EVE J. HIGGINBOTHAM, MD
What is my pearl for increasing the adherence of patients to their therapy? Education. When one considers that more than 80 million individuals in the United States are health illiterate, it is staggering! As physicians, we are attempting to change behavior, a goal that eludes most of us in the 15 minutes we spend with our patients in our offices. Thus, we must repeatedly ask open-ended questions of our patients so that we can tease out the gaps in their knowledge and fill them over a period of time. The educational process must be modified based on the patient's learning needs and social circumstances. For example, a person who only finished the ninth grade will need information to be conveyed at a sixth-grade level. In contrast, a college graduate may gather information on the Internet, so suggesting trusted sources on the Web will be important.
What do we teach? Topics will include not only a definition of glaucoma, the importance of taking prescribed medication, and its potential side effects, but also how to instill medications (ie, waiting between drops and the benefits of punctal occlusion and lid closure). One thing I have learned from my interactions with David Satcher, MD, PhD, the United States' 16th surgeon general, is the dominant role that behavior, socioeconomic factors, environment, and policy plays in the American landscape of health disparities. I believe educating each of our patients goes a long way in improving adherence and ultimately will reduce the burden of glaucoma in our communities.
GEORGE L. SPAETH, MD
The most important tip on how to help patients take care of themselves appropriately is to recognize that "compliance" is antithetical to good care. Compliance is about the doctor controlling the patient. Good self-care is about the patient controlling the doctor.
At least one report shows that many physicians are not aware whether their patients take their medications properly.1 That means that many doctors do not know how well their patients care for themselves. Assessing that ability is an essential responsibility of the physician. It can be done well.
Patients who know how to care for themselves take their medications appropriately. In many cases, the medications that physicians prescribe are appropriate. Patients who know how to care for themselves will usually follow their physician's advice, but not always. Sometimes the advice is poor. (Why would any independent person do anything just because he was ordered to do it?)
Compliance is a term usually applied to the situation in which patients do not take their medications in the manner suggested to them by their physician. There are many reasons for this behavior:
- There was no explanation by the physician
- The physician's explanation was wrong
- The physician's explanation was unclear
- The patient was not given understandable, explicit, written instructions
- The medication caused predictable, tolerable side effects that were not explained to the patient
- The medication caused predictable intolerable side effects
- The medication caused unpredictable intolerable side effects
- The requested regimen did not jibe with the patient's lifestyle
- The patient did not understand why the medication should be used
- The patient had unrealistic expectations about what the medication was intended to accomplish
- The patient's self-care skills were poor or non-existent
My first tip for ensuring that patients receive appropriate care is not to use the word compliance, not to expect patients to be compliant, and not to ask them to be. My second tip (and the more important one) is to know your patients and their ability to care for themselves. Adjust treatment appropriately by taking that into account. Third, when patients do not use medications as ordered, consider that maybe they made the right decision. Finally, when appropriate treatment would have prevented the patient's disease from worsening, but the disease becomes worse, we clinicians should blame ourselves, not the patient.
DAVID S. FRIEDMAN, MD, MPH, PhD
Although there are many approaches to helping patients adhere to medical therapy for glaucoma, the single most important strategy in my practice is proper communication. Only through developing a nonjudgmental environment where patients are comfortable admitting to poor adherence can the root causes of the problem be detected and addressed. I frequently start these conversations with a phrase like most people have difficulty taking drops every day. I often do not even ask a question. This open statement sets the tone that it is understandable that patients do not take medications as prescribed and that it is okay for them to tell me if they are having problems.
I then follow up with specific questions about their drop-taking behavior. I try to learn whether or not patients understand when and how to take their medications. If they do not, I can provide instructions. Next, I ask specifically about barriers, including costs, difficulty when traveling, falling asleep before taking the drops, and so on. Finally, I ask how many times they missed their drops in the last 2 weeks. Patients who admit to me that they have missed drops are a concern, and I make a note to follow up with them and to work through strategies that might help them be more regular in their dosing.
This approach to my time with patients has fundamentally changed the nature of my interactions with them. I have a more complete picture of the challenges they face than when I used to say, "Doing okay with the drops?"
MICHELE C. LIM, MD
Patients' adherence to prescribed therapy is a major obstacle in the treatment of glaucoma. Adherence is challenging for numerous reasons: glaucoma is a chronic disease, it is costly to treat, and patients perceive no immediate benefit from taking their medication.
My first tip is to educate patients as much as possible regarding their disease and treatment. I hand out a booklet from the Glaucoma Research Foundation that provides useful information on glaucoma and how to use eye drops. Research shows that educating patients may influence their adherence to prescribed medical therapy. In one study,2 adherence improved by 50% when patients received education regarding their glaucoma medication.
Another tip is to use linking reminders. I encourage patients to link the use of their eye drops with some other routine they perform at home. For example, I suggest putting their bottle of eye drops next to their toothbrush to help them remember to use the medication. Forgetfulness was identified as a top risk factor for patients' nonadherence in one study,3 so any steps to trigger their memory are helpful.
A third tip is to recognize factors related to personality type that may have some influence on patients' adherence to prescribed therapy. Studies have shown that patients with glaucoma may fear going blind and may exhibit more somatic complaints.4 Allaying their fears regarding their general visual health may help them to deal with their diagnosis and enable them to acquire a more positive attitude about taking their medications.
Finally, automated telephone reminders can be helpful. My colleagues and I use an automated telephone voice system, originally designed to alert patients to their doctor's appointments, to remind patients to take their drops. This effort is part of a study on adherence we are conducting that is also looking at the relationship between personality type and adherence to prescribed glaucoma medication.
David S. Friedman, MD, MPH, PhD, is a professor of ophthalmology in the Wilmer Eye Institute and a professor of international health in the Johns Hopkins Bloomberg School of Public Health in Baltimore. He is also a senior ophthalmologist with Helen Keller International in New York. Dr. Friedman may be reached at (410) 614-1342; dfriedma@jhsph.edu.
Eve J. Higginbotham, MD, is the dean and senior vice president for academic affairs at the Morehouse School of Medicine in Atlanta. As a professor of ophthalmology, she also sees patients at the Emory Eye Center in Atlanta. Dr. Higginbotham may be reached at (404) 752-1728; fcwejh6786@aol.com.
Michele C. Lim, MD, is an associate professor of ophthalmology with the Glaucoma Service of the University of California, Davis, and she is the vice chair and medical director of the University of California, Davis, Eye Center in Sacramento. Dr. Lim may be reached at (916) 734-6818; michele.lim@ucdmc.ucdavis.edu.
George L. Spaeth, MD, is the Louis J. Esposito research professor at Wills Eye Institute/Jefferson Medical College in Philadelphia. Dr. Spaeth may be reached at (215) 928-3960; gspaeth@willseye.org.
