This article was adapted from “Chasing compliance,” which originally appeared in the June 2017 issue of Glaucoma Physician.

Compliance can be a huge hurdle in the management of glaucoma patients who:

• Need medication for the rest of their lives
• Wait at the pharmacy to receive prescribed medications
• Pay an office copay every three to four months
• Pay medication copays
• Undergo many in-office tests.

What’s more, studies have shown that noncompliant patients tend to be dissatisfied with the wait time or cost of the examination, and that noncompliance with medicine use is linked to increased disease severity.^1,2

Each visit, they wait for the doctor to say, “Everything looks good. Keep taking your drops, and we will see you in four months.” Imagine how this must feel to them, especially when their vision isn’t getting better.

Like other subspecialties and disease states in ophthalmology, glaucoma specialists strive to achieve that “20/happy” patient.

In our practice, we identified five key ways to improve compliance and achieve greater patient satisfaction.

1. Educate patients.

Everything begins and ends with patient education; it is the foundation for following the other tips listed below. We view the first appointment as the initial “investment” in the patient.

My staff and I spend a few more minutes to ensure patients understand that glaucoma is progressive, not reversible, and often has no symptoms. We stress that not every patient needs the same treatment or target pressure. We manage expectations by explaining that they need to see us every four to six months, whether they are treated or not, and that we need to conduct multiple tests every year to ensure the glaucoma isn’t progressing.

Also, our patients also know that the target pressure range is evolving and may change if the nerve is not stable. And, I educate patients on the impact of not consistently taking the prescribed medication.

2. Manage cost concerns.

Cost has become an even bigger issue as more and more branded drops are substituted for generics. Many patients don’t understand the differences between their medications, let alone differences between branded versus generic medications. Also, they often return to our office on a medication we did not prescribe. This can happen when the patient goes to the pharmacy and is told the cheaper substituted medication is the “same as the one prescribed.”

As consumers, we place value in everything we purchase, whether a car, computer, phone, or even coffee; we justify the cost based on our understanding of the value, so it is imperative that patients understand the value of the medication we prescribe.

To this end, we give all patients a form whenever we prescribe a brand-name medication (See Table 1). This form helps distinguish the subtleties between the proprietary medication and its generic counterpart.

Also, we tell patients to ask the pharmacy about the difference in cost after running it through insurance. In a study we conducted in our office, using this educational technique, we found that 65% of our patients changed to a brand-name medication after they understood the difference.

3. Understand dosing regimens.

Staff need to be aware of the patient’s dosing regimen, as it is another important barrier to compliance. For example, studies have demonstrated that adding a second or third bottle decreases compliance.^3,4 We offer selective laser trabeculoplasty (SLT)as a first-line therapy and are more aggressive offering SLT before adding a second or third medication. Now with the various microinvasive glaucoma surgery (MIGS) options, we can surgically reduce the drop burden earlier in the disease, even in mild to moderate patients. Regardless of how well controlled their intraocular pressure (IOP) and optic nerve head are, if the patient complains of cost, we offer SLT or MIGS options.

However, when additional medications are necessary, I try to maximize one class of medication, if at all possible, by either switching within class or encouraging compliance with current medications before I add a second one. If I add medications, I try to find complementary mechanisms of action and often rely on combination medications to achieve the target IOP.

Also, I provide written instructions for all medications prescribed — even if it’s just one medication — and suggest reminder strategies for taking medications (for example, setting a daily alarm or marking off each day on a calendar when the drops are used).

Patients can integrate their medication regimen into their daily routine by storing the medications next to their toothbrush or pillbox to serve as a visual reminder. In addition, we always ask family and caregivers to be present at the appointment, because this second person can also help patients remember the treatment plan.

4. Address side effects.

Managing side effects of medications is a fundamental part of glaucoma patient management. Setting proper expectations ahead of time can decrease the “shock” of an adverse event. For instance, telling a patient a drop might burn or turn the eye a bit red prepares the patient, so he or she doesn’t overreact if an adverse event does occur.

Staff must also understand that the physician may change the time of dosing, which can also help address side effects. In a nonpublished study we conducted in 2007, we asked patients taking a prostaglandin analogue who complained of morning hyperemia to self report hyperemia when the dosing time was changed to earlier in the day and tears were used five minutes after. By changing the time of dosing from bedtime to earlier in the evening, patients reported 50% less hyperemia.

5. Treat concomitant conditions.

A major part of my practice involves identifying and treating coexisting conditions, namely ocular surface disease. Very few other conditions in the eye have as many associated symptoms, including, pain, redness, photophobia, and, most important, fluctuating vision.

These symptoms can affect quality of life and often impact our patients’ ability to stay compliant with our recommendations. Although providers are focused on the IOP, patients are focused on the symptoms of dry eye. If we don’t address those symptoms, it’s hard for patients to trust us, and they may stop taking their medications.

Doctors are often overwhelmed and don’t have time to focus on dry eye during their busy day. After conducting a retrospective analysis on patient’s symptomology, we found “fluctuating vision” provided the highest sensitivity to dry eye diagnosis.

Now, I just ask patients, “Does your vision fluctuate throughout the day or with each blink?” If they say “yes,” I work on the premise that they have ocular surface disease until proven otherwise.

Sometimes, the dry eye disease can be confused with adverse events from glaucoma drops. Although adding more medications affects compliance, when adding a dry eye drop, we are treating unpleasant symptoms that can help their vision. This is why they are often more compliant when adding dry eye medications to their daily medication regimen.

Conclusion

At the end of the day, we’re trying to protect our patients from losing vision while helping them to maintain a high quality of life. It’s not always easy, but keeping these five key tips in mind can help. OP

References

1. Kosoko O, Quigley HA, Vitale S, et al. Risk factors for noncompliance with glaucoma follow-up visits in a residents’ eye clinic. Ophthalmology. 1998;105(11):2105-2111.
2. Ung C, Murakami Y, Zhang E, et al. The association between compliance with recommended follow-up and glaucomatous disease severity in a county hospital population. Am J Ophthalmol. 2013;156(2):362-369.
3. Friedman DS, Hahn SR, Gelb L, et al. Doctor-patient communication, health-related beliefs and adherence in glaucoma results from the Glaucoma Adherence and Persistency Study. Ophthalmology. 2008:115(8):1320-1327.
4. Gurwitz JH, Glynn RJ, Monane M, et al. Treatment for glaucoma: adherence by the elderly. Am J Public Health. 1993:83(5):711-716.

Inder Paul Singh, MD, is a glaucoma specialist who practices at the Eye Centers of Racine and Kenosha, in Wisconsin.