Patient Education: Strategies for Improving Compliance

The human element is essential for gaining your patient's cooperation with their treatment regimen.

BY E. RANDY CRAVEN, M.D.

Lack of medication compliance leads to unnecessary disease progression and a lower quality of life,^1-3 yet only about 50% of patients typically take their medicines as prescribed.⁴ While patient non-compliance is a universal healthcare issue, adherence rates among patients with chronic conditions, in contrast to acute conditions, is exceptionally low, dropping most dramatically after the first 6 months of therapy.^1-3

Compliance is a notoriously daunting challenge in the treatment of glaucoma. One seminal study using an electronic monitoring device showed that patients overestimate their compliance; physicians cannot accurately judge who is adherent and who is not; and that the rate of compliance with glaucoma medications was significantly higher in the 24-hour period preceding the patient's return appointment than in the study's entire 4- to 6-week observation period.⁵ As a glaucoma specialist, I address the compliance challenge with patient education, keeping the number of prescription medications required for optimal management to a minimum, and when possible, considering the cost of the drugs that I prescribe. I believe this strategy will work for other specialties as well.

Compliance and Patient Education

Years of patient observation have taught me that one of the primary reasons for inconsistent prescription drug use is that patients do not understand the illness well enough to be motivated to help prevent it from worsening. When patients divulge that the reason they are taking a medication is because they have been told to do so by their physician, it implies that they do not have a basic understanding of the disease process.

The cornerstone of our patient education plan is a verbal contract. Because glaucoma patients are asymptomatic in the majority of cases, they are not motivated to comply with their treatment regimen to alleviate discomfort, so we have to drive home the seriousness of the disease. I explain the importance of following the prescribed regimen and describe the eventual impact of untreated — or undertreated — elevated IOP. We then engage the patient in a discussion of treatment options including efficacy, potential side effects and cost. We also ask if the plan will fit with their lifestyle. I essentially offer them a verbal "contract," so that we are both on the same page and they accept or decline it. If they decline, then we tweak the plan until it reflects an alternative with which the patient can agree to comply.

Sometimes the patient's hesitation to accept the contract is based on something as basic as an inability to open an eye drop bottle because of advanced arthritis. It is better to learn about this during the treatment planning stage, so that together you can consider other options rather than sending the patient home with prescriptions that will either go unfilled or unused.

I always tell patients that if they find that the plan is not working for them, they should tell me so that we can work together on a different strategy to help save their vision.

Dosing Frequency

A study by Eisen and colleagues suggested that the single most important action that healthcare providers can take to improve compliance is to select medications that permit the lowest daily prescribed dose frequency.⁶ Dr. Higginbotham supports the connection between combination drugs and improved compliance.⁷ In her retrospective study examining the patterns of patient persistency with one combination therapy vs. two or three bottles of glaucoma medications over 1 year, Dr. Higginbotham found that subjects with a prescription for a single combination glaucoma therapy were the most persistent in prescription adherence. Subjects who had two prescriptions were less persistent and those with three different prescriptions were the least persistent. Persistency was defined as having a refill within 120 days of the initial or preceding refill.

Additionally, a 2007 study by Alan Robin et al used a medical monitoring device to gauge the adherence of 62 glaucoma patients.⁸ Thirty-one were prescribed only a prostaglandin analogue and 31 were prescribed both a pros taglandin analogue and an adjunctive medication. The researchers found that while adherence to the prostaglandins q.d. regimen was good in both groups, adherence to the adjunctive medication in the two-drug group was significantly poorer.

The more medications that are added to a regimen, the less enthusiastic patients are about participating in the process. When I start a glaucoma patient on an IOP-lowering medication, I generally prescribe a pros tag landin analogue as the first-line treatment. When additional IOP lowering is needed, I may first switch within the prostaglandin analogue class before adding a second medication to the regimen. If I still need to introduce an adjunctive therapy, I'll look for medications that have demonstrated IOP lowering with less dosing frequency required and that work with the other medications a patient may be taking.

The Comfort Factor

Another, perhaps more obvious, compliance-related factor is the ocular comfort associated with the prescribed medication. Patients experiencing irritation, itching or pain when instilling drops are less likely to be compliant. In my initial dialogue with patients and at follow-up appointments, I make sure to ask patients about their ocular comfort and overall experience using the medication. This allows me to set and manage patient expectations early on and adjust the prescribed regimen as needed before it potentially becomes a compliance barrier.

Compliance and Cost

Although the Medicare Prescription Drug plan has significantly increased drug coverage among seniors, Part D enrollees do not get as good a deal as those enrolled in employer-based programs or those who have Veterans prescription coverage benefit, according to a 2006 survey of more than 16,000 seniors by the Kaiser Family Foundation, the Commonwealth Fund and the Tufts-New England Medical Center.⁹ While the Medicare drug law achieved its primary goal of providing drug coverage to most seniors who previously lacked it, the survey found that a significant number of seniors in Part D plans are paying sizeable amounts out of pocket for their medications and delaying or not filling their prescriptions for cost reasons. As a result, when choosing prescription drugs, I try to make sure they are covered by as many of the regional and national health plans as possible.

Compliance Barriers

A survey commissioned by the National Community Pharmacists Association found a major disconnect between consumers' beliefs and their behaviors when it comes to taking medicines correctly.¹⁰ Some of the findings of the survey include: Almost half of those polled (49%) said they had forgotten to take a prescribed medicine; nearly one-third (31%) had not filled a prescription they were given; nearly three out of 10 (29%) had stopped taking a medicine before the supply ran out; and almost one-quarter (24%) had taken less than the recommended dosage. Facts like these underscore the importance of patient education whether for short-term pre- and postoperative NSAIDS, anti-infectives or topical drops such as glaucoma medications, the latter which may be a life-long commitment.

Taking an Interest

While some practices rely on videos or handouts to help patients understand their disease state and the importance of consistent treatment, I find that the human element results in a significant improvement in patient compliance. My entire staff is trained to discuss a patient's symptoms and the rationale for the recommended regimen, as well as to inquire about how the patient is dealing with the prescribed medications. Simply asking if the patient is taking the prescription is not enough. It is critical to ascertain how the therapy plan fits in with the patient's lifestyle to ensure its continued use.

I have found that discussing treatment options, eliciting an affirmative response to the recommended regimen and then having the patient repeat the plan back to me significantly improves patient compliance patterns. OM

References

1. Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288:462-467.
2. Cramer J, Rosenheck R, Kirk G, Krol W, Krystal J. Medication compliance feedback and monit5oring in a clinical trial: predictors and outcomes. Value Health. 2003;6:566-573.
3. Haynes RB, McDonald HP, Garg AX. Helping patients follow prescribed treatment: clinical applications. JAMA. 2002;288:2880-2883.
4. Osterberg L, Blaschke T. Adherence to Medication. N Engl J Med. 2005;353:487-497.
5. Kass MA, Meltzer DW, Gordon M, Cooper D, Goldberg J. Compliance with topical pilocarpine treatment. Am J Ophthalmol. 1986;101:515-523.
6. Eisen SA, Miller DK, Woodward RS, Spitznagel E, Przybeck TR. The effect of prescribed daily dose frequency on patient medication compliance. Arch Intern Med. 1990;150:1881-1884.
7. Higginbotham E, Walt JG, Chiang TH, Guckian A. Number of prescription bottles as a factor affecting persistency in glaucoma. Poster presented at the Annual Meeting of the American Glaucoma Society; March 1-4, 2007; San Francisco, CA.
8. Robin AL, Novack GD, Covert DW, Crockett RS, Marcic TS. Adherence in glaucoma: objective measurements of once-daily and adjunctive medication use. Am J Ophthalmol. 2007;144:533-540.
9. Kaiser Family Foundation, the Commonwealth Fund and the Tufts-New England Medical Center. 2006. Available at: http://content.healthaffairs.org/cgi/content/full/26/5/w630?ijkey=wpOorB7zwSX6c&keytype=ref&siteid=healthaff. Accessed Sept. 21, 2007.
10. Enhancing Prescription Medicine Adherence: A National Action Plan. Available at: Http://www.talkaboutrx.org/documents/enhancing_prescription_medicine_adherence.pdf. Accessed Sept. 21, 2007.

E. Randy Craven, M.D., is the principal of Glaucoma Consultants of Colorado, PC, located in Denver, Colo. He states no financial interest in the products listed in this article. He can be e-mailed at ercraven@glaucdocs.com.