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      Optimizing medicines management: From compliance to concordance

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          Abstract

          Medication prescribed but not consumed represents a huge loss in drug and prescribing costs and an enormous waste of expensive medical time. In this article we discuss what is known about compliance and adherence, explore the concept of concordance and demonstrate its fundamental difference from both. Not all patients are ready or suitable for shared decision making in management of their condition, some still preferring a doctor-led decision but an increasing number want a partnership approach. By opening up and rebalancing the discussion about medication, we can expect a consultation which is more satisfying for both parties and flowing from this, more effective, focused prescribing of medication which is more likely to be adhered to by the patient. We examine the extent to which doctor and patient behaviors are currently compatible with this change of concept and practice, look at available consultation models which might be useful to the reflective practitioner and consider what actions on the part of the doctor and the healthcare system could promote medicine prescription and utilization in line with this new approach based on partnership.

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          Most cited references 87

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          A meta-analysis of the association between adherence to drug therapy and mortality.

          To evaluate the relation between adherence to drug therapy, including placebo, and mortality. Meta-analysis of observational studies. Electronic databases, contact with investigators, and textbooks and reviews on adherence. Review methods Predefined criteria were used to select studies reporting mortality among participants with good and poor adherence to drug therapy. Data were extracted for disease, drug therapy groups, methods for measurement of adherence rate, definition for good adherence, and mortality. Data were available from 21 studies (46,847 participants), including eight studies with placebo arms (19,633 participants). Compared with poor adherence, good adherence was associated with lower mortality (odds ratio 0.56, 95% confidence interval 0.50 to 0.63). Good adherence to placebo was associated with lower mortality (0.56, 0.43 to 0.74), as was good adherence to beneficial drug therapy (0.55, 0.49 to 0.62). Good adherence to harmful drug therapy was associated with increased mortality (2.90, 1.04 to 8.11). Good adherence to drug therapy is associated with positive health outcomes. Moreover, the observed association between good adherence to placebo and mortality supports the existence of the "healthy adherer" effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behaviour.
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            Meta-analysis of correlates of provider behavior in medical encounters.

            This article summarizes the results of 41 independent studies containing correlates of objectively measured provider behaviors in medical encounters. Provider behaviors were grouped a priori into the process categories of information giving, questions, competence, partnership building, and socioemotional behavior. Total amount of communication was also included. All correlations between variables within these categories and external variables (patient outcome variables or patient and provider background variables) were extracted. The most frequently occurring outcome variables were satisfaction, recall, and compliance, and the most frequently occurring background variables were the patient's gender, age, and social class. Average correlations and combined significance levels were calculated for each combination of process category and external variable. Results showed significant relations of small to moderate average magnitude between these external variables and almost all of the provider behavior categories. A theory of provider-patient reciprocation is proposed to account for the pattern of results.
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              Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials.

              We wanted to identify published randomized trials of interventions to alter the interaction between patients and practitioners, develop taxonomies of the interventions and outcomes, and assess the evidence that such interventions improve patients' health and well-being. Undertaking a systematic review of randomized trials, we sought trials in primary and secondary care with health-related outcomes, which we found by searching MEDLINE, HealthSTAR, and PsycINFO bibliographic databases through 1999. We also completed one round of manual citation searching. Thirty-five trials were included. Most were set in primary care in North America. Trials were heterogeneous in populations, settings, interventions, and measures. Interventions frequently combined several poorly described elements. Explicit theoretical underpinning was rare, and only one study linked intervention through process to outcome measures. Health outcomes were rarely measured objectively (6 of 35), and only 4 trials with health outcomes met predefined quality criteria. Interventions frequently altered the process of interactions (significantly in 73%, 22 of 30 trials). Principal outcomes favored the intervention group in 74% of trials (26 of 35), reaching statistical significance in 14 (40%). Positive effects on health outcomes achieved statistical significance in 44% of trials (11 of 25); negative effects were uncommon (5 of 25, 20%). Simple approaches to increasing the participation of patients in the clinical encounter, such as providing practitioners with a note from patients about their concerns beforehand, showed promise, as did more complex programs providing specific information about disease and attention to emotion. Apparently similar interventions varied in effectiveness across studies. Successful interactions between patients and their practitioners lie at the heart of medicine, yet there are few rigorous trials of well-specified interventions to inform best practice. Trial evidence suggests that a range of approaches can achieve changes in this interaction, and some show promise in improving patients' health. To advance knowledge further, we need to replicate promising studies using rigorous methods. These should include explicit theoretical frameworks designed to link effects on key communication and interaction characteristics through to effects on health outcomes.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                December 2007
                December 2007
                : 3
                : 6
                : 1047-1058
                Affiliations
                [1 ]Clinical and Communication Skills Unit, Barts and the London, Queen Mary’s School of Medicine and Dentistry, University of London London, England, UK
                [2 ]Department of Neurology, Institute of Neurological Sciences, Southern General Hospital Glasgow, Scotland, UK
                Author notes
                Correspondence: Annie Cushing Clinical and Communication Skills Unit, Centre for Medical Education, Barts and The London, Queen Mary’s School of Medicine and Dentistry, Robin Brook Centre, St Bartholomew’s Hospital, London EC1A 7BE, England, UK, Tel +44 207 882 2089 Email a.m.cushing@ 123456qmul.ac.uk
                Article
                2387303
                18516274
                © 2007 Dove Medical Press Limited. All rights reserved
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