compliance
The Challenge of Compliance
Educating glaucoma patients is the key to success.
BY BRIAN FRANCIS, M.D. AND VIKAS CHOPRA, M.D.

Compliance with medical therapy is one of the most significant problems facing health care throughout the world. An estimated 1.8 billion medical prescriptions are filled each year in the United States, with more than 50% of the medications taken incorrectly. Failure to use medications as directed leads to an astounding extra cost of $100 billion annually.1 These wasteful costs take the form of hospitalizations, surgeries, loss of productivity and excessive treatments.

There are three general forms of noncompliance. These involve medications, follow-up care and treatment delay or refusal. This article will discuss the barriers to compliance from a patient and physician perspective and suggest some methods to overcome these problems.

Why Patients Are Not Compliant

The first barrier to compliance is unresolved patient concerns.2 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 definite and immediate feedback, it is difficult to convince patients 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. Most patients have heard horror stories of an adverse outcome of treatment from their peers, or from the physician's nemesis, the Internet.

The second barrier is poor communication between doctor and patient. Patients need to be told not only how to use medications, but when to use them and why they are necessary. Patients should be instructed on the risks and benefits of treatment as well as those of non-treatment. Finally, most patients forget about half of what we tell them.

The final barrier is regimen complexity. The average American who is over 65 takes four medications for chronic conditions. Most of the patients with glaucoma are in this age group and have concurrent medical problems. When more than two total medications (not just ophthalmic) are being taken, the rate of compliance drops from 70% to about 50%.3

Ophthalmic medications can be 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.4 This patient population was using pilocarpine q.i.d and unknowingly received a bottle with a microchip sensor attached to monitor dosing. The researchers found that 28% to 59% of patients were noncompliant. However, 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 vs. good compliance.

Creating 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 to be working together toward a common goal: 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 his/her 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, medications in terms of mechanism of action 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 in nature. These should be accompanied by an explanation and a plan for treatment. Visual aids from the patients' own diagnostic tests, such as visual fields, optic nerve photographs or optic nerve and nerve fiber analysis 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, Glaucoma Research Foundation or even pharmaceutical companies are useful in that they are presented in lay language and provide a reference that patients 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 set of ears 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. 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 it also fosters mutualism with the physician and gives patients a feeling of involvement in their health care.

Presenting the Surgical Option

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 if more conservative methods have failed. With any surgical procedure, education is paramount. Most patients fear surgery and its related complications, and we must dispel these fears with a rational discussion of risks and benefits.

All methods for increasing compliance take more time and care during a patient visit, but through practice organization much of this can be delegated to other healthcare personnel in our offices. This "team" approach may prove to be more effective than the standard office visit approach.

A New Approach to Compliance

Using a novel, multi-disciplinary approach, we are currently performing a randomized, controlled and single-blinded trial at the Doheny Eye Institute, Keck School of Medicine, University of Southern California (USC), to test the hypothesis that the medication compliance rate in the multi-disciplinary intervention group will be higher than the rate in the "usual-care" control group. 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. The second goal of the study is to identify patient characteristics and demographics that are associated with medication noncompliance in glaucoma patients. 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, patients must take responsibility for their own medical 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 noncompliance.

Brian Francis, M.D., is an associate professor of ophthalmology on the Glaucoma Service of the Doheny Eye Institute, Keck School of Medicine, USC, Los Angeles. He can be reached via e-mail at bfrancis@usc.edu. Vikas Chopra, M.D., is assistant professor of ophthalmology on the Glaucoma Service of the Doheny Eye Institute, Keck School of Medicine, USC, Los Angeles. He can be reached via e-mail at vchopra@usc.edu.

References

1. Urquhart J. Pharmacoeconomic consequences of variable patient compliance with prescribed drug regimens. Pharmacoeconomics. 1999;15:217-288.

2. Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shelvin M. Medication compliance: a healthcare problem. Ann of Pharmacoth. 1993;27(S):5-19.

3. Greenberg RN. Overview of patient compliance with medication dosing: a literature review. ClinTher. 1984;6:591-599.

4. Kass MA, Meltzer DW, Gordon M, Cooper D, Goldberg J. Compliance with topical pilocarpine treatment. Am J Ophthalmol. 1986;101:515-523.