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Concordance
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Concordance
We need to define concordance for ourselves
From Mr B. Shooter, MRPharmS
With how many patients do I have concordant discussions, asked the last
line of your editorial last week (11 October p480) in your preview of
the series of papers that you published on this subject. Not many I thought.
My family criticise my paternalism; overall my staff enjoy it. But what
about my patients?
When I returned to your question I realised that we community pharmacists
needed to define concordance for ourselves and then reflect upon our
practice. As progress has been made over the years, with the advent of
computerised patient medical records and prescriptions, both pharmacist
and patient have now joined the prescriber and the industry: together
we make up the team whose functioning is responsible for at least some
of the health gain that the population of this country has experienced
over the last couple of decades.
My pharmacist managers and myself have little evidence of non-compliance
but I am sure this indicates that more and relevant practice research
is required to help us understand the problem from other perspectives.
I will define concordance in community pharmacy as “the facilitating
of the sharing of information by both pharmacists and their patients”.
In other words providing an atmosphere conducive to either party asking
questions of the other for the benefit of the health improvement of the
patient.
If that is the case we have begun to have concordant discussions with
our patients but we are only at the start of this important process.
Barry Shooter
Romford, Essex
Concordance and “failures”
From Mrs I. Gummerson, MRPharmS
The case of Mrs D mentioned in the article (PDF 65K) “Compliance, concordance
and respect for the patient’s agenda” (PJ, 11 October, pp498–500),
illustrates where current practice (in this case, of a general practitioner)
can fail the patient. The author, Paul Bissell, is a medical sociologist
who interviewed a 40-year-old Asian woman diagnosed with type 2 diabetes.
It is the well-meaning health care professionals that make her feel she
is a failure, because she cannot adhere to the diet. “They are
blaming me,” she says.
What else could have been done by the health care professionals involved?
I was surprised that metformin had caused “episodes of hypoglycaemia,
losing consciousness on several occasions”, since metformin does
not usually cause this. I wonder whether she was also on a sulphonylurea.
It would have been interesting for her blood to be tested at these “hypo” times,
to get the true picture. People who get genuine hypos should be taught
about the warning signs and how to deal with them. A blood glucose meter
is useful to detect blood glucose fluctuations through the day, for targeting
a regular meal or snack.
The hypos need investigating, Mrs D needs to understand what they mean
and her medication adjusted if necessary. She needs to be “hypo-free” without
running high glucose levels.
Dr Bissell did not mention whether she said she regularly took her medicines.
The benefits of taking her medicines regularly should be reinforced.
It may be useful to discuss ways of remembering to take daily doses if
this is an issue. Adherence could be reinforced at each meeting. It could
be a win-win situation —
being easier to carry out than trying to lose a lot of weight.
Mrs D needs help in adhering to the medication; the health professional
should talk to her about staying healthier.
Her depression needs assessing, and the appropriate treatment giving.
A depressed person is less likely to adhere to health care advice and
medication.
This patient has already had a bruising experience with lifestyle advice.
Perhaps agreeing on a small, sustainable weight loss at each meeting,
would give her an easier target. She could get together with a support
group — look at new ways of cooking, have a gossip and some fun
(after all, she is only 40).
At a recent meeting a diabetologist was illustrating a “failure” patient
who had been referred to him from a GP practice. This person was not
reaching the primary care trust health targets. Boxes could not be ticked
for targets of blood pressure, blood glucose, cholesterol, etc, so she
was deemed a failure.
However the specialist showed us that over a 10-year period since she
had been diagnosed, her weight had decreased by 5kg (although she was
still obese), her BP and cholesterol had gone down somewhat, but the
targets had still not been reached. He emphasised that, if she had followed
no advice and taken none of her medication over the 10 years, she would
have been much worse by now. She was in fact a success but had not reached
the targets.
That is the point I hope that medication review and supplementary prescribing
pharmacists keep in mind: be positive; acknowledge all successes and
help people to change in small manageable ways.
Irene Gummerson
Wakefield, West Yorkshire
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