Ask any health care professional to discuss the treatment of a chronic medical condition, such as hypertension, and before long the issue of non-compliance will enter the discussion. Previously, our health care professional may have used the term "non-adherence", being aware that taking medicines involves more than slavish attention to a prescriber's instructions. But now that the lexicon also includes "concordance", our professional is again comfortable to describe patients' medicine taking behaviour as either compliant or non-compliant. Speaking of patient compliance used to draw accusations of paternalism; in the present climate, so long as the tenets of concordance are accepted, then "compliance" is back in vogue, and aiming for compliance is again a laudable goal.
Concordance, being the fortunate collision between the prescriber's biomedical representation of illness and the patient's real-world view, has received considerable attention over the past two years. Proponents argue that achieving concordance during an encounter between prescriber and patient will result in better compliance; this seductive message has helped place concordance on the top of both professional and research agendas. However, we would suggest that deficits in concordance constitute one missing link in the as yet unformed chain of pharmaceutical care. Moreover, we would argue that undue concentration on concordance will deflect the profession from solving more significant problems associated with the use of medicines, and that concordance cannot bring about the expected health improvement unless these shortcomings are resolved.
As a starting point, we should be concerned with the relationship between diagnosis and the commencement of therapy. Two significant problems may arise in this relationship: first, a failure to treat patients with drug therapy for which there is a compelling indication, and, secondly, and conversely, a propensity to treat patients who would not be expected to benefit from medicines but who are none the less exposed to the risk of adverse effects. For example, 50 per cent of patients with hypertension elude diagnosis, while others are incorrectly labelled hypertensive following just one measurement of blood pressure. We believe, along with others,1 that this area of investigation - essentially, checking that a valid indication exists - is a fundamental aspect of therapy and must be the first step in the pharmaceutical care model.
Having confirmed the need for drug therapy, we should be concerned with problems that occur in the post-diagnosis stages of pharmaceutical care: drug selection (is this evidence based?), optimisation of treatment (is this patient based?), treatment effects (are these being monitored?), and, finally, outcomes (are these being evaluated and acted upon?).
A recent systematic review of beta-blockade after myocardial infarction concluded that beta-blockers, although clearly effective for long-term secondary prevention of myocardial infarction, are underutilised and that their omission leads to avoidable mortality and morbidity.2 In such studies, there is no doubt as to the patient's diagnosis, the evidence for treatment is well-established for certain class members, and yet up to 50 per cent of patients fail to receive appropriate therapy.2,3
Making pharmaceutical care work is a unique collective challenge for pharmacists. Consider the enormous treatment gap in hypertension: of the half billion people worldwide with hypertension, only 75 million (15 per cent) are receiving effective treatment, exposing vast numbers of people to a future of heart disease, stroke or renal failure. Estimates suggest that an average reduction in diastolic blood pressure of 5–6mmHg in everyone with hypertension could reduce the incidence of coronary heart disease by 14 per cent and stroke by 42 per cent.4 World Health Organisation guidelines have revised the target for treatment from 140/90 to 130/85mmHg, but how many patients are receiving this standard of care?
On the basis of outcomes from randomised controlled trials, there is clear evidence for diuretics and b-blockers in uncomplicated hypertension and indications for specific agents in certain clinical situations. But who is making sure that diabetics with proteinuria receive an ACE-inhibitor, or that MI patients are prescribed an appropriate b-blocker? Do data exist which define the scale of inappropriate drug selection, and has the extent of antihypertensive-related drug misadventuring been determined?
Before signing up to concordance, there is clearly a professional requirement to ensure that all elements of pharmaceutical care are linked together in a manner which is optimal for the individual patient. If the chain is not properly formed, then improved compliance with inappropriate treatment will at best waste resources and at worst lead to an increasing burden of iatrogenic disease. The current status of pharmaceutical care affords two alternative courses of action: we can focus on the last link, concordance, and hope that this is sufficient to secure the process, or we can address the chain that starts with prescribing decisions and culminates in the outcomes experienced by our patients.
The authors invite those who are interested in charting the shortcomings of pharmaceutical care delivery to send an e-mail to: chainmakers@druginfo.demon.co.uk