Compliance Conundrums

The doctor-patient relationship is still paramount when it comes to glaucoma compliance.

BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR

It's no secret that patient adherence to medical therapy is the major problem in the treatment of glaucoma. A recent multi-site study published in the Canadian Journal of Ophthalmology found that more than 50% of patients were "either noncompliant or demonstrated improper administration technique."¹

"Lack of compliance is the number one reason why medical therapy for glaucoma fails," affirms Louis B. Cantor, M.D., director of glaucoma service, Indiana University School of Medicine, Indianapolis. "It is not because the medicines don't work; it's just because they don't get in to the patient's eyes." This unfortunate truism of glaucoma care is soon to become a more pressing problem for physicians, as the Baby Boom generation comes into its senior years and incidences of ocular diseases such as glaucoma increase. A 2004 report from the National Eye Institute predicted that the number of diagnosed cases of glaucoma in the United States would increase from 2.2 million to 3.6 million by 2020.² Interviews with glaucoma specialists indicate that improving compliance may be as simple—and as difficult—as getting back to some basic concepts.

Education, Education, Education

The first step is explaining what glaucoma is, in language that patients can understand. Thomas K. Mundorf, M.D., a glaucoma specialist in private practice in Charlotte, N.C., agrees that the physician's communication skills are critical in ensuring compliance. This lesson was driven home to him when he was a resident doing rounds. One day he had to tell a patient that she had glaucoma, then explained why she needed glaucoma therapy and that the hospital was going to start her on those medications. As he walked away to get his attending physician, he heard a woman seated next to his patient ask her what her doctor had said. The patient replied, "I don't know."

"So I asked my chairman, Dr. Richard Weaver, what to do about a situation like that," Dr. Mundorf recounts. "He gave me probably one of the best clues of my career. He said, ‘Dr. Mundorf, you understand the disease and you understand what can happen. You have to take the responsibility of helping your patient understand.’

"And from then on, I've understood that compliance really starts in the doctor's office, it starts when you make the diagnosis, how you explain to the patient the diagnosis, and you talk about what can happen, and then you start talking about options for treatment," Dr. Mundorf says. "It really does begin with the doctor to use the language that a patient will understand."

Dr. Cantor describes glaucoma to patients as a disease that damages the optic nerve and likens that nerve to a main telephone cable that transports messages from the eye to the brain, in this case resulting in vision loss. "And when that's gone, your vision is gone," he says. "Then I try to put in perspective how much damage they have; 90% of those connections between your eye and your brain are gone and are never coming back. Our goal is to save what's left."

The asymptomatic nature of glaucoma makes it particularly important to make sure this education gets through to the patient. Patients may not perceive symptoms from their glaucoma, but they often do perceive them from their prescribed medication, so it is crucial that they understand what the medication will do for them. "It is important to really highlight what the risks of glaucoma are and where they are in that spectrum," Dr. Cantor says.

Being sure to educate patients about possible side effects from medication also helps to head off noncompliance. Dr. Mundorf recommends letting patients know at the outset of treatment what their options are, what the side effects of the medication you have chosen might be, and how you will address any side effects.

"You can say, ‘We'll change, I'm not going to use something that I think will harm your eyes and we have several options,’" Dr. Mundorf says. "I think that takes the first big step into developing the confidence that your patient needs to have in you so you have that long-term relationship."

Even just a few minutes spent talking with the patient can be enormously helpful if spent the right way. "I don't leave until I've asked the question, ‘Do you have any more questions?’" says Dr. Mundorf. "That gives them the feeling that I've given them all the time that they need."

But education may have its limitations, as Dr. Cantor points out. "We keep saying, we've got to educate patients, we've got to educate patients — we keep putting the burden back on the patient. ‘If only they did what we told them to do, they'd be okay,’" he says. "I think there is also a point where we as physicians are asking a patient to do something he can't do."

He includes adding second and third medications to patients' dosing schedule in that category, as well as expecting patients to administer drops when it is physically difficult for them to do so, and forgetting the patient's economic realities. Dr. Cantor says that it is incumbent on the physician to simplify glaucoma therapy as much as possible, which may mean prescribing a fixed-combination drop instead of two separate medications, or resorting to surgery.

There's No Substitute for the Physician…

The specialists interviewed believe that the patient must receive his or her education from the physician, and not from staff. "I'm a dinosaur, I'm in solo practice," explains Dr. Mundorf. "If you want to use, say, physician extenders or other staff, I think that's fine. But I decided when I went solo that the patients were coming to see me and I was going to do a lot of the hands-on." He notes that one of patients' biggest complaints about their doctors is that not only do they run behind, but that when the patient does finally get the doctor in the exam room, the doctor spends very little time there. "I don't think doctors would like to be treated that way," Dr. Mundorf points out.

E. Randy Craven, M.D., principal of Glaucoma Consultants of Colorado, in Denver, finds that his younger glaucoma patients resist dealing much with staff. "Patients don't have the patience for technicians that they used to have," he says. "And it's just in the last few years that I've seen that. I think it's generational change characteristic of people who are younger — I know if I went to an office, I wouldn't want to mess with the tech, I'd want the doctor, and then to get out of there." Dr. Craven accommodates this desire, because he says it contributes to a good doctor-patient relationship, which in turn increases the likelihood of compliance. "I think a good bedside manner is more important in glaucoma treatment than it is anywhere else."

He recommends spending 30 seconds with each patient just reviewing the reasons why he or she is there and the purpose of the treatment you have chosen. "If you just do that every time people come in, then the patient is better with the whole concept of ‘this is why I come to see this doctor,’ and it's really important."

…But Teamwork Helps

Not that the physician can do it alone. These experts agreed that glaucoma treatment must be a "team effort" to succeed. Both staff and any patients' caregivers must be enlisted.

"Your office certainly has to be cued in because a lot of times your patients call in questions, or they will spend more time with your staff than they do with you," says Dr. Cantor. "There is no one who comes in contact with the patient who can't play a role in improving the ability of our patients to utilize medications better."

The more significant role, however, is played by any caregivers the patient has in his or her life. Because many glaucoma patients are elderly, they may be forgetful about issues such as taking their medications when scheduled, or about remembering the doctor's instructions precisely. "It's particularly frustrating when you have patients who appear to be having difficulty with their medicines and are coming into the office by themselves," Dr. Cantor notes.

In an effort to circumvent such problems, Dr. Mundorf finds out if anyone has accompanied the patient to the appointment and invites the patient to bring that person into the exam room. "I will say something like, ‘Who's with you? Do you want them to come in and hear this so they're not going to ask you, What did the doctor say? And you're not going to have to say it back to them?’ That takes a load off them, and it also keeps them from misstating what I said. And I will try to ask the caregiver if her or she has any questions," he says.

If a spouse or family member has not been accompanying a patient who seems to be having problems with compliance, Dr. Cantor specifically asks for that person to attend the next appointment. And he has heard of an excellent means of motivation. "I thought this was really clever, especially with men who often come to the office by themselves, if the wife isn't coming," he says. "Now, this was a woman doctor, so she can probably get away with this — she calls and says to the wife, ‘You're going to be living with an old man; do you want to live with an old blind man?’ And this doctor says that virtually 100% of the time, the wife is there the next visit, and the patient asks, ‘What the hell did you say to her?’ Because the wife is now all over it.

"It shows the importance of involving the family. Family members can have a huge impact. It's crucial to involve others; it's not just that person in the chair who is going to have deal with this: it's their family and friends."

If having the caregiver come along for an appointment just doesn't seem feasible, Dr. Mundorf advises requesting that he or she call the physician to discuss the patient's treatment.

Caregivers, however, are not always the answer to compliance problems. Dr. Craven notes that sometimes the person accompanying the patient to a visit is merely transporting him or her, such as a nursing home attendant, rather than someone who could affect compliance.

Dr. Mundorf points out that when the patient is living in a nursing home or assisted-living facility, the employees who would assist the patient with medications are often over-stressed. "I have a couple of patients in assisted-living scenarios and I write in their treatment plans, ‘Please wait 5 minutes between the [two kinds of] drops,’" he says. "And some of my patients are aware enough that they see the caregiver is not waiting. The patient reminds them to wait, and they say, ‘We don't have time.’ I've even called the nursing facility, saying, ‘I've asked for this. I understand your problem, but you can't be putting the second drop in on top of the previous one.’ If I hear about it, I'll try to communicate with the facility director or someone by phone; that's all I can do."

Dosing and Technique

In addition to prescribing as few medications as possible to lower the patient's IOP, designing a dosing schedule that works with his or her lifestyle, as well as checking on administration technique, can have a significant positive impact on compliance.

When it comes to setting up a dosing schedule, it is best not just to dictate to the patient. "If you tell them to use it at a specific time, you should always ask if that is going to be a problem," Dr. Mundorf advises. "You may say to use the drop at night, assuming that means bedtime. But that patient may fall asleep every night on the sofa watching television. Then he stumbles to bed, so he forgets about the drops." Instead, Dr. Mundorf recommends linking it to some activity they do each evening, such as eating dinner.

If the timing of drug administration is not an issue, he says to ask the patient what time of day is best for him or her to take the medicine. If the patient takes other medications each day at, say, breakfast, instruct the patient to take the glaucoma drops at that time as well. Dr. Cantor tells patients to place the medications next to their toothbrushes or coffee machines.

Checking a patient's ability to administer drops is also essential, Dr. Mundorf says, because some patients have very little experience doing so. He specifically asks patients about that, and he says that a large number do not. He then hands them a bottle of artificial tears and asks them to demonstrate their technique. "After I recover from my horror, I show them how to do it correctly and say, I want you to take this bottle of tears and your sample of your glaucoma medicine. Use the tears today and tomorrow to practice getting your technique down. The day after tomorrow, start your medication."

Helping patients improve their administration technique should also lead to less medicine wasted as it rolls down their cheeks instead of making it into their eyes. This translates into patients having to purchase fewer bottles of medication — a definite help with compliance, especially during an economic downturn.

Dr. Cantor emphasizes that patients should call if they have any questions about their new medications. "I tell them they can call us if they perceive any problems. I try to make patients feel that there is an open line of communication, that they can call us without feeling they are bothering us with stupid stuff."

Compliance and Technology

Given the generational change underway in the United States, Dr. Craven believes that technology can soon be an effective tool in boosting compliance. E-mails and text messages reminding patients to take their medicines would work with the new "wired society."

"There's a service from one of the dental companies called something like ‘Smile Reminder’ and it sends you a text message once a month with information about your teeth," Dr. Craven says. "I know that dentists are having a lot of success with it. I wouldn't be surprised if docs started doing stuff like that, because we're going to have to do something to be effective about making sure patients know what they need to do. I think they might pay attention to a short sound-bite text message."

He believes that e-mailing patients video clips that demonstrate drop administration would also be helpful reminders once they leave the physician's office. Ultimately, though, he says the doctor-patient relationship will continue to be the key element to successful compliance. "It's really our job as physicians to convince the patient that the reason they're using the medication is to help them." OM

References

1. Kholdebarin R, Campbell RJ, Jin YP, Buys YM. Multicenter study of compliance and drop administration in glaucoma. Can J Ophthalmol. Aug 2008; 43:454-461.

2. National Eye Institute. Prevention of Blindness Data Tables; Summary of Eye Disease Prevalence Data. http://www.nei.nih.gov/eyedata/pbd5.asp. Published April 12, 2004. Updated December 2006. Accessed Oct. 15, 2008.