American Academy of Ophthalmology Web Site:
Original URL:

July/August 2005


Patient Compliance: Can It Be Improved?
By Richard P. Mills, MD, MPH

Three months ago, Opinion waved a red flag that patients are not planning to comply with a regimen of prescribed treatment when they say, “But doctor . . .” Unfortunately, red flags are not commonly waved by patients, which explains the difficulty we have in identifying the non- compliers. Patients feel uncomfortable admitting their imperfection in performing such a simple task as using eyedrops. They know when they should be using them, all right, and can parrot that back to the person who tallies the interval history for the office visit. Across medicine, in every chronic disease studied to date, compliance rates are a lot lower than predicted by the doctors taking care of patients.

Way ahead of his time some years ago, Michael A. Kass, MD, and his colleagues¹ devised an eyedrop bottle that sensed whenever it was inverted. The times and dates of the inversions were kept in a microchip memory until the patient came for a follow-up visit, and the data were downloaded onto a computer and analyzed. Much of what we know about compliance in glaucoma we learned from that seminal study.

So, you say, all we need to do is use such an eyedrop bottle and we’ve got the noncompliers busted. If we had such a compliance monitor in general use, it would certainly be another red flag we could use to identify the poorly compliant patient. But it would also serve to drive the noncompliance further underground. Remember back to your preteen years. That’s when I learned how to be devious about deviant behavior, as I suspect you did, too. Innocent enough, but you were learning how to be noncompliant and get away with it. Maybe there was a book in the bookcase that you thought your parents didn’t want you to read. You got it out and put it back so nobody could tell it had been removed. Later on, maybe you smoked and you didn’t want your parents to know. Who knew the septic tank would back up from all the cigarette butts? As soon as glaucoma noncompliers figure out how they got busted, at least some of them will invert the bottle on schedule, twice a day.

But identifying patient noncompliance is really the smaller part of the problem. Fixing it is the bigger challenge. How do you convert a noncomplier into a model patient? I’d bet you use strategies in your office that work, at least some of the time. The trouble is, nobody outside your office knows about them. Maybe others could benefit from your ideas. Reducing patient noncompliance in glaucoma is one area in which our interests as ophthalmologists exactly parallel those of our ophthalmic pharmaceutical industry partners.

The American Glaucoma Society recently received an unrestricted grant to allow it to solicit, prioritize, and then distribute best practices to improve patient utilization of recommended glaucoma care. Details of the program are being finalized, and a public announcement is due shortly.² As an incentive to submit ideas, there will be cash prizes for the best ideas submitted from ophthalmologists, from ophthalmic support personnel and from patients.  Be thinking of your suggestions.  What do you do when you see a red flag?  Or even, when you don't?

1. Am J Opthalmol 1986;101:515-523.
2. Watch for details at


Dr. Mills is secretary-elect of the American Glaucoma Society and is a speaker for Alcon, Carl Zeiss Meditec, Merck and Pfizer, and a consultant for Allergan.