SP0162 A longitudinal study of the need for concordance
Authors: BA Chewning, J Wiederholt
Journal: Annals of the Rheumatic Diseases (2001)

<h3>Background</h3> In the past 5 years, there has been growing acknowledgment that patients need to be active in their medication management. The Client Centred Model (1) as well as the Concordance Framework (2) stress the importance of providers supporting patients to assume an active role in monitoring and evaluating their regimen benefits and side effects. Particularly as prescription drug use continues to grow (37% increase in the number of prescriptions dispensed between 1992–1998 in the US (3)), there is an urgent need to conceptualise and reframe how patient-provider partnerships apply specifically to medication management. <h3>Objectives</h3> This paper presents findings regarding how people with arthritis attempt to control their ever changing, complex regimens over time. Second, this paper examines the potential of the Concordance Framework and Client-Centred Model for reframing the nature of the patient-provider partnership to enhance patients’ sense of control related to their overall quality of life. We will explore how the concept of Concordance alters our view of the frequently complex and frustrating process of medication management. <h3>Method</h3> A longitudinal study of 689 patients with the formal diagnosis of osteoarthritis (OA) or rheumatoid arthritis (RA) was conducted to identify patient perceptions, decision-making and behaviour related to their medication management. Face to face interviews with the Brief Medication Questionnaire (BMQ), health quality of life questionnaires (AIMS2 and SF-36) and telephone interviews were conducted in waves centred around patient visits every 6 months for 2 years. Data about medication regimens were abstracted from the clinic medication profile record for each visit. <h3>Setting</h3> Three rheumatology clinics in the United States participated in the study: 1) a university clinic; 2) a private clinic; 3) a Veterans Administration clinic. Patients were enrolled at the time of a regular clinic visit. <h3>Key findings</h3> At baseline, 50% of patients had at least one co-morbidity and 22% had at least two comorbidities. Almost half (48%) of patients in the sample had complex regimens with 8 or more medications at any one time period. The majority of physicians altered their medication orders every 6 months for patients. Hence many patients faced complex, shifting regimens. Patients reported they evaluated the effectiveness and side effects of individual medicines based largely on symptoms. There were 248 reported deviations in the scheduled medications at baseline and the majority (61%) were intentional, largely based on symptoms. These deviations are viewed differently when one applies the compliance perspective versus the Concordance Framework. While the compliance perspective is somewhat pejorative with respect to patient behaviour, Concordance suggests the need for greater agreement between patient and health professional regarding how best to calibrate and manage the regimen to meet the patient’s priorities. The longitudinal nature of our study shifted attention away from compliance to the process of seeking better regimens in the absence of “perfect regimens”. Implications for the psychology of managing arthritis regimens between visits and the need for patient-provider partnerships using both the unique expertise of the patient and provider are explored.