The many paths to adherence

Patients will bring their own priorities to medication. A doctor’s job is adapting.

By Robert Stoneback, Associate Editor

The issue of patient adherence, especially glaucoma adherence, seems like it will always be under investigation. For the past 20 years, it’s held the interest of George Spaeth, MD, a glaucoma specialist at Philadelphia’s Wills Eye Hospital.

As it has many others.

In 1995, Dr. Spaeth and his colleague found that 59 out of 100 patients did not use their eyedrops as prescribed for reasons including forgetfulness, inconvenience and unaffordability.¹

In 2011, other researchers wrote that patients’ adherence to glaucoma medication is a “constant challenge,” but that they are more likely to follow through if they better understand the reasons for treatment and if their regimen is simplified.²

And this past November, a study in the Journal of Glaucoma examined 250 randomly selected glaucoma patients, seen by five glaucoma specialists. The study concluded that since IOP targets were exceeded on nearly one-third of visits, management changes and active decision-making were needed to improve care.³

However, the most important thing for an ophthalmologist to remember about patient adherence, according to Dr. Spaeth, is that no two patients are alike.

“The only approach that works is the approach that works for the patient under consideration, and that is different with each patient, because every patient is unique,” says Dr. Spaeth.

Personalized treatment

“Some patients need to have things to remind them to do things, such as a cell phone set for a certain time of day, or to have their drops [put] beside their toothbrush because they always brush their teeth at night,” says Dr. Spaeth.

Shan C. Lin, MD, clinical spokesperson for the AAO, also recommends the use of smartphone apps to assist with adherence. Dr. Lin, who is also director of Glaucoma Service at the University of California, San Francisco School of Medicine, says studies have found “promising” results when using electronic reminders for eyedrops.

Other patients may find eyedrops too uncomfortable and decide not to use them. In these cases, prescribing eyedrops would be bad care, and alternatives such as surgery or laser treatment should be considered instead, says Dr. Spaeth.

“It is the physician’s responsibility and opportunity to know into which of these categories the patient falls. If the physician cannot do that, then he or she should learn how, and if he or she cannot learn, how he or she should stop practicing medicine.”

Angelo P. Tanna, MD, associate professor of ophthalmology and director of the Glaucoma Service at Northwestern University Feinberg School of Medicine, Chicago, finds some patients respond better to having a written schedule or a reminder to assist them with an eyedrop schedule. Studies have shown that some types of eyedrops, such as prostaglandin analogue eyedrops, are similarly effective regardless of the time of day used, so patients should use them when they wake up if they find it easier to do so, he says.

For Dr. Lin, a most difficult pre-existing condition for eyedrop adherence is dementia. In those situations, he involves the patient’s family or close friends to help remind them to take their eyedrops. He also coordinates with social services to assist these patients with drops.

Educate the patient

Along with fine-tuning the treatment to the individual, Dr. Tanna makes the patient a partner in the treatment process.

“In my view, the key thing is, one, to make sure the patient understands the disease process … they have to understand what glaucoma is and what the goal of treatment is,” he says.

For many patients, it can just be a matter of constantly talking to them about the nature of their disease and how their medicine is helping them.

In some cases, Dr. Tanna has seen patients stop using their eyedrops because their vision did not improve, not realizing the drop’s purpose is to lower IOP. If the patients had known, they may have continued to take them, he says.

Dr. Spaeth and Dr. Lin agree.

“Some patients simply haven’t had things explained to them,” adds Dr. Spaeth. “The moment you explain things so they understand, then they become totally adherent.”

Dr. Lin says another value point is to spend time talking with patients on a level they can comprehend. “It behooves us to spend the extra few minutes to ensure the patient understands. I also have diagrams in each exam room to help explain what glaucoma is and how the drops work.”

Getting to know your patients goes a long way towards learning if they’re effectively taking their medication, says Dr. Tanna. The technicians in his clinic help with this by asking what medications they’re taking. This gives them a chance to demonstrate how well they know their treatment regimen. If they show unfamiliarity, this can be a clue that they need further education.

Doctors should also prepare patients for potential medical side effects, such as hyperemia. This will build trust and confidence in the physician and increase the likelihood of adherence, according to Dr. Tanna.

Be flexible

Patients ultimately want to do something that’s not only beneficial to them but fits into their lifestyle, says Dr. Spaeth. He recalls a colleague who was liked and respected by her patients, but would prescribe pilocarpine for them to use five times a day. Most patients can’t fit five doses of any medicine into their daily routine since it doesn’t easily correlate to their existing schedule.

“It was poor treatment to ask the patients to do something that they could not do. This is the whole secret to having patients take medications properly,” Dr. Spaeth says. A medication routine needs to be built around each individual’s lifestyle.

Dr. Spaeth sees current medical care as focusing too much on “normalizing” every patient, which is detrimental to patients in the long run, he says. Medical students hear that they must not relate to their patients and that averages are healthy, he continues. Reliance on electronic health records can lead to further standardization of patients, creating another obstacle for individualized care, Dr. Spaeth says.

What’s important is to treat each patient “as a unique, deserving person,” he says. OM

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