Like many of my colleagues, I find compliance to be a huge hurdle in the management of glaucoma patients. It is difficult, if not impossible, to keep them on track. Consider all that they face:
- Needing medication for the rest of their lives
- Waiting at the pharmacy to receive prescribed medications
- Paying an office copay every 3 to 4 months
- Undergoing one of many in-office tests.
What’s more, studies have shown that noncompliant patients tend to be dissatisfied with the wait time or cost of the examination, and that noncompliance with medicine use is linked to increased disease severity.1,2
In the end, each time, they’re waiting for the doctor to say, “Everything looks good, keep taking your drops, and we will see you in 4 months.” Imagine how this must feel to them, especially when their vision isn’t getting any better.
Like other subspecialties and disease states in ophthalmology, we glaucoma specialists are striving to achieve that “20/happy” patient. In our practice, we have learned that there are five key ways to improve compliance and achieve greater patient satisfaction.
1 Educate Patients
Everything begins and ends with patient education; it is the foundation for following the other tips listed below. We view the first appointment as the initial “investment” in the patient.
My staff and I spend a few more minutes to ensure patients understand that glaucoma is progressive, not reversible, and often has no symptoms. We stress that not every patient needs the same treatment or target pressure. We also manage expectations by explaining that they’ll need to see us every 4 to 6 months, whether they’re treated or not, and that we’ll need to conduct multiple tests every year to ensure the glaucoma isn’t progressing.
Our patients also know that the target pressure range is evolving and may change if the nerve is not stable. And, I educate patients on the impact of not consistently taking the prescribed medication.
2 Manage Cost Concerns
Cost has become an even bigger issue as more and more branded drops are being substituted for generics. Many patients don’t understand the differences between their medications, let alone differences between branded versus generic medications.
Patients often return to our office on a medication we did not prescribe. This can happen when the patient goes to the pharmacy and is told the cheaper substituted medication is the “same as the one prescribed.”
As consumers, we place value in everything we purchase, whether a car, computer, phone, or even coffee; we justify the cost based on our understanding of the value, so it is imperative that patients understand the value of the medication we prescribe.
To this end, we developed a form that we give to all patients whenever we prescribe a brand-name medication (See Table 1 on page 16). This form helps distinguish the subtleties between the proprietary medication and its generic counterpart.
| Brand Name | Generic |
|---|---|
| Only one company makes the product | Multiple companies can make the product. Each company may use different components in the solution. |
| FDA requires multiple large multi centered studies to prove efficacy and safety of the active and inactive medication | FDA only requires smaller studies to confirm at least 80% equivalence of the active molecule — no studies on the inactive ingredient. |
| FDA has tight oversight over the inactive ingredients in the bottle – preservative, PH, buffering agent, solution and the bottle itself | NO FDA oversight on the inactive ingredients and bottle — they can affect the efficacy and tolerability of the drop. Also variability in how the drops come out depending on bottle construction. |
| With each refill, you will always get the same medication from the same manufacturer | With every refill, you may get a different generic manufacturer who may use different components – efficacy and tolerability may change with a different company. |
Patients are also told to ask the pharmacy to tell them the difference in cost after running it through insurance. In a study we conducted in our office, using this educational technique, we found that 65% of our patients changed to a brand-name medication after they understood the difference.
3 Simplify the Dosing Regimen
The dosing regimen is another important barrier. Multiple studies have demonstrated that adding a second or third bottle decreases compliance.3,4 We offer SLT as a first-line therapy and are more aggressive offering SLT before adding a second or third medication. Now with the various MIGS options, we can surgically reduce the drop burden much earlier in the disease, even in mild to moderate patients. Regardless of how well controlled their IOP and ONH are, if they’re complaining of cost, we offer SLT or MIGS options.
However, when additional medications are necessary, we try to maximize one class of medication, if at all possible, by either switching within class or encouraging compliance with current medications before we add a second one. If we do add a medication, we try to find complementary mechanisms of action, and often rely on combination medications to achieve the target IOP.
I also provide written instructions for all medications prescribed — even if it’s just one medication — and suggest reminder strategies for taking medications. For example, setting a daily alarm or marking off each day on a calendar when the drops are used.
Patients can integrate their medication regimen into their daily routine by storing the medications next to their toothbrush or pillbox to serve as a visual reminder. In addition, we always ask family and caregivers to be present at the appointment, because this second person can also help patients remember the treatment plan.
4 Address Side Effects
Managing side effects of medications is a fundamental part of glaucoma patient management. Setting proper expectations ahead of time can decrease the “shock” of an adverse event. For instance, telling a patient a drop might burn or turn the eye a bit red prepares the patient, so he or she doesn’t overreact if an adverse event does occur.
Changing the time of dosing can also help. In a nonpublished study we conducted in 2007, we asked patients taking a PGA who complained of morning hyperemia to self report hyperemia when the dosing time was changed to earlier in the day and tears were used 5 minutes after. By changing the time of dosing from bedtime to earlier in the evening, patients reported 50% less hyperemia.
5 Treat Concomitant Conditions
A major part of my practice involves identifying and treating coexisting conditions, namely ocular surface disease. There are very few other conditions in the eye that have as many associated symptoms, including, pain, redness, photophobia, and most important, fluctuating vision.
These symptoms can affect quality of life, and often impact our patients’ ability to stay compliant with our recommendations. Although we, as providers, are focused on the IOP, patients are focused on the symptoms of dry eye. If we don’t address those symptoms, it’s hard for patients to trust us, and they may stop taking their medications.
Doctors are often overwhelmed and don’t have time to focus on dry eye during their busy day. After conducting a retrospective analysis on patient’s symptomology, we found “fluctuating vision” provided the highest sensitivity to dry eye diagnosis. Now, I just ask patients, “Does your vision fluctuate throughout the day or with each blink?” If they say “yes,” I work on the premise that they have ocular surface disease until proven otherwise.
Sometimes, the dry eye disease can be confused with adverse events from glaucoma drops. Although adding more medications affects compliance, when adding a dry eye drop, we are treating unpleasant symptoms that can help their vision, which is why they’re often more compliant when adding dry eye medications to their daily medication regimen.
At the end of the day, we’re trying to protect our patients from losing vision while maintaining a high quality of life. It’s not always easy, but keeping these 5 key tips in mind can help. GP
References
- Kosoko O, Quigley HA, Vitale S, et al. Risk factors for noncompliance with glaucoma follow-up visits in a residents’ eye clinic. Ophthalmology. 1998;105(11):2105-2111.
- Ung C, Murakami Y, Zhang E, et al. The association between compliance with recommended follow-up and glaucomatous disease severity in a county hospital population. Am J Ophthalmol. 2013;156(2):362-369.
- Friedman DS, Hahn SR, Gelb L, et al. Doctor-patient communication, health-related beliefs and adherence in glaucoma results from the Glaucoma Adherence and Persistency Study. Ophthalmology. 2008:115(8):1320-1327.
- Gurwitz JH, Glynn RJ, Monane M, et al. Treatment for glaucoma: adherence by the elderly. Am J Public Health. 1993:83(5):711-716.
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