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

14.3.5 Clinical Environment. Continuity of care and short waiting periods in the office are associated with higher compliance in patients being treated for hypertension,36'48 and it seems logical that this should also apply to patients being monitored for other chronic conditions, such as glaucoma. Missed visits by glaucoma patients have been associated with being a glaucoma suspect, being dissatisfied with extended clinic waiting time, and not being prescribed ocular hypotensive drops.49,50 One study found fewer visits with an ophthalmologist to be the strongest risk factor for medication noncompliance.39 Continuity of care not only facilitates the development of a good patient-physician relationship but also allows for reinforcement of education about glaucoma and glaucoma therapy. Brown et al.8 found that uniform teaching by one doctor in a private practice resulted in an improved ability of patients to administer their medications, compared to patients who received variable information from different doctors at each visit in a clinic setting. This obstacle particularly affects underprivileged patients who may have reduced access to office-based physicians and may be more likely to obtain care from other sources, such as hospital outpatient departments or emergency departments.51-54 The office and clinic staff should play a major role in providing information to glaucoma patients and instructing them about proper technique of eye drop administration.

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