What patients hear and how they hear it affects their adherence

Patient adherence is “the single most important modifiable factor that compromises treatment outcome.”¹ Patient adherence, or how a patient’s behavior (i.e. taking prescribed medication) follows the prescribed recommendations from the health care provider, affects the safety of the patient and determines the stability of their disease.² For example, and specific to glaucoma, recent studies show poor patient adherence is strongly associated with VF progression rate.³

Because glaucoma treatment usually involves some degree of topical therapy, here I offer a discussion on the words we say and how we say them, which affects patient adherence in glaucoma management.

1 WHAT WE SAY...

Each office visit is an opportunity to provide patient-centric glaucoma education. Therefore, the visit should begin and end with a simple discussion regarding the patient’s condition and the purpose of the associated treatment(s). Focusing on simple, repeatable glaucoma statements throughout the patient’s visit builds understanding.

Enhance these simple, repeatable glaucoma statements with in-office images of the patient’s test results (ONH photos, OCT images, VF results), in-office handouts and links to credible websites to deepen patient understanding.⁴

Perhaps equally important as what we say, is also what the patients say. In other words, we should pay attention to the questions that patients ask and give them an opportunity to, in their own words, share their understanding to help them gain “operational knowledge.”⁵ The patient-centric education may go something like this:

One of the main risk factors related to glaucoma is high eye pressure — a range unique to each patient — and if it is too high for too long, it may lead to optic nerve damage. When the optic nerve does not work as well, it may make parts of our vision dimmer or darker. These changes may be difficult for you to recognize, especially in early stages of disease like yours.

The purpose of the visit today was to check your side vision and try to detect any early, correlating glaucoma damage. Here are the results from your tests today (show VF results).

From what we have talked about, and from what your test results show today, what is your understanding of what glaucoma is and why we have you using eyedrops? (Pause, listen.)

What questions do you have about your test results and visit today that I can help answer? (Pause, listen.)

2 HOW WE SAY IT...

The difference between the above example being just a monologue vs. a productive dialogue has to do with provider positioning and posture. In other words, I recommend an almost knee-to-knee, hands-off-of-the-keyboard, eyes-away-from-the-monitor position with an unhurried, approachable, concerned posture.

Studies show provider behavior directly affects the patient’s adherence, and that there is much that we can do to set the tone early on, and ideally throughout, our long-term care relationship.⁶ Actions (on behalf of the provider) may speak louder than words.

SOME FINAL WORDS

Some words to practice by:

• “No drug can work unless it is taken.”⁸
• “The best treatment can be rendered ineffective by poor adherence.”²
• “Increasing the effectiveness of adherence interventions might have a far greater impact on the health of the population than any improvement in specific medical treatments.”⁹

Considering what we say and how we say it may help improve outcomes and lives. OM

REFERENCES

1. World Health Organization. Adherence To Long-Term Therapies: Evidence For Action. Annexes. https://www.who.int/chp/knowledge/publications/adherence_annexes.pdf . 12/09/20.
2. World Health Organization. Adherence To Long-Term Therapies: Evidence For Action. Introduction. https://www.who.int/chp/knowledge/publications/adherence_introduction.pdf . Accessed 12/09/20.
3. 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(4):477-483.
4. Johnson A, Sandford J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home: systematic review. Health Educ Res. 2005;20(4):423-429.
5. Skorpen JB, Malterud K. What did the doctor say--what did the patient hear? Operational knowledge in clinical communication. Fam Pract. 1997;14(5):382-386.
6. Tsai JC. Medication adherence in glaucoma: approaches for optimizing patient compliance. Curr Opin Ophthalmol. 2006;17(2):190-195.
7. Marcus C. Strategies for improving the quality of verbal patient and family education: a review of the literature and creation of the EDUCATE model. Health Psychol Behav Med. 2014;2(1):482-495.
8. European Glaucoma Society Terminology and Guidelines for Glaucoma, 4th Edition - Chapter 3: Treatment principles and options Supported by the EGS Foundation: Part 1: Foreword; Introduction; Glossary; Chapter 3 Treatment principles and options. Br J Ophthalmol. 2017;101(6):130-195.
9. Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2002;(2):CD000011.

DR. LIFFERTH practices at Grossnickle Eye Center as a consultative optometrist with an emphasis in glaucoma management, and he is a member of the Optometric Glaucoma Society. For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at austinlifferth@yahoo.com.