American Academy of Ophthalmology Web Site: www.aao.org
Original URL:

 
Glaucoma

Why Patients Don’t Comply

By Miriam Karmel, Contributing Writer
 
 

At a time when ocular hypotensive agents are considered to be so effective that many Eye M.D.s prescribe up to five drops per day before resorting to surgery, a significant number of patients aren’t following doctors’ orders and taking those meds.

Doctors need to take this matter seriously, argued Harry A. Quigley, MD. While medications are doing a better job of lowering IOP, and some are easier to use, the problem of noncompliance still needs work, said Dr. Quigley, professor of ophthalmology at Johns Hopkins’ Wilmer Eye Institute.

Lulled Into Complacency
There are numerous reasons for noncompliance. Doctors may not be spending enough time talking to patients about their disease and the importance of adhering to a medical regimen, said Dr. Quigley. “We don’t know the rate at which a doctor is fully instructing the patient,” he said, adding, “more research into patient and doctor behavior modification is very much needed.”

This is especially critical with an asymptomatic disease. As Alan L. Robin, MD, noted, many patients figure, “If it doesn’t hurt, it can’t be bad.” Sometimes, though, the medicine does hurt. “People are much less likely to comply if any side effects [are] associated with the medicine,” said Dr. Robin, associate professor of ophthalmology at the Wilmer Eye Institute and at Johns Hopkins’ Bloomberg School of Public Health.

Also, people get busy and forget—or they may not know how to take their medications. For example, it’s common practice to put patients on as many as five drops a day, before resorting to surgery. But drops must be spaced from each other by five minutes or they’ll dilute the effect of each, Dr. Robin said. “Compliance is definitely linked to the complexity of the medicine you’re using.”

The risk of progression: deterioration over a 12-year period.
Caption: The path of least resistance—that is, ignoring the issue of noncompliance—leads downhill, experts warn. (This image shows progression over a 12-year period.)

Yet as Dr. Quigley noted, there’s evidence that some doctors simply say, “You have glaucoma. Take these drops,” without any further discussion. “If that is what’s going on,” he said, “then we need to alter it.”

Reality Check: Patient Behavior
Whatever the reason, ophthalmologists must find a better way of ensuring that patients follow their orders, or some will go blind, Dr. Robin warned. He cited a study done in Olmsted County, Minn., in which 25 percent of patients under the care of Mayo Clinic physicians went blind in at least one eye over a 20-year period. Less-extreme estimates range from 4 percent to 10 percent bilateral blindness. One study found that it took 12 years for some people to lose their vision.

“I can tell you that one of the reasons people go blind is that we assume they take their medicines,” Dr. Robin said.

But a sizeable percentage of the patient population doesn’t follow through. When it comes to compliance, the population falls roughly into three groups, Dr. Quigley said:

  • About 40 percent are “the concerned sufferers,” or those who take their own self-interest to heart and “will do almost anything you tell them.” They are taking six kinds of vitamins and have heard on TV that they should eat salmon. “If you tell them to jump, they say, ‘How high?’”
  • Roughly 10 to 20 percent of the population won’t act in their own self-interest. They are self-abusive and/or alcoholic, and they smoke. There’s some evidence, said Dr. Quigley, that it doesn’t matter what you tell them. “They’re not going to do what you say.” Dr. Robin agreed. “There are people who are actually aggressive and don’t want to take their meds. I don’t think patient education will help them.” From a doctor’s perspective, it may be difficult to identify them, but they are often the same patients who don’t show up for their appointments.
  • Finally, there is the 40 percent in the middle—those who might comply if they better understood their disease. “We could be improving their understanding of the disease and outcome by doing something,” Dr. Quigley said. That something could be as simple as reminding patients to take their medicine, or doing a better job of explaining why they should take it.


Reality Check: Cost
Cost can be a significant barrier to compliance, so with all of the controversy surrounding the new prescription drug bill, scheduled to go into effect in 2006, it’s a good time to look at the issue.

A survey of California seniors who take prescription drugs (for all conditions) found that nearly one in five did not fill a prescription or skipped doses to make their medications last longer. The Kaiser Family Foundation study, released in late 2002, found that nearly twice as many seniors without drug coverage skipped medications due to cost than did those with some form of drug coverage (29 percent vs. 16 percent). Compliance was further compromised in persons with chronic conditions, such as diabetes (40 percent) and hypertension (35 percent).

The study suggests that compliance might be improved if patients were better informed. More than three-fourths reported never having heard of California’s drug discount program, available to all seniors with a Medicare card.

Physicians can help by being sensitive to cost, said Dr. Robin. Because of patient complaints regarding drug costs, Dr. Robin put together a chart for his patients comparing prices of commonly prescribed glaucoma medications. His survey of six Baltimore pharmacies found price discrepancies as high as $20 or more for brand-name drugs, including Xalatan (latanoprost), Betoptic (betaxolol) and Trusopt (dorzolamide).

While shopping around helps, the cost of maximal medical therapy, which many doctors resort to as a way of avoiding surgery, can be steep. For instance, Donald L. Budenz, MD, associate professor of ophthalmology at
the University of Miami, puts patients on a regimen of dorzolamide-timolol (Cosopt), twice a day; brimonidine (Alphagan), twice a day; and a prostaglandin analogue, once a day. In Baltimore, based on Dr. Robin’s research, that would range from $220 to $296 per month.

Given the cost, Dr. Robin is an advocate of proceeding to surgery sooner rather than later. If a glaucoma operation costs about $1,000 per eye, and medication costs around $3,000 per year, “from a taxpayer and patient perspective, that’s a no-brainer,” he said.

________________________________
Tips for Boosting Compliance

Dr. Robin advises physicians to consider the following:

  • Are you sure your patients are taking their drops?
  • Are they taking their drops as instructed?
  • Have you described the treatment plan in simple language and asked patients to repeat your instructions so you know that they understand?
  • If they run out of one prescription, are they waiting for other medications to run out before refilling it, to avoid too many trips to the pharmacy?
  • If they are undermedicating, is it because the drops sting, or is cost a factor?

Dr. Quigley suggests simplifying the regimen:

  • Prescribe the medication most likely to be used.
  • Prescribe the fewest number of medications.
  • Prescribe medications that require the fewest daily applications.
  • Use instructional pictures and videos.
  • Reinforce the importance of compliance at each visit.
  • Reschedule missed appointments.
  • Involve the family.

________________________________
When Cost Is an Issue

Buying prescription drugs is not unlike buying a Chevrolet, said Dr. Robin. “You can buy the same car from three different dealers. Why not buy it from the cheapest?” Here are some resources for patients:

EyeCare America. The ECA publishes a pharmaceutical directory for the medically underserved describing free or discount eyedrop programs of major manufacturers. Go to www.eyecareamerica.org, click on “Volunteer” and “United States.”

AARP. At least 25 states offer some sort of Medicare prescription discount program. For a state-by-state listing of pharmacy assistance programs, go to www.aarp.org/bulletin and look under “Web Exclusive: State Resources.”

Drug Companies. Seven drug companies banded together to form “Together Rx,” offering discounts on prescription drugs to Medicare enrollees who lack coverage and have incomes below $28,000 ($38,000 for couples). For more information, call 800-865-7211 or visit www.togetherrx.com. Eli Lilly runs a similar program. Call 877-795-4559 or visit www.lillyanswers.com. And Pfizer offers its drugs for a flat $15 per month fee. Call 800-717-6005 or visit www.pfizerforliving.com.