Reasons For Noncompliance

Each mentally and physically competent patient has ultimate responsibility for compliance, but how a patient arrives at the decision to comply or not to comply with medical treatment is based on many factors. A patient's beliefs about health and disease, influenced by personal, societal, cultural, and financial factors, as well as the amount of information he or she has about the disease, play a significant role in this decision. In addition, other factors, such as the nature of the disease, the nature of the medical regimen, the patient-physician relationship, and the clinical environment, all play a role in the decision to adhere to treatment. Using hierarchical cluster analysis, Tsai et al.19 identified 71 distinct barriers to medication compliance among patients with glaucoma. These obstacles were then grouped into four distinct categories: situational/environmental factors (e.g., lack of social support, difficulty with travel away from home, competing activities, major life events), regimen factors (e.g., side effects, cost, complexity, recent change), patient factors (e.g., knowledge, memory, motivation, comorbidity), and provider factors (e.g., dissatisfaction with physician, communication). Situational and environmental factors were thought to account for nearly half of these compliance obstacles, while the medical regimen was thought to account for one-third of the problems. Patient and provider factors were responsible for the remaining obstacles.19 Some of these factors are addressed below.

14.3.1 Patient Factors. The large literature on compliance with medical regimens has shown limited correlation between noncompliance and age, sex, socioeconomic status, marital status, level of schooling, and race.20,21 In general, studies addressing patients with glaucoma confirm these observations.1,2,8,14,22-24 Despite some conflicting data, most studies indicate that gender is not an important indicator of compliance.1,3,8,10,14 Likewise, a patient's age, marital status, educational level, and socioeconomic status have not been reliably linked to noncompliance with eye drops for glaucoma.1,2,8,23,24

While age as an independent variable is not significantly related to the level of compliance, age is often accompanied by diseases that may influence adherence. Elderly patients are more likely to suffer from multiple chronic diseases, and approximately 20% to 30% take three or more medications.25 Polypharmacy is associated with increased risk of adverse drug reactions, drug interactions, and poor compliance.25 Forgetfulness, poor visual acuity, parkinsonism, tremor, and hemi-

plegia have all been cited as reasons for noncompliance.14 Falling asleep prior to bedtime medications or being unable to walk independently to the kitchen to use refrigerated drops can interfere with drug administration. Other physical hindrances to compliance with eye drops include difficulties with positioning the head, aiming the dropper bottle, and squeezing the bottle. Kass et al.23 found that 20% of patients relied on another person to administer their eye drops. Winfield et al.9 evaluated 200 patients who were prescribed eye drops for various reasons, including glaucoma; 57% of these patients admitted difficulty administering their drops, and when directly observed, only 20% instilled a drop correctly on the first try. In another study, 27% of patients were unable to put drops into each eye on the initial attempt; Uniform teaching of drop administration was correlated with an increase in the patients' ability to instill eye drops properly.8 These studies reinforce the idea that proper eye drop instillation needs to be taught and, equally important, observed in all patients starting glaucoma therapy. Teaching alone, however, may not be enough for some patients with physical disabilities. In such cases, patients should be made aware of commercially available aids to instill medication, including Auto-squeeze, Autodrop, and Opticare.26,27

Patients with poor reading skills face particular difficulty accessing the health care system, understanding treatment regimens and consent forms, and following physician instructions.28-32 Printed materials are frequently given to patients without first assessing the patient's ability to read or to read English-language materials.33 Many materials require a higher level of literacy than that of the general popula-tion.31,34 Physicians should evaluate the written documents they distribute and revise them to meet the reading level of their patients. They should also consider alternatives, such as photoessays, audiotapes, and videotapes for nonreaders or the visually impaired. Many patient materials are available in multiple languages.

Personal health beliefs play an important role in compliance with therapy. These beliefs include the patient's perceived vulnerability to the disease, the perceived benefit of treatment, and the perceived burden of treatment.

Patients who perceive themselves as having a serious medical problem are more compliant with the prescribed therapy.35,36 That is, the patient must be willing and capable of accepting the illness before accepting the treatment.37 This is especially relevant to glaucoma, given its typically asymptomatic nature. In a study of patients with ocular hypertension, better compliance with follow-up appointments was seen in the group who were prescribed treatment with eye drops than in those who were to be monitored without medication.22 This study suggests that those who were not treated did not perceive a potential health problem and were more likely to be lost to follow-up. In addition, adherence to glaucoma therapy among patients with the diagnosis of glaucoma may be higher than in patients followed as glaucoma suspects.16

A study by Bloch et al.2 found that patients were more likely to comply with glaucoma therapy if they had another chronic medical problem in addition to glau-coma.2 These researchers suggest that this finding may be a result of the more clearly defined ''sick role'' of those patients who require more medical therapy; however, there is some evidence that patients must also perceive glaucoma to be a serious disease before being compliant with therapy.2 Patients with multiple medical problems 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

Table 14.2 Compliance Rate by Dosage Schedule

Dosage

Compliance

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