if the atient wants any other information * Gives information in manageable chunks * Avoids jargon * Avoids jargon * Checks atient understanding * Checks atient understanding Deciding with the atient Deciding with the atient * Discusses other otions or issues of imortance to the atient * Discusses other otions or issues of imortance to the atient * Negotiates mutually accetable lan * Negotiates mutually accetable lan * Safety nets so atient knows where to go if they exerience roblems or have further questions and how to followu * Safety nets so atient knows where to go if they exerience roblems or have further questions and how to followu 525
SECTION FIVE Pharmacy services and monitoring the medicinetaking atient Box 46.2 The evidence for concordance s Catchhrases useful in involving atients in decisions about their medicines: giving out medicines in a harmacy Eliciting the atient s view * How do you feel about starting on a new medication? * Do you feel you will be able to take this medicine as suggested by your doctor? * What do you think about taking this medicine on a regular basis? * How have you been getting on with your medicines? (reeats) * What makes you think that [articular roblem] might be due to the medicine? Eliciting atient concerns * Do you have any concerns about starting this medication? * How can I hel you with this medicine? * Is there anything else you would like to know about? * Is there anything in articular that worries you? * Have you had any bad exeriences with this kind of thing in the ast? * Could you tell me a bit more about that? Giving atients the amount of information they want * Can I give you some more information about that? * What do you know about it? * Would you like to know more? * What do you want to know about it? * Are there some more questions I can answer for you? * Would you like to go away and read this and think about it a bit more? Deciding with the atient orepr * You re quite right to worry about that kind of thing it can haen with some medicines. How would you feel about giving this one a go for a month or so and see how you get on? * How do the good and bad effects of taking this medicine weigh u for you? Already resented has been the Haynes Cochrane review regarding the use of interventions to hel atients take their medicines: that current methods of imroving adherence are comlex and not very effective. Much of the information available about concordance relates to the doctor atient consulta tion. As shown in Box 46.1, the concordant aroach can be readily adated to the harmacy situation after a rescribing decision has been made. Examles are handing out new or reeat rescritions, in reeat disensing or in conducting a medicines use review. Yet harmacists also have a role before treatment decisions about medicines are made: when giving over the counter advice or as harmacist indeendent re scribers. The next sections will look at evidence draw ing uon a redominantly medical literature and may aear to be relevant only in the latter situation, i.e. before rescribing decisions are made. However, the evidence has resonance nc for the range of harmacy consultations, s, both before and after treatment deci sions have been made. These are groued under the headings of: eliciting the atient s view; develoing raort ort with the atient; roviding information; and the theraeutic alliance. Eliciting the atient s view Previous research tells us that atients have beliefs about their medicines and illness, and that these beliefs can affect their medicine taking behaviour. For examle, individual atients will vary in their confidence in the medicine to hel them. They may have doubts about a medicine and test whether the medicine is having an effect by stoing it on occa sions. Patients may believe that they will become immune or addicted to a medicine if they take it long term. These beliefs can occur even when we know these medicines are not associated with a true harmacological deendence. Many eole consider rescribed or over the counter medicines, articularly in comarison with herbal or homoeoathic roducts, to be unnatural, artificial and otentially harmful to their bodies. They might see themselves as being anti drugs eole where doing without a medicine is the referred course of action, only resorting to medicine taking when it is absolutely necessary. Evidence also suggests that atients make comlex judgments about their medicines, weighing u the benefits and drawbacks of taking a medicine within PROPERTY RTY do OF ELSEVIER EVIER ER of: en ncfi s 526
Concordance CHAPTER 46 Box 46.3 Cometency framework for shared decision making with atients: summary. (After Clyne et al 2007 with the ermission of NPC Plus) Listening Listens actively to atients Building a artnershi Communicating Hels the atient to interret information in a way that is meaningful to them Context With the atient, defines and agrees the urose of the consultation Managing a shared consultation Knowledge Has utodate knowledge of area of ractice and wider health services their individual atient exerience. All of these atient beliefs have their own rationality when viewed from the atient s ersective of taking medicines within the context of their everyday life. Research on doctor atient consultations suggests that these beliefs are imortant because, if not elicited, they can lead to misunderstandings in con sultations when rescribingri decisions are made. Misunderstandings in consultations can be caused by non disclosure of information from either the doctor or the atient, disagreement about causes of side effects or failure of communication about a decision reached by the doctor. Misunderstandings arise when atients do not lay an active role in the consulta tion by stating their views and beliefs about the med icine or illness under discussion. The consequence of consultation misunderstandings can be non adherence to rescribed medication. While research has rimar ily focused on doctor atient consultations, it can be hyothesized that eliciting the atient s views and beliefs on their medicine and medicine taking behav iour is equally imortant in harmacist atient or harmacist customer interactions as well. The Data base of Individual Patients Exeriences of Illness and Health (DIPEx) is a website which gives videoclis of Sharing a decision Understanding Exloring Deciding in Monitoring Recognizes that the atient is an individual Discusses illness and treatment otions, including no treatment Decides with the atient the best management strategy Agrees with the atient what haens next rip atients exeriences. It may be useful when rofes sionals want to gain insight into what it is like from a atient s ersective to exerience a articular ill ness or face a secific health related decision (see Aendix 5). PROPERTY PERTY OF ELSEVIER EVIER Develoing raort with the atient Concordance is focused on a consultation rocess and, as such, is rimarily concerned with rofessional atient communication. Although we all tend to think of ourselves as good communicators, to articiate in a concordant consultation is actually very difficult. If it seems easy, you are robably not doing it right! All of the generic communication skills such as active listening, avoiding jargon, giving information in chunks or a little bit at a time, using oen ques tions, aroriate body language, encouraging the atient to ask questions, treating the atient as an equal and being non judgmental are imortant. Other skills, such as resenting information in a way the atient is able to understand, without being atroniz ing, are essential. Both eole in the consultation need 527
t oo SECTION FIVE Pharmacy services and monitoring the medicinetaking atient to exlore each other s viewoint and confirm that they understand where the other erson is coming from. While a atient may sontaneously volunteer their ersonal beliefs or views, if they do not, it is down to the skill of the rofessional to elicit the atient s view and ensure that the atient feels com fortable enough to discuss this information. Emathy lays a key art in concordance. Emathy is distinct from symathy. Emathy involves fully un derstanding an individual s emotions, while symathy is simultaneously being affected by another s emo tions. In interactions with atients, emathy allows for recognition and acknowledgement of the atient ersective. Professionals dislay their accetance of the legitimacy of the atient s view by communicat ing their understanding of the atient s situation. In cluded within this are exressions of concern, a general willingness to hel and an acknowledgement of the efforts the atient may have made thus far in terms of trying to manage their medicines and illness. It requires the rofessional to be able to deal sensi tively with otentially embarrassing or unleasant issues. In a concordant consultation it can be useful to overtly draw attention to the structure of the interac tion and signost when a different issue or change of subject will take lace. This includes roviding infor mation in a logical sequence but may also consist of statements such as I would now like to move on to discussing otential otions, is that okay with you? or There are three ways in which this medicine e can hel you. Firstly,... or I d now just like to summarize some of the things we ve discussed. Summarizing information at various oints in the interaction, asking if the atient has any questions as well as safety netting identifying aroriate follow u or what to do if something changes or further questions arise are imortant. onp Providing information Studies over the years have consistently shown that atients want information about their medicines. When atients are asked what they would like to know, they frequently resond that they want to know about side effects, what the medication does, any lifestyle changes they might need to undertake and how to take the medication. Surveys suort the view that, while most atients have considerable con fidence in their medicines, 30% also have concerns, articularly with regard to side effects. Patients want to know information even when the information con tains bad news or in terms of side effects, no matter how rare. This may be imractical during a tyically brief harmacy encounter. Should the atient wish to have information beyond the more frequent and seri ous side effects, this information can be rovided in a written format. Nonetheless, it is not unusual for atients, when asked retrosectively about whether they would have liked more information about a re scribed medicine, to state that they would have liked more. Information should be rovided in a manner which takes account of what the atient may already know and what, and how much, information they would like to receive. Patients should be offered information on treatment otions, to including non harmacological otions or the choice to have no treatment. Addres sing the no treatment otion is imortant, even when there is only one drug of choice or when the doctor has already rescribed the medicine. If the atient has reservations rva or concerns about a medi cine that were not resolved before the medicine was rescribed, the atient will simly walk out of the harmacy and not take it. This is the harmacist s oortunity ty to rovide information on both the ben efits and risks of taking and not taking a medicine, which may influence the atient s decision making rocess long after they have left the harmacy. Throughout this rocess, it is imortant for both har macist and atient to communicate their thoughts, erceived dilemmas or uncertainties in treatment otions, ideas and reactions to new ieces of informa tion. Only through this rocess can a mutually agree able treatment lan be devised. PROPERTY PERTY OF efelsevier CONTEN NTENT ty Verbal information can be suorted with written information, the most familiar written format being the atient information leaflet (PIL). Euroean Union legislation requires a comrehensive medicines infor mation leaflet to be rovided in every medicines ack. There is strict guidance on the information to be in cluded in this leaflet and, most recently, requirements on the readability of these leaflets. PILs often do not increase atient knowledge, nor do atients value them. This may, however, change as it is now recom mended that the wording in PILs be tested with atients. Findings from studies have indicated that atients would like information to be tailored to their articular illness and circumstances, to hel with decision making before rescribing occurs, and for it to contain a balance of benefit and harm information. PILs are not the only way of communicating information. As well as verbal communication and 528
Concordance CHAPTER 46 information from PILs, other written information can include condition or medicine secific information guides, or use can be made of video, DVD or other interactive media. Information can also be resented in the form of a decision aid. Decision aids are atient decision suort tools which facilitate evidence based atient choice. They normally have a number of in formational elements. They rovide information on available treatment otions, consider the atient s values for benefits versus harm, and facilitate the atient s articiation in treatment decisions. Like other educational materials they can be rovided as booklets, DVDs, videos or as interactive media. A systematic review of decision aids by O Connor et al (2003) has shown that they can increase atient knowledge, imrove the roortion of atients with realistic ercetions of benefits and harms, reduce the roortion of atients who are undecided after coun selling and decrease the roortion of atients who are assive in decision making. There is a library of decision aids at the Ottawa Health Research Insti tute s website covering a broad range of clinical con ditions and health issues (see Aendix 5). On this website library, each decision aid is rated using a series of internationally agreed quality criteria. Many of these decision aids are American but can be adated d to the UK setting. Online initiatives such as NPCi through the National Prescribing Centre will also make available Web based atient decision aids from late 2007 to suort an evidence based atient choice aroach. A major issue for all tyes of written, comuter based, audio, video and interactive ive information is the quality of information available (see Ch. 23). Much of the information availablele is oor, articularly with regard to roviding accurate and adequately detailed clinical information to assist atients in decision mak ing. Other issues exist, such as ensuring toics of relevance to atients are included and that uncertain ties in treatment need to be clearly communicated. A number of tools have been develoed to assess the quality of health information such as the DISCERN tool and the International Patient Decision Aids Stan dards (IPDAS) instrument. The tools use a range of criteria to judge the issue information, such as: * Information accuracy, comrehensiveness and reliability * Clarity of aims and target audience * The comrehensibility and balance of information * References to sources * How u to date it is * Suort for shared decision making * Transarency of authorshi and sonsorshi (if any). Pharmacists are not the only eole who need to be able to judge the quality of health information. Patients are active information seekers and, although their most common source of health information is the doctor, other sources such as the Internet are increasingly laying a art. The harmacist is in an excellent osition to act as the atient s Internet guide : to rovide advice on accessing and under standing Web resources, to direct them to high quality Internet sites and to discuss with them any information affecting their decision to take, or not take, a medicine. This will show the harmacist as a resource for accessing and discussing medicines infor mation to which atients will be likely to return in the future. Communicating risk A key asect of sharing information with atients is the ability to communicate risk: to rovide informa tion on the effectiveness of a medicine or the likeli hood o o of a side effect occurring. Pharmacists often use words such as rarely or commonly to indicate to atients how frequent a articular side effect is likely to be exerienced. In an effort to standardize the interretation of these words, the Euroean Union (EU) has issued a guideline banding the level of risk into five grous from very common to very rare (Box 46.4). However, even this aroach may not ensure consistency. Evidence suggests that the general ublic has a tendency to reliably overestimate the risk associated with these words in comarison with the risk frequency intended by the EU. Healthcare ro fessionals also consistently overestimate the risk level associated with these words, although not to the same lep PROPERTY PERTY wo OF teelsevier Box 46.4 EU recommended verbal descritors and their frequency range Verbal descritor Very common >10% Common 1 10% Uncommon 0.1 1% Rare 0.01 0.1% Very rare <0.01% EU assigned frequency level 529
SECTION FIVE Pharmacy services and monitoring the medicinetaking atient magnitude that the lay ublic does. The use of these verbal descritors can lead to eole erceiving there is a greater risk to their health than there actually is, suggesting that they need to be used in combination with actual numbers in order to effectively commu nicate the intended risk level. Exressing risks as natural frequencies (e.g. 3 out of 10 eole will exerience dizziness with this med icine) facilitates greater understanding of risk than resenting it as a robability statement (e.g. there is a 30% chance of dizziness with this medicine). As well as textual (or verbal) and numerical resentations of risk, other visual forms can be used such as bar charts, icons (showing how many eole in 100 are affected), ie charts, tables or survival curves. Grahical infor mation may result in greater accuracy in determining the relative quantitative difference between risks, although icons have been found to be quite helful to decision making. Further research is needed on atient references and the benefits of alternative risk formats. It is also ossible that different eole may refer different formats to aid their individual understanding of risk information. Verbal, textual, visual, grahical and numerical formats may all have a lace and the key to communicating risk is a flexible aroach. A greater desire for involvement ent in decision making is associated with a reference ence for more comlex risk information so the need for alternative risk formats, and flexibility in aroach, ach, is essential. A number of factors have been shown to imrove eole s understanding of risk information. n. Including both verbal or text information ion and numerical or grahical information on risks can aid understanding. Presentation of information which h is both ositive and negative rovides a more balanced view of the bene fits and risks of taking a articular medicine. Taking account of the starting or baseline risk levels can also imrove the accuracy of eole s judgments about, for examle, the benefit associated with introducing a new medication (e.g. reduction in stroke risk). This allows eole to anchor their ercetion at their start ing level of risk and extraolate more accurately to the otential decrease in stroke risk with starting a new medication. Finally, whether a risk is resented as an absolute risk reduction or relative risk reduction can also influ ence eole s ercetion of risk. Absolute risk reduc tion is the difference in risk between a control grou and a treatment grou. Relative risk reduction is the event rate in the treatment grou divided by the event rate in the control grou subtracted from one. For examle, if a new hyertensive drug decreases the risk of stroke from 0.004% to 0.003%, the relative risk reduction is 25% although the absolute risk re duction is only 0.001%. Relative risk reduction sounds much more imressive and is more ersuasive. Abso lute risk reduction is the referred method for con veying accurate risk information and should be used on its own or in combination with the relative risk reduction. The theraeutic alliance What are the benefits of a theraeutic alliance with atients? Once harmacists have engaged with atients in a harmacy consultation and a lan of action regarding medicines has been mutually agreed, what are the benefits of this rocess? Reviews have shown that good adherence ence to medication is associat ed with a decreased d mortality. This includes adher ence to lacebo or beneficial drug theray suggesting that there is a healthy adherer effect, where adher ence to drug theray may be a roxy for overall healthy behaviours. The question then becomes, does concordance ordancē ce imrove adherence or affect other health outcomes? With concordance embracing a range of cometences around the rofessional and atient sharing beliefs, references and information in a collaborative consultation rocess, the evidence for concordance affecting adherence deends uon how concordance has been defined. Patients rarely voice their concerns about medicines, unless encour aged to do so, and the issue of whether or not atients are taking their medicines is not always discussed in a consultation. Many of the elements erceived to be necessary for concordance (such as establishing whether or not both the rofessional and atient ex ress their oints of view, whether the rofessional resects the atient s ersective on their illness and medicine use, or whether both work together towards shared decisions) aear not to be taking lace in ractice, or only taking lace to a limited extent. For these reasons, finding evidence that concordance imroves adherence or other health outcomes is difficult. icp PROPERTY RTY foo OF ELSE LSEVI SEVIER There is evidence on secific asects of commu nication which are relevant for concordance. When atients are given information about treatment otions and coached to ask questions about their condition, they are more involved in the consultation and have better health outcomes. Imrovement in health outcomes can, for examle, include s 530
Concordance CHAPTER 46 decreased blood ressure or blood sugar levels, an imroved subjective evaluation of overall health or increased functionality in terms of activities of daily living. When rofessionals share treatment decision making with atients and focus on the atient as a erson and not merely a disease state, atient satis faction is likely to be increased. Effective communi cation involving activities such as encouraging the atient to ask questions, roviding information and suort and sharing the decision making rocess has been shown, across a range of research studies, to imrove emotional health, resolve symtoms, im rove function and reduce ain. Concerns about concordance Concerns about concordance centre on four issues: * Time. That a concordant consultation will take too long * Anxiety. That roviding information to atients makes them anxious and they will either exerience the side effects that have been described to them and/or sto taking their medication * Peole do not want to articiate in decisions about their medicines * Concordance will lead to unreasonable atient demands for exensive medicines ines and healthcare. Time is a concern for all healthcare e rofessionals. Aroaches such as concordance which have the o tential to increase consultation times are an issue in any busy harmacy setting. Research suggests that using a concordant aroach ach with atients may take longer initially, but as rofessionals gain exerience and roficiency in this aroach, consultation times will decrease. There is also some evidence that if rofessionals do not ick u on atient clues, defined as direct or indirect comments made by atients about ersonal asects of their lives or emotions, then consultations will be longer. It seems that if a atient has issues or ideas which they hint about during a consultation, it is best to address these issues oenly. If not, the atient may feel obliged to continue seek ing oortunities throughout the interaction to allude to these issues and this may ultimately rolong the consultation further. It is also now ossible to searate the rovision of information about otions from the consultation ro cess. This has been facilitated through the use of de cision aids and other interactive media. Patients can access the information outside of the consultation and have time to think about their otions, discuss them with relevant others, make a list of questions to ask the healthcare rofessional and then articiate as an informed atient in the consultation with their healthcare rofessional. This may be the best solution to deal with issues of time, i.e. de coule the rovi sion of information about otions from the constraints on consultation length. Decision aids do not relace a consultation with a healthcare rofessional but may enhance informed discussion by giving atients the time to think about the issues of imortance to them, having taken account of the clinical information in the decision aid. There is a concern that telling atients about the side effects of their medicines can lead to them exeriencing these side effects. This comes from the idea that humans are suggestible; that telling eole about a side effect makes them exerience it. The research on whether forewarning of side effects fects affects eole s adherence can be conflicting. Yet the weight of research evidence indicates that rovision of information about side effects does not increase anxiety nor does it affect a atient s adher ence. W e. What does seem clear is that how this informa tion is resented can affect adherence. So resenting information on both ositive and negative effects of treatment, in a manner understandable (without being atronizing) to lay eole, that links into lay theories of illness and treatment (see Ch. 3) and which romotes informed choice can avoid the otential negative consequences of information over load or information anxiety. Patients do not always want to be involved in deci sions about what treatment is best for them. It is well known that there are a roortion of atients that want the doctor (most commonly) to decide what treatment is right for them. However, u to two thirds of atients either want to decide for themselves after the doctor has exlained the otions to them or want to do so in artnershi with a healthcare rofes sional. While older eole are less likely to want a more active role in decision making than younger, more affluent eole, half of those aged over 65 and those in lower social classes want to have a say in decisions about their care. Peole need to be involved in decision making to the extent that they want to be. The best way to do this is to ask them. There is a view that if the atient s view takes riority in an interaction between healthcare rofes sional and atient, the atient will simly demand exensive medicines or healthcare services at the op PROPERTY PERTY OF ELSEVIER 531
SECTION FIVE Pharmacy services and monitoring the medicinetaking atient exense of those who are less articulate but more in need of health care. Given the current emhasis on the need to ration scarce healthcare resources, this is a otentially valid concern. Highrofile cases in the oular ress with atients demanding exensive treatments reinforce this concern. Concordance is about both arties exressing their views and if a healthcare rofessional has reservations about a articular treatment otion (e.g. that it is of uncertain benefit or the costs outweigh the benefits), they need to exlain this rationale to the atient. A common cause of litigation is oor communication between rofessionals and atients, such as devaluing or failing to understand the atient s ersective. The alternative is not to inform atients of all otions because one otion may be articularly exensive. This can lead to atients seeking out this information on their own and raising a legitimate comlaint that they were not informed about all otions. Unreasonable demands may occur in a consultation but, rovided both arties exress their views and the rationale behind their views as art of a concordant consultation rocess, there is unlikely to be a basis for litigation against an individual ractitioner. In the end, both arties may need to agree to differ. Conclusion Concordance is an oortunity for harmacists to engage with atients on an equal level to understand their ersective on taking medicines. It argues for oenness in the consultation where both rofessional and atient are able to exress ess their views. Information is exchanged which may be clinical, ersonal, exeriential and otentially worrying. Decisions are based on all tyes of information which are relevant for subsequent medicine taking. Ultimately it is yins hoed that this will make the best use of medicines and, in situations where the atient has decided not to take a medicine, recognizes that an agreement to differ to include the oen acknowledgement of the atient s ersective is referable to the atient going away with concerns or issues which remain unaddressed. KEY POINTS * Concordance romotes the view that atients have a legitimate and valuable ersective on taking decisions about their health care * The concet of concordance arose because of the need for innovative aroaches to hel atients with their medicines * Nonadherence may be unintentional or intentional * The Code of Ethics indicates that harmacists have a duty to assist atients ts reach their own decisions * The concordance model shares features with other models of effective communication * Eliciting atient views is the first stage in establishing a concordant relationshi * Because concordance is concerned with the consultation, tion, it is essential to have a good atient harmacist relationshi * Emathy lays a key role in concordance * Patients want information and different techniques can be used including the use of decision aids, PILs, the Internet, medicine guides, video and DVDs * When communicating risk to atients, harmacists need to ensure that atients have understood the information fully and have received the breadth and deth of information they desire * The ultimate aim of concordance is to establish a PROPERTY RTY OF ELSEVIER E*EL EVIER SAMPL MPLE a h theraeutic alliance between atient and healthcare rovider There are strategies for reducing concerns about concordance, articularly with resect to the time it involves * s 532