Marjorie Weiss and Nicky Britten explain what concordance is and what it is not
Marjorie Weiss is senior lecturer at the University of Bath school of pharmacy and Nicky Britten is professor of allied health care research at the Peninsula Medical School, Exeter
Concordance seems to mean different things to different people. For some, it is merely the latest in a series of terms used to describe compliance and, more recently, adherence. For others, it is a radical shift in the way we think about how patients take medicines. Our aim is to describe what we think concordance is about, how it differs from previous ways of thinking about medicine-taking, and the implications for health care professionals.
Concordance is fundamentally different from either compliance or adherence in two important areas: it focuses on the consultation process rather than on a specific patient behaviour, and it has an underlying ethos of a shared approach to decision-making rather than paternalism.
Concordance refers to a consultation process between a health care professional and a patient. Compliance refers to a specific patient behaviour: did the patient take the medicine in accordance with the wishes of the health care professional? For this reason it is possible to have a non-compliant (or non-adherent) patient. It is not possible to have a non-concordant patient. Only a consultation or a discussion between the two parties concerned can be non-concordant.
Sharing of power
Crucially, concordance advocates a sharing of power in the professional-patient interaction. Concordance values the patient’s perspective, acknowledging that the patient has expertise in his or her body’s experience of illness and response to treatment. This expertise is different from the professional’s scientific expertise in drug treatment selection but is of equal relevance and value in terms of deciding on best management. A concordant consultation is one that includes both these views in the decision-making process regarding management. This is contrasted with the paternalistic approach underlying compliance: the patient is assumed to take an essentially passive role in the consultation and to be obedient to the health care professional’s advice. Paternalism is still possible in concordance provided it reflects the patient’s preference for involvement in the decision-making process and that this preference has been actively elicited in the consultation. Health care professionals sometimes assume a patient wants a paternalistic approach — that they should make the decision on how best to treat them. However, research suggests that professionals are often unable accurately to “guess” a patient’s preferred role in decision making.1 It would seem that the best way to find out if patients want to be involved in decision making is to ask them.
Why do we need concordance? Put simply, the older models of adherence have had only a limited effect on patient medicine-taking behaviour. A recent review of adherence2 concluded that the full benefits of medication cannot be realised at currently achievable levels of adherence, underlining the inadequacies of the paternalistic approach for ensuring the best use of medicines.3 Will concordance ensure a more effective use of medicines — less drug wastage and fewer hospital admissions due to the iatrogenic effects of drugs? We do not know — the impact of concordance on patient outcomes is still unknown. Definitive evidence is difficult to ascertain as the concordance “package”, including its several constituent parts (eg, exploring patient medication concerns, working together with patients to develop a treatment regimen), has rarely been evaluated comprehensively. Most of the evidence to date concerns an evaluation of one or more elements of concordance or the evaluation of an approach allied to concordance, such as “patient-centredness” or “shared decision-making”. Nonetheless, a recent systematic review of the literature relevant to concordance found that two-way communication between patients and professionals about medicines led to improved satisfaction with care, knowledge of the condition and treatment, adherence, health outcomes and fewer medication-related problems.4
Not all health care professionals will welcome concordance; some will have reservations about giving the patient’s view primacy. It is possible for patients to reject what may be considered (by the professional) to be best clinical practice even when they have been fully informed as to the nature and consequences of this decision. In these situations, concordance does not detract from the autonomy of the health care professional to document such events fully or refuse to supply or prescribe a medicine in situations considered to be pharmaceutically unsafe. Even so, health care professionals may believe they are at risk of litigation should a patient who has refused best treatment suffer an adverse event as a result. However, research evidence suggests this is unlikely. Levinson et al conducted a study among physicians who had a history of previous malpractice claims and those with no previous malpractice history. They found that physicians with no previous history of malpractice claims had better communication consultation skills, using more facilitative talk such as soliciting the patient’s opinion and encouraging them to talk.5 In this context, concordance is about raising to a level of explicitness those decision making processes, by both the patient and health care professional, which were previously unelaborated or occurred outwith the consultation.3
Another major concern for health care professionals is time. Will discussion of patients’ views give rise to long consultations that would be impractical in primary care? There is some evidence that discussion of patients’ views does not necessarily lead to longer consultations6 and may in any case save time in the longer term through resolution of misunderstandings. Other researchers suggest that using such an approach will take longer initially but this will settle and reduce as a professional gets more proficient in this approach.7 Time is an important issue given the current structural limitations of the primary care practice setting. However it should not be used as an excuse for not trying out concordance.
A shift in thinking
Concordance is a shift in how we think about medicine-taking. It challenges us to find out the real concerns patients have about taking medicines and into working with patients to discover imaginative solutions on how they can make best use of their medicines. Is it not worth a try?
1. Strull WM, Lo B, Charles G. Do patients want to participate in medical decision making? JAMA 1984; 252:2990–4.
2. Haynes RB, Montague P, Oliver T, McKibbon KA, Brouwers MC, Kanani R. Interventions for helping patients to follow prescriptions for medications (Cochrane review). In: The Cochrane Library, Issue 1, Update Software, Oxford. 2001.
3. Britten N, Weiss MC. What is concordance? In: Bond C (editor). A concordance reader. London: The Pharmaceutical Press. In press.
4. Cox K, Stevenson F, Britten N, Dundar Y. A systematic review of communication between patients and health care professionals about medicine-taking and prescribing. London: GKT Concordance Unit, King’s College; 2003.
5. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication — the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277:553–9.
6. Belle Brown J. Time and the consultation. In: Jones R et al (editors). Oxford textbook of primary medical care. Oxford: Oxford University Press. In press.
7. Stewart M, Belle Brown J, Weston WW. Patient-centred interviewing Part III: five provocative questions. Can Fam Physician 1989;35:159–61.