[Improved eyedrop administration and compliance in glaucoma patients. A clinical study]

Improving eye-drop administration skills of patients - A multicenter parallel-group cluster-randomized controlled trial

Background

Eye-drop administration errors occur in the majority of patients and increase the risk for treatment failure or systemic adverse events. While lacking knowledge is the principal error cause, most patients overestimate their skills and are unaware of often substantial knowledge gaps. Therefore, the impact of including motivational patient education on long-term eye-drop administration skills of patients was investigated.

Methods

This is a cluster-randomized controlled trial in German community pharmacies. Patient education in both groups comprised observation of the patient during eye-drop administration to identify individual errors, pharmaceutical counseling, and teach-back evaluation of the training. In the intervention group, motivational communication techniques were included to increase error awareness and readiness for patient education. In addition, intervention patients were trained on repeated errors until administration was performed correctly. In contrast, patients in the control group only received feedback on erroneous administration steps without another assessment and reinforced training.

Results

In total, 152 adult patients were eligible to the study and 91 patients (intervention group N = 46) agreed to participate in a 1-month, 6-month, and 12-month follow-up. Patient education significantly increased the proportion of patients correctly administering eye-drops from 6% (7 out of 56 intervention patients, 1 out of 82 control patients) at baseline to 35% (12 out of 30 intervention patients, 12 out of 39 control patients, p ≤ 0.001) at the 1-month follow-up, and 64% (11 out of 15 intervention patients, 17 out of 29 control patients, p ≤ 0.001) at the 6-month follow-up irrespective of group allocation. In some patients previously resolved errors recurred during follow-up visits. This emphasizes the need for periodical reevaluation of patient administration skills and the provision of prevention strategies besides education.

Conclusion

Patient education that included demonstration of administration skills and verbal and written counseling on observed errors improved eye-drop administration skills irrespective of the communication technique applied. Whereof, high drop-out rates limited the power to detect a difference between groups. In particular, periodic demonstration of administration skills seemed important for sustainable improvement of administration skills. However, further error prevention strategies such as additional education materials or support by a caregiver may be necessary in some patients.

Treatment patterns and medication adherence of patients with glaucoma in South Korea

Background/aims

This study aimed to investigate treatment patterns and medication adherence of glaucoma. It also identified key factors associated with non-adherence.

Methods

It was a cross-sectional, observational study. Patients who use eye-drops for ≤2 years were recruited at 15 eye clinics from March to November 2013. Data were collected through self-administered questionnaires and medical chart review. Medication adherence was evaluated using patients’ self-report on pill count and defined as patients’ administering drug for ≥80% of prescribed days. Medication adherence rate was calculated by dividing actual number of administration from total prescribed number of administration for 7 days. Patients whose self-reported prescription was different from total daily doses of physicians' prescription were considered as non-adherent.

Results

A total of 1050 patients included, and medication adherence rate was evaluated in 1046 patients whose verification of adherence was available. Of the total, 27.4% were non-adherent, and the medication adherence rates of the total, the adherent, and the non-adherent were 90.6±17.8%, 96.8±5.5% and 56.6±24.7%, respectively. The most commonly used medication was prostaglandin (PGA) alone and the second was combination of two-class (β-blocker and carbonic anhydrase inhibitor (CAI)) and three-class combination of PGA, β-blocker and CAI followed. In multivariate analysis, the risk of non-adherence was 1.466 times greater in males than in females (95% CI 1.106 to 1.943) and 1.328-fold greater as the daily number of administration was increased (95% CI 1.186 to 1.487).

Conclusion

Approximately, one-third of the patients were non-adherent, and males and increased daily number of administration were associated with non-adherence. It highlights that more systematic treatment strategies should be considered for better medication adherence, leading to effective glaucoma management.

Mirror-hat device as a drop delivery aid: a pilot study

OBJECTIVE

To evaluate the effectiveness of a novel mirror-hat drop delivery aid.

DESIGN

Prospective, observational study.

PARTICIPANTS

Sixty eyes from 30 subjects with primary open-angle glaucoma or ocular hypertension attending the glaucoma unit at the Toronto Western Hospital.

METHODS

The mirror-hat device consists of a magnifying mirror attached to a brimmed cap. The aid was provided to subjects who self-administered topical antiglaucoma medications. Drop instillation technique (time taken to instill a drop, number of drops dispensed, drop contact location, and contamination of bottle tip) was evaluated with and without the device. Subjects also completed a survey regarding drop administration and satisfaction with the device.

RESULTS

Subjects were less likely to contaminate the bottle tip by touching their eye/eyelid when using the device than without the device (13% vs 37%, respectively, p = 0.02). Twenty-six subjects (86.7%) indicated they could see the drop using the device versus 12 (40%) who reported they saw the drop without the device (p = 0.0005). There were no statistically significant differences in any of the other outcomes. No predictive factors were associated with improved drop administration technique while using the device including uncorrected near-visual acuity, lens status, and glaucoma severity.

CONCLUSIONS

Use of the mirror-hat aid is associated with significantly less bottle-tip contamination and better visualization of the drop than without the device; however, the device did not help to reduce time, number of drops, or accuracy when administering eye drops.

Adherence and persistence with glaucoma therapy

Adherence and persistence with chronic therapies is crucial to prevent disease progression, such as in glaucoma. Patients report high rates of adherence, which are not supported by pharmacy claims analysis. This article reviews the literature regarding methods to assess adherence and persistence and the patient behaviors that pose challenges to proper treatment. Rates for persistence are generally below 50% at 1 year. Differentiating efficacy of eyedrops from lack of adherence presently confounds ophthalmic treatment. Additionally, as intraocular pressure (IOP) can appear controlled by short-term adherence, the physician can be fooled into believing the patient's glaucoma is well-controlled. Likewise, when progressive worsening is noted despite good IOP control, it can be problematic whether the patient's target pressure needs to be lowered or adherence needs to be improved. White-coat adherence is common, in which patient adherence rises sharply 1 week before the appointment with the physician, then declines rapidly following the appointment. White-coat adherence may make it difficult to assess IOP control over the longer term; cycling behavior with medication use is well-documented. Adherence and persistence rates differ by class of drug, with higher rates associated with prostaglandin use. We review findings from The Glaucoma Adherence and Persistency Study that identified behaviors associated with poor adherence. Greater physician awareness of adherence and persistence issues is necessary in order to help the patient become more adherent.

Self-application of single-use eyedrop containers in an elderly population: comparisons with standard eyedrop bottle and with younger patients

PURPOSE

To test whether patients aged >or=80 years can safely and successfully apply eyedrops from a single-use eyedrop container without support, and to compare the results with those of younger patients using single-use containers and older patients using standard eyedrop bottles.

METHODS

Patients aged >or=80 years who had no physical or mental conditions hindering self-application of eyedrops and actually did so because of glaucoma or dry eyes were included consecutively in the study group (n = 44) in order to perform self-application of eyedrops from single-use eyedrop containers. Patients were observed meticulously by two investigators, who documented practical problems during the procedure in a checklist. In control group A (n = 22), glaucoma or sicca patients aged between 50 and 65 years applied drops from single-use eyedrop containers; in control group B (n = 28), glaucoma or sicca patients aged >or=80 years used a traditional eyedrop bottle.

RESULTS

Successful application of the drops into the conjunctival sac was achieved by 57% in the study group (95% and 89% in control groups A and B, respectively). Scratching of the eyedrop container along the conjunctiva or cornea was observed in 68% of the study group (41% and 61% in control groups A and B, respectively). Frequency of problems during opening and self-application of single-use eyedrop containers in the study group showed an inverse correlation to visual acuity in the better eye and previous experience with this kind of eyedrop container.

CONCLUSION

Older patients have massive problems in self-administering eyedrops from single-use containers. Factors influencing the success of self-application may include the patient's previous experience with this kind of eyedrop container and the patient's visual acuity.

Prevalence and determinants of non-adherence to topical hypotensive treatment in Dutch glaucoma patients

BACKGROUND

To assess the prevalence and determinants of non-adherence to topical hypotensive treatment in glaucoma patients in order to support interventions targeting enhancement of patient adherence.

METHODS

One-hundred and sixty-six glaucoma patients, recruited by nationwide multi-stage sampling, filled in an extensive and carefully developed questionnaire covering various theoretically relevant determinants of patient adherence which were categorized as psychosocial aspects, barriers and skills.

RESULTS

Prevalence of self-reported non-adherence was 27.3%. Younger patients (<55 years of age) had a higher risk of being non-adherent. Forgetfulness, unavailability of eye drops and difficulties with holding the bottle above the eye when applying the eye drops were the most cited reasons for non-adherence. Fifty percent of the patients indicated that they required more information on the correct administration of eye drops. There was no association between non-adherence and sex, level of education, type of insurance, duration of disease or family history of glaucoma.

CONCLUSIONS

Non-adherence to topical glaucoma medication is fairly common. Aids that minimize forgetfulness and delivery systems facilitating the delivery of medications to the eye could be considered to enhance patient adherence before advancing to other therapies with additional risks and costs.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

Evaluation of the Xal-Ease™ latanoprost delivery system

PURPOSE

The purpose of this study was to compare drops of latanoprost dispensed using the Xal-Ease (Pfizer Ophthalmics, New York, New York) delivery system with drops dispensed manually.

METHODS

Twenty-four 2.5-mL bottles of Xalatan (Pfizer Ophthalmics) were evaluated with or without the delivery system. Individually dispensed drops were counted. The total volume dispensed was measured to the nearest 10 microL. Statistical analysis compared group means by analysis of variance. P values less than 0.05 were considered significant.

RESULTS

The overall mean volume was 2,850 microL. Overall mean drops per bottle (n = 24) were 90.3 +/- 6.3. Using the Xal-Ease, mean drops per bottle were 93.0 +/- 3.4 and without it, 87.7 +/- 7.5 (n = 12 each).

CONCLUSIONS

With Xal-Ease, mean drops per bottle (5) were statistically significantly greater when compared with standard dispensing (P = 0.0393). This result is accounted for by more consistent individual drop volume and greater volume using the delivery system.

[Glaucoma in the aged--barriers to understanding and compliance]

Glaucoma is a relatively common ocular disease among adults aged >65 years. However, knowledge about glaucoma, the physical capacity to perform self-application of antiglaucomatous drops, and general compliance may be massively restricted in the older population owing to significantly increasing comorbidity and other factors (e.g. their social and financial situation). Additional efforts by ophthalmologists, the pharmaceutical industry and health politics are required to improve knowledge and compliance among elderly glaucoma patients.

Compliance et persistance

PURPOSE

1) To summarize the literature on compliance (the extent to which the patient's behaviors correspond with the provider's recommendations) and persistence (total time on therapy) in patients with open-angle glaucoma or ocular hypertension. 2) To suggest guidelines to improve these two parameters, which are both essential and integral elements of optimizing patient care.

METHODS

Compliance-related research published between 1980 and March 2005.

RESULTS

Medication compliance has mostly been investigated and measured using patient self-reports, electronic monitoring, and medication possession ratio. Noncompliance-related problems are underestimated, complex, unpredictable and frequent. Noncompliance rates of at least 25% have been reported. The main obstacles to medication compliance are situational/environmental or related to the side effects or complexity of the medication regimen. Persistence with glaucoma medications has also been proven to be poor. Based on retrospective studies using survival analyses, fewer than 25% of patients may be persistent over 12 months. Persistence rates differ from one treatment to another and may fluctuate with time in the same patient.

CONCLUSIONS

Improving the quality of information, the patient-physician relationship, and educating patients are all crucial. Simplification of the treatment regimen and selection of medications with the fewest systemic and ocular side effects must be a priority. Accurately assessing patient compliance and persistence are indispensable to reducing mistakes from either medication noncompliance or lack of persistence with poor efficacy and to avoid unnecessary changes in a patient's therapeutic regimen or surgery.

Determinants of eye drop size

Ophthalmic solutions are available for multidose or single-dose administration in a wide variety of glass and plastic dropper bottles which deliver drops with a volume between 25 and 70 microl. From a biopharmaceutical and economic point of view, however, smaller volumes of 5 to 15 microl should be instilled. In this review, the technical, pharmaceutical, and therapeutic aspects of eye drop formation and delivery are presented. The different types of containers are described and the determinants of eye drop size are discussed, such as the design and physical characteristics of the dropper tip and bottle, the physico-chemical properties of the solution, and the manner in which the patient dispenses the drops. Preferred and alternative instillation techniques and aids to facilitate the administration of eye drops by elderly patients are described.

An improved technique of eye drop self-administration for patients with limited vision

PURPOSE

To describe a new, highly accurate, tactile technique to increase accuracy in the self-administration of eye drops.

DESIGN

Interventional case series.

METHODS

Ten adult patients with loss of fixation (< or = 20/400) in one eye and ten adult patients with loss of fixation in both eyes instilled one drop of artificial tears in each eye using the technique normally employed at home. The time required to instill each drop, the number of drops squeezed from the bottle, and location of the drops' landing points on the face or eye were recorded. The patients were then instructed in a new technique for instillation, guided through the procedure once, and allowed to practice until comfortable with it. All measurements were then repeated.

RESULTS

In patients with loss of fixation in one eye, an additional 3.2 +/- 4.1 seconds were required to instill a drop using the new technique (P <.0001, paired t test; range, -7-18 seconds). The mean number of drops dispensed decreased by 0.1 +/- 0.6 drops (P =.60, paired t test; range, -2-1 drop). The accuracy of drop placement increased from 80.0% to 82.5% (P =.32, paired t test). In subjects with loss of fixation in both eyes, using the new technique increased the time needed to instill a drop by 3.8 +/- 3.8 seconds (P <.0001, paired t test; range, -3-13 seconds). The average number of drops dispensed decreased by 0.1 +/- 0.6 drops (P =.25, paired t test; range, -2-1 drop). The accuracy of placement increased from 63.0% to 85.0% (P =.001, paired t test).

CONCLUSIONS

This technique of drop instillation may be beneficial for patients with significant visual impairment in both eyes.

The Finnish evidence-based guideline for open-angle glaucoma

In most patients, chronic open-angle glaucoma is a slowly progressive disease. Eyes with very high intraocular pressure (IOP > 30 mmHg) represent an exception to this and should be treated and followed extremely intensively. As lowering IOP is, so far, the only means of treating glaucoma, the majority of research reports deal with the IOP-lowering effect of the treatment. The primary goal of treatment, however, is to prevent glaucomatous damage to the structures and function of the eye. The effectiveness of treatment is monitored with optic disc and retinal nerve fibre layer imaging and with visual field examinations. If the glaucomatous changes are progressing, more effective treatment should be given. In the course of follow-up, it should be noted that the changes in the optic nerve structure and function appear and progress at different time-points with delays of up to several years. The assessment of abnormalities is dependent on the examination method and requires a great deal of experience on the part of the examiner. The important risk factors in glaucoma are elevated IOP (even if IOP is within normal range in half of patients ), age, positive family history, exfoliation, race and myopia.

Self-reported eye disease in elderly South Asian subjects from an inner city cluster in Bradford: a small-scale study to investigate knowledge and awareness of ocular disease

PURPOSE

To investigate various issues relating to eye diseases in a sample of 200 South Asian residents living in an inner city regional cluster in Bradford.

METHODS

Door to door interviews were carried out by one investigator who spoke English, Punjabi and Urdu. Visual acuity and pinhole acuity were measured using a portable LogMAR acuity chart. A structured questionnaire investigated various issues including self-reported eye disease, knowledge of eye disease, the effectiveness of various sources for eye-related information, the importance of early detection of eye diseases and the need for adequate control of systemic diseases linked to eye diseases such as diabetes.

RESULTS

Data revealed poor knowledge of self-reported eye diseases and of the importance of early detection and inadequate knowledge of the link between the control of systemic disease such as diabetes and ocular complications. Language barrier problems and poor utilisation of available ocular health care services were also evident.

CONCLUSIONS

These data, although not exhaustive, give an insight into various factors that affect the ocular health of the South Asian community in Bradford.