Patients' and physicians' perceptions of the travoprost dosing aid: An open-label, multicenter study of adherence with prostaglandin analogue therapy for open-angle glaucoma or ocular hypertension

Disparities in Eye Care Access and Utilization: A Narrative Review

This narrative review summarizes the literature on factors related to eye care access and utilization in the United States. Using the Healthy People 2030 framework, this review investigates social determinants of health associated with general and follow-up engagement, screenings, diagnostic visits, treatment, technology, and teleophthalmology. We provide hypotheses for these documented eye care disparities, featuring qualitative, patient-centered research. Lastly, we provide recommendations in the hopes of appropriately eliminating these disparities and reimagining eye care.

Aiding Adherence to Glaucoma Medications: A Systematic Review

PURPOSE

To provide a comprehensive assessment of the strategies studied to date that focus on improving glaucoma medication adherence.

METHODS

A systematic review of the literature was conducted in MEDLINE (PubMed), Embase (Elsevier), and Scopus (Elsevier) from inception to March 1, 2021, of publications describing a device or strategy used to improve glaucoma medication adherence.

RESULTS

42 studies described by 50 papers were included. Five categories were identified: reminder systems, medication simplifications, behavioral change programs, education, and alternative engagement strategies.

CONCLUSION

Most studies (40 of the 42) addressed the question of improved adherence directly, with 26 finding improved adherence. Notably, 14 examined the clinical effects of the intervention, either in terms of intraocular pressure (IOP) or visual fields. Only three found an improvement in IOP. None demonstrated a between group difference in visual field progression.

Patients’ adherence to topical antiglaucoma medications in a tertiary care hospital

Objectives

Adherence to glaucoma medications is a central factor to control intraocular pressure and manage glaucoma effectively. This study aims to assess the level of adherence of glaucoma patients to ocular hypotensive agents and determine factors contributing to non-adherence in the Aseer region.

Methods

This was a single-centre, prospective cross-sectional study carried out in Aseer Hospital, Saudi Arabia. Data were collected through a customized questionnaire adapted from the Morisky, Green and Levine Medication Adherence Questionnaire (MGLS).

Key findings

Of the 102 glaucoma patients, 63 (61.8%) were non-adherent to their glaucoma medications. About 48 (76.2%) of them reported that they have no background information about glaucoma. Older participants (37, 58.7%; >50 years) showed a low adherence level compared with the younger individuals. Contributing factors to non-adherence include forgetting the dose time (32, 50.8%), illiteracy (31, 49.2%; P = 0.313), economic problems (26, 41.3%; P = 0.286) and lack of information about prescribed medications (15, 23.8%; P = 0.188).

Conclusions

No significant relationship was found between medication adherence and patient’s demographic data or their background knowledge about glaucoma. Despite the need for improving the glaucoma patient’s knowledge of their disease and the importance of medication adherence, an additional strategy as alerts by smartwatches should be encouraged to improve the adherence level.

Clinical effectiveness of brinzolamide 1%-brimonidine 0.2% fixed combination for primary open-angle glaucoma and ocular hypertension

The main first-line treatment strategy for glaucoma is to reduce intraocular pressure (IOP) by topical ocular hypotensive medications, but many patients require multiple medications for adequate IOP control. Fixed-combination therapies provide several benefits, including simplified treatment regimens, theoretical improved treatment adherence, elimination of the potential for washout of the first drug by the second, and the reduction in ocular exposure to preservatives. β-Adrenoceptor antagonists (particularly 0.5% timolol) are the most commonly used agents in combination with other classes of drugs as fixed-combination eyedrops, but they are contraindicated in many patients, owing to local allergy or systemic side effects. A fixed-combination preparation without a β-blocker is therefore warranted. This paper reviews the clinical effectiveness of brinzolamide 1% and brimonidine 0.2% fixed combination (BBFC) for use in patients with primary open-angle glaucoma and ocular hypertension. We searched PubMed and the ClinicalTrials.gov registry, and identified three randomized controlled trials comparing BBFC vs its constituents (brimonidine vs brinzolamide), and one comparing BBFC with unfixed brimonidine and brinzolamide. All of the studies demonstrated mean diurnal IOP to be statistically significantly lower in the BBFC group compared with constituent groups and noninferior to that with the concomitant group using two separate bottles. The safety profile of BBFC was consistent with that of its individual components, the most common ocular adverse events being ocular hyperemia, visual disturbances, and ocular allergic reactions. Common systemic adverse effects included altered taste sensation, oral dryness, fatigue, somnolence, and decreased alertness. BBFC seems to be a promising new fixed combination for use in glaucoma patients. However, long-term effects of BBFC on IOP, treatment adherence, and safety need to be determined.

Morning dosing of once-daily glaucoma medication is more convenient and may lead to greater adherence than evening dosing

PURPOSE

To determine if adherence and convenience of once-daily glaucoma medication is greater in the morning or the evening.

DESIGN

Prospective, randomized crossover treatment trial.

PATIENTS AND METHODS

Thirty patients newly diagnosed with glaucoma or ocular hypertension requiring intraocular pressure (IOP) reduction were started on travoprost eye drops and randomized to either morning or evening administration for 1 month. They were then crossed over to the opposite dosing schedule for the following month. Adherence was monitored using an automated dosing aid.

MAIN OUTCOME MEASURES

Adherence was compared between morning versus evening dosing and first versus second month dosing. Demographic characteristics were obtained, treatment effect was measured, and patients completed a post-study questionnaire regarding the convenience of the 2 dosing regimens.

RESULTS

Patient adherence overall was good (89.3%). There was no statistically significant difference (P=0.07) in adherence between morning dosing (90.9%) and evening dosing (87.3%). Adherence in the first month (91.7%) was superior to the second month (86.5%). There was no significant difference in IOP response between morning and evening dosing. Patients found morning dosing more convenient than evening dosing.

CONCLUSIONS

Early adherence to treatment with a prostaglandin analogue is good, but patients prefer morning administration to evening administration. This may lead to greater adherence with morning administration, particularly among men. Adherence decreases from the first to second month after initiation of treatment. IOP response to this treatment is not significantly affected by morning versus evening administration.

Assessing adherence factors in patients under topical treatment: development of the Topical Therapy Adherence Questionnaire (TTAQ)

Medication adherence rates strongly depend on favorable disease outcomes. It is known that medication adherence rates are lower for topical treatment than for systemic treatment. However, to date no validated instrument for the assessment of adherence factors in topical treatment is available. The aim of this study was to develop a new questionnaire to assess adherence risk factors in topical treatment. The development of the Topical Therapy Adherence Questionnaire (TTAQ) and Patient Preference Questionnaire (PPQ) was based on a systematic literature review, and qualitative patient focus interviews and expert focus groups’ input. The psychometric properties and comprehensibility of the TTAQ and PPQ were assessed in a feasibility study with 59 psoriasis patients. Our first preliminary results indicate that the TTAQ and PPQ are psychometrically sound and reliable measures for the assessment of factors influencing topical treatment adherence. The questionnaires are currently being further developed and various parameters (e.g., time point of assessment) are currently being tested in an exploratory pilot study with ca. 2,000 psoriasis patients receiving topical treatment in a European clinical trial. The use of the final versions of TTAQ and PPQ in clinical practice may facilitate the early identification of specific non-adherence factors in patients under topical treatment, which could enable designing and applying adherence-enhancing interventions according to the patient’s individual needs.

Adherence improvement in Dutch glaucoma patients: a randomized controlled trial

PURPOSE

To study the effect of patient education and the TravAlert(®) -Eyot(®) drop guider on intraocular pressure (IOP) and adherence in patients with primary open angle glaucoma (POAG) or ocular hypertension (OHT) monitored with the TravAlert(®) dosing aid.

METHODS

Multicentre, randomized, controlled clinical trial among 18 Dutch hospitals. Patients were randomized to one of the four study arms: (1) use of the dosing aid, (2) use of the dosing aid with the drop guider, (3) use of the dosing aid together with patient education or (4) use of the dosing aid and drop guider together with patient education. IOP was recorded at baseline and after 3 and 6 months. Data on adherence generated by the dosing aid were collected and studied at the end of the study.

RESULTS

Mean IOP dropped from 20.3 ± 5.7 mmHg at baseline to 16.3 ± 4.0 mmHg (right eye) after 6 months and from 20.2 ± 5.9 mmHg to 16.4 ± 4.1 mmHg (left eye). The mean adherence rate was 0.91 ± 0.1. IOP and adherence rate were not statistically different between the study arms. Patients with 'drug holidays' had a significantly higher mean IOP after 6 months. Patients who used the drop guider were less adherent. A lower adherence level was also associated with new patients with glaucoma and patients with a lower level of knowledge on glaucoma.

CONCLUSION

Patient education is especially useful for new patients with glaucoma. The use of a drop guider does not improve adherence. Especially patients with 'drug holidays' are at risk for developing uncontrolled IOP levels.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity.

MAIN RESULTS

Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive.

AUTHORS' CONCLUSIONS

Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.

Do adherence rates and glaucomatous visual field progression correlate?

PURPOSE

To assess the relation between visual field progression and adherence rate in patients with glaucoma using Travatan Dosing Aid® (TDA).

METHODS

In this 36-month retrospective study, 35 patients with primary open-angle glaucoma on travoprost or travoprost/timolol fixed combination monotherapy were submitted to ophthalmic examination and to visual field (VF) test from 2007 to 2009. Adherence was recorded with TDA. The association between VF progression (from 2007 to the end of the follow-up period) and a number of predictors (adherence rates at 12 months) was tested by means of chi-square test (or Fisher exact test) or Mann-Whitney test as appropriate.

RESULTS

The mean (±SD) adherence rates were 71.9%±27.8% after 1 month of follow-up and 76.8%±20.9% at 12 months. A total of 25 (71.4%) patients with stable VF had a median adherence rate (IQR) of 85% (75%-97%); patients who worsened (n=10; 28.6%) recorded a median (IQR) adherence of 21% (9%-45%) (p<0.001). No association was found between VF progression and any of the other variables (age, sex, schooling, visual acuity, intraocular pressure (IOP) at baseline and over time, other ocular diseases, time since diagnosis and actual therapy, number of concomitant systemic therapies). Patients who were at least 90% adherent did not progress, while 43.5% of the patients with lower adherence worsened (p=0.01).

CONCLUSIONS

Our data suggest that adherence rate may play a role in glaucomatous damage and/or progression; the target IOP therefore should be adjusted by adherence rates. Monitoring tools, educational programs, use of videos, a better doctor-patient relationship, or other means to improve adherence are desirable and necessary to preserve visual function.

Measurement of treatment compliance using a medical device for glaucoma patients associated with intraocular pressure control: a survey

OBJECTIVE

To identify and characterize treatment compliance profiles of glaucoma patients and evaluate the association with intraocular pressure (IOP).

METHODS

A computerized device (Travalert((R))) that recorded daily instillation times and eye-drop counts was given for 3 months. Patients were declared compliant when at least 2 drops were instilled per day. Compliance rates were calculated for weekdays and weekends, separately, over 8 consecutive weeks. A principal components analysis (PCA) was followed by an ascendant hierarchical classification (AHC) to identify compliance groups.

RESULTS

140 patients were recruited (mean age 65.5 years; 51.8% female) of whom 83.6% had primary open-angle glaucoma with mean IOP 23.9 mmHg before Travalert((R)) use. 60.7% were treated with DuoTrav((R)) (travoprost timolol fixed combination) and 39.3% with travoprost. The PCA identified two axes (compliance and treatment weeks). The AHC identified 3 compliance groups: 'high' (56.6%, approx. 80% compliance), 'medium' (21.2%, approx. 50% compliance), and 'low' (22.1%, approx. 20% compliance). Demographics and glaucoma parameters did not predict low compliance. Final mean IOP was 16.1 mmHg, but higher in the low compliance group (17.7 mmHg, P = 0.02).

CONCLUSIONS

Compliance measurement by a medical device showed compliance rates <80% by 50% (approx.) of patients, significantly impacting IOP control. No demographic or glaucoma variable was associated with low compliance.

Monitoring adherence rates in glaucoma patients using the Travatan Dosing Aid. A 6-month study comparing patients on travoprost 0.004% and patients on travoprost 0.004%/timolol 0.5% fixed combination

OBJECTIVE

To assess adherence in glaucoma patients using the Travatan Dosing Aid (TDA); to record differences in adherence by age, sex, therapy, systemic therapies, years from diagnosis, type of therapy and intraocular pressure (IOP).

RESEARCH DESIGN AND METHODS

Sixth-month cohort study; fifty-six Caucasian, primary open-angle glaucoma patients on travoprost (T) or travoprost/timolol fixed combination (TTFC) monotherapy were submitted to four visits: at baseline and months 1, 3 and 6 (M1, M3, M6). Adherence was recorded with TDA and classified as 'high' if greater than 90%. Self-reported and physician-presumed adherence data were collected. Kruskall-Wallis and Fisher's exact tests were applied.

RESULTS

Thirty-two patients (54.2%) were treated with T. Age, sex, level of schooling, presence of systemic comorbidities, duration of current therapy and IOP were similar between T and TTFC. Seventeen subjects (30.3%) recorded high adherence at every visit, 13 (23.2%) at two visits, 26 (46.4%) otherwise. Adherence was maintained over time with a slight decrease from month 1 to month 6 without statistical differences within and between groups. Adherence was statistically influenced by age (p = 0.007) and duration of therapy (p = 0.004).

CONCLUSION

The typical nonadherent patient is elderly. TDA records indicate that only a minority of patients are really adherent: predictive models to screen for poor adherence are needed.

An exploratory study of factors influencing glaucoma treatment adherence

PURPOSE

To understand the factors that influence glaucoma treatment adherence with medication taking, prescription refills, and appointment keeping to develop an intervention for a specific population.

PATIENTS AND METHODS

In-depth interviews were conducted with 80 individuals diagnosed with open-angle glaucoma, glaucoma suspect, or ocular hypertension. Additional eligibility requirements were that all participants were: between the ages of 18 to 80; white or African American; spoke and understood English; and were taking daily doses of topical glaucoma treatments for at least the past year. Cross-tabulations and chi2 tests were conducted to compare adherent and nonadherent individuals, classified as such based on self-report and medical chart/pharmacy data.

RESULTS

Compared with adherent participants, nonadherent participants were less likely to: believe their eye doctors spent sufficient time with them; ask their eye doctor if they had any questions; know of benefits to taking their glaucoma medication regularly; and have someone help them take their glaucoma medications or drive them to eye appointments. Conversely, compared with adherent individuals, nonadherent participants were more likely to have difficulty remembering to take their medications and to believe their glaucoma would affect their eye sight in the future.

CONCLUSIONS

Nonadherent glaucoma patients struggle with a variety of issues related to consistent use of glaucoma medicine and routine eye care. Interventions are needed to address these modifiable factors related to glaucoma treatment adherence.

Personality traits, depression, and objectively measured adherence to once-daily prostaglandin analog medication in glaucoma

PURPOSE

To investigate the influence of personality traits, depression, and training on objectively measured adherence to once-daily prostaglandin analog medication.

METHODS

Adherence was measured with the Travalert Dosing Aid on 58 consecutive, regularly followed-up glaucoma patients already on self-administered travoprost. Before the 3-month data-collection period all patients received training on use of the device. Psychologic characteristics were measured using the State-Trait Anxiety Inventory, Eysenck Personality Questionnaire, and Beck Hopeless Scale and Depression Inventory. An adherent day was defined as travoprost instillation at 9 PM +/-2 hours.

RESULTS

Adherence was 77% for the total period. Social desirability was higher than normal (U test, P<0.0001). Seven patients (12.1%) showed mild-to-moderate depression, which was not significantly associated with decreased adherence (Kruskal-Wallis test, P=0.071). Severity of glaucoma, number of ocular and systemic medications, satisfaction with the recording device, and socio-economic characteristics had no influence on adherence.

CONCLUSIONS

Objectively measured adherence to once-daily prostaglandin analog medication was good, and not influenced by treatment characteristics or patient factors including mild-to-moderate depression. The elevated social desirability suggests that self-reported adherence is not a reliable measure of adherence in glaucoma.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information and ongoing support according to patient need, may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, ZETOC and OpenSIGLE. In addition, we searched research registers of ongoing studies. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 15 January 2009.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We calculated the mean difference for continuous data and relative risks for dichotomous data. Where appropriate, we pooled data using a fixed-effect model.

MAIN RESULTS

Eight trials met the inclusion criteria. There was considerable heterogeneity of interventions and reported outcome measures and therefore, meta-analysis was limited to two studies. Overall, studies were not of high quality due to small sample sizes, missing data and short term follow-up. Three of five drug comparison studies provided evidence that reducing the frequency of drops can improve adherence. However, the study that compared the least frequent regime with one of the most complicated, showed no difference in reported adherence. A small study of thirteen patients found a reminder device beneficial to adherence levels yet only one of two studies involving education and individualised care planning was found to be successful.

AUTHORS' CONCLUSIONS

Interventions involving simplified dosing regimes, reminder devices, education and individualised care planning, did show improvements in adherence rates. However, due to inadequate methodological quality and heterogeneity of study design we are unable to advocate any particular interventions at this time.

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.

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.