Relationship between electronically measured medication adherence and vision-related quality of life in a cohort of patients with open-angle glaucoma

African American patient-provider communication about glaucoma vision quality-of-life

BACKGROUND/OBJECTIVES

Little is known about African American patient-provider communication about glaucoma-related quality-of-life. The objectives of this study were to: (a) examine associations between patient socio-demographics and vision quality-of-life, (b) describe the extent to which eye care providers and patients discuss glaucoma-related quality-of-life, and (c) examine associations between patient and provider characteristics, whether the patient was in the intervention or usual care group, and whether the patient and provider discuss one or more glaucoma-related quality-of-life domains.

METHODS

Adult African American patients with glaucoma who reported non-adherence to glaucoma medications were enrolled from three sites. Patients completed a vision quality-of-life VFQ-25 assessment. Patients were randomized into intervention and control groups with intervention group members receiving a glaucoma question prompt list and watching a video before a provider visit. Audio recordings from these visits were transcribed and assessed for glaucoma-related quality-of-life discussions.

RESULTS

One hundred and eighty-nine patients were enrolled. Glaucoma-related quality-of-life was discussed during 12.3% of visits (N = 23). Patients initiated discussion 56.5% (N = 13) of the time and providers 43.5% (N = 10) of the time. Patients with worse health literacy (p < 0.001), more depressive symptoms (p < 0.05), and more severe glaucoma (p < 0.001) were significantly more likely to have worse vision-related quality-of-life. Glaucoma-related quality-of-life was significantly more likely to be discussed when African American patients saw African American providers (p < 0.05).

CONCLUSION

Patients and providers rarely discussed the patient's glaucoma-related quality-of-life. The intervention did not significantly increase communication about glaucoma-related quality-of-life. Residency programs should consider enhancing training regarding discussing patients' quality-of-life.

Patient-Centered Outcomes After a Medication Adherence Intervention: a Pilot Study

PRCIS

Self-determination theory (SDT) guided behavioral interventions are effective in improving several patient-centered metrics, including glaucoma-related distress. However, whether improvement in patient-centered metrics can drive an improvement in medication-taking behavior remains to be seen.

OBJECTIVE

The 7-month Support, Educate, Empower (SEE) personalized glaucoma coaching program was previously shown to improve glaucoma medication adherence by 21 percent points. This study's goal was to assess the impact of the SEE program on self-determination theory (SDT) metrics and other patient-centered outcome measures.

PARTICIPANTS AND METHODS

Glaucoma patients (≥40 y old, taking ≥1 medication) self-reporting poor medication adherence were recruited at the University of Michigan. Eight surveys (with 10 subscales) were completed before and after the 7-month SEE program. Three surveys assessed changes in SDT (Treatment Self-regulation Questionnaire, Healthcare-Climate Questionnaire, Perceived Competence) while the others assessed participants' Glaucoma Knowledge, Glaucoma Medication Self-efficacy, Glaucoma-related distress, Perceived benefits, confidence asking and getting questions answered.

RESULTS

Thirty-nine participants completed the SEE program. Significant improvements were in 7 subscales, including all three SDT tenets of competence (mean change =0.9, SD =±1.2, adjusted P =0.0002), autonomy (0.5, ±0.9, 0.044), and relatedness ( P =0.002). Glaucoma-related distress (-2.0, ±3.2, 0.004), confidence in asking questions (1.1, ±2.0, 0.008), and confidence in getting questions answered (1.0, ±2.0, 0.009) also improved. Glaucoma-related distress was correlated with perceived competence ( r =-0.56, adjusted P =0.005), and an increase in perceived competence was associated with a decrease in glaucoma-related distress (β=-0.43, 95% CI -0.67 - -0.20, adjusted P =0.007).

CONCLUSIONS

The SEE program improved participants' autonomous motivation, perceived support, perceived competence, glaucoma-related distress, and competence. These results point to the promising potential of SDT-guided behavioral interventions in improving patient-centered metrics.

Comparing the Effectiveness and Adherence between Fixed and Non-Fixed Dorzolamide/Timolol Maleate in Open-Angle Glaucoma Patients in Hospital Universiti Sains Malaysia

Introduction

Glaucoma is an irreversible chronic eye disease in which intraocular pressure (IOP) control is important. This study aimed to assess the IOP-lowering effects and adherence scores between fixed combination dorzolamide/timolol maleate (FCDT) and non-fixed combination dorzolamide and timolol XE (NFDT) in open-angle glaucoma (OAG) patients.

Methods

A randomised controlled trial in a parallel, single-blinded study involving 60 OAG patients was conducted. The patients were randomised into FCDT or NFDT based on a block randomisation technique. A pre-study run-in with Gutt timolol was administered for two weeks. IOP was assessed at baseline, month 1 and month 3, with a bottle weight measurement at month 3.

Results

Only 55 OAG patients were analysed, with 8.4% dropping out. A statistically significant mean IOP reduction was observed in each group from baseline to month 1 (FCDT: mean difference [MD] = 4.93, 95% confidence interval [CI] = 4.00, 5.86); NFDT: MD = 4.92, 95% CI = 4.024, 5.82) and from baseline to month 3 (FCDT: MD 5.17, 95% CI = 4.19, 6.15; NFDT: MD = 4.85, 95% CI = 3.874, 5.82). The overall FCDT mean IOP was significantly lower by 1.02 mmHg (95% CI = -2.01, -0.02) than NFDT (F(1, 53) = 4.19; P = 0.046). A significant interaction was observed between time and treatment at month 3, with the mean IOP for FCDT being lower by 1.22 mg than for NFDT (P = 0.037). The mean adherence score was significantly higher in the FCDT group than in the NFDT group (t stat (df) = 3.88 (53); P < 0.001). The reduction in IOP between the groups became non-significant after adherence was adjusted (F(1, 52) = 2.45; P = 0.124).

Conclusion

Both drugs showed a decrease in IOP but more so in FCDT. However, no difference was found in terms of medication adherence. An emphasis on treatment compliance is needed.

Review of glaucoma medication adherence monitoring in the digital health era

Current glaucoma treatments aim to lower intraocular pressure, often with topical ocular hypotensive medications. Unfortunately, the effectiveness of these medications depends on sustained patient adherence to regimens which may involve instilling multiple medications several times daily. Patient adherence to glaucoma medications is often low. Recent innovations in digital sensor technologies have been leveraged to confirm eyedrop medication usage in real-time and relay this information back to providers. Some sensors have also been designed to deliver medication reminders and notifications as well as assist with correct eyedrop administration technique. Here, we review recent innovations targeted at improving glaucoma medication adherence and discuss their limitations.

Increased Near Activities Function Associated With Increased Glaucoma Medication Adherence Among Support, Educate, Empower (SEE) Participants

PRECIS

Higher levels of near vision-related quality of life (VRQoL) were associated with higher adherence to glaucoma medications after adjusting for important confounding variables among participants in the Support, Educate, Empower (SEE) personalized glaucoma coaching pilot study.

PURPOSE

To investigate the association between VRQoL and glaucoma medication adherence.

MATERIALS AND METHODS

Subjects were recruited for the SEE program, a prospective noncontrolled cohort study examining the impact of a personalized coaching program on glaucoma medication adherence. Glaucoma patients seen at the University of Michigan over 40 years old, taking ≥1 glaucoma medication, and self-reported poor adherence on 2 validated scales were recruited. Demographic details and VRQoL using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) were collected. Participants' medication use for each prescribed glaucoma medication was captured electronically using a medication events monitoring system. The association between VRQoL and medication adherence was assessed with Pearson correlation coefficient (r) and linear regression.

RESULTS

Among the 95 eligible participants 49.5% were female, 55.3% were Caucasian, and mean age (±SD) was 63.8±10.5 years. Mean adherence to glaucoma medication was 73.8%±21.0%. Mean NEI VFQ-25 composite score was 81.6±14.5. Better medication adherence was significantly and positively correlated with better functioning in domains of ocular pain (r=0.20, P=0.048), near activities (r=0.29, P=0.004), and role difficulties (r=0.22, P=0.036). Linear regression models adjusting for known correlates of medication adherence (age, sex, race, income), showed a 10-unit increase in self-perceived near activities function was associated with a 2.2% increase in medication adherence (95% confidence interval, 1.0%-5.4%; P=0.0056).

CONCLUSION

Better self-perceived near activities function was associated with increased glaucoma medication adherence.

Investigation of visual and physical factors associated with inadequate instillation of eyedrops among patients with glaucoma

Purpose

The aim of this study was to investigate the frequency of eyedrop instillation failure and its related physical and visual function factors among glaucoma patients who used hypotensive eyedrops daily.

Subjects and methods

Patients with a history of self-instillation of one or more ocular hypotensive ophthalmic solutions for six or more months were enrolled. Definitions of instillation failure were eyedrop instillation other than on the eye surface; eyedrop contact with eyelashes; eyedrop bottle tip contact with the eyelashes, eye surface or ocular adnexa; or two or more drops instilled with one instillation trial. To clarify factors related to instillation failure, we used visual function tests and investigated cervical spine extension angles during instillation, pinching strength, physical ataxia (evaluated using the Scale for the Assessment and Rating of Ataxia), motor dysfunction of the upper limbs (evaluated using the Disabilities of the Arm, Shoulder and Hand questionnaire), and vision quality (evaluated using the National Eye Institute Visual Function Questionnaire 25).

Results

Of 103 total subjects, 61.2% satisfied the definition of instillation failure. Instillation of the eyedrop other than at the cul-desac (76.2%) was the most frequent reason for failure, followed by contact of the tip of the eyedrop bottle (22.2%) and instillation of the same or more than two eyedrops in a single attempt (11.1%). Advanced age, a shallow cervical spine extension angle, weak pinching strength, poor motor dysfunction of the upper limbs, the degree of ataxia, poor best-corrected visual acuity, and visual field scores were significant risk factors for instillation failure. Vision quality may have some relation to instillation failure.

Conclusion

It is highly recommended that instillation failure be routinely investigated even among patients with adequate experience using eyedrops and that correct therapies are chosen in a patient-based fashion.

Assessing Health Care Burden in Glaucoma Patients with and Without Physical or Mental Comorbidities

BACKGROUND

Glaucoma is a collection of eye diseases that damage the eye's optic nerve resulting in vision loss and blindness. Treatment for glaucoma is primarily pharmacologic; however, studies have shown patients have difficulty adhering to topical regimens. The reasons for potentially poor adherence are numerous, including influence from a myriad of either physical or mental comorbid conditions faced by many glaucoma patients. Neither adherence nor associated outcomes have been estimated in these 2 groups of glaucoma patients.

OBJECTIVES

To (a) characterize glaucoma patients with and without select physical or mental comorbidities and (b) estimate differences between the 2 groups for 3 types of outcomes: health care resource use (HCRU; office-based/outpatient-based provider visits, emergency room visits, inpatient stays, home health provider days, prescription fills); health care expenditures; and health-related quality of life (HRQoL) as measured by the physical and mental component scores of the Short Form-12.

METHODS

We used first-year data from each glaucoma patient's 2-year panel survey in the Medical Expenditure Panel Survey (MEPS) database, 2003-2014. Two groups were created using ICD-9-CM codes collected by MEPS to compare glaucoma patients with and without at least 1 selected physical or mental comorbid condition. Between-group comparisons in the outcomes of interest (HCRU, expenditure, HRQoL) were estimated using multivariable regression analyses while adjusting for socio-demographic and clinical characteristics at baseline.

RESULTS

We identified 2,928 unique glaucoma patients during the 11 years of collected data, including 1,539 (53%) who had at least 1 physical or mental comorbid condition of interest. Comparing those with at least 1 select physical or mental comorbidity to those without (n = 1,389), unadjusted HCRU and expenditures were greater in patients with a physical or mental comorbidity (all P < 0.05). After adjustment, significant associations with increased HCRU remained for office-based provider visits and home health provider days (each P < 0.01). Average total expenditures were $12,324 in those with comorbidities and $8,590 for those without. HRQoL (unadjusted and adjusted) was lower in those with a physical or mental comorbid condition (all P < 0.05).

CONCLUSIONS

Some differences in HCRU and expenditures were accounted for by differences in baseline characteristics between those with and those without 1 or more physical or mental comorbid conditions, but differences remained after adjustment. Results suggest that glaucoma patients with physical and mental comorbidities may experience greater HCRU and associated expenditures, and lower HRQoL, when compared with glaucoma patients without these comorbidities With this knowledge, future work may include estimating the effect of the number of these comorbid conditions on each of the 3 types of outcomes.

DISCLOSURES

This study received funding support from Allergan. During the time this work was conducted, Serbin was a postdoctoral fellow who was supported by a training grant from Allergan to the University of Washington. Campbell is an employee of Allergan. Serbin, Devine, and Basu each have nothing to disclose. This study was presented as a poster at the International Society for Pharmacoeconomics and Outcomes Research Meeting; May 20-24, 2017; Boston, MA.

Influence of new treatment modalities on adherence in glaucoma

PURPOSE OF REVIEW

It is well known that glaucoma patients are not adherent to their therapeutic regimens. The issue of nonadherence is multifactorial and includes inadequate communication between doctors and patients, resulting in significant costs associated with enhanced disease progression. Therapeutic regimens are risk factors which often influences adherence rates. Thus, alternative treatment modalities, especially those risk factors that do not rely on patients' cooperation, may enable improvements in long-term outcomes of glaucoma in patient.

RECENT FINDINGS

The studies selected for this review were divided into new medications, especially advancements in pharmaceutical approaches to treat glaucoma and new ways of delivering the medication, new surgical methods, especially minimally invasive surgery methods for glaucoma, and new studies about adherence in glaucoma.

SUMMARY

Surprisingly, a very few studies on glaucoma medication or surgery addressed the concept of adherence. However, adherence is discussed in studies which consider psychological aspects of patients or communication issues between doctors and patients. Although these studies were performed in clinical settings, the issue of adherence is not addressed; despite it has significant effect on long-term outpatient care. A combination of both aspects, adherence and miscommunication, should be considered in studies.

Investigation of medication adherence and reasons for poor adherence in patients on long-term glaucoma treatment regimes

PURPOSE

Long-term treatment adherence for a chronic asymptomatic condition is a demanding task for many patients. Treating progressive glaucoma can also be confounding for physicians, particularly when management relies on assumption of adherence. This study investigated associations between self-reported adherence and frequency of medication changes due to glaucoma progression.

METHODS

A total of 128 participants with primary open angle glaucoma were recruited from glaucoma clinics in Flinders Eye Center, South Australia, and completed confidential questionnaires. Information was obtained regarding beliefs about glaucoma and their treatment. Adherence was assessed using the four-item Morisky, Green and Levine Medication Adherence Questionnaire (MGL). Medical records were analyzed for the number of medication changes, due to glaucoma progression.

RESULTS

Adherence to topical glaucoma medication was categorized as 'high' in 41.4% (Morisky, Green and Levine (MGL). Data were analyzed for behaviors affecting adherence, history of adherence, and reasons for changed adherence. Chi-squared test demonstrated that there was no significant association noted between adherence and changes in medication regime (χ² (2,128)=0.968, P=0.915); however, a significantly lower adherence was detected if participants had difficulties with their drop regime (χ² (2,128)=7.24, P=0.027) or had help with drop insertion (χ² (1,128)=9.77, P=0.008).

CONCLUSION

This study revealed a higher rate of non-adherence than has previously been demonstrated in other studies. This may be attributed to the unique design of the confidential questionnaire and the independent and sympathetic questioning techniques used. Further work to develop a specific glaucoma medication adherence questionnaire would be valuable to enhance glaucoma management.