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VIEWS & REVIEWS: Ike Iheanacho You do agree, don’t you? BMJ 2008; 336: 894-a [Full text]

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No, I don't agree

Jeffrey K Aronson   (4 May 2008)

Re: No, I don't agree

Ike Iheanacho   (9 May 2008)

No, I don't agree 4 May 2008
Jeffrey K Aronson, Reader In Clinical Pharmacology University Department of Primary Health Care, Rosemary Rue Building, Old Road Campus, Oxford OX3 7L Send response to journal: Re: No, I don't agree	Ike Iheanacho encourages us to espouse ‘concordance’. In doing so he pays less attention to the evidence1 than I would have expected of the Editor of Drug and Therapeutics Bulletin. Originally, the definition of concordance implied that the prescriber and patient should come to an agreement about the regimen that the patient would take. In passing, I note that ‘compliance’ can mean ‘Accord, concord, agreement; amicable relations (between parties)’ (Oxford English Dictionary), which seems to me to be in concord with this definition of concordance. This may partly explain the confusion between these terms, reflected in the titles of some publications, in which ‘concordance’ is used as a synonym for ‘compliance’ or ‘adherence’.2-4 In fact, the definition of concordance has shifted since it was first invented. The original definition was ‘an agreement reached after negotiation between a patient and a health care professional that respects the beliefs and wishes of the patient in determining whether, when and how medicines are to be taken’.5 However, a negotiated agreement is not relevant to the interaction between a clinician and a patient; we cannot, for example, negotiate the ideal dosage or route of administration. The focus of concordance has therefore shifted from the consultation to how to communicate with and support the patient,5 which are relevant. A search of Pubmed for papers whose titles include the word ‘concordance’ yields about 1300 results, well over 95% of which are nothing to do with agreement between clinicians and patients. They use the term in the sense of correspondence. For example ‘physician and patient gender concordance’ means that the physician and patient are of the same sex; ‘patient–physician racial and ethnic concordance’ means that they are of the same race or ethnic origin; ‘language concordance’ is the use and understanding of the same language. However, clinicians’ views about therapy can never be perfectly concordant with those of patients. The best that can be hoped for is that the clinician explains clearly and advises appropriately and the patient decides whether to accept the advice and to adhere to the proffered therapy, with suitable support from the clinician, or to reject the advice, either outright or by subsequent non-adherence (adherence not always being beneficial). Concordance has become a shibboleth that has been accepted uncritically in certain quarters in the absence of evidence of its benefits and harms and of the balance between them. Authors do not write about testing the concept of concordance. They write about achieving concordance,6 promoting it,7 improving it,8 and enhancing it,4 even when they admit at the same time that supportive evidence of benefit is rare,6 and although doubts about its benefits have been expressed and possible harms mentioned.9 What evidence there is, is limited1; there is no evidence on possible harms and little discussion about them. Some of the types of research on concordance that are desirable have been mentioned in a thoughtful review,5 and the National Institute for Health and Clinical Excellence in the UK is conducting a critical appraisal of the evidence on shared decision making, although the report is not expected until December 2008.10 Not all patients want to be more involved in decisions about their management. In a study of 344 patients with rheumatoid arthritis, 78% thought that patients should feel free to make everyday decisions about medical problems, but 75% thought that doctors should make important decisions and over 50% thought that patients should go along with doctors’ decisions, even if they disagreed with them.11 On the other hand, many patients want more information–in the same study, significantly more patients wanted information than wanted to be involved in making decisions. However, up to 80% of information given to patients during medical consultations is forgotten at once, and almost half of what is remembered is remembered incorrectly12; measures to improve this would be welcome. More education of clinicians in the practical aspects of prescribing is also desirable.13 The word of choice to describe a patient’s medicine-taking behaviour is ‘adherence’.5 The word ‘concordance’, when used to imply a negotiated agreement between prescriber and patient, is misleading and inaccurate. It was invented with excellent intentions14 but has failed to live up to expectations. We should ditch it and talk instead about what really matters to patients in their conversations with health-care professionals–the quality of communication and support that they receive. References 1. Aronson JK. Time to abandon the term ‘patient concordance’. Br J Clin Pharmacol 2007; 64: 711-3. 2. Newell K. Concordance with asthma medication: the nurse’s role. Nurs Stand 2006; 20: 31–3. 3. Badger F, Nolan P. Concordance with antidepressant medication in primary care. Nurs Stand 2006; 20: 35–40. 4. Banning M. Enhancing older people’s concordance with taking their medication. Br J Nurs 2004; 13: 669–74. 5. Horne R, Weinman J, Barber N, Elliott R, Morgan M. Concordance, Adherence and Compliance in Medicine Taking. Report for the National Coordinating Centre for NHS Service Delivery and Organization R & D (NCCSDO). Available at http://www.sdo.lshtm.ac.uk/files/project/76-final-report.pdf. 6. Lim AY, Ellis C, Brooksby A, Gaffney K. Patient satisfaction with rheumatology practitioner clinics: can we achieve concordance by meeting patients’ information needs and encouraging participatory decision making? Ann Acad Med Singapore 2007; 36: 110–5. 7. Hobden A. Strategies to promote concordance within consultations. Br J Community Nurs 2006; 11: 286–9. 8. Brooks J, Ersser SJ, Lloyd A, Ryan TJ. Nurse-led education sets out to improve patient concordance and prevent recurrence of leg ulcers. J Wound Care 2004; 13: 111–6. 9. Ferner RE. Is concordance the primrose path to health? It might not make much difference. BMJ 2003; 327: 821–2. 10. National Institute for Health and Clinical Excellence. Medicines Concordance (Involving Patients in Decisions About Prescribed Medicines). Available at http://guidance.nice.org.uk/page.aspx?o=267072. 11. Neame R, Hammond A, Deighton C. Need for information and for involvement in decision making among patients with rheumatoid arthritis: a questionnaire survey. Arthritis Care Res 2005; 53: 249–55. 12. Kessels RPC. Patients’ memory for medical information. J R Soc Med 2003; 96: 219–22. 13. Aronson JK. A prescription for better prescribing. Br J Clin Pharmacol 2006; 61: 487–91. 14. Marinker M. Personal paper: writing prescriptions is easy. BMJ 1997; 314: 747. Competing interests: A longer version of this paper first appeared as reference 1.
Re: No, I don't agree 9 May 2008
Ike Iheanacho, Editor, Drug and Therapeutics Bulletin BMA House, Tavistock Square, London WC1H 9JR Send response to journal: Re: Re: No, I don't agree	Jeffrey Aronson makes some interesting points about the concept of concordance, which, as acknowledged, he has already published elsewhere. However, it is a little puzzling that he uses my article as a pretext for merely restating such views. In particular, his response offers no direct criticism of the piece, other than suggesting incorrectly that it represents an unquestioning endorsement of the use of the term concordance. In reality, the article starts by saying that concordance is not working as an idea in everyday clinical practice. It also highlights how there is no consensus about what concordance actually means (a key problem, of course, when considering how the concept could be tested), and makes a case for the continuing use of ‘adherence’ (not concordance) in describing the extent to which patients stick to professionals’ recommendations. Furthermore, it makes clear that concordance might not be a realistic goal in the clinical setting and takes issue with those professionals who say concordance when they really mean compliance (presumably because they think it is fashionable to do so). The article also rubbishes the notion of "improving patient concordance". If Jeffrey Aronson disagrees with any or all of these points, it would have been helpful if he had argued accordingly in his response. Competing interests: None declared