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Reply to: Dumping adherence: a person-centred response for primary care

Reply to: Dumping adherence: a person-centred response for primary care To the Editor, We highly appreciate the comment by Granger et al. (1) on our publication ‘Association of depression and anxiety with adherence in primary care patients with heart failure—cross-sectional results of the observational RECODE-HF cohort study’ (2). The authors focus on one of our study’s finding that a strong interpersonal relationship between patient and general practitioner (GP) might have the potential to improve medication adherence. Here, Granger et al. suggest to ‘dump’ the concept of adherence altogether and replace it by a person-centred approach, an interesting idea which we would like to further discuss here. The importance of person-centred care Granger et al. point out the importance of person-centred care including the importance of knowing the person behind the patient. Instead of prescribing medication and measuring the success of treatment by medication adherence, this person-centred approach offers the possibility to explore, describe and evaluate prescribing and medication-taking in a context that focusses on the person rather than the patient. We agree with this viewpoint. Practical guidelines based on evidence-based medicine provide the foundation for treatment. Shared decision-making is central to the concept of adherence, which reaches beyond prescribing medication and additionally includes non-pharmacological treatment options. Ideally, it facilitates choosing between treatment modalities by considering the individual needs and preferences of the person suffering from a condition. This is also compatible with the principle of patient-centred care as described by Scholl et al. (3). Haynes et al. expand this reasoning by stating that treatment planning should in addition consider the clinical state and circumstances of the suffering person, and the physicians’ clinical expertise (4). Time attributed to person-centred care requires monetary compensation The patient’s narrative, the person’s preferences, as well as the treatment plan need to be explored and documented very carefully. Once the treatment is planned and medication is prescribed, a feedback process should be installed from which success or failure indicators may be derived illustrating the quality of the collaborative partnership. Such highly individual approach as proposed by Granger et al. requires time, which is currently poorly reimbursed. Probably, however, monetary compensation is a strong facilitator for implementing a person-centred approach into clinical practice. Understanding the patient’s motivation We support the idea of person-centred care, based on a trustful relationship between GP and patient, as an immanent part of the definition of adherence. In our study (2), we found an association between reduced medication adherence and both psychosocial distress and higher educational level. The first might be due to the potential impact of psychosocial distress on cognitive function and the emotional weight attributed to a particular medication: patients might forget taking their medicine, they would usually take or avoiding to take it as a result of fears of side effects, etc. The latter might reflect the autonomy of highly educated patients in deciding about their own medical treatment. These contrasting aspects underline the broad range of factors potentially driving non-adherence, which need to be communicated and addressed in a trustful relationship between physician and patient. Multimorbidity beats medication adherence A person-centred approach might be particularly important for elderly multimorbid patients taking multiple medicines. Here the potential damage of medication interaction may contradict medication adherence, e.g. if the number of medications have grown over the years without ever being reviewed for appropriateness and possible reduction. Keeping adherence Thus, there are good reasons for implementing the person-centred approach promoting the patient’s individual narrative before planning the treatment by shared decision-making. Should we necessarily dump adherence? Unlike ‘compliance’, i.e. the patient obeys the doctor’s decisions, ‘adherence’ is perceived as an act of will on the side of the patient. It is based on mutual agreement between patient and physician on treatment goals and modalities. Of note, the term adherence may also inappropriately be used in situations, where decisions have not been shared between physicians and patients. We therefore propose to keep the term in clinical practice, but become better aware of the question, whether we are really looking at adherence or its paternalistic sibling, i.e. ‘compliance’. In our study, we measured adherence in a large cohort by questionnaire and not by interview. We have no information on how the patients’ needs and preferences were considered when planning the treatment. Therefore, we could not specify, whether a particular patient was adherent or compliant to medication instead, which is a limitation of the study. However, the person-centred approach as described by Ekman et al. (5) is a highly individual approach which is hard to investigate in a large number of patients. Future research may first investigate the level of adherence in a larger cohort study and then try to understand the reasons for non-adherence by a qualitative person-centred approach. We therefore propose to keep the concept of adherence in research as well, given that its terminology is used correctly, as long as there is no better construct available. By doing so, we need to keep in mind that when implementing research findings into clinical practice the limitations of such research need to be carefully considered. Declaration Funding: this letter was funded by departmental resources. Ethical approval: not applicable. Conflict of interest: Marion Eisele, Gabriella Marx and Eva Blozik are members, and Martin Scherer is current president of the German College of General Practitioners and Family Physicians. Sigrid Boczor received fees for lecturer/statistical consulting of Asklepios Medical School GmbH during the study. Eva Blozik is employed at Helsana Health Insurances, Switzerland. Stefan Störk is member of the German Cardiac Society and of the writing group of the National Guideline Heart Failure Care. Christoph Herrmann-Lingen receives royalties from Hogrefe Huber publishers for the German HADS, is current president of the German College of Psychosomatic Medicine, chairs its working group on Psychosomatics in Cardiology, is member of the German Society for Cardiology and of other scientific societies for psychosomatic and behavioural medicine. All other authors declare that they have no conflicts of interest. References 1. Granger BB , Britten N, Swedberg K, Ekman I. Dumping adherence: a person-centred response for primary care . Fam Pract 2020; XXX: 1–3 . doi:10.1093/fampra/cmaa060 OpenURL Placeholder Text WorldCat 2. Eisele M , Harder M, Rakebrandt A et al. Association of depression and anxiety with adherence in primary care patients with heart failure—cross-sectional results of the observational RECODE-HF cohort study . Fam Pract 2020; XXX: 1–8 . doi:10.1093/fampra/cmaa042 OpenURL Placeholder Text WorldCat 3. Scholl I , Zill JM, Härter M, Dirmaier J. An integrative model of patient-centeredness—a systematic review and concept analysis . PLoS One 2014 ; 9 ( 9): e107828 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Haynes RB , Devereaux PJ, Guyatt GH. Physicians’ and patients’ choices in evidence based practice . BMJ 2002 ; 324 ( 7350): 1350 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Ekman I , Swedberg K, Taft C et al. Person-centered care—ready for prime time . Eur J Cardiovasc Nurs 2011 ; 10 ( 4): 248 – 51 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

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References (5)

Publisher
Oxford University Press
Copyright
Copyright © 2021 Oxford University Press
ISSN
0263-2136
eISSN
1460-2229
DOI
10.1093/fampra/cmaa106
Publisher site
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Abstract

To the Editor, We highly appreciate the comment by Granger et al. (1) on our publication ‘Association of depression and anxiety with adherence in primary care patients with heart failure—cross-sectional results of the observational RECODE-HF cohort study’ (2). The authors focus on one of our study’s finding that a strong interpersonal relationship between patient and general practitioner (GP) might have the potential to improve medication adherence. Here, Granger et al. suggest to ‘dump’ the concept of adherence altogether and replace it by a person-centred approach, an interesting idea which we would like to further discuss here. The importance of person-centred care Granger et al. point out the importance of person-centred care including the importance of knowing the person behind the patient. Instead of prescribing medication and measuring the success of treatment by medication adherence, this person-centred approach offers the possibility to explore, describe and evaluate prescribing and medication-taking in a context that focusses on the person rather than the patient. We agree with this viewpoint. Practical guidelines based on evidence-based medicine provide the foundation for treatment. Shared decision-making is central to the concept of adherence, which reaches beyond prescribing medication and additionally includes non-pharmacological treatment options. Ideally, it facilitates choosing between treatment modalities by considering the individual needs and preferences of the person suffering from a condition. This is also compatible with the principle of patient-centred care as described by Scholl et al. (3). Haynes et al. expand this reasoning by stating that treatment planning should in addition consider the clinical state and circumstances of the suffering person, and the physicians’ clinical expertise (4). Time attributed to person-centred care requires monetary compensation The patient’s narrative, the person’s preferences, as well as the treatment plan need to be explored and documented very carefully. Once the treatment is planned and medication is prescribed, a feedback process should be installed from which success or failure indicators may be derived illustrating the quality of the collaborative partnership. Such highly individual approach as proposed by Granger et al. requires time, which is currently poorly reimbursed. Probably, however, monetary compensation is a strong facilitator for implementing a person-centred approach into clinical practice. Understanding the patient’s motivation We support the idea of person-centred care, based on a trustful relationship between GP and patient, as an immanent part of the definition of adherence. In our study (2), we found an association between reduced medication adherence and both psychosocial distress and higher educational level. The first might be due to the potential impact of psychosocial distress on cognitive function and the emotional weight attributed to a particular medication: patients might forget taking their medicine, they would usually take or avoiding to take it as a result of fears of side effects, etc. The latter might reflect the autonomy of highly educated patients in deciding about their own medical treatment. These contrasting aspects underline the broad range of factors potentially driving non-adherence, which need to be communicated and addressed in a trustful relationship between physician and patient. Multimorbidity beats medication adherence A person-centred approach might be particularly important for elderly multimorbid patients taking multiple medicines. Here the potential damage of medication interaction may contradict medication adherence, e.g. if the number of medications have grown over the years without ever being reviewed for appropriateness and possible reduction. Keeping adherence Thus, there are good reasons for implementing the person-centred approach promoting the patient’s individual narrative before planning the treatment by shared decision-making. Should we necessarily dump adherence? Unlike ‘compliance’, i.e. the patient obeys the doctor’s decisions, ‘adherence’ is perceived as an act of will on the side of the patient. It is based on mutual agreement between patient and physician on treatment goals and modalities. Of note, the term adherence may also inappropriately be used in situations, where decisions have not been shared between physicians and patients. We therefore propose to keep the term in clinical practice, but become better aware of the question, whether we are really looking at adherence or its paternalistic sibling, i.e. ‘compliance’. In our study, we measured adherence in a large cohort by questionnaire and not by interview. We have no information on how the patients’ needs and preferences were considered when planning the treatment. Therefore, we could not specify, whether a particular patient was adherent or compliant to medication instead, which is a limitation of the study. However, the person-centred approach as described by Ekman et al. (5) is a highly individual approach which is hard to investigate in a large number of patients. Future research may first investigate the level of adherence in a larger cohort study and then try to understand the reasons for non-adherence by a qualitative person-centred approach. We therefore propose to keep the concept of adherence in research as well, given that its terminology is used correctly, as long as there is no better construct available. By doing so, we need to keep in mind that when implementing research findings into clinical practice the limitations of such research need to be carefully considered. Declaration Funding: this letter was funded by departmental resources. Ethical approval: not applicable. Conflict of interest: Marion Eisele, Gabriella Marx and Eva Blozik are members, and Martin Scherer is current president of the German College of General Practitioners and Family Physicians. Sigrid Boczor received fees for lecturer/statistical consulting of Asklepios Medical School GmbH during the study. Eva Blozik is employed at Helsana Health Insurances, Switzerland. Stefan Störk is member of the German Cardiac Society and of the writing group of the National Guideline Heart Failure Care. Christoph Herrmann-Lingen receives royalties from Hogrefe Huber publishers for the German HADS, is current president of the German College of Psychosomatic Medicine, chairs its working group on Psychosomatics in Cardiology, is member of the German Society for Cardiology and of other scientific societies for psychosomatic and behavioural medicine. All other authors declare that they have no conflicts of interest. References 1. Granger BB , Britten N, Swedberg K, Ekman I. Dumping adherence: a person-centred response for primary care . Fam Pract 2020; XXX: 1–3 . doi:10.1093/fampra/cmaa060 OpenURL Placeholder Text WorldCat 2. Eisele M , Harder M, Rakebrandt A et al. Association of depression and anxiety with adherence in primary care patients with heart failure—cross-sectional results of the observational RECODE-HF cohort study . Fam Pract 2020; XXX: 1–8 . doi:10.1093/fampra/cmaa042 OpenURL Placeholder Text WorldCat 3. Scholl I , Zill JM, Härter M, Dirmaier J. An integrative model of patient-centeredness—a systematic review and concept analysis . PLoS One 2014 ; 9 ( 9): e107828 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Haynes RB , Devereaux PJ, Guyatt GH. Physicians’ and patients’ choices in evidence based practice . BMJ 2002 ; 324 ( 7350): 1350 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Ekman I , Swedberg K, Taft C et al. Person-centered care—ready for prime time . Eur J Cardiovasc Nurs 2011 ; 10 ( 4): 248 – 51 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Family PracticeOxford University Press

Published: Oct 1, 2020

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