Compliance with medical therapy is one of the most significant global public health concerns facing society today. With glaucoma in particular, there are an ever increasing number of patients burdened with the disease due to the aging population profile. It is known to be a leading cause of blindness in African Americans and the second leading cause of legal blindness in the United States. Since the majority of glaucoma and glaucoma suspect patients are initially managed with medical therapy, it is especially important that medical therapy be initiated and continued properly. Despite the availability of very effective pharmacologic therapies, poor compliance occurs in an estimated 25 to 60% of patients. The true extent of the problem in terms of disease progression, loss of sight and economic costs due to loss of productivity for the individual and cost of more aggressive medical care (as a result of disease progression) are substantial.
The term compliance is sometimes used interchangeably with adherence. They both describe the agreement between the medical regimen prescribed by the treating physician and actual patient practice. However, adherence implies a more active role of the patient in the process and indicates a responsibility of both parties to achieve success.
Glaucoma is a chronic disease with mild or no symptoms early on, and treatment designed to prevent worsening rather than to improve visual function. The consequences of non-adherence are not felt immediately but are delayed by as long as several years. Thus, by its nature, glaucoma is a perfect setup for non-compliance.
There are three general categories of non-compliance: medications, follow up care and treatment delay or refusal. In this article we will discuss the barriers to compliance from a patient and physician perspective and some methods to overcome these.
The first barrier to compliance is unresolved patient concerns.[1]
Patients often are uncomfortable or unable to ask questions of their physician. Indeed, the average doctor interrupts the patient after 12 seconds of speaking. Even if this interruption is not verbal, body language and attitude convey volumes about our levels of impatience. Individuals have differing self perceptions of health and the priority that health and medical care takes in their lives. Many are in disagreement or denial about their health problems, especially in asymptomatic diseases such as glaucoma. Without a definite and immediate feedback, it is difficult to convince a patient that they should commit to a lifetime of therapy. There is also a common belief that treatment will not work, leading to a tendency to self-treat, or discontinue treatment. Finally, there is a fear of adverse events arising from treatment, especially surgery.
The second barrier is poor communication between doctor and patient.
Patients need to be told not only how to use, but when to use, and why to use medications. They should be instructed on the risks and benefits of treatment (medicine and surgery) as well as those of non-treatment. Finally, keep in mind that patients typically remember less than 50% of what is discussed during a visit.
The final barrier is regimen complexity.
The average American over age 65 takes 4 chronic medications. Most of the patients with glaucoma are in this age group and have concurrent medical problems. When more than 2 total medications (not just ophthalmic) are used, the rate of compliance drops from 70% to about 50%[2]. Ophthalmic medications can be more difficult to administer, with accuracy of drops getting into the eye, washout of drops and lacrimal drainage of special concern. The often quoted study of Kass et al demonstrates the difficulties of compliance in a glaucoma population[3]. This patient population was using pilocarpine four times daily, and unknowingly received a bottle with a microchip sensor attached to monitor dosing. They found that 28 – 59% of patients were non-compliant. Furthermore, the patients’ perception was that they were compliant with 97% of their doses. The treating physicians were not able to predict which patients had poor versus good compliance.
Now that we have identified some of the causes of poor compliance, what are some of the methods we as physicians can take to prevent them?
The first revolves around the physician-patient interaction.
We must work to create a feeling of mutualism with the patient, or working together towards a common goal: that being their good health. Even if a physician is not comfortable interacting on a personal level, concern about a patient’s welfare is important and can involve asking about side effects, problems with medications or just a general change in their condition. If open ended questions are not eliciting a response, then specific questions about known side effects of current medications or symptoms of glaucomatous visual loss may be helpful. Explanations about the disease and its consequences and about medications, their actions and potential side effects all help to foster this relationship.
Educational or “fear arousing” health messages can be useful if they are appropriate and not alarmist. If they are perceived as such, the patient may undergo denial or simply give up hope and stop therapy and follow up all together. These should be accompanied by an explanation and a plan for treatment. Visual aids that are from the patient themselves such as visual fields, optic nerve photographs or optic nerve and nerve fiber analyses are quite helpful in this regard. These are particularly useful when discussing progression of disease and recommendations for more aggressive therapy, such as surgery.
These health messages blend with patient education.
Literature from such groups as the American Academy of Ophthalmology or Glaucoma Research Foundation or even from pharmaceutical companies are useful in that they are in lay language and give the patient a reference that they can take home and refer to again over time. Education is not only important at diagnosis, but on follow up visits. We need to reinforce our original message and further explain treatments and prognosis. Written instructions are not only helpful for the patient but can provide excellent chart documentation. The presence of family members is important to provide another perspective and involve the patient’s support group.
Additionally, simplifying the treatment regimen aids in compliance.
This can take the form of critically evaluating a medicine regimen to see if multiple medications are necessary, especially when adding medications. If one suspects a loss of effect over time, that medication should be discontinued and its efficacy reevaluated. Monotherapy is helpful in decreasing complexity and cost. Combination medications are helpful in patients on multiple medical therapy as they reduce complexity as well as ocular preservative exposure and the chance of medication washout. The recent advent of dosing aids not only reminds patients to take their medications, but also fosters mutualism with the physician and gives the patient a feeling of involvement in their health care. The physician must be aware of side effects and actively seek them out. A patient that has good control of intraocular pressure but severe local or systemic side effects is not a success, and will likely be non-compliant. Finally, we need to be aware of cost related issues and prescribe the therapy with the best balance between efficacy and economics.
Finally, the decision for surgery may arise because of poor compliance, side effects, desire to reduce medical therapy, or poor control of disease.
With the advent of technologies such as laser trabeculoplasty, endoscopic cyclophotocoagulation and trabecular surgery, the decision for surgery may take place earlier in the treatment algorithm. Filtration surgery is also a powerful treatment tool once more conservative methods have failed. With any surgical procedure, education is paramount. Most patients have a fear of surgery and its related complications, and we must dispel these by a rational discussion of risks and benefits. I find that these fears are often based on the personal experiences of a friend or relative that underwent surgery for a different set of circumstances altogether.
Improving adherence with glaucoma medications through patient education is important but not as practical or effective when performed by the physician alone. A multi-disciplinary approach involving the physician, technicians or nurses, social workers and pharmacists may be more effective.
Doheny Glaucoma Compliance Study
Using a novel, multi-disciplinary approach, we are currently performing a randomized, controlled, single-masked trial at the Doheny Eye Institute, University of Southern California, to determine whether this is hypothesis is valid. Patients are randomized to the control group receiving the usual care, and the intervention group with the multi-disciplinary approach. The first goal of the study is to demonstrate that multi-disciplinary intervention will improve patient adherence to glaucoma medications. The multi-disciplinary intervention involves video- and brochure-based patient education; personalized counseling by a pharmacist and an ophthalmologist; and regular follow-up telephone calls by a pharmacist and an ophthalmologist. Refill data collected from pharmacies at regular intervals provide the data for this analysis.
The second goal of the study is to identify patient characteristics and demographics that are associated with medication noncompliance in glaucoma patients. Patient questionnaires are administered that record patient demographics such as age, education, insurance, employment, ethnicity, gender, marital status and income. Patient knowledge about glaucoma and its treatment, number of years with glaucoma, family history, perception of the physician and pharmacist, general health perception and smoking and alcohol consumption are also tested. Understanding which patient characteristics are predictive of noncompliance in this patient population could help clinicians in identifying noncompliant patients and providing additional counseling to those patients.
Ultimately, the patient must take responsibility for their own health and compliance with therapy. However, we as physicians have an obligation to facilitate this and help them to understand the importance of therapy and the consequences of non-compliance. With the increasing penetration of electronic records and communication, the multi-disciplinary approach to medical therapy will likely gain widespread use. This may have the dual benefits of better patient outcomes and a decreasing time burden to physicians that are already facing increasing demands.
REFERENCES:
- Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shelvin M. Medication compliance: a healthcare problem. Annals of Pharmacotherapy 1993, 27(S):5-19.
- Greenburg RN. Overview of patient compliance with medication dosing: a literature review. Clinical Therapeutics 1984;6:591-599.
- Kass MA, Meltzer DW, Gordon M, Cooper D, Goldberg J. Compliance with topical pilocarpine treatment. Am J Ophthalmol 1986,101:515-523.