EyeNet Magazine

Clinical Update: Glaucoma
Cracking the Noncompliance Code
By Jean Shaw, Contributing Writer

Glaucoma specialists know full well that ocular hypotensive medications are effective—so effective that surgery can be avoided in many patients. What still remains elusive, however, is getting patients to completely “buy in” to their treatment regimens.

“If we’re going to rely on a nonsurgical approach for glaucoma management, then we need to realize that nonadherence is a very significant problem,” said James C. Tsai, MD, chairman and professor of ophthalmology and visual science at Yale University.

Scope of the Problem

While estimates of noncompliance vary, many studies show that most new patients do not finish their first year still taking their eyedrops on a regular basis. And in a study Dr. Tsai conducted while he was at Vanderbilt University, respondents identified 71 unique reasons why they had difficulty complying with their prescribed treatment regimens, varying from medication side effects to environmental obstacles.1

While cost is often blamed as a major factor in noncompliance, it did not play a role in Dr. Tsai’s study. As he said, “All of the patients we studied had some kind of health insurance to help cover their medication cost.”

He also cautioned that simply handing out traditional patient education material isn’t enough. “Physicians often think, ‘If we only educated the patients better, they would understand the consequences of their medication nonadherence.’ But the subjects in our study told us time and again that they understood the ramifications [of noncompliance], but that situational or environmental obstacles existed that impeded their ability to fully comply. Almost half of the 71 ‘unique situations’ we identified were situational or environmental factors. The bottom line is, it is very difficult and challenging to structure medication adherence patterns into the busy daily schedules that we all have.”

He added, “This is why we need to come up with alternative approaches to minimizing nonadherence. There are unique situational barriers for everyone; the physician cannot simply use a one-size-fits-all approach. It must be very individualized and targeted to the specific patient.”

Searching for Solutions

What, then, can effectively help reach patients and turn this situation around? In an attempt to identify effective solutions, the American Glaucoma Society (AGS) launched a research project, known as the Patient Care Improvement Project.

The AGS set out to identify the “best practices” for enhancing and supporting patient compliance in the fundamental areas of taking their eyedrops as prescribed and returning for follow-up care, reported Paul P. Lee, MD, JD, on behalf of the AGS Quality of Care Subcommittee, which headed up the effort.

The AGS cast a wide net, soliciting ideas from physicians, ophthalmic support personnel and patients. In addition, the AGS contracted with investigators at Vanderbilt University to construct an interactive Web site, which was used to collect respondents’ descriptions of common reasons for noncompliance and recommended solutions.

All told, some 400 participants registered and submitted ideas. An AGS committee evaluated and ranked the ideas, choosing the final 43 winning suggestions from 10 physicians, 10 support personnel and 10 patients. The winners were honored and awarded monetary prizes last fall at Glaucoma Subspecialty Day, held in conjunction with the Academy’s Annual Meeting.

Additional aspects of the project include stimulating further research on compliance; as part of this, a research grant of $50,000 has been awarded to Steven L. Mansberger, MD.

Taking a Tip From Diabetes Research

When it comes to the study of compliance with prescribed treatment, “The diabetes literature is probably 20 to 30 years ahead of the glaucoma literature on this topic—but that’s fine, as we can use the existing information and knowledge for our own purposes and understanding,” said Dr. Tsai.

In particular, diabetes researchers have literally revolutionized medicine over the past several decades by investigating the issue of patient self-care. As it happens, the Vanderbilt researchers who collaborated with the AGS on the Patient Care Improvement Project are experienced diabetes researchers who have investigated such issues as adherence to prescribed diets. They also collaborated with Dr. Tsai on his study of compliance barriers in glaucoma care.

And one of the patients who responded to the AGS survey referred to the similar challenges that affect diabetes and glaucoma care: “I notice there are counseling sessions for diabetics regarding strict diet and using their medications, so why not for glaucoma? This counseling should be mandatory and free.”

Spreading the Word

Now that the results are in, “We’re fortunate to have some insightful and thoughtful ideas,” said Dr. Lee, professor of ophthalmology at Duke University. “And collating them and bringing them together has insight for all of us.”

The AGS will be disseminating a compendium of the best ideas this summer to the ophthalmic community. Of the winning suggestions, some clearly require further development, such as those involving eyedrop bottle design, which obviously would require attention from the drug companies.

Eyedrop adherence. As Dr. Lee pointed out, “Some of the best ideas came from patients themselves.” Several patients contributed their own personal strategies for combating forgetfulness and keeping track of drop instillation. For instance, one woman uses a watch that can be programmed with up to 12 daily alarms and text messages. When the alarm sounds, she simply reads the text message. Another noted that she keeps a log of the times when she uses her eyedrops and when she’s involved in other activities, so that she can identify what throws her off schedule and figure out potential solutions.

Other suggestions covered developing habitual ways of taking the drops, to build associations between common daily routines—such as taking drops in alphabetical order, as one patient does—as well as simple tools that could help patients keep track of instillation, such as dry erase white board charts that patients could use to check off a drop schedule.

Keeping appointments. Respondents also suggested a number of ways to encourage patients to keep their follow-up appointments. Several people suggested developing a buddy system—a classic element of self-care programs. One physician suggested that patients who agreed to participate in a buddy system could remind one another to go to their appointments and form a local glaucoma support group.

And one of the most intriguing ideas involves having patients write themselves a note about their next appointment, which would then be mailed from the office as the actual appointment date drew nearer.

The novelty factor—getting a letter from yourself—would serve to remind the patient of how important follow-up care is, said Peter W. DeBry, MD, who contributed the idea and practices in Las Vegas.

What about those physicians who are in a university setting? As Dr. Tsai noted, “Our situation is slightly different, but some of the suggestions are not so exclusive to the community setting, and there are things we can do—for instance, making the front desk staff aware of bus and alternative transportation schedules.”

The Bottom Line

This compilation of practical suggestions is “long overdue,” said Dr. Tsai. “We realize that we need to think outside of the box.”

1 Tsai, J. C. et al. J Glaucoma 2003;12:393–398.

The AGS survey was made possible with support from an unrestricted educational grant from Pfizer.

M. Roy Wilson, MD, has been named the 2007 AGS Subspecialty Day Lecturer. His presentation, “Risk Factor: The Concept, the Evolution and the Practice,” will be a highlight of this year’s Subspecialty Day glaucoma program.

For full listings of all five of this year’s Subspecialty Day programs, see your Advance Program, which should arrive in the mail this month, or go to www.aao.org/annual_meeting.

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