Phuture 12 2005

Opening Message Concordance aims to engage patients in equal partnership with health professionals in the decision making process relating to every aspect of their health management and therapy. Through fostering concordant approaches, progress towards greater understanding and improved healthcare outcomes can be made. With a growing number of medications and limitations on resources worldwide, it is critical to ensure that therapy is as effective as possible whilst minimising harm and risk. As the health professionals of today and the future we recognise the importance of role of the patient in concordant partnerships to maximise healthcare outcomes and quality of life.

A Message From IPSF IPSF is pleased to present this year's Phuture supplement addressing concordance. Concordance is not widely understood in some areas of the world, and is often confused with the term compliance. Concordance is a model of practice that engages patients as an equal partner in their treatment and care. Pharmacists are integral in the concordance model as they are readily accessible and play a major role in educating patients on disease states and treatment modalities. Education allows patients to participate as fully in their treatment plan as they desire, a central principle of concordance. The pharmacist's role as an integrated member of the health care team also ensures that patients' information and their wishes with regard to treatment are adequately communicated to all health care providers.

Our hope for this supplement is to provide our members with more information on this model to strengthen their practice skills. We are pleased to provide a variety of articles on the topic, ranging from historical development of the model to examples of concordance in clinical practice. We also invited students to share their experiences with concordance, and discuss their role in changing practice.

Thank you very much to all of our contributors - you have given us much to think about!

Lesley A. Zwicker Chairperson of Pharmacy Education

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The Concordance Model Caroline Kelham - Project Manager, Medicines Partnership ckelham@medicines-partnership.org The origins of concordance There is a problem at the heart of modern medicine. Approximately half the people prescribed medicines - either for long-term illness or in the short-term do not take them in the recommended doses. This imposes a huge burden of avoidable ill-health and premature mortality on patients, as well as significant cost to the consumer and health funders through wasted medicines, drug resistance and, more importantly, in dealing with preventable illness and complications.

The concept of concordance first came to prominence through the publication in 1997 of the report of the 'Enquiry into the Causes and Consequences of Non-compliance in Medicine Taking' based at the Royal Pharmaceutical Society of Great Britain.1 This enquiry confirmed that around 50% of medicines for long-term conditions are not taken as prescribed and made further investigations into what was known about the difficulties patients have in taking medicines.

The enquiry concluded that patients are not the passive recipients of prescribing decisions, but have their own views about medicines, how they should be used and how medicine taking fits in with their daily lives. Whilst these beliefs play a very important role in a patient's decision whether to take a medicine, health professionals often know very little about them.

The group also suggested a remedy, and they called it Concordance. It was a new way for prescribers and patients to agree about medicines together. It looked for an alliance to be struck by prescribers and patients - an agreement on how medicines would be used to solve the problem under discussion, after both of them had had their say.

This approach ultimately recognises that the decision whether to take a medicine or not ultimately lies with the patient.

A successful prescribing process will be an agreement that builds on the experiences, beliefs and wishes of the patients to decide when, how and why to take medicines. This agreement may not always be easy to reach, but without exploring and addressing these issues patients may not be able to get full benefit from the diagnosis and treatment of the illness.

Why concordance is not compliance?

Some people have used the word concordance as a politically correct version of compliance - using terms like 'patient concordance with medication was recorded at three months'. However, compliance and concordance are two valid terms measuring different things: Compliance measures patient behaviour: the extent to which patients take medicines according to the prescribed instructions.2 Concordance measures a consultation process: shared decision making about medicines between a healthcare professional and a patient, based on partnership, where the patient's expertise and beliefs are fully valued.

Key principles of the concordance model Concordance is essentially a process of successful prescribing and medicine taking, based on partnership and shared decision-making. The key principles of the model are as follows:

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Patients have enough knowledge to participate as partners - Patients have access to information about their condition, the treatment options available and the risks and benefits - of different options relative to their own situation - Education empowers patients to manage their own health - Patients feel confident in asking questions and engaging in a discussion about medicines Health professionals are prepared for partnership - Health professionals are equipped with the necessary skills to engage patients - Health professionals regard it as important to invest time in reaching an informed agreement Prescribing consultations involve patients as partners - Patients are invited to talk about medicines-taking - Professionals explain the agreed treatment fully - Patients are as involved as they want to be in treatment decisions - Patients and Health Professionals reach a joint understanding of the decision - Patients' ability to follow treatment is checked Patients are supported in taking medicines - Medications are reviewed regularly with patients - All opportunities are used to discuss medicines and medicine taking - Practical difficulties in taking medicines are addressed - Information is effectively shared between professionals To read more about the concordance model and the efforts that are being made to put these key principles into practice in the UK visit www.medicines-partnership.org.

References 1. From Compliance to Concordance, Royal Pharmaceutical Society of Great Britain, 1997.

2. Weiss M, Britten N. What is concordance? The Pharmaceutical Journal 2003 Oct 11; 271(7270):493.

Engaging Patients In The Concordance Model - What Can Pharmacists Do? Geraldine Mynors - Head of Projects, Medicines Partnership gmynors@medicines-partnership.org An article in this supplement by Caroline Kelham describes the concordance approach to prescribing and medicine taking - something that is essential if patients are to get the most out of their medicines. Shared decision making during consultations where medicines are prescribed is central to the approach, so what can pharmacists contribute given that they are often not directly involved in prescribing medicines?

The answer is that there is plenty that pharmacists can do - and it can make a great deal of difference to patients.

Information giving Pharmacists can be a vital source of medicines information. If patients are to participate in treatment decisions in a meaningful way, they need information. A public opinion survey we carried out in the UK in 2004 1 showed that many people feel they don't have enough information about the options open to them, or the benefits and risks of particular treatments. Forty-four percent of people who had been prescribed a new medicine over the previous year felt that they didn't know enough about other possible medicines or treatments. One in five felt they didn't know enough about

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potential side effects, and one in three said that there is not enough information available about the risks and benefits of medicines.

- This is supported by evidence from a recent international study where half of UK patients said that their doctor told them about treatment choices, and asked for their ideas and opinions only occasionally or not at all 2 .

So pharmacists can really help to fill in the gaps. But offering patients information in a way that they find helpful is about more than just communicating clearly. It's also a matter of asking about what they want to know, and how they would like to receive it - for some people a print out of a high quality page from the internet may be ideal, for others a web address, for others the telephone number of a patient organisation support group or helpline they can call.

Information is most likely to be absorbed when it is seen by patients to be salient and tailored to them.

Helping patients to voice their agendas Beyond acting as an information resource and signpost, pharmacists can help prepare patients for partnership in prescribing consultations by helping them to think through their questions and concerns in advance. Several studies have shown patients rarely fully voice their 'agendas' during consultations and that the most commonly unvoiced issues are worries, patient ideas and information relating to the patients' own lifestyle and social context. This can frequently lead to misunderstandings and miscommunication between patients and professionals, and goes some way towards explaining why so many patients take away prescriptions that they then choose not to stick to.

Even an intervention as simple as encouraging a patient to write down the questions, concerns and issues that they would like to raise during a consultation 3, either with the pharmacist or with another health professional can help to avoid this situation. The concept of 'power questions' is one which is increasingly being explored in the UK 4 , and involves giving patients suggested questions which they should feel comfortable to ask at any time. Examples of 'power questions' developed by Medicines Partnership for 'Ask about Medicines Week' include: -

What does this medicine do?

How long will I need to use it?

How and when should I take it?

Should I avoid any other medicines, drinks, foods or activities when I am taking this medicine?

What are the possible risks and side effects and what should I do if they happen to me?

How do I know this medicine is helping?

What if I stopped taking it, or took a lower dose?

Why do I need to carry on with this medicine if I am symptom free?

If I forgot a dose, what should I do?

Is there anything that can help remind me to take my medicines?

Displaying these within the pharmacy or including them in patient information can be a great help in encouraging patients to be open about what they would like to talk about.

Support for effective medicine taking Pharmacists have many interactions with patients which offer the opportunity to explore how they are taking medicines and help them reach informed choices, as well as resolving practical problems in relation to medicine taking. Formal opportunities increasingly exist, as pharmacists shift the balance of their roles from dispensing towards offering clinical services. One such service which will be available throughout the UK from April 2005 is community pharmacy based 'medicines use review', a structured consultation with a patient to explore how they are getting on with their medicines and agree to recommendations for the prescriber to optimise medicines use. But many informal opportunities also exist at the time of dispensing or other patient contact. Make no assumptions about how patients are using their medicines, ask open questions and you will be surprised at what a difference you can make.

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References 1.MORI Research sponsored by Medicines Partnership: The Public and Prescribed Medicines 2004 (available at 1.www.medicines-partnership.org).

2.Schoen C, Osborn R, Huynh PT, Doty M, Davis K, Zapert K, Peugh J. Primary Care And Health System 2.Performance: Adults' Experiences In Five Countries.Health Aff (Millwood). 2004 Oct 28.

3.Barry CA, Bradley CP, Britten N, Stevenson FA, and Barber N. Patients' unvoiced agendas in general practice con 3.sultations: qualitative study. BMJ 2000; 320: 1246-1250.

4.Better Information, Better Choices, Better Health, Department of Health 2005 available from www.dh.gov.uk.

Concordance In Practice: Patient Care In A Pharmacist-Managed Anticoagulation Service Christie A. Robinson University of California, San Francisco Drug Information Specialty Resident 2005-2006 Pharmacists practice in various outpatient, hospital and community settings as providers of anticoagulation management. Pharmacist-managed anticoagulation services have been shown in several studies to reduce health care costs and improve patient care.1,2,3,4 This type of service supports the concordance model as it provides an opportunity for more extensive patient counselling, education and support whereby concordant partnerships may be fostered.

It was my privilege to personally serve as a pharmacist in an anticoagulation outpatient clinic during my Pharmacy Practice Residency in the United States. Our clinic provided care for indigent patients maintained on oral or parenteral anticoagulation therapy as prophylaxis against thromboembolic diseases. We emphasised medication management, education, effective written and verbal communication of therapy and continuity of care. Patients were able to participate in the anticoagulation clinic through physician referrals and managed under a collaborative agreement with the cardiology attending.

Our initial interview with a new patient included a full history and intensive education and dialogue on the anticoagulation medication's mechanism of action, indication, dosing, frequency, adverse effects and side effects. During follow up visits, the patient would have their INR checked. Once results were available, the patient's blood pressure, heart rate, and weight would be documented. The patient would then be asked a series of questions to determine if their INR was a result of too low or high a dose, a change in their diet, new medications, missed doses or additional doses taken. Patients were also asked how they had been feeling since their last visit and if they had experienced any signs or symptoms of bruising or bleeding.

The anticoagulation management I provided as a pharmacist was a patient-focused service, and the environment in which it was provided was both comforting and educational. During counselling sessions, questions were initially phrased in an open-ended manner in order to engage patients in two way communication and gather as much information as possible. Often, other issues were discovered that we were able to refer to the primary care provider, or address immediately in collaboration with the primary care provider. Developing a respectful and trusting equal partnership with patients is extremely important and we worked to establish this by scheduling follow up appointments with the same student pharmacist or pharmacist. Once patients became familiar with their provider of anticoagulation services, communication became more open and care was more successfully provided.

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Pharmacist-managed anticoagulation clinics allow an open environment where pharmacists work as equal colleagues with other healthcare professionals. Training in this practice as a pharmacist was as one of the most rewarding experiences I had as a one year Pharmacy Practice Resident and I thank my programme for allowing me such an amazing opportunity.

References 1. Anderson RJ. Cost analysis of a managed care decentralized outpatient pharmacy anticoagulation service. Journal 1.of Management Care Pharmacy. 2004 Mar-Apr;10(2):159-65.

2. Dager WE, Branch JM, King JH, White RH, Quan RS, Musallam NA, Albertson TE. Optimization of inpatient war 2.farin therapy: impact of daily consultation by a pharmacist-managed anticoagulation service. Annals of Pharmacotherapy. 2000 May;34(5):567-72.

3. Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagula 3.tion control, patient outcomes, and health care costs. Archives of Internal Medicines 1998 Aug 10-24;158(15):1641.

4.Wilt VM, Gums JG, Ahmed OI, Moore LM. Outcome analysis of a pharmacist-managed anticoagulation service.

4.Pharmacotherapy. 1995 Nov-Dec;15(6):732-9.

Concordance: A Student Note Keon Green 4th Year Pharmacy student University of Technology, Jamaica Very few Jamaicans are aware of concordance and how it relates to the healthcare system. Having visited the website www.medicines-partnership.org and reading different articles about this concept of equal partnership between health professionals and patients, I could not help but think how I could share this information with the public. I found the article, "What Is Concordance?" 1 insightful. Consequently, I decided to make copies with the hope of distributing them.

A good opportunity came when I did my Community Clerkship Rotation as part of my term work. I sought the permission of a physician who I was working with as to whether I could leave the copies of the article in the reading corner of his waiting room. Having discussed the concept of concordance with him, he granted me permission. On one particular occasion when I visited his office I noticed that several of his patients were busy delving into this article, and I observed people as they read. To my surprise, a big discussion about concordance ensued with people in the waiting room openly voicing welcoming statements on the topic.

As an obligatory requirement of my Community Pharmacy Clerkship, I was expected to do a Pharmaceutical Care Work-up of a selected patient for my case presentation. My chosen patient suffered from Paget's disease, diabetes type II and hypertension and recently prostate cancer. He understands the need to take all his medication yet he intentionally does not comply with his anti-hypertensive medications. The discussions between the patient, physician and the pharmacy helped to establish a better rapport amongst them all.

Pharmacy students can help educate their peers, the public and other healthcare professionals on the principles of concordance. Working closely with practicing pharmacists in clerkship rotations or part-time jobs provides an avenue for conveying this message.

Reference 1. Weiss M, Britten N. What is concordance? The Pharmaceutical Journal 2003 Oct 11; 271(7270):493.

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Concordance - Developing Patient-Centred Practice In Community Pharmacies Marja Airaksinen, Professor, Ph.D. (Pharm.)

Division of Social Pharmacy University of Helsinki, Finland E-mail: marja.airaksinen@helsinki.fi Introduction Patient-centred drug therapy that is based on partnerships in medicine taking has become the "gold standard" in health care. 1,2 This has also challenged pharmacists to reconfigure their services provision to meet the requirements of concordance and patient autonomy. But what does patient-centred practice mean? How can pharmacists develop competency and skills needed in a new approach to the patient? The aim of this article is to discuss the role of communication skills in this process.

Teaching pharmacists a new approach to communication with the patient It is crucial to teach pharmacists a new approach to communication with the patient.3,4 Patients should be regarded as an active medicine user, an active partner in communication with whom pharmacists are expected to establish a professional relationship based on trust, open communication and mutual decision-making. These principles are mentioned as prerequisites for performing pharmaceutical care services, e.g., by the FIP statements. 5,6,7 Pharmacists should also have an understanding of their role in the multidisciplinary team, in supporting the patient and the flow of information to the patient from different sources, with emphasis placed on electronic information.

There is an urgent need for the development of courses on counselling skills. The process should begin at the student level to ensure that, as pharmacy students graduate, they are trained in patient-orientated counselling and adopt this approach from the very beginning. Current practitioners also need to be supported in changing their routines and adapting to new behaviour patterns.

Developing training courses on communication skills An effective learning process to develop communication skills needs to focus on the principles of two-way communication, patient-orientation and concordance, self-evaluation and personal development, collective learning, strategic planning and quality assurance.

The learning process also needs to be systematic and horizontally designed, and based on constructive and experimental learning.8 It needs to start with an introduction to medication counselling as a process e.g., by using the USP Guidelines or some other instrument to facilitate detailed analysis of performance. It is also important to integrate theory and practice, e.g., by giving rehearsal assignments to students during their internship period.

The learning methods should consist of a mixture of labs, lectures, seminars, group-work, self-study and role-plays.

We have found role-plays and socio-drama especially useful. They help in processing a picture of patients' needs and in rehearsing one's own skills and dialogue. Learning can be intensified by using colleagues or trained actors as standardised patients.

Long-term development plans are needed in pharmacies How do you develop new patient-centred dialogue? According to our experiences and experiences in other countries, an extensive learning process is needed at the an extensive learning process is needed at the pharmacy level that involves individual pharmacists to develop personal competency, the whole working society to change the communic-

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-ation culture; pharmacy owners to incorporate professional services into the vision and business strategy of the pharmacy, local consumers to educate themselves to take an active role in self-management, and other healthcare providers to agree on the new roles in multidisciplinary teams. 4,9,10 Practising pharmacists require systematic and planned training, or even coaching to make a change. 4,9,10 To make this happen in Finland, each pharmacy has been encouraged to develop a long-term action plan that takes into account local conditions by applying principles of strategic planning. The recommended period for this action plan has been set at two years to make a permanent change. Pharmacies have also been encouraged to incorporate patient-counsellingspecific feedback measures into their quality management systems.

For the development plan, current practices need to be evaluated in a wider perspective than the customer-pharmacist interaction in order to implement good quality patient information. The three key dimensions crucial in this respect are (1) understanding the needs of the customers, (2) modifying service processes, including resources and facilities to integrate counselling, and (3) developing competency of the personnel.

Practitioners also need practical guidelines and resources based on concordance in acquiring a new practice. They need to learn how to process in-house guidelines to construct their communication patterns and produce repetitive quality. These mutual decisions within the working society of what to tell to the patient about the treatment can be done at the general level, but more and more pharmacies have been processing treatment-based guidelines for different patient groups (e.g., those on antihypertensive medication, antibiotics etc).

IPSF promoting international co-operation There is a need for international cooperation in developing new innovations in training concordance-based communications. Steps have been already taken to establish a forum for sharing resources. The efforts made by IPSF in this respect are highly appreciated and welcome, as well as their pioneer work by promoting Patient Counselling Events.

References 1. Institute of Medicine. Crossing the quality chasm - A new health system for the 21st century. Committee on Quality .1.of health Care in America. National Academy Press, Washington, DC, 2003.

2. From compliance to concordance. Achieving shared goals in medicine taking. London: Royal Pharmaceutical .2.Society of Great Britain and Merck Sharp & Dohme, 1997 (available on the Internet: www.concordance.org).

3. Katajavuori N, Valtonen S, Pietil? K, Pekkonen O, Lindblom-Yl?nne S, Airaksinen M. Myths behind patient coun .3.selling: A patient counselling study of non-prescription medicines in Finland. J Soc Adm Pharm 19:129-136, 2002.

4. Kansanaho H, Pietil? K, Airaksinen M. Can a long-term continuing education course in patient counselling promote .4.a change in the practice of Finnish community pharmacists? Int J Pharm Pract 11:153-160, 2003.

5. International Pharmaceutical Federation (FIP). Pharmaceutical Care. FIP Statement of Professional Standards. .5.Available on the Internet: www.fip.org.

6. International Pharmaceutical Federation (FIP). The role of the pharmacist in encouraging adherence to long-term .6.treatments. FIP Statement of Professional Standards. Available on the Internet: www.fip.org.

7. International Pharmaceutical Federation (FIP). Responsible Self-Medication. FIP Statement of Professional .7.Standards. Available on the Internet: www.fip.org.

8. Aslani P, Bosnic-Anticevich S, Sainsbury E, Koo M, Roberts A, Krass I. The 12th International Social Pharmacy 8..Workshop: A report of the Teachers' Workshop held in Sydney, Australia, 2002. Pharm Educ 2:213-219, 2002.

9. De Almeida Neto A, Kelly F, Benrimoj SI. Shaping practice behaviour: novel training methodology. Int J Pharm Pract .9.9:203-210, 2001.

10. De Almeida Neto A, Benrimoj SI, Kavanagh DJ, Boakes RA. Novel educational training program for community 10..pharmacists. Am J Pharm Educ 64:302-307, 2000 .

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