Strategies To Improve Compliance

Numerous strategies have been employed to improve patient compliance. Some of these are listed in table 14.4.

14.5.1 Simplification of Regimen. As described above, compliance diminishes as the frequency and complexity of dosing increases. One of the most effective approaches a physician can have toward glaucoma therapy is to keep the regimen as simple as possible. One way is to prescribe daily dosing of medications instead of twice daily when possible. Using the lowest number of medications to achieve the desired therapeutic effect is also helpful, and this is aided by combination eye drops such as

Table 14.4 Improvement of Compliance

Educate

1. Explain glaucoma and rationale for treatment.

2. Anticipate and explain possible side effects.

3. Demonstrate drop administration.

Simplify

1. Prescribe least number of medications and lowest number of daily doses for desired therapeutic effect.

2. Tailor dosing schedule to daily events.

3. When changing regimen, change only one medication at a time.

Communicate

1. Reemphasize information about glaucoma on return visits.

2. Use printed information and videotapes.

3. Consider use of questionnaire to elicit difficulties with compliance.

Use Memory Aids

1. Have printed templates for medication schedules available.

2. Offer medications with compliance caps for appropriate patients.

3. Make patients aware of aids, such as eye drop instillation frames.

Gather Direct Information

1. Ask patients to use medication monitors.

2. Ask patients to share pharmacy records of refills.

dorzolamide-timolol (Cosopt). Finally, tailoring the dosing times to daily events, such as meals and bedtime, helps to cue the patient to take medications on schedule.3,41,63

14.5.2 Improvement of Patient-Physician Relationship. Sackett64 has pointed out that ''the easiest way to begin helping patients with low compliance is to pay more attention to them.'' This can be accomplished by inquiring at each visit if any problems were encountered with medications. Time can be taken to explicitly review instructions for drop use. The use of a short questionnaire may be helpful, allowing the physician to give feedback and reinforce instructions. These two aspects of physician behavior, showing concern and giving explanations, correlate positively with compliance.65-67

14.5.3 Patient Education. Too frequently, physicians assume that, because they have explained the disease process of glaucoma at the initial diagnosis, the patients will retain the information. In fact, most patients do not recall instructions given during any one outpatient visit68 and may be especially prone to forget instructions given at an initial visit because of nervousness, shock at the diagnosis, or the large amount of information given in a short period of time. Because patients are more compliant with treatment if they understand their disease,3,14,56,69 it is important that they understand glaucoma, the use of eye drops, the goals of treatment, and the consequences of defaulting. A rudimentary understanding of the pharmacology of the medications is also required to help avoid irregular spacing of doses or overuse of medications. Instruction in proper eye drop administration, including hand washing, sterile technique, drop separation in time, and punctal occlusion or eyelid closure, should be demonstrated by the physician or another health worker at the outset of therapy and should be reinforced periodically during follow-up visits. Patients should also be warned about potential side effects so they do not automatically discontinue a medication when a side effect occurs. They should be advised of serious side effects and instructed to call the office if they experience an alarming symptom.

It is beneficial to have a team approach to compliance so the patient receives reinforcement from different personnel in the office. Technicians and nurses can question patients about their medication schedules, check bottles, clarify instructions, and observe eye drop administration during office visits. Family members, friends, and coworkers can be enlisted to increase compliance. The pharmaceutical industry and national foundations provide literature and videotapes with information about glaucoma, treatment, and instructions for eye drop use and, in some cases, will sponsor support and discussion groups for patients. It is important to utilize resources such as these in combination with other strategies mentioned previously to help in the ongoing process of enhancing patient compliance.

14.5.4 Memory Aids. Printed medication timetable cards or sheets are an important method to aid patient compliance (see also Figure 11.2). These are most helpful if they list the drug name, eye to be given the dose, and the time of dose. The memory sheets can also include general information about drop-instillation technique, such as leaving 5-minute intervals between different eye drops and the use of eyelid closure and punctal occlusion.70 The sheets can be made with colored dots that correspond to the color-coded bottle caps of different medications.71 Large-print labels can be affixed to medication bottles72 to aid patients with poor visual acuity.

Refill reminders, in the form of postcards or telephone calls from the pharmacist, have been shown to improve compliance.73 However, such reminder systems are not in extensive use in the United States74 and may cause confusion if the physician has changed a medication or the patient receives an inappropriate refill reminder.59 The C Cap ("C" for "compliance") is a memory aid designed to help patients remember to use their glaucoma medications at prescribed intervals. A window in the cap displays a number corresponding to the next scheduled dose; for example, a 1 or 2 appears in the window on medications prescribed twice daily. Each time a dose is taken and the cap is replaced on the bottle, the display number advances to the next scheduled dose.75 In one study, this device helped significantly more patients achieve compliance with their regimens (67% vs. 41% prior to using the C Cap) and resulted in an IOP drop of 1.7 mm Hg.76

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