Solve Compliance Defiance
Here are three ways you can remove the Roadblocks to Patient compliance.

Kirk Smick, O.D., Morrow, Ga., and Charles Ficco, O.D., Atlanta Ga

The reasons for noncompliance with cataract surgery medications, as with other ophthalmic medications are many, though the most popular excuses are: “I didn’t use the drops because I don’t understand the point of using them in the first place;” “When I got home, I couldn’t remember what your instructions were, and I didn’t want to bother you, so I improvised;” and “I didn’t use the medicines you prescribed because there are too many different dosing schedules to remember.” To remove these roadblocks to compliance in your cataract patients, follow these three tips, which we have implemented in our practice and have found very successful. (In addition, you can use some of these tips to solve other ocular medication compliance issues, such as those encountered with glaucoma patients.)
1. Educate the patient on the outcomes of noncompliance Prior to the cataract surgery, educate the patient not only on what he can expect, but the possible negative outcomes to his vision if he doesn’t comply with the pre- and postoperative medications prescribed. For example, we educate our cataract patients about cystoid macular edema (CME) and then transition to a conversation about the importance of using a non-steroidal anti-inflammatory drug (NSAID) to prevent CME. (See “Our Back-Up Plan,” below.) Other complications that can arise from non-compliance: Post-op infections, endophthalmitis and secondary glaucoma. We also send our staff to frequent continuing education (CE) courses that explain the process and procedures of cataract surgery as well as the involved patient psychology. (Patients can sense when you really care abou tthe quality of their outcome.) These courses guarantee that everyone (staff, you, the surgeon) is on the same page, as far as ensuring patients are well educated on the procedure and the proper care necessary for a successful and speedy recovery. And, from a practice management standpoint, we’ve found this method to be partly responsible for an increased number of pre-cataract surgery patients in our office.
2. Develop an instruction form One of the reasons patients create their own medication-taking instructions or don’t take their medications at all is because we, their eyecare provider, don’t provide them with explicit directions to which they can refer. Instead, many of us provide our patients with verbal instructions that we expect them to remember. Then again, some of us write our instructions down and hand them to our patients, but we all know the old adage about doctors’ handwriting. Also, what may sound clear and understandable to us may not sound that way to our patients, and many of our patients don’t ask for clarity for fear of being perceived as unintelligent. To remove all these compliance roadblocks, develop a drug instruction form that includes a picture of the medication and clearly typed instructions in a fairly large font size to ensure it’s not only legible, but viewable. (Try this form out on a family member or friend prior to dispensing it.) We give this form to patients who’ve just undergone cataract surgery (See a copy, below). While we instruct patients to use drops prior to surgery to prevent infection, the form we use specifically addresses the patient’s post-op experience.
3. Standardize dosing Another way to ensure your cataract patient isn’t confused about his medication regimen: Keep all his medications on the same dosing schedule. The typical patient undergoing cataract surgery is a senior citizen, and prescribing an NSAID, an anti-infective and a steroid q4h after the surgery, rather than prescribing a varied medication schedule, reduces confusion, thus helping to keep these patients on track. By educating the pre-cataract surgery patient on the outcomes of non-compliance to his medications, developing an easily understandable medication instruction form and standardizing the dosing of the NSAID, anti-infective and steroid post-surgically, you will conquer compliance defiance in many of your patients, ensuring successful outcomes and referrals of their family and friends.

OUR BACK-UP PLAN
Regardless of the steps you take to ensure a healthy surgical outcome,
non-compliance with medications pre-surgery will always
be an issue with some patients.
So, we believe it’s important to play it safe with regards to the patient’s
health, and plan for non-compliance.
Therefore, we treat our cataract surgery patients with a fourth-generation
fluoroquinolone, gatifloxacin, (Zymar, Allergan) pre-operatively
to prevent them from developing an infection. This way, if a patient
hasn’t complied with the pre-operative medication regimen that we
have prescribed, we can feel confident that any bugs are eradicated
within 15 minutes, and our surgery schedule stays on track.
In addition, we prescribe Zymar to post-surgical patients because
it contains benzalkonium chloride (BAK). BAK aids in precluding contamination,
which could introduce an infection into a potentially
already compromised post-surgical eye. This preservative has
been shown in the medical literature to protect the eye from fungal infections.

Dr. Ficco is a graduate of Nova Southeastern University College of Optometry. He completed his residency in ocular disease at Bascom Palmer Eye Institute and subsequently joined the optometric staff there where he was the director of the externship program. He currently is the Clinic Director, Residency Supervisor, and Externship Coordinator at Clayton Eye Center in Atlanta, GA and an advisor for Allergan. E-mail him at charficco@aol.com.