As with other chronic, asymptomatic diseases, patients’ adherence to their prescribed glaucoma medication regimen is often poor, ranging from 10-83% depending on the definition and the method of measurement.^1-4 And as clinicians know all too well, poor adherence to glaucoma drops is associated with an increased risk of glaucomatous vision loss.⁵

Clinicians also know well that patients might not adhere to their prescribed medication regimen for a variety of reasons and that changing behavior is challenging. We can be encouraged, however, by the results of recent studies of interventions designed to improve medication adherence and adopt them in our own practices.

REASON FOR HOPE: THE STUDIES

SEE

The Support, Educate, Empower (SEE) program included an in-person counseling session with a (non-physician) glaucoma coach trained in motivational interviewing. Of the three glaucoma coaches in the study, one was an ophthalmic technician, one was a health educator and one was a social worker. All three completed a 16-hour course in motivational interviewing. In a motivational interviewing approach, the interviewer and participant engage in a dialogue encouraging the participant to consider personal priorities and identify strategies for success that have personal meaning. The coach used a web-based tool developed for the study to generate an education plan tailored to the participant.

Participants received telephone calls designed to boost support between the in-person sessions; automated medication dosing reminders were also employed. Medication adherence was measured by an electronic monitor for a 3-month period before the initial educational visit and throughout the 7 months of follow-up.

Of the 100 participants enrolled in the study, electronic monitoring of medication adherence revealed suboptimal adherence for 48 participants, making them eligible for the SEE program, while 47 were ineligible and five dropped out before the end of the monitoring period. For study participants, the average medication adherence improved from 60% at baseline to over 80% (p <0.0001) after completing the SEE program. Ninety-five percent of participants showed some amount of improvement in adherence with this program.⁶

MAGIC

The 2022 Medication Adherence in Glaucoma to Improve Care (MAGIC) study was a randomized controlled trial conducted in a population of veterans with glaucoma who reported poor adherence to their prescribed drops. We designed the intervention to be multifaceted given the many reasons why people might struggle with glaucoma medications. It included an educational session with the participant and their companion if that person was involved in administering drops or reminding the participant to administer drops.

In the session, an ophthalmic technician led a discussion regarding glaucoma, the possibility of blindness and the benefit of treatment. In addition to their clinical experience as an ophthalmic technician, the interventionist received 4 hours of dedicated training on glaucoma and glaucoma medication adherence from the investigator. The technician utilized printed brochures designed to be appropriate for people of varying reading levels, a 3D model eye, a survey that guided individualized problem-solving and a printed dosing schedule. For example, if a participant reported falling asleep before taking their bedtime dose of a prostaglandin analog, the technician might suggest changing the schedule to morning dosing. The technician assessed eyedrop administration technique and recommended drop aids if needed. As discussed in further detail below, two drop aides are available from VA’s Rehabilitation and Prosthetic Services at no charge to veterans.

Participants also received a smart bottle made by AdhereTech that provided alerts (visual or audible, per participant preference) to missed doses. The smart bottles are not routinely available for the VA but were purchased through funds from the grant awarded by the VA to conduct the study. Two hundred participants were randomized to the intervention or to usual care. In the 6 months following the intervention, the mean proportion of prescribed doses taken on schedule was higher for participants in the intervention group compared with controls (85% vs 62%, p < 0.0001).⁷

It is encouraging to find that in two prospective clinical studies, interventions designed to improve adherence resulted in meaningful change, but how can the lessons learned from these studies be applied in the real world?

A LOOK AT THE LESSONS

Team approach

In both studies, education was provided by a team member other than the treating physician. This is certainly not to say that the physician should not engage the patient in discussions about adherence, but it suggests that non-physician team members can be very effective educators. The additional education that the coach/interventionist received ranged from 4 to 16 hours between the two studies.

In the MAGIC trial, educational sessions and individualized troubleshooting were conducted with the involvement of the participant’s companion if a companion was involved in the glaucoma care in any way. Cost analysis of the intervention, interestingly, showed the intervention was most cost-effective when a companion was involved. Cost-effectiveness of the MAGIC intervention was assessed as an incremental cost-effectiveness ratio that takes into account the difference in total health-care costs between the intervention arm and the usual care arm and the number of additional participants who achieve medication adherence from the intervention arm compared to the control arm. The incremental cost difference was -$149,400, favoring the MAGIC intervention, and 38 additional participants were at least 80% adherent to their medications.

In subgroup analysis of the 20% of participants who included a companion in the educational session, the cost savings was even greater with an incremental cost-effectiveness ratio of $2,423, and 50 additional participants at least 80% adherent. We did not explore the reasons why involving a companion in the intervention is associated with less total health-care costs, but I would hypothesize that “four ears are better than two.”⁸

Dosing reminders

Patients with glaucoma report many reasons for poor adherence, but one of the most common is plain old forgetfulness.⁹ In both SEE and MAGIC, participants used devices that could alert them to missed doses. Although such devices are not easily available outside of the research setting, automated dosing reminders via mobile devices can also be effective in supporting proper medication adherence.¹⁰ Such reminders may be available through patients’ health plans or free apps such as EyeDropAlarm (Figure).

Low-tech reminder aids such as printed schedules posted on the refrigerator, notepads with the date and check boxes for dosing events, phone alerts or alarm clocks, or simply positioning the bottle in a routine position (for example, to one side of the coffee maker before administering the drop and to the other afterwards) can all be effective, depending on the patient.

Perhaps one lesson from motivational interviewing in SEE and the personalized trouble-shooting in MAGIC is that collaborating with patients to determine that mnemonic strategy that will work best for them (versus offering standard recommendations for all) is an effective strategy for improving timeliness of dosing.

Education

Interventions in both studies included disease education. While it is difficult to parse out which elements of multifaceted interventions are most effective, providing education about glaucoma is something that all of us can do with readily available resources. It is worthwhile to consider clear health communication strategies to ensure that the educational messages that we deliver are available to all patients. Such strategies include limiting dense text and utilizing clean graphics.¹¹

We should be careful making assumptions about what our patients may or may not know about glaucoma. We did not find any relationship between disease severity and glaucoma disease knowledge.¹² Our patients are better served if we provide comprehensive education to everyone.

Drop administration aids

Even patients who have been taking glaucoma drops for years may struggle with properly instilling a drop into the eye.¹³ In one study, 80% of patients interviewed reported not remembering anyone ever having shown them how to correctly instill eyedrops.¹⁴ In the MAGIC trial, drop administration aids including the Autodrop and Autosqueeze (both Owen Mumford)¹⁵ were prescribed if the ophthalmic technician assessing administration technique believed such aids would be helpful. Many such devices are available at low cost, particularly from online vendors.

However, even a low-cost aid is a waste of money if it does not address the patient’s specific need. For example, if a patient can aim the drop perfectly but can’t squeeze the bottle, Autodrop will not help. If a patient can aim and squeeze the bottle but is administering a stream of drops with every dosing event, they may not need an aid at all but rather instruction on how to administer a single drop.

Assessing drop administration technique (by the patient or companion) allows the care team to choose the most appropriate device, if applicable.

COST

One important barrier to medication adherence is rarely present in clinical studies such as SEE and MAGIC but is massively important in real life — cost. In an annual survey regarding health topics that is administered to a representative sample across the United States, participants with glaucoma reported they could not afford prescribed medications more frequently than participants without glaucoma (8.2% vs 6.4%, p=0.02416).¹⁶

Addressing the significant burden of medication cost with our patients frankly and, perhaps, repeatedly, may help ensure the sustainability of our treatment plan. Generic medications and laser trabeculoplasty often offer at least as effective pressure lowering as higher cost branded medications.

BLUEPRINT FOR BETTER ADHERENCE

Given the multitude of barriers that can make proper medication adherence challenging for our patients, it is easy for clinicians to become jaded and suspect that their efforts are inconsequential. We believe, however, that a thoughtful and multipronged approach can be effective at reducing preventable vision loss by helping our patients better self-manage their disease. OM

REFERENCES

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2. Tielsch JM, Katz J, Singh K, et al. A population-based evaluation of glaucoma screening: the Baltimore Eye Survey. Am J Epidemiol. 1991;134:1102-1110.
3. Gurwitz JH, Glynn RJ, Monane M, et al. Treatment for glaucoma: adherence by the elderly. Am J Public Health. 1993;83:711-716.
4. Patel SC, Spaeth GL. Compliance in patients prescribed eyedrops for glaucoma. Ophthalmic Surg. 1995;26: 233-236.
5. Newman-Casey PA, Niziol LM, Gillespie BW, Janz NK, Lichter PR, Musch DC. The Association between Medication Adherence and Visual Field Progression in the Collaborative Initial Glaucoma Treatment Study. Ophthalmology. 2020;127:477-483.
6. Newman-Casey PA, Niziol LM, Lee PP, Musch DC, Resnicow K, Heisler M. The Impact of the Support, Educate, Empower Personalized Glaucoma Coaching Pilot Study on glaucoma medication adherence. Ophthalmol Glaucoma. 2020;3:228-237.
7. Muir KW, Rosdahl JA, Hein AM, Woolson S, Olsen MK, Kirshner M, et al. Improved glaucoma medication adherence in a randomized controlled trial. Ophthalmol Glaucoma. 2022;5:40-46.
8. Williams AM, Theophanous C, Muir KW, Rosdahl JA, Woolson S, Olsen M, et al. Within-trial cost-effectiveness of an adherence-enhancing educational intervention for glaucoma. Am J Ophthalmol. 2022;244:216-27.
9. Newman-Casey PA, Robin AL, Blachley T, Farris K, Heisler M, Resnicow K, et al. The most common barriers to glaucoma medication adherence: A cross-sectional survey. Ophthalmology. 2015;122:1308-1316.
10. Boland MV, Chang DS, Frazier T, et al. Automated telecommunication-based reminders and adherence with once-daily glaucoma medication dosing: The Automated Dosing Reminder Study. JAMA Ophthalmology. 2014;132:845-850.
11. Williams AM, Muir KW, Rosdahl JA. Readability of patient education materials in ophthalmology: a single-institution study and systematic review. BMC Ophthalmology. 2016;16:133.
12. Robinson CG, Schempf T, Williams AM, Muir KW, Woolson S, Olsen M, et al. Glaucoma knowledge and disease severity in a veteran population: The medication adherence in glaucoma to improve care (MAGIC) study. Ophthalmology Glaucoma. 2022:S2589-4196(22)00216-2.
13. Stone JL, Robin AL, Novack GD, et al. An objective evaluation of eyedrop instillation in patients with glaucoma. Arch Ophthalmol. 2009;127:732-736.
14. Tatham AJ, Sarodia U, Gatrad F, Awan A. Eye drop instillation technique in patients with glaucoma. Eye (Lond). 2013;27:1293-1298.
15. AutoDrop & AutoSqueeze 2022 [Available from: https://www.owenmumford.com/us/medical-devices/eye-care/autodrop-autosqueeze . Accessed Jan. 26, 2023.
16. Gupta D, Ehrlich JR, Newman-Casey PA, Stagg B. Cost-related medication nonadherence in a nationally representative US population with self-reported glaucoma. Ophthalmol Glaucoma. 2021;4:126-130.

Kelly W. Muir, MD, MHSc, is a glaucoma specialist practicing at the Duke Eye Center and the Durham Veterans Affairs (VA). She is the director of fellowship programs at Duke and the section chief at the VA. Her research interests include measuring and improving adherence to prescribed glaucoma medications with special attention to improving visual outcomes in vulnerable populations. She reports no financial disclosures.

Jay K. Rathinavelu, BSE, is a medical student at the Duke University School of Medicine.