Ординатура / Офтальмология / Английские материалы / Glaucoma Medical Therapy Principles and Management_Netland_2008

248 Glaucoma Medical Therapy

were more likely to be compliant with glaucoma therapy if they rated their glaucoma as their most troubling illness, while the noncompliers rated their other illnesses as more troubling.

The perception of the severity of glaucoma was also important in determining compliance in patients who were newly diagnosed with the disease.1 Patients who were already taking a number of medications for other ailments were less likely to fill their prescriptions for glaucoma medications, perhaps because they thought glaucoma was ‘‘the least of their problems.’’ On the other hand, if patients were started on multiple glaucoma medications at the initial diagnosis, they were more likely to be compliant than patients treated with a single agent. It is postulated that these patients perceived their glaucoma to be severe enough to warrant aggressive therapy.

It has been shown that a patient’s knowledge of glaucoma is positively correlated with compliance. Compliant patients are more likely than noncompliers to know that intraocular pressure (IOP) plays a role in glaucoma,6 to know the name of their eye disease and the possible effect of no treatment,14 and to appreciate the connection between glaucoma and blindness.2

Another important determinant of compliance is the patient’s social support system. Relatives and friends can provide transportation to appointments, remind patients to refill prescriptions and take medication, and may actually instill eye drops for some individuals.

14.3.2 Disease Factors. Characteristics of a particular disease are generally poor indicators of compliance; increasing severity of the disease, escalating symptoms, and increasing disability do not necessarily result in better compliance and, in fact, may

sometimes lower compliance with therapy.38 In patients with glaucoma, neither the duration of treatment2,8,14,23 nor the severity of the disease2,4,8,14 is significantly

related to compliance with therapy. A retrospective cohort study in a group-model health maintenance organization found that glaucoma severity, measured by higher IOP and visual field loss, did not correlate with compliance.39 A clinician’s view of the severity of glaucoma may be very different from the patient’s perception of the severity of his or her disease.

14.3.3 Treatment Factors. The tolerability, safety, dosing, and stigma of a treatment regimen have substantial impact on patient compliance. One of the major factors influencing compliance is daily dose frequency and the overall complexity of the

therapeutic regimen. Numerous studies have documented a decrease in compliance with increased prescribed daily frequency of eye drops14,24,40–42 or medications in

general43 (table 14.2). When Patel and Spaeth24 classified glaucoma patients into three groups, those who had been prescribed one medication once or twice daily, one medication more than twice daily, and more than one medication daily, they found that the percentage of patients reporting missed doses was 51.2%, 60.7%, and 67.7%, respectively. Using an unobtrusive electronic monitor, Kass et al.44 found that patients administered a mean of 82.7% of timolol doses prescribed twice daily versus 77.7% of pilocarpine doses prescribed four times daily.

Inconvenient dosing regimens are associated with defaulting. Patients may miss doses while at work or when they are away from home (and away from the

Note: P < 0.05 when comparing compliance of onceand twice-daily groups with that of either threeor four-times-daily groups.

Source: Modified by permission of the publisher from Greenberg RN. Overview of patient compliance with medication dosing: a literature review. Clin Ther. 1984;6:591– 599. Copyright 1984 by Excerpta Medica, Inc.

medication), and are more likely to miss doses in the middle of the day for this reason.3,14,24

The health care claims data reported by Nordstrom et al.16 demonstrated significantly higher persistence and adherence to glaucoma therapy with the use of prostaglandins (administered once daily), compared with topical beta blockers, carbonic anhydrase inhibitors, and alpha agonists (administered twice daily).

The cost of the medication can be an additional obstacle to compliance for many patients.24,45 Patients may be unable to afford the medications or even the copay-

ments for the medication prescribed.

Side effects or perceived side effects of a medication may negatively influence compliance. One study using willingness-to-pay surveys found that patients placed a higher value on eye drop medications that did not produce blurring of vision, drowsiness, or inhibition of sexual performance than they did on once-a-day use or the use of combination products.46 In fact, 85% of patients were willing to pay, on average, 40% more for a medication that did not cause visual blurring. Uncomfortable side effects were the cause cited for stopping medication in 64% of glaucoma patients in one study.2 In contrast, another study24 found no correlation between side effects and noncompliance. It is possible that the patients’ attitudes toward the disease and the side effects played a greater role than the actual side effects.3 It is imperative to educate patients regarding the potential side effects of medication to avoid alarm or self-discontinuation when they are encountered.

14.3.4 Patient–Physician Relationship. In long-term patient–physician relationships, compliance is improved if the patient is satisfied with the doctor and believes that

the physician is warm, concerned, thorough, accessible, and provides useful information about the disease and its treatment.5,36,47 It is clear, however, that factors

other than patient satisfaction affect compliance. In a study by Patel and Spaeth,24 98% of patients reported that their doctors were helpful and friendly, but 59% of patients were still noncompliant with their medications. It has been suggested that a combination of knowledge about the disease and its treatment and faith in the doctor motivates patients to use medications as prescribed.37

It is often recommended that patients bring their eye drop bottles to each office visit. This is an indirect measure of adherence but may be useful in detecting gross noncompliance. In some medical systems, it may be possible to monitor the frequency of prescription refills, which, again, is an indirect measure of adherence but does provide information to the physician.

14.5 STRATEGIES TO IMPROVE COMPLIANCE

Numerous strategies have been employed to improve patient compliance. Some of these are listed in table 14.4.

14.5.1 Simplification of Regimen. As described above, compliance diminishes as the frequency and complexity of dosing increases. One of the most effective approaches a physician can have toward glaucoma therapy is to keep the regimen as simple as possible. One way is to prescribe daily dosing of medications instead of twice daily when possible. Using the lowest number of medications to achieve the desired therapeutic effect is also helpful, and this is aided by combination eye drops such as

Table 14.4 Improvement of Compliance

Educate

1.Explain glaucoma and rationale for treatment.

2.Anticipate and explain possible side effects.

3.Demonstrate drop administration.

Simplify

1.Prescribe least number of medications and lowest number of daily doses for desired therapeutic effect.

2.Tailor dosing schedule to daily events.

3.When changing regimen, change only one medication at a time.

Communicate

1.Reemphasize information about glaucoma on return visits.

2.Use printed information and videotapes.

3.Consider use of questionnaire to elicit difficulties with compliance.

Use Memory Aids

1.Have printed templates for medication schedules available.

2.Offer medications with compliance caps for appropriate patients.

3.Make patients aware of aids, such as eye drop instillation frames.

Gather Direct Information

1.Ask patients to use medication monitors.

2.Ask patients to share pharmacy records of refills.

252 Glaucoma Medical Therapy

dorzolamide–timolol (Cosopt). Finally, tailoring the dosing times to daily events, such as meals and bedtime, helps to cue the patient to take medications on schedule.3,41,63

14.5.2Improvement of Patient–Physician Relationship. Sackett64 has pointed out that ‘‘the easiest way to begin helping patients with low compliance is to pay more attention to them.’’ This can be accomplished by inquiring at each visit if any problems were encountered with medications. Time can be taken to explicitly review instructions for drop use. The use of a short questionnaire may be helpful, allowing the physician to give feedback and reinforce instructions. These two aspects of phy-

sician behavior, showing concern and giving explanations, correlate positively with compliance.65–67

14.5.3Patient Education. Too frequently, physicians assume that, because they have explained the disease process of glaucoma at the initial diagnosis, the patients will

retain the information. In fact, most patients do not recall instructions given during any one outpatient visit68 and may be especially prone to forget instructions given at an initial visit because of nervousness, shock at the diagnosis, or the large amount of

information given in a short period of time. Because patients are more compliant with treatment if they understand their disease,3,14,56,69 it is important that they

understand glaucoma, the use of eye drops, the goals of treatment, and the consequences of defaulting. A rudimentary understanding of the pharmacology of the medications is also required to help avoid irregular spacing of doses or overuse of medications. Instruction in proper eye drop administration, including hand washing, sterile technique, drop separation in time, and punctal occlusion or eyelid closure, should be demonstrated by the physician or another health worker at the outset of therapy and should be reinforced periodically during follow-up visits. Patients should also be warned about potential side effects so they do not automatically discontinue a medication when a side effect occurs. They should be advised of serious side effects and instructed to call the office if they experience an alarming symptom.

It is beneficial to have a team approach to compliance so the patient receives reinforcement from different personnel in the office. Technicians and nurses can question patients about their medication schedules, check bottles, clarify instructions, and observe eye drop administration during office visits. Family members, friends, and coworkers can be enlisted to increase compliance. The pharmaceutical industry and national foundations provide literature and videotapes with information about glaucoma, treatment, and instructions for eye drop use and, in some cases, will sponsor support and discussion groups for patients. It is important to utilize resources such as these in combination with other strategies mentioned previously to help in the ongoing process of enhancing patient compliance.

14.5.4 Memory Aids. Printed medication timetable cards or sheets are an important method to aid patient compliance (see also Figure 11.2). These are most helpful if they list the drug name, eye to be given the dose, and the time of dose. The memory sheets can also include general information about drop-instillation technique, such as leaving 5-minute intervals between different eye drops and the use of eyelid closure and punctal occlusion.70 The sheets can be made with colored dots that

correspond to the color-coded bottle caps of different medications.71 Large-print labels can be affixed to medication bottles72 to aid patients with poor visual acuity.

Refill reminders, in the form of postcards or telephone calls from the pharmacist, have been shown to improve compliance.73 However, such reminder systems are not in extensive use in the United States74 and may cause confusion if the physician has changed a medication or the patient receives an inappropriate refill reminder.59 The C Cap (‘‘C’’ for ‘‘compliance’’) is a memory aid designed to help patients remember to use their glaucoma medications at prescribed intervals. A window in the cap displays a number corresponding to the next scheduled dose; for example, a 1 or 2 appears in the window on medications prescribed twice daily. Each time a dose is taken and the cap is replaced on the bottle, the display number advances to the next scheduled dose.75 In one study, this device helped significantly more patients achieve compliance with their regimens (67% vs. 41% prior to using the

C Cap) and resulted in an IOP drop of 1.7 mm Hg.76

14.6 LOOKING FORWARD

In a recent editorial, Friedman et al.77 make a strong case for a more dynamic approach to the care of glaucoma patients. They point out the importance of identifying all patients with glaucoma, retaining these patients under active care, and facilitating adherence with treatment. It seems likely that electronic compliance monitors will be commercially available in the near future. Physicians and patients could agree to use these devices and to share the information on compliance to improve patient care. Similarly, physicians and patients could agree to share information about prescription refills. With this information, physicians could actively monitor patient adherence and persistence with therapy. The information would allow physicians to make rational recommendations about changing medical therapy, enlisting help from friends and relatives, or performing surgery. Data from electronic monitors and prescription refill records could also be used to assess the value of medication questionnaires, educational programs, and behavioral interventions. Data would allow physicians to determine the most effective approaches for different groups of patients.77

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