SPECIAL SECTION: PATIENT COMPLIANCE

Are patients telling the whole truth?

Maybe not. And when they tell half truths about compliance, read between the lines.

By Wendy Lyons Sunshine, contributing editor

Imagine a Mrs. Peters, age 82. She insists she follows treatment instructions, but says, “I just ran out of my eye drops.”

That’s strange. According to her chart, she still has two weeks of doses left.

“That’s a big red flag,” says H. George Tanaka, MD. He regularly hears such a claim: Elderly patients can’t aim the bottle properly or they put in more than one drop. Then, their medication runs out before they can get a refill, putting their vision at risk.

“It’s hard to admit to the doctor that ‘I’m having trouble with these eye drops’,” says Parag Parekh, MD, of ClearView Eye Consultants in State College, Pa.

Patients may have the best of intentions, but can lack dexterity or follow-through to comply to treatment. Between age-related forgetfulness, vision impairment and tiny bottles that are difficult for arthritic fingers to squeeze correctly, it’s a recipe for nonadherence. “We see it every day, multiple times a day, where drops are too expensive or they burn and sting and cause redness, and so the patient doesn’t like side effects and doesn’t take them every day,” says Dr. Parekh.

Having an open, non-judgmental attitude helps unearth problems. Several doctors recommend phrases such as, “Many people have trouble taking the drops — are you finding that? Is it ever hard to remember to take the drops?”

Playing detective

“Checking IOP only tells us if the patient put in the drops the morning of their visit,” says Dr. Tanaka, a clinical instructor at California Pacific Medical Center in San Francisco. He compares it to brushing your teeth before visiting a dentist. Instead, Dr. Tanaka looks for eyelash growth and increased skin pigment around the eyelids, which are side effects of regular prostaglandin use.

Even patients who seem to be able to discuss bottle cap color may not be following the protocol. A December 2015 study in Ophthalmology found that glaucoma patients can have color-vision deficiency that makes communicating with them about the bottle cap color an unreliable indicator of compliance.¹

Researchers have resorted to equipping conventional medication bottles with electronic sensors to measure dosing frequency and the amount of medicine that is released.² In a similar way, practitioners can request reports from the pharmacy on refill frequency. “That helps tell a lot, because we don’t have to ask the patient,” says Rishi P. Singh, MD, a staff physician at Cleveland Clinic Cole Eye Institute. “We can tell from looking at their med history what is taking place.”

Teaching good technique

What looks like noncompliance can actually be poor eye-drop technique. A January 2016 study in PLoS One suggests that proper eye-drop technique is dependent on three factors: whether a drop is actually placed on the eye surface; whether patients have washed their hands and avoided touching the dropper tip; and whether the right number of drops, or too many, were squeezed out.³

Retinal specialist Sandra Montezuma, MD, assistant professor in the Department of Ophthalmology and Visual Neurosciences at the University of Minnesota, adds another factor: making sure the patient waits long enough between multiple meds. She realized that poor technique led to postoperative inflammation in some patients. So she and colleagues experimented with training videos. The results, published in Clinical Ophthalmology in August 2016, confirmed her suspicion.⁴ “Many people think that they are doing a good job administering their own medication when actually they are not,” she says. “The patient could be actually putting the eye drop on his or her cheeks. Elderly people often need more than one attempt.” Watching the training video significantly improved their technique, which backs up studies that show education improves compliance.⁵ Dr. Montezuma now asks her patients to demonstrate how they apply drops and plans to run the training video in her reception area.

Creative and choice strategies

Many eye-care professionals have found successful methods of reminding patients to take medication. In a study published in JAMA Ophthalmology, the adherence rate in 20 participants who received automated, once-daily text or voice messages increased from 54% to 73%.⁶

Dr. Parekh gives his patients a daily drop-scheduling chart. He may “assign” a family member to put in the drops. “I also try to make a positive association. For example, if you love to have a glass of wine every day, make yourself a promise that you don’t take the glass of wine until you take the eye drops,” he says.

Dr. Tanaka suggests tying the drop to a daily activity like brushing teeth. For patients who fall asleep watching TV and forego their nighttime dose, he advises they take that drop in the morning, even though it’s prescribed for bedtime. For those with serious compliance problems, Dr. Tanaka sometimes suggests selective laser trabeculoplasty. The one-time procedure can be an effective alternative to the initial or second drop.

Also, drug choice may impact compliance. A study in Clinical Ophthalmology found that bimatoprost 0.01% had a higher compliance rate than travoprost Z 0.004% solution.⁷ Potential factors included treatment efficacy, the frequency and nature of adverse ocular effects and cost. If cost is a barrier to certain medications, doctors can explore coupons, samples and generics.

Suggested resources for readers

To help with patient compliance, Dr. Montezuma recommends these tips for administering eye drops: http://tinyurl.com/OMcompliance.

Also, Dr. Parekh suggests giving patients a medication reminder sheet, like the one below:

Emphasize the outcome

“We can never truly measure compliance,” says Dr. Tanaka. “But we can measure the effect of non-compliance on the disease.”

Dr. Montezuma tells open-angle glaucoma patients, “Because the eye does not have any symptoms like pain, it could be difficult to remember applying the eye drops. But, like having high blood pressure, taking the medication is important even when they are asymptomatic.

“Once you make patients realize that conditions like glaucoma can progress despite any eye symptoms, they are more likely to be compliant.”

Dr. Singh has an effective strategy to help patients stop fibbing. “I tell them, ‘It is better [for me] to know you weren’t taking it than that it didn’t work.’”

There’s a lot he can do to help them take the treatment, but if it doesn’t work they may run out of options or be looking at an expensive second- or third-line agent. “That can resonate with them, so they are willing to be honest. That usually works out very well.” OM

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