No patient is 100% compliant. Even your best patients sometimes miss their drops. But do you have any idea how often? Probably more often than you think.
One of the problems: both patients and their doctors tend to overestimate compliance.
Fortunately, you hold the keys to compliance: patient education, communication and trust.
Scope of the Problem
These findings may put the problem into perspective:
Most people believe they are highly compliant when it comes to taking their prescription medicationstwo-thirds of patients say they follow their physicians instructions extremely closely. Yet nearly nearly three-fourths admit to some form of non-compliant behavior.1
One-third of patients dont fill a prescription they are given.1
Nearly half of glaucoma patients discontinue their drops within six months.2
Regardless of age and sex, poor compliance is just as likely to involve well-educated, higher-income people as those at lower socioeconomic levels.3
Doctors consistently underestimate non-compliance, perhaps by as much as half.4
Barriers to Compliance
Numerous factors prevent glaucoma patients from taking their drugs as they should. Some of the major barriers include:
Cost. At least one in 10 Americans cite cost as a barrier to medication compliance.5 More than ever, cost is a major factor, says optometrist Ben Gaddie, of Louisville, Ky. This is especially true for the retired populationthose most likely to have glaucomawho are being affected the most by the current state of the economy.
Side effects. Nearly half of the respondents to one survey reported not taking their medicines due to concerns about side effects.6 And, when you ask about side effects, dont just ask about routine ocular effects of stinging and redness. Sometimes the patient identifies side effects that arent even related to the drug, such as, My blood pressure has been higher since I started the drops, so I stopped taking them, says optometrist and registered pharmacist Jill Autry, of
Too many drugs. The more medications, the worse compliance is likely to be. Among patients age 65 and older, 82% take at least one prescription medicine, more than half (53%) take three or four prescription medicines, and as many as one-third take eight or more prescription medicines.7
6 Simple Compliance Solutions 1. Tie the drug to a daily task. If the patient is on a once-daily drug, suggest taking it along with something the patient does every daynext to the toothbrush, for example, says Ben Gaddie, O.D. Then it wont be easily forgotten. 2. Make it timely. You can prescribe a twice-daily drop for 8 oclock in the morning and 8 oclock at night, but does that work for the patient? I have so many patients who get up at noon and stay up until 2:00 in the morning, says Kelliann Dignam, O.D. So ask out about their lifestyle, and prescribe the medication accordingly. 3. Streamline the Rx. If possible, give patients the fewest number of drops. Studies show that patients on once-daily regimens are much more likely to comply than patients who are required to take medicine multiple times each day.13 Specifically, persistence and adherence are substantially better with once-daily prostaglandins than with other glaucoma drug classes.2 4. Be a proper dropper. Tell patients to use only one drop at a time, not two, says Jill Autry, O.D., R.Ph. The eye cant even hold two drops, so thats just medicine down the drain. Also, tell patients to wait five minutes between drops to avoid washout. And, instruct the patient about nasolacrimal occlusion to get the most medicine out of the drop. 5. Make it mail order. Although pharmacists at the drug store can be helpful in instructing patients about their medicines, Dr. Autry always recommends that patients with chronic conditions use mail order. Mail order pharmacies can deliver a three-month supply right to the patients doorstep, she says. It takes just a phone call every three months instead of a monthly trip to the drug store, so theres no excuse for running out of drops. And, its cheaper because the patient has only one co-pay every three months. 6. Use patient assistance programs. Since cost is a factor for so many patients, dont hesitate to suggest patient assistance programs. Have a staff member help the patient get on the program. There are general programs, such as RxHope (www.rxhope.com), and also programs from companies that make glaucoma drugs: Alcon Cares: 1-800-222-8103 Allergan: 1-800-553-6783 Merck: 1-800-727-5400 Pfizer Connection to Care:
Changes in routine. One of the primary barriers to compliance is nothing major, says Dr. Autry, but just the minor disruptions of everyday life. It could be travel, babysitting the grandchildren, going to a party, a death in the family or a flare-up from another disease they may have.
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Physical or material barriers. These barriers can be anything, such as physical problems in administering the drop due to arthritis, or a snowfall that prevents them from getting the refill at pharmacy, or having trouble reading the small print on the label, Dr. Autry says.
You. At times, the doctor is the problem. The doctor may fail to establish trust with the patient.8 Or, the doctor may not provide adequate education.9 Of course, this important part of compliance is something you control.
Determine Non-Compliance
Non-compliance is a slippery thing, and theres no surefire way to know which patients arent complying. That said, here are some warning signs:
Progression despite medication. If the optic nerve or visual field is getting worse, but the patients intraocular pressure is at or below target, suspect noncompliance, says optometrist James L. Fanelli, of
Drug or dosing dropouts. Dont simply ask, Are you taking your drops as you should? Patients will say, Yes, of course. Ask open-ended questions instead, Dr. Autry says. Ask patients what medicines theyre taking. Ask when and how often theyre taking their them. Also, without being confrontational, ask, How often would you say you miss your drops? Such open-ended questions promote honest discussion, Dr. Autry says.
Keep an Rx trail. I keep a carbon copy of every prescription I write and put it in the patients chart, Dr. Gaddie says. Also, we document when the pharmacy calls and requests a refill, so I have a pretty good idea when patients are getting their medications.
Check the bottle. Ask patients to bring in their bottles, Dr. Gaddie says. Not only will you be able to check that theyre taking the right drug, you can see how much medication is in the bottle to get an idea of how much has been used.
Communication/Education
At then end of the day, it all comes down to communication by the doctor, Dr. Gaddie says. If patients dont understand the diseasewhich causes no symptoms and can be expensive to treatits going to be difficult for them to buy into a lifelong treatment program.
Indeed, better understanding of the disease can improve regimen compliance by up to 10 times.10
Heres how to get patients to buy in to their therapy:
Hold hands. Glaucoma patients require a lot of handholding. Dr. Fanelli takes this literally. When he delivers the diagnosis, he holds the patients hand, looks him or her straight in the eye and says, I will take care of you. This verbal commitment underscores the serious of the disease, he says, as well as the doctors involvement. This doctor-patient rapport is critical to compliance. On the other hand, when patients level of trust in the doctor is low, they are more likely to forgo using their medications.8
Show them ocular proof. Give them everything youve got to help explain the idea of glaucoma and the seriousness of the disease. For Dr. Gaddie, this includes digital photos, visual fields, imaging printouts, patient education videos, pamphlets, Internet resources, etc. Patients really appreciate the opportunity to kind of see inside their own body and try to understand their disease that frankly we dont understand fully, he says.
Speak plainly. Use lay terminology to explain glaucoma, Dr. Autry says. She compares the optic nerve to cable television, and once this cable goes out, its not coming back on, she says. The shows over.
Also, talk openly about vision loss. Say, You will go blind if we dont treat this now. Patients who dont understand the link between vision loss and their drops are less likely to comply.9
Write it down. You cant rely on the Rx or verbal instructions. For instance, one study found that 60% or more of patients could not correctly report what their doctors told them about medication use when questioned at zero to 80 minutes after receiving the information.11 So, provide written instructions, says Kelliann Dignam, attending optometrist at the Baltimore VA Medical Center. Write out the name of the drug, when the patient should take it, and how often to take it. And, to be perfectly clear, include a photo of the bottle on the instruction sheet.
Ask again. After explaining the disease and the drug regimen, ask the patient to tell you what hes just learned.12 This provides the opportunity to review the information and to clear up any misunderstandings. It also opens the door for the patient to ask questions for clarification.
Review the Rx regularly. Just as you expect the patient to be persistent with their medication, you must be persistent with their education. Give them a quick refresher course at every follow-up visit, Dr. Autry says. Review their medication and ask how they take it. Even if they seem to be taking it correctly, ask if they have any problems taking it. The answer could bring up cost issues, side effects or physical barriers that might not come up otherwise.
SLT: Not Just a Last Resort
When all else fails, then its time to send the patient for selective laser trabeculoplasty (SLT), right?
Not any more. SLT should now be offered as a first-line option, says Dr. Dignam.
Were now in the age of laser vision correction, she says. Younger [glaucoma] patients, in my experience, are more likely to accept it as a first-line therapy, so I do think were obligated to present it from the beginning.
Likewise, she offers it again the first time she suspects non-compliance. Consider referring for SLT sooner rather than later, Dr. Dignam says. Dont wait until the patient is in end-stage glaucoma or splitting fixation, where an IOP spike can be detrimental.
Of course, it should be offered to patients if they have physical problems taking the drops, have trouble paying for them, are not achieving target pressure, or are simply poor compliers.
It wont get them off all their eye drops, and it is temporary, Dr. Dignam says. But, it will lower IOP, and it acts as an insurance policy in case they miss taking their drop.
In the near future, Dr. Autry foresees a day when her electronic medical records system will print out a weekly report that says, for example, which glaucoma patients and suspects didnt show up for their three-month follow-up appointments. This alone could greatly increase how you keep patients on track and handle non-compliers.
But, until then, your best bet to get glaucoma patients to comply is to provide thorough education right at the time of diagnosis, and keep it up at every follow-up visit.
1. National Community Pharmacists Association Web site. Take As Directed: A Prescription Not Followed. December 15, 2006. Available at: www.ncpanet.org/media/releases/2006/take_as_directed.php (Accessed July 1, 2008).
2. Nordstrom BL, Friedman DS, Mozaffari E, et al. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol 2005 Oct;140(4):598-606.
3. Osterberg L, Blaschke T. Adherence to medication.
4. Bieszk N, Patel R, Heaberlin A, et al. Detection of medication nonadherence through review of pharmacy claims data. Am J Health Syst Pharm 2003 Feb 15;60(4):360-6.
5. Kennedy J, Morgan S. A cross-national study of prescription nonadherence due to cost: data from the Joint Canada-United States Survey of Health. Clin Ther 2006 Aug;28(8): 1217-24.
6. Prescription Drug Compliance a Significant Challenge for Many Patients. Harris Interactive Web site. March 29, 2005. Available at: www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=904 (Accessed July 1, 2008).
7. American Society of Health-System Pharmacists Web site. Medication Use Among Older Americans. June 2001:5. Available at: www.ashp.org/s_ashp/docs/files/PR_Over65.pdf (Accessed July 2, 2008).
8. Piette JD, Heisler M, Krein S, Kerr EA. The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Arch Intern Med 2005 Aug 8-22;165(15): 1749-55.
9. 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 Mar 3. [Epub ahead of print]
10. Zimmerman TJ, Zalta AH. Facilitating patient compliance in glaucoma therapy. Surv Ophthalmol 1983 Dec;28 Suppl: 252-8.
11. Gottlieb H. Medication nonadherence: finding solutions to a costly medical problem. Drug Benefit Trends. 2000; 12(6):57-62.
12. Boyle D, Dwinnell B, Platt F. Invite, listen, and summarize: a patient-centered communication technique. Acad Med 2005 Jan;80(1):29-32.
13. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther 2001 Aug;23(8):1296-310.
