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Improving Medication Adherence to Reduce Vision Loss in Patients with Glaucoma: Low Hanging Fruit?
Editorial Improving Medication Adherence to Reduce Vision Loss in Patients with Glaucoma: Low Hanging Fruit? Alan R. Morse, JD, PhD - New York, New York Nonadherence with glaucoma medications is ubiquitous and manifest nonadherence early in the course of their treatment well known. Failure to take medications as prescribed can and would not have been included in the sample. Particuresult in decreased treatment effectiveness and outcomes, larly noteworthy is their inclusion of the Health Belief increased complications, worsened health status, and higher Model based on an individual’s perceptions of the imporoverall healthcare costs. While the number is unknown, each tance and effectiveness of treatment and their own ability to year many individuals with glaucomaddiagnosed and overcome the challenges of adherence, that is, self-efficacy. undiagnoseddwill lose vision. Although approximately Focusing on patient perceptions and beliefs is an important half of all patients with glaucoma do not follow their component of patient engagement; using patient-centered medication regimens1 or discontinue medication use within constructs to address patient-specific issues such as adher6 months,2 9% of all prescriptions are never even filled.3 ence has great promise. Using the Health Belief Model and Even when medications are provided at no cost and self-efficacy theory in clinical practice can help to educate patients are aware that they are being monitored, patients efficiently and effectively and to reinforce their adherence rates are only approximately 70%.4 Patients fail ability to affect the course of glaucoma. to adhere to recommended medication regimens for many There is, however, no free lunch. Although highly desirreasons, including the absence of disease symptoms, low able,9 physicianepatient communication is an often overlooked but essential element in engaging patients in levels of health literacy, not understanding the importance their own care. When physicians communicate well, of treatment, difficulty in administration, mental health adherence rates are 19% higher than for patients whose status, or forgetfulness, among others.5 Patients with lower adherence rates have poorer physicians communicate less 8 outcomes,6 although this has effectively, and physicians who Newman-Casey et al report the not yet been demonstrated in receive training in effective outcomes after using crosslong-term studies. Attempts to communication are able to address glaucoma medication sectional survey data from 190 increase their patients’ adherence 10 11 nonadherence have not resulted patients with glaucoma to identify by 12%. Friedman et al found that 14% of patients do not in durable behavior change and the most frequent barriers to understand that they are at risk for significantly improved adheradherence vision loss, and among these ence rates.1,2 This may be a function of study design, and patients, nonadherence is trials with longer-term end points are needed. Medications particularly high. Health (il)literacy’s contribution to are the first-line treatment for glaucoma, and improving nonadherence has been understudied. As health literacy adherence can result in better control of intraocular preslevels decline, the importance of effective sure.7 Medications can slow glaucoma progression and physicianepatient communication increases; patient reduce vision loss, but poor adherence leaves thousands of instructions won’t work if they can’t be read and, even Americans each year with vision loss that could have been then, do not address patient-specific questions. Decreased prevented. health literacy places additional burdens on ophthalmologists In this issue, Newman-Casey et al8 report (see page to be sure that their patients understand the need for and 1308) the outcomes after using cross-sectional survey data proper use of their medications. from 190 patients with glaucoma to identify the most Patientephysician communication enhances the opporfrequent barriers to adherence. Patients were asked to rate 10 tunity for information to be clarified, absorbed, and incorcommonly cited barriers, with life stress included as an 11th porated into patients’ routines. Effective communication, choice. The same barriers were the top 3 for both adherent however, requires time and “the problem with physand nonadherent patientsdforgetfulness, difficulties with icianepatient communications is the illusion that it instilling eye drops, and medication schedulesdwith 61% occurred.”12 Tarn et al13 found that in an average office visit of 16 minutes, only 5% (49 seconds) was spent discussing of participants citing multiple barriers. Approximately half new medications and their proper use. Moreover, most of each group was skeptical that glaucoma would lead to communication between physicians and patients tends to vision loss, which of course would make them less likely to be unilateral. Increasing patient participation enhances the adhere to medication protocols. The convenience sample by opportunity for information to be absorbed and used. Newman-Casey et al emphasized patients with long-term Focusing on patients who are nonadherent requires medication use, and therefore was skewed toward those meaningful, skilled physician inquiry as well as patient who are likely to be more adherent, because patients tend to
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Ó 2015 by the American Academy of Ophthalmology Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ophtha.2015.04.019 ISSN 0161-6420/15
Editorial rapport. The need to see more patients makes it unlikely that most physicians will commit the time necessary to identify their patients at risk for nonadherence so that they may focus attention on them. Because of the high rate of nonadherence, it may be more efficient to address reminders and other efforts toward all patients. Using professionals including psychologists, social workers, nurse educators, pharmacists, and others to involve patients in their care and to educate them about the consequences of nonadherence may be helpful. However, like physicians, their time is limited. Developing reimbursement models allow other professionals to work with patients to understand glaucoma and to help with adherence to treatment regimens, which could expand options for communication while also relieving physicians of this timeconsuming task. Patients can’t use information they don’t have. Another important consideration for future studies is the inclusion of subpopulations at elevated risk, such as blacks and Hispanics, and the need for subgroup analyses. Quigley and Vitale14 estimated the prevalence rate for black persons older than 40 years to be 4.62%, approximately 3 times the rate for white patients (1.55%), with glaucoma rates in Hispanics being approximately the same as those for blacks. Moreover, blindness resulting from glaucoma is at least 6 times more prevalent among blacks.15 Friedman et al found being black a strong predictor of nonadherence. In fact, Dreer et al16 found race to be the only independent predictor of adherence, with black persons approximately one third less likely than white patients to adhere to medication regimens. The poorest adherence with glaucoma therapy is among black patients,17 the group most at risk of having glaucoma and therefore the group who should receive increased and specially focused attention. Efforts to improve adherence should focus on differences and disparities in healthcare access and use among population subgroups and should be culturally sensitive. Health and cultural beliefs play a role in nonadherence and contribute to disparities in outcomes, because suspicion and mistrust of the medical system, particularly among black patients, have been identified as factors associated with nonadherence.18 Trust is related to the extent that patients adhere to prescribed medications and maintain long-term medical care relationships.19 Ignoring race- or ethnicitybased differences underplays their importance in improving medication adherence rates in glaucoma. Finally, medication reminders improve adherence.20 Boland et al21 found that adherence was improved 35%, from a base rate of 54% to 73% using telephone or text medication reminder messages. The type of reminder may be a critical factor. For example, Saeedi et al22 found that e-mail and texting may be useful, but only with younger patients. Other kinds of reminders also may be demographic specific, but this has not yet been established and warrants further investigation. Treating glaucoma without addressing nonadherence is inefficient for physicians and ineffective for patients; medications work only if used properly. When medications are ineffectivedregardless of whether it’s due to
nonadherence, efficacy, or other factorsdlaser treatment or incisional surgery can be effective and do not require patient adherence, only surgical consent. For patients receiving medications to control intraocular pressure, reminder systems coupled with good patient communication can help. However, no treatment can effectively address glaucoma that has not been diagnosed. Greater efforts should focus on early diagnosis so that appropriate treatment can be initiated as early as possible. Medication nonadherence in patients with glaucoma is epidemic. Improving adherence can help reduce vision loss in individuals with glaucoma and should be a top public health priority. References 1. Olthoff CM, Schouten JS, van de Borne BW, Websers CA. Noncompliance with ocular hypotensive treatment in patients with glaucoma or ocular hypertension: an evidence-based review. Ophthalmology 2005;112:953–61. 2. Nordstrom BL, Freidman DS, Mozaffari E, et al. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol 2005;140:598–606. 3. Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophthalmol 2008;53: S57–68. 4. Okeke CO, Quigley HA, Jampel HD, et al. Adherence with topical glaucoma medication monitored electronically: the Travatan Dosing Aid study. Ophthalmology 2009;116: 191–9. 5. Waterman H, Evans JR, Gray TA, et al. Interventions for improving adherence to ocular hypotensive therapy. Cochrane Database of Systematic Reviews 2013;4:CD006132. 6. Sleath B, Blalock S, Covert D, et al. The relationship between glaucoma medication adherence, eye drop technique and visual field defect severity. Ophthalmology 2011;118:2398–402. 7. Haynes RB. Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews 2002;2:CD000011. 8. Newman-Casey PA, Robin AL, Blachley T, et al. The most common barriers to glaucoma medication adherence: a crosssectional survey. Ophthalmology 2015;122:1308–16. 9. American Academy of Ophthalmology Preferred Practice Patterns Glaucoma Panel. Primary Open-Angle Glaucoma Preferred Practice Patterns. San Francisco, CA: American Academy of Ophthalmology; 2010. 10. Zolnierek KBH, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Medical Care 2009;47:826–34. 11. Friedman D, Okeke C, Jampel H, et al. Risk factors for poor adherence to eyedrops in electronically monitored patients with glaucoma. Ophthalmology 2009;116:1097–105. 12. Page L. Why should your noncompliance harm my income? Medscape Business of Medicine. 2014. Available at: http:// www.medscape.com/features/content/6006314?src¼wnl_edit_ bom_weekly&uac¼33688AY#vp_5. Accessed March 13, 2015. 13. Tarn DM, Paterniti DA, Kravirz RL, et al. How much time does it take to prescribe a new medication? Patient Educ Counsel 2009;72:311–9. 14. Quigley HA, Vitale S. Models of open-angle glaucoma prevalence and incidence in the United States. Invest Ophthlamol Vis Sci 1997;38:83–91.
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Ophthalmology Volume 122, Number 7, July 2015 15. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med 1991;325:1412–7. 16. Dreer LE, Girkin CA, Campbell L, et al. Glaucoma medication adherence among African Americans: program development. Optom Vis Sci 2013;90:883–97. 17. Dreer LE, Girkin C, Mansberger SL. Determinants of medication adherence to topical glaucoma therapy. J Glaucoma 2012;21:234–40. 18. Boulware LE, Cooper LA, Ratner LE, et al. Race and trust in the health care system. Public Health Rep 2003;118:358–65. 19. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived
quality and use of health care. Arch Intern Med 1999;159: 997–1004. 20. Quigley HA. Reminder systems, not education, improve adherence: a comment on Cook et al. Ann Behav Med 2015;49:5–6. 21. Boland MV, Chang DS, Frazier T, et al. Automated telecommunication-based reminders and adherence with once-daily glaucoma medication dosing: the automated dosing reminder study. JAMA Ophthalmol 2014;132:845–50. 22. Saeedi OJ, Luzuriaga C, Ellish N, Robin A. Potential limitations of e-mail and text messaging in improving adherence in glaucoma and ocular hypertension. J Glaucoma 2014 Sep 26. [Epub ahead of print]
Pictures & Perspectives Warty Dyskeratoma of the Eyelid Warty dyskeratoma (WD) of the right lower eyelid in a 60-year-old woman presenting as a slowly growing papule. Benign and malignant epithelial neoplasms were considered in the clinical differential (Fig 1). Histologically, the lesion was an endo-exophytic epithelial neoplasm composed of uniform keratinocytes with zones of acantholysis and dyskeratosis with corps ronds and corps grains (Fig 2). The cause of WD is unknown. The presence of acantholysis and dyskeratosis suggests a localized error in epithelial maturation and cohesiveness akin to that seen in Darier disease (ATP2A2 mutation). Attempts to define human papillomavirus as pathogenic have been uniformly unsuccessful.
PAUL O. PHELPS, MD1 MOLLY A. HINSHAW, MD2 HEATHER D. POTTER, MD1 1 University of Wisconsin e Madison, Department of Ophthalmology and Visual Sciences, Madison, Wisconsin; 2 University of Wisconsin e Madison, Department of Dermatology, Madison, Wisconsin
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Ó 2015 by the American Academy of Ophthalmology Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ophtha.2015.04.019 ISSN 0161-6420/15
Editorial rapport. The need to see more patients makes it unlikely that most physicians will commit the time necessary to identify their patients at risk for nonadherence so that they may focus attention on them. Because of the high rate of nonadherence, it may be more efficient to address reminders and other efforts toward all patients. Using professionals including psychologists, social workers, nurse educators, pharmacists, and others to involve patients in their care and to educate them about the consequences of nonadherence may be helpful. However, like physicians, their time is limited. Developing reimbursement models allow other professionals to work with patients to understand glaucoma and to help with adherence to treatment regimens, which could expand options for communication while also relieving physicians of this timeconsuming task. Patients can’t use information they don’t have. Another important consideration for future studies is the inclusion of subpopulations at elevated risk, such as blacks and Hispanics, and the need for subgroup analyses. Quigley and Vitale14 estimated the prevalence rate for black persons older than 40 years to be 4.62%, approximately 3 times the rate for white patients (1.55%), with glaucoma rates in Hispanics being approximately the same as those for blacks. Moreover, blindness resulting from glaucoma is at least 6 times more prevalent among blacks.15 Friedman et al found being black a strong predictor of nonadherence. In fact, Dreer et al16 found race to be the only independent predictor of adherence, with black persons approximately one third less likely than white patients to adhere to medication regimens. The poorest adherence with glaucoma therapy is among black patients,17 the group most at risk of having glaucoma and therefore the group who should receive increased and specially focused attention. Efforts to improve adherence should focus on differences and disparities in healthcare access and use among population subgroups and should be culturally sensitive. Health and cultural beliefs play a role in nonadherence and contribute to disparities in outcomes, because suspicion and mistrust of the medical system, particularly among black patients, have been identified as factors associated with nonadherence.18 Trust is related to the extent that patients adhere to prescribed medications and maintain long-term medical care relationships.19 Ignoring race- or ethnicitybased differences underplays their importance in improving medication adherence rates in glaucoma. Finally, medication reminders improve adherence.20 Boland et al21 found that adherence was improved 35%, from a base rate of 54% to 73% using telephone or text medication reminder messages. The type of reminder may be a critical factor. For example, Saeedi et al22 found that e-mail and texting may be useful, but only with younger patients. Other kinds of reminders also may be demographic specific, but this has not yet been established and warrants further investigation. Treating glaucoma without addressing nonadherence is inefficient for physicians and ineffective for patients; medications work only if used properly. When medications are ineffectivedregardless of whether it’s due to
nonadherence, efficacy, or other factorsdlaser treatment or incisional surgery can be effective and do not require patient adherence, only surgical consent. For patients receiving medications to control intraocular pressure, reminder systems coupled with good patient communication can help. However, no treatment can effectively address glaucoma that has not been diagnosed. Greater efforts should focus on early diagnosis so that appropriate treatment can be initiated as early as possible. Medication nonadherence in patients with glaucoma is epidemic. Improving adherence can help reduce vision loss in individuals with glaucoma and should be a top public health priority. References 1. Olthoff CM, Schouten JS, van de Borne BW, Websers CA. Noncompliance with ocular hypotensive treatment in patients with glaucoma or ocular hypertension: an evidence-based review. Ophthalmology 2005;112:953–61. 2. Nordstrom BL, Freidman DS, Mozaffari E, et al. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol 2005;140:598–606. 3. Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophthalmol 2008;53: S57–68. 4. Okeke CO, Quigley HA, Jampel HD, et al. Adherence with topical glaucoma medication monitored electronically: the Travatan Dosing Aid study. Ophthalmology 2009;116: 191–9. 5. Waterman H, Evans JR, Gray TA, et al. Interventions for improving adherence to ocular hypotensive therapy. Cochrane Database of Systematic Reviews 2013;4:CD006132. 6. Sleath B, Blalock S, Covert D, et al. The relationship between glaucoma medication adherence, eye drop technique and visual field defect severity. Ophthalmology 2011;118:2398–402. 7. Haynes RB. Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews 2002;2:CD000011. 8. Newman-Casey PA, Robin AL, Blachley T, et al. The most common barriers to glaucoma medication adherence: a crosssectional survey. Ophthalmology 2015;122:1308–16. 9. American Academy of Ophthalmology Preferred Practice Patterns Glaucoma Panel. Primary Open-Angle Glaucoma Preferred Practice Patterns. San Francisco, CA: American Academy of Ophthalmology; 2010. 10. Zolnierek KBH, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Medical Care 2009;47:826–34. 11. Friedman D, Okeke C, Jampel H, et al. Risk factors for poor adherence to eyedrops in electronically monitored patients with glaucoma. Ophthalmology 2009;116:1097–105. 12. Page L. Why should your noncompliance harm my income? Medscape Business of Medicine. 2014. Available at: http:// www.medscape.com/features/content/6006314?src¼wnl_edit_ bom_weekly&uac¼33688AY#vp_5. Accessed March 13, 2015. 13. Tarn DM, Paterniti DA, Kravirz RL, et al. How much time does it take to prescribe a new medication? Patient Educ Counsel 2009;72:311–9. 14. Quigley HA, Vitale S. Models of open-angle glaucoma prevalence and incidence in the United States. Invest Ophthlamol Vis Sci 1997;38:83–91.
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Ophthalmology Volume 122, Number 7, July 2015 15. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med 1991;325:1412–7. 16. Dreer LE, Girkin CA, Campbell L, et al. Glaucoma medication adherence among African Americans: program development. Optom Vis Sci 2013;90:883–97. 17. Dreer LE, Girkin C, Mansberger SL. Determinants of medication adherence to topical glaucoma therapy. J Glaucoma 2012;21:234–40. 18. Boulware LE, Cooper LA, Ratner LE, et al. Race and trust in the health care system. Public Health Rep 2003;118:358–65. 19. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived
quality and use of health care. Arch Intern Med 1999;159: 997–1004. 20. Quigley HA. Reminder systems, not education, improve adherence: a comment on Cook et al. Ann Behav Med 2015;49:5–6. 21. Boland MV, Chang DS, Frazier T, et al. Automated telecommunication-based reminders and adherence with once-daily glaucoma medication dosing: the automated dosing reminder study. JAMA Ophthalmol 2014;132:845–50. 22. Saeedi OJ, Luzuriaga C, Ellish N, Robin A. Potential limitations of e-mail and text messaging in improving adherence in glaucoma and ocular hypertension. J Glaucoma 2014 Sep 26. [Epub ahead of print]
Pictures & Perspectives Warty Dyskeratoma of the Eyelid Warty dyskeratoma (WD) of the right lower eyelid in a 60-year-old woman presenting as a slowly growing papule. Benign and malignant epithelial neoplasms were considered in the clinical differential (Fig 1). Histologically, the lesion was an endo-exophytic epithelial neoplasm composed of uniform keratinocytes with zones of acantholysis and dyskeratosis with corps ronds and corps grains (Fig 2). The cause of WD is unknown. The presence of acantholysis and dyskeratosis suggests a localized error in epithelial maturation and cohesiveness akin to that seen in Darier disease (ATP2A2 mutation). Attempts to define human papillomavirus as pathogenic have been uniformly unsuccessful.
PAUL O. PHELPS, MD1 MOLLY A. HINSHAW, MD2 HEATHER D. POTTER, MD1 1 University of Wisconsin e Madison, Department of Ophthalmology and Visual Sciences, Madison, Wisconsin; 2 University of Wisconsin e Madison, Department of Dermatology, Madison, Wisconsin
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