Is it just a word?

Posted on May 14, 2010 in Patient Care | 2 comments

What’s in a word? The evolving concepts of compliance, persistence, adherence and concordance

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We all know that our patients would do better if they just listened to the sage counsel we offered them.

Do as we say and not as we do.

Change your diet, eat your veggies, but avoid the dirty dozen,[1] unless they are organic; eat as much as you want of the dark green plants, but if it tastes good, you probably can’t have it. And don’t forget your daily fiber, both soluble and insoluble. And eat some fish a few times a week, but only the right fish, not the ones with mercury or PCBs.[2]

Exercise more, and then some more, and then some more, at least 30 minutes a day, 5 times a week, or 20 minutes, if vigorous, 3 times a week,[3] break a sweat, but don’t get too winded (unless you’ve had a recent stress test,[4] and make sure you warm up, cool down, and drink just the right amount of water.

For goodness sakes, stop smoking now. Call this number and/or take this pill, set a quit date and get some help. You can do it. Be positive.

It is okay to drink a little, but not too much (2 glasses of wine or equivalent a day for the gentlemen, but only half that for the ladies).[5]

Stay calm, relax, meditate, but naps may not be a good idea so don’t fall asleep.

Get a good night’s sleep, but don’t use OTC sleep aids and don’t exercise in the evenings, only in the AM.

Wash your hands all the time and cover your mouth when you cough, but don’t touch you face. And antibacterial soaps may or may not be a good idea.[6]

And we haven’t said a wise word yet about all the fabulous preventive care we offer and how patients must allow us to painfully and embarrassingly probe where we might find hidden diseases in their most private parts before the disease can cause more misery than we caused looking for them.

And most importantly, please, please, take all the marvelous medications exactly as we prescribed them, mostly for problems that would have been solved if they had listened to our advice in the first place.

Why don’t they just do as they are told?

After all, we all know medicine only works if it is taken. Even Hippocrates complained 2400 years ago that his patients were not following his learned advice.

Today, rates of compliance with our prescriptions range typically from 50% to 75% depending on the strictness of the definition and the period studied. Most definitions draw the line at taking 80% of the medication to be in compliance, but how do you count doses taken 6 hours apart when the label says every 12 hours? Is there a difference between 79% of the doses and 20% of the doses? The line is the very vague and ambiguous and varies from study to study.

More certain is that poor compliance and nonpersistence (defined as not starting and finishing the whole course of therapy as recommended) with prescribed medication regimens result in not only increased morbidity and mortality from a wide variety of illnesses, but also increased healthcare costs.

Here are some alarming facts.

• Approximately 125,000 people with treatable ailments die each year in the United States because they do not take their medication properly.
• Between 14% and 21% of patients never even fill their prescriptions.
• Sixty percent of patients cannot identify their own medications.
• Up to 50% of all patients ignore instructions concerning their medication.
• Improper self-administration of medicine is an important factor leading to about one-fourth of all nursing home admissions.
• Twelve percent to 20% of patients take other people’s medicines.
• Hospital costs estimated at $8.5 billion annually are due to patient noncompliance.
• We providers are only savvy to about 10% of the patients who don’t follow our marching orders.

The way out of the mess is not to double the dose of the untaken med or bark out the orders louder and give the handout in a bolder font.

The way out of the mess is a paradigm shift.

And it has already begun with a change of language.

See if this helps.

The term “compliance” suggests the whiff of paternalism and, in the context of a patient’s expected compliant behavior, seems to point the blame on patients when their behavior does not meet with healthcare professionals’ lofty recommendations. This is a blatant abrogation of our role in the therapeutic transaction.

So let’s change our language.

The World Health Organization tried to change the undertone of the blame associated with compliance by introducing the term “adherence.” The working assumption is that “adherence” implies that the patient agrees with the prescribed recommendations rather than passively obeying.[7] Really the big change here is that we recognize the patient may actively decide not to follow our treatment plan, but there is no finger of blame associated with that decision. It was the patient’s choice.

Did it help? No data shows that patient buy-in makes a difference in patient adherence, but it sure feels more honest to share the responsibilities.

Next step was to have the Royal Pharmaceutical Society of Great Britain (1997) step into the controversy. They formed a working committee to evaluate and discuss introduction of the term “concordance” as an alternative concept for adherence.

“Maintenance” and “fidelity” were briefly considered but were quickly dismissed for the obvious reasons of the baggage they carry outside of their potential work as medical terms.

“Concordance” sweetly implies the development of a partnership between patients and healthcare providers. Ideally this is based on realistic expectations as opposed to misunderstanding and hidden facts. If we accept what some authors have described, that the terms “compliance” and “adherence” are ideological, then they in fact inform how healthcare providers communicate their thoughts on expected patient behavior. We advise, they comply or, if you prefer, they adhere. Or not. Alternatively, the term “concordance” suggests that patients and healthcare professionals have come to a mutually agreed therapy through a process of negotiation and shared-decision-making. We learn from each other and go forward, hand in hand.

As a term, “concordance” totally ignores the thorny dilemmas that providers face daily. What do you do if patients’ preferences are in conflict with the prevailing evidence? What do you do if patients reject a treatment because they do not understand the risks or benefits correctly? And most worrisome, what to do if patients’ preferences could result in harm to themselves or
others?

As expected, the data is limited regarding the term “concordance” in healthcare literature, and again healthcare researchers have failed to show whether patient alliance, negotiation, or shared-decision-making result in a change to adherence behavior.

Maybe we are swinging too far in attempt to be fair and egalitarian when the reality is that practitioners hold most of the cards based on their usually superior knowledge and experience.

Recently it has been suggested that the term “concordance” should not be used to replace either “compliance” or “adherence.” The terms “compliance” and “adherence” examine to what extent patient behavior matches the prescriber’s advice. In contrast, the term “concordance” is not directly related to behavior. Concordance is about a more patient-centered consultation.

Concordance is a different animal than compliance and adherence.

Let’s be honest, achieving concordance in every clinical encounter is not going to happen. Even the most educated and self-reliant patients may often behave in a relatively passive way. They simply are wise enough to know it is not in their best long-term interest to threaten the relationship with the professional on whom they depend for future care. While some patients may wish to share in decision-making, we all know that many do not. True patient involvement in clinical decisions remains rare. Truth be told, the term “adherence” is probably a better reflection of what happens in practice. Adherence emphasizes the patient’s right to choose to follow a prescriber’s recommendations, but also tries to emphasize that failure to do so should not be a reason for blame.

I suggest it all comes down to communication. Are we on the same page, do we share the same vision of what needs to be done and how to do it? Are we engaging the patient and honestly selling the benefits and risks of the therapy?

That has less to do with the choice of terms, compliance or adherence or concordance, and more to do with connecting with the patient.

Please share your opinions.

Brian Koffman, MD
Published on May 14, 2010

References

1. Leamy E, Evans S. The ‘dirty dozen’ of fruits and vegetables. Good Morning America Web site. 2009 August 13. http://abcnews.go.com/GMA/story?id=8315670&page=1. Accessed May 8, 2010.
2. Mercury contamination in fish: a guide to staying healthy and fighting back. Natural Resources Defense Council Web site. http://www.nrdc.org/health/effects/mercury/guide.asp. Accessed May 8, 2010.
3. Physical activity and public health guidelines. American College of Sports Medicine Web site. http://www.acsm.org/AM/Template.cfm?Section=Home_Page&TEMPLATE=CM/HTMLDisplay.cfm&CONTENTID=7764. Accessed May 9, 2010.
4. Richardson A. The cardiac stress test. A must before starting an exercise program. Suite101.com Web site. http://sportsinjuries.suite101.com/article.cfm/the_cardiac_stress_test. Accessed May 8, 2010.
5. Alcohol, wine and cardiovascular disease. American Heart Association Web site. http://www.americanheart.org/presenter.jhtml?identifier=4422. Accessed May 8, 2010.
6. Gardner A. FDA to re-examine anti-bacterial chemical in soaps, cleansers. US News & World Health Report Web site. http://health.usnews.com/health-news/managing-your-healthcare/policy/articles/2010/04/08/fda-to-re-examine-anti-bacterial-chemical-in-soaps-cleansers.html. Updated April 8, 2010. Accessed May 8, 2010.
7. Sabaté E, et al. Adherence to Long-Term Therapies. Evidence for action. World Health Organization. Geneva, 2003.