their medical therapy within the first 6 months of treatment [5, 11, 14]. Friedman et al. used pharmacy claims data to study compliance and found that only 10% of patients had continuously refilled their medication during the first year of therapy [3]. Clearly, a determination of the issues involved is necessary to prevent perpetuation of this behavior and eventual loss of vision in the glaucoma population. Adherence and persistence rates vary with estimates at 3 years after initiation of treatment ranging from 15 to 58% [16].

30.1.3  What Are the Challenges Facing

Patients in Terms of Adherence

and Persistence?

There are a variety of challenges that patients face with adherence to a medical regimen. Lack of motivation is the main adversary, especially when dealing with the concept of lifelong therapy of an asymptomatic disease. It is often difficult to accept the diagnosis in the first place and then to acquiesce to the daily intrusiveness of eye drops, which may have irritating side effects. At the time of diagnosis, it is helpful to educate the patient about the disease. Having the patient watch informational videos with their family members and then giving them literature to take home may dispel fears about their diagnosis. Only after they have digested the significance of having glaucoma, treatment principles can be reviewed and discussed thoroughly. Before that, their fears may impair their ability to process new information. Taking the time to give patients full disclosure of the common side effects encountered with their new medications is invaluable to ensuring persistence. Also, patients need to be reminded and educated about the importance of maintaining lowered intraocular pressure during every subsequent visit. Repetitive inquiry about medication use is essential to confirm persistence to the treatment regimen. Open communication can only further engender a trusting patient-physician relationship.

It is critical not to neglect the fact that social and cultural issues play a role in poor adherence among groups of different ethnicities. A study by Owsley et al. interviewed focus groups of older African Americans and their eye physicians [13]. They found that among older

African Americans, trust and open communication were significant barriers to adherence. In contrast, the eye care providers interviewed did not perceive that communication was a problem with their patients. This suggests that eye physicians must be aware of different communication needs that different patients have. Social and cultural factors may be impediments to adherence as a reflection of inadequate access to healthcare, deficient income, and distance to providers. It is important to identify these limiting factors so that arrangements can be made to prevent gaps in treatment. Furthermore, incorporating a reminder system for appointment scheduling and follow-up for missed appointments is important [8, 18].

Other reasons behind poor adherence include the demographics and lifestyle interests of the glaucoma population. Most patients are elderly with numerous comorbidities that may increase their medication and cost burden. Apart from problems with instilling medications, another major obstacle is remembering to use them. Patel and Spaeth ascertained that the main reasons patients do not follow a medication schedule include forgetfulness (39%), being away from home and medications (26%), inconvenient timing and frequency (9%), and side effects (2%) [14]. From this study, we can ascertain that incorporating new medications into any patient’s daily routine creates formidable obstacles.

Summary for the Clinician

››Despite the real possibility of vision loss, adherence and persistence to medical treatment is surprisingly low – estimated to be 15–58% 3 years after initiation of therapy.

››Adherence is the regular use and correct admin­ istration of medications as prescribed.

››Persistence is the period of time in which there is consistent use of the prescribed regimen.

››The asymptomatic and chronically progressive nature of glaucoma contribute to the problems of adherence and persistence.

››Acceptance of the diagnosis, intrusiveness of treatment, lack of education, fear, social/cultural issues in different ethnicities also contribute to the problem.

30.2  How Can One Help Patients to Be More Compliant with Treatment?

The key to promoting adherence is participating in active and open discussions with our patients regarding their medication usage. It is a well-established fact that physicians cannot predict which patient will be adherent, and therefore the onus is on us to help encourage medication use through nonjudgmental dialogue [7, 18]. Phrasing questions empathetically, such as “Sometimes it is hard to add a new medication into your daily routine. Have you been able to do this successfully?” Acknowledging that missing doses is a common problem sets an accepting tone that promotes frank disclosure of medication usage or non-use. Patients are usually not forthcoming with admissions of poor adherence, as they would rather fulfill the role of the “good” patient. Self reported compliance may be highly overrated as demonstrated by Kass et al. who monitored patient compliance with an electronic device and found that patients self reported a substantially higher rate of adherence than what was measured by the monitor [7].

Table 30.1  Barriers to adherence and persistence

Situational/environmental factors (49%)

 Lack of support

 Major life events

 Travel away from home

 Competing activities

 Change in routine

Medication regimen factors (32%)

 Refills

 Cost of medications

 Complexity

 Side effects

Patient factors (16%)

 Knowledge

 Memory

 Motivation

 Comorbidities

Provider factors (3%)

 Dissatisfaction

 Communication

As a physician faced with possible medication failure to control IOP, it is even more critical to actively discuss medication use with the patient.

To encourage a helpful discussion regarding medication usage, it is salient to remember to ask directed questions. When asking if a patient has taken his/her eye drops, phrase it as an open-ended question and not as one that will elicit a simple yes or no answer. One example would be to ask the patient to tell you how they use their medication, therefore requiring an explanatory answer. During the office visit, try to ascertain reasons why drops are not being used. Patients may have issues with comprehension of the disease, why they have to take drops, ability to instill medications, or lack of a support system. Although the time with our patients may be limited by our burgeoning clinic schedules, it is important to decipher and address them early on. Also, never underestimate the ability of members of your eye care team. The technicians can easily identify these issues while working up the patient and therefore provide the physician with invaluable information.

However, identifying patients is only half the battle. The other half is discovering a means to overcome the patient’s difficulties. Tsai et al. identified and categorized barriers that create noncompliance as seen in Table 30.1 [19]. Certainly, some of these factors are beyond control, but working with our glaucoma population to overcome some of the stated obstacles in Table 30.1 can certainly supply essential tools for adherence. For instance, having family members present during visits provides a second set of ears that can remind the patient of important instructions. Involving family members and friends automatically recruits them as a ready support system for the patient.

With the ever-changing landscape of medical insurance, patients face a quagmire of difficult decisions about medical plans. For those who cannot afford glaucoma medications, many pharmaceutical companies offer special assistance programs. Offering to help set up patients in these programs can only further solidify their trust in your care. Also, accommodating changes in drug coverage requires awareness and plasticity on the physician’s part to readily substitute medications and fill the needs of the patient.

Summary for the Clinician

››Participate in active and nonjudgmental discussions with patients regarding medication usage.

››Use directed, open-ended, empathetic questions.

››Be aware that the patient may be trying to please you, the physician, with their answers.

››Try to ascertain why drops are not being used as directed. Your eye care team can be helpful with this ascertainment.

››Table 30.1 categorizes reasons barriers to nonadherence­.

››Recruit family members to visits as a second pair of ears and a support system for the patient.

››Insurance can create barriers as well. Be knowledgeable about special assistance programs the patient can take advantage of and be flexible about changes in drug coverage.

30.3  How Can One Educate Patients

to Realize the Long-Term Impact

of Glaucoma and Encourage

Adherence?

Approaching adherence to glaucoma treatment mirrors the chronicity of the disease; it is an ongoing pursuit. Every follow-up visit is a chance to underscore the importance of daily administration of medications. Building a solid physician-patient relationship with clear communication reinforces a patient’s faith in benefit of treatment and therefore their likelihood to follow up with care [2, 4]. As stated earlier, knowledge and comprehension of glaucoma empowers the patient to take an active role in their eye care. Handing out educational brochures helps to solidify their understanding. If patients are continuously confused about when to take their medications, provide them with a dated medication schedule that clearly outlines in which eye the medication is to be used, how many times a day, and how many hours apart (Table 30.2). Associating the color of the cap of the bottle with the

Table 30.2  One example of a chart that can be handed out to patients to help minimize confusion regarding drop instillation. Brand name or generic name is circled or highlighted. Also circle or highlight frequency of instillation in the correct column corresponding to the eye that should receive the drop

Twice daily drops should be used in the morning and evening. Three times daily drops should be used morning, afternoon, and evening. Allow 5 min between drops. Close your eyes or press along the inner corners of your eyes after instilling drops

medication name considerably facilitates medication identification. This is especially important in patients with multiple eye drops. Also, remind them that the drops need to be separated by at least 5 min when there are different drops at the same dosing time.

Firsttimedropusersshouldbeidentifiedandinstructed by your staff about proper techniques of eye drop administration. Usually, informational videos about glaucoma cover this area but it never ceases to amaze us how many people who present for follow-up care already taking drops still comment that they were never really taught how to instill them. In our office, we compile a list of first time drop users and follow up with a call later in the month to check in with the patient and answer any further questions they might have. Often at the time of instruction, we have the patient demonstrate drop instillation with a bottle of artificial tears so that we can critique

technique and make helpful suggestions. Also at the time of initiation of medical therapy, encourage the patient to link drop usage with a habitual daily activity. For instance, the patient may choose to store the eye medications in the bathroom so that he or she can link the administration of eye drops to dental hygiene. Counseling the patient on potential side effects is very important to ensure adherence and persistence. Reminding patients to either keep their eyes closed for a minute or practice punctual occlusion as a means to decrease drug absorption into the nasal mucosa also decreases likelihood of these side effects.

The importance of simplifying a medical regime cannot be overstated. Stewart et al. found that once a day dosing increased patient satisfaction [18]. Adherence is highest among the patients taking the prostaglandin analogs [11]. This is hardly a surprise as these agents are highly effective, have the least worrisome side effects, and most importantly, require only one daily dosage. However, most patients require more than one medication as demonstrated by the Ocular Hypertension Treatment Study, which found that at 5 years, 40% of subjects required more than one medication to achieve the target pressure of 20% below baseline [6]. When adjunctive therapy is needed, adding a second medication that also requires a once daily regime, such as a beta blocker agent dosed in the morning, maintains an

uncomplicated regimen. Formulas combining two different drugs into a single drop can be helpful in further simplifying dosing. Importantly, always keep in mind the potential cost of new medications so that affordability doesn’t become a major problem for adherence.

Local support groups also offer additional assistance for our patients. These groups can provide a forum for discussion and interchange of ideas that transfer essential tools to understand and cope with glaucoma. Have this information readily available to the patients as a handout or posted on a bulletin board in the waiting room. The American Glaucoma Society’s Patient Care Project was undertaken to award ideas that could augment patient compliance. The best ones are listed in Table 30.3. In addition, it is helpful to identify those with low or limited vision in order to address their special needs and to provide them with information about local low vision clinics.

In conclusion, adherence is a major problem that we all have to contend with when treating a patient with glaucoma. It is not easy to identify patients who have trouble with their medication usage and it is therefore essential to approach each glaucoma patient in a consistent manner, one that underscores education, empathy, and active dialogue. With these tools we can surely overcome barriers to adherence and create a strong patient-physician relationship.