compliance

Compliance Solutions

How to respond to common glaucoma patient problems.

Leo Semes, O.D., F.A.A.O., Birmingham, Ala.

One of the challenges in managing glaucoma patients is assuring compliance for this chronic condition. With any repetitive process or, in the case of glaucoma, chronic condition, there can be any number of barriers to compliance.

Most clinicians can think of examples of barriers to compliance and their patients' replies to why they have not taken their medication. Here I will explain the solutions to common patient responses.

“I forget to take my medication”

The most prevalent reason for patients missing doses is forgetfulness. It is easy to presume that patients understand their diagnosis and even something as seemingly simple as eye drop administration. For those who recall multiple administrations of drops to lower intraocular pressure (IOP) in days past, the advent of the prostaglandin analogs with once daily administration revolutionized glaucoma management. What could be easier than one drop in the eye once a day?

One way to remind patients is to instruct them to associate the dosing time with an activity that they perform routinely. This can be ablutions at the end of the day with the dropper bottle on the patient's sink or an alarm-clock setting with the dropper bottle on the patient's night stand. Absent these specifics, I try and find something else that will be a consistent reminder. Think creatively, such as using the patient's favorite TV program or a mealtime as reminders. Once that patient gets into the routine of regular dosing, it becomes a habit.

A contemporary version of a dosing reminder is the EyeDROPS application (HarPas International, LLC) available for iPhone. This free application serves as a reminder for patients to remember dosing and can be programmed for any medication, even helping to avoid confusion when using multiple medications by allowing the user to take a photos of the bottles.

Also, consider the patient's lifestyle and how dosing may interfere with it by making modifications that will facilitate compliance. A question that surfaces with evening dosing of the prostaglandin analogs, for instance, arises when the patient's work schedule is something vastly different than “9-to-5.” In pre-marketing studies, evening dosing was found superior. What this translates into for practical purposes is to have the patient dose before going to sleep. This coincides with the pharmacologic activity but is a discussion beyond the scope of this topic.¹

Make the dosing regimen as simple as possible to facilitate compliance. A great asset here is q.d. dosing with the prostaglandin analogs. In a tribute to C. Everet Coop, M.D., the former surgeon general of the United States, keep in mind that “Medications don't work for patients who don't take them.”

Think creatively, such as using the patient's favorite TV program or a mealtime as reminders.

“I can see fine. It must not be that serious.”

Lack of compliance often arises from a “failure to communicate” (with apologies to Strother Martin and Paul Newman in Cool Hand Luke as well as Gun ‘N Roses' “Civil War”). In other instances, poor compliance occurs because of a lack of understanding on the part of the patient despite appropriate communication on the part of the provider. Regardless, giving the patient a thorough understanding of the disease, through both spoken instructions and printed materials, can foster better patient-provider communication.

So as a first step in overcoming barriers to communication and assuring patient compliance, tell patients that glaucoma, while not painful, is a disorder with potentially blinding consequences. Without alarming the patient or creating undue anxiety, we need to emphasize the lifetime nature of minimizing the number-one risk factor: elevated IOP and its modulation.

Patients need to have the understanding that IOP-lowering strategies are a lifetime commitment because the glaucomas are progressive conditions without treatment. What is known about glaucoma management is that the only means to manage the condition is to lower IOP. So, patients must understand that primary open-angle glaucoma and normal-tension glaucoma as well as ocular hypertension are managed by reducing IOP. Clinicians should look at appropriate means to communicate with patients regarding what is, in the cases just mentioned, generally painless but comes with potentially significant consequences.

In a sense, you must presume illiteracy. While this may be an over-simplification, it may be easier to treat all patients as if they need to be constantly reminded. Take each visit as an opportunity to review the condition and medication. If there have been changes in the patient's history/health profile, make changes accordingly.¹

Also, be sure to answer any patient questions and review side effects with the patient and family members. Remember to emphasize the hyperemia, periocular changes and potential iris color changes that may occur from medication use. In addition, refer the patient to the package insert (and review it to become familiar with it yourself). One of the important aspects of the package insert besides listing potential side effects is the FDA-approved dosing. This will come into play when additive therapy is indicated, for example. The topical carbonic anhydrase inhibitors and alpha-adrenergic agents are indicated for t.i.d. dosing. Deviating from this schedule is considered off-label and must be communicated to the patient and entered into the chart.¹

Again, explain that glaucoma is a chronic disease, which is reflected in elevated IOP measurements, and that patients are at greater risk for disease progression and vision loss. It is easy in a busy clinical setting to simply add additional drops when this situation occurs, but we should take a step back and determine whether elevated IOP readings are a trend or simply a blip. Having empathy for the patient's situation is a starting point here.

One suggestion is to ask the patient if he/she has encountered any problems with the drops. An open-ended question such as, “What problems are you having with your drops?” is often an ice-breaker to better patient communication.

This comes from a paradigm developed by Steven Hahn, M.D., an expert in patient compliance and a practicing internist. The strategy is intended to encourage the patient's truthful response. It also allows the patient to express any misgivings about taking the drops, such as ocular redness. The most prevalent side effect of the prostaglandin analogs is conjunctival hyperemia. Patients and others may notice this and find it objectionable. So, at the outset, this is something that can be communicated (and then reiterated) but balanced against the efficacy and simplicity of the treatment strategy.²

“I'm having trouble…”

A variety of issues can arise even when patients remember their medication and know the risks associated with glaucoma. Since we all administer eye drops to patients frequently, it is easy to presume that everyone knows how to do this. However, taking this for granted with a newly diagnosed glaucoma patient may be making too much of a leap of faith. Therefore, you should instruct the patient how to properly use the dropper bottle.

Start by asking the patient to demonstrate eye drop administration with tear supplements. If necessary, have a trained technician assist the patient with this skill when this is not easy for a patient to accomplish. These two steps may be useful in establishing rapport with the patient, too.

Assure that there are those to assist if the patient is or becomes unable to administer the drops, as this is another aspect of care that is easy to overlook. Be sure to portray and reinforce the team concept, and the patient is a very important member of that team. When patients have someone in the household assisting with drop instillation, those individuals should be familiar with the reason for the patients taking drops and when and how they should be administered. Perhaps having those people demonstrate administration or just serving as reminders is as comforting to have as resources.

One of the more interesting barriers to drop administration is being unable to open the sealed bottle. While this packaging procedure is necessary for the obvious sterility reasons, think about how difficult it may be for some-one who has arthritis or who struggles to even open the bottle or squeeze it to administer the drops. In this situation, the team approach is crucial.

Finally, work with your patients to keep their prescriptions up-to-date. Ask the patient at each visit whether a renewal of the prescription is needed.

“I can't afford the medication.”

Be sympathetic to drug costs by making modifications to the patient's regimen to achieve the treatment goal without being unduly financially burdensome. Every major manufacturer of IOP-lowering drops has some means of patient assistance. Depending on the program, different qualifications may be needed. These can include income qualification or need demonstration. So, when the patient initiates this conversation, you the optometrist can refer him/her to the particular company's policy for a patient assistance program. For an index of programs by drug name, visit EyeCareAmerica.org.

Also, take the time to discuss the patient's insurance restrictions. A helpful resource here is FingertipFormulary.com. After choosing the medication, it is possible to select your jurisdiction and the patient's insurance carrier to determine the tier for any particular drug.¹

It's all about the patient

Using our knowledge of glaucoma and its management with IOP-lowering topical drops, we can set the stage for good patient compliance. Portraying this template to the patient and reinforcing at each encounter will be helpful in not only initiating good compliance with our instructions but also maintaining life-long adherence for the benefit of the patient. OM

1. Budenz DL. A clinician's guide to the assessment and management of nonadherence in glaucoma. Ophthalmology. 2009 Nov;116(11 Suppl):S43-7.
2. Hahn SR. Patient-centered communication to assess and enhance patient adherence to glaucoma medication. Ophthalmology. 2009 Nov; 116: S37-42.

Dr. Semes is an associate professor and director of continuing education at the University of Alabama Birmingham School of Optometry. He is a founding member of the Optometric Glaucoma Society. Send comments to optometricmanagement@gmail.com.