Monitoring compliance with pilocarpine therapy

Factors Affecting Follow-Up Adherence of Glaucoma Patients

PURPOSE

The objective of our study is to understand the factors associated with non-adherence to the physician's follow-up advice by persons with glaucoma.

METHODS

We use a four-year panel dataset containing demographic, clinical, and intervention details and doctor's advised follow-up date for a random sample of 2,622 glaucoma patients from an Indian tertiary eye care hospital. We model this unique "advised follow-up date" in multivariate logistic regressions to identify factors associated with patients' coming early or late as against on-time. An OLS regression also examines an association between delayed follow-up and declining visual acuity.

RESULTS

Demographic variables such as age, gender, distance to hospital, IOP, and visual acuity were not associated with delayed adherence to follow-up. Patients advised to review within 2 months (p < .001), paying patients (p < .001), and those habituated to routine follow-up (diabetes patients) (p < .01) are less likely to delay care-seeking. Patients are more likely to come on-time in visits immediately after clinical interventions relative to later ones (p < .001). Our second analysis reveals the presence of cataract and the very first post-surgery visit as factors influencing patients to come early. Our third analysis reveals that a higher proportion of delayed visits had resulted in worsening of vision in the glaucoma-affected eye.

CONCLUSION

Our results suggest that active counselling by doctors, especially for routine follow-up visits, can help in better follow-up adherence and prevention of glaucoma-related visual impairment.

Barriers and enablers to medication adherence in glaucoma: A systematic review of modifiable factors using the Theoretical Domains Framework

PURPOSE

Nonadherence to medication reduces treatment effectiveness, and in chronic conditions it can significantly reduce health outcomes. In glaucoma, suboptimal adherence can lead to sight loss, which places a greater financial burden on society and reduces patients' quality of life. Interventions to improve adherence have so far had limited success and lack robust theoretical underpinnings. A better understanding of the determinants of medication adherence behaviour is needed in order to develop interventions that can target these factors more effectively. This systematic review aims to identify modifiable barriers and enablers to glaucoma medication adherence and identify factors most likely to influence adherence behaviour.

RECENT FINDINGS

We searched CINAHL, MEDLINE, PsycINFO, EMBASE, the Cochrane Library and sources of grey literature up to August 2022 for studies reporting determinants of glaucoma medication adherence. Data describing modifiable barriers/enablers to adherence were extracted and analysed using the Theoretical Domains Framework (TDF), a behavioural framework consisting of 14 domains representing theoretical factors that most likely influence behaviour. Data were deductively coded into one of the TDF domains and inductively analysed to generate themes. Key behavioural domains influencing medication adherence were identified by frequency of study coding, level of elaboration and expressed importance. Eighty-three studies were included in the final synthesis. Four key domains influencing glaucoma medication adherence were identified: 'Environmental Context and Resources', 'Knowledge', 'Skills' and 'Memory, Attention and decision processes'. Frequently reported barriers included complex eyedrop regimens, lack of patient understanding of their condition, forgetfulness and difficulties administering eyedrops. Whereas simplified treatments, knowledgeable educated patients and good patient-practitioner relationships were enablers to adherence.

SUMMARY

We identified multiple barriers and enablers affecting glaucoma medication adherence. Four theoretical domains were found to be key in influencing adherence behaviour. These findings can be used to underpin the development of behaviour change interventions that aim to improve medication adherence.

Deception in clinical trials and its impact on recruitment and adherence of study participants

Deceptive practices by participants in clinical research are prevalent. It has been shown that as high as 75% of participants withheld information to avoid exclusion from studies. Self-reported adherence has been found to be largely inaccurate. Overcoming deception is a critical issue, since the safety of study participants, the integrity of research data and research resources are at risk. In this review article, we examine deception from the perspective of investigators conducting clinical trials; we describe the types (concealment, fabrication, drug holidays and collusion), prevalence, risks, and predictors of deception, and propose an approach to reduce the impact of deception, especially on adherence, in clinical trials.

Factors contributing to nonadherence to follow-up appointments in a resident glaucoma clinic versus primary eye care clinic

PURPOSE

To determine the rate of adherence to follow-up appointment recommendations in a resident glaucoma clinic with no mechanism for reminders, compared to a resident cataract and primary eye care (CPEC) clinic in which telephone reminders were used, and to identify factors that contribute to adherence in each patient group.

METHODS

This retrospective cohort study included subjects in the CPEC clinic who received telephone reminders and those in the glaucoma clinic who did not. Each sample was selected to have a similar proportion of follow-up recommendations for 1, 3, and 6 months. Subjects were considered adherent if they returned within a specified timeframe.

RESULTS

A total of 144 subjects from the glaucoma clinic and 151 subjects from the CPEC clinic were included. There was no significant difference between follow-up adherence rates of patients who received telephone reminders and those who did not (odds ratio [OR] =1.35, 95% confidence interval [CI] 0.79-2.32, P=0.28). Patients who were on more than two ocular medications were more likely to return for follow-up (OR=3.11, 95% CI 1.53-6.35, P=0.0018). Subjects between the ages 50 and 80 years were more likely to be adherent compared to their younger and older peers (P=0.02).

CONCLUSION

The follow-up adherence of patients in a CPEC clinic who received telephone reminders was similar to patients in a glaucoma clinic who did not receive any intervention to increase their adherence. Younger (⩽50 years old) and elderly (⩾80 years old) subjects, as well as patients using less than two glaucoma medications, were less likely to adhere to their follow-up appointments.

[The influence of the Travalert(®) dosing aid on medical treatment compliance and the quality of life of glaucoma patients]

PURPOSE

To study compliance in the medical treatment of glaucoma, its possible association with other factors, and quality of life of patients with glaucoma.

MATERIAL AND METHODS

Longitudinal prospective study of 60 patients with ocular hypertension or glaucoma who were treated with travoprost, or with a fixed combination of travoprost/timolol nightly. All subjects were given a Travalert(®) dosing aid and were reviewed after one and four months. Strict and relative compliance data were collected on each visit. The relationship between compliance and other variables was studied using univariate analysis. To analyse quality of life, patients were given self-assessment STAI anxiety questionnaires after the first and last visits.

RESULTS

Relative compliance for the four months was significantly greater than the strict compliance (P=.001). In the group of least compliance the number of patients on treatment with combination therapy was significantly higher than those on monotherapy. In the lost cases, the number of men was significantly higher than women. No association was found in the other variables. The anxiety was similar to that in the normal population.

CONCLUSIONS

Compliance is very important in the treatment of glaucoma, and our study provides objective data through the use of Travalert dosing aid with relative compliances of 70%. Patients with combined therapies have lower compliance than those on monotherapy.

Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systematic review

PURPOSE

This study summarizes findings from objective assessments of compliance (or adherence) and persistence with ocular hypotensive agents in patients with glaucoma and ocular hypertension.

DESIGN

Systematic literature review.

METHODS

A PubMed and reference list search was conducted across publication years 1970-2010, using these terms and variants: "compliance," the equivalent term "adherence," and "persistence" in patients with these conditions and therapies. Summaries of selected studies were stratified by measurement method (electronic monitor, prescription fills review, medical chart review). Measures of central tendency across studies were calculated for commonly-reported compliance or persistence measures.

RESULTS

Fifty-eight articles met all inclusion/exclusion criteria: measurement of compliance-electronic monitoring (seven studies reported in 14 articles), measurement of compliance/ persistence-prescription records (36 studies in 38 articles), and measurement of persistence- medical chart review (six studies in six articles). From electronic monitoring, most therapy-experienced patients took medication consistently, but ≥20% met criteria for poor compliance. From prescription records, only 56% (range 37%-92%) of the days in the first therapy year could be dosed with the medication supply dispensed over this period. At 12 months from therapy start, only 31% (range 10%-68%) of new therapy users had not discontinued, and 40% (range 14%-67%) had not discontinued or changed the initial therapy. From medical chart review, only 67% (range 62%-78%) of patients remained persistent 12 months after starting therapy.

CONCLUSIONS

Evidence provided by this review suggests that poor compliance and persistence has been and remains a common problem for many glaucoma patients, and is especially problematic for patients new to therapy. The direction of empirical research should shift toward a greater emphasis on understanding of root causes and identification and testing of solutions for this problem.

Effect of reminder cards on compliance with antihypertensive medication

Objective

Poor compliance to antihypertensive medications has been identified as a primary cause of uncontrolled blood pressure (BP), with consequent increases in hypertension-related morbidity and mortality. Therefore, any measure known to improve compliance should be encouraged. This study assessed the impact of reminder cards on compliance to antihypertensive therapy.

Method

A field trial was undertaken in pharmacies located in the districts of Lisbon and Porto. Eligible participants comprised those aged 30–74 years, prescribed an angiotensin-converting enzyme inhibitor (ACEI) in monotherapy, and taken on a once-daily regimen. Patients were allocated to control group (CG) or intervention group (IG), the latter being provided with a reminder card, an alarm-type device due to remind the patient of the time to take his medication. Patients were monitored monthly during 3 months for compliance and blood pressure control.

Key findings

Seventy-one patients participated in the study (intervention: 35; control group: 36). Compliance was similar between the groups in the first 2 months of follow-up (97.1% IG vs 94.9% CG at first follow-up and 97.5% IG vs 94.2% CG at second follow-up) and higher in the intervention group at the end of the study (97.3% IG vs 87.3% CG; P = 0.011). There were no mean blood pressure differences between compliant and non-compliant subjects at the end of the study (P value for differences in systolic BP (Psyst) = 0.580; and P value for differences in diastolic BP (Pdlast) = 0.175).

Conclusion

This small-scale study indicates a possible positive impact on patients' compliance resulting from the use of reminder cards. However, this needs confirming in larger scale studies with longer monitoring periods.

Noncompliance with drug therapy of glaucoma: a review about intervening factors

Glaucoma is defined as an optic neuropathy, characterized for loss of visual field and injury of the optic nerve, being considered as the second cause of blindness in the world, which could be prevented by the use of antiglaucoma eyedrops. The lack of adhesion of the patient to the drug treatment can culminate with loss of the vision. The objective was to revise possible literature data regarding intervening factors for noncompliance and explain estimated rates of noncompliance. A systematic review about the subject was carried out in the period of January to June of 2006. Articles had been searched in two data bases, in the National Library of Medicine (PUBMED) and in the Literature Latin American and Caribbean Health Sciences (LILACS) using the following keywords: glaucoma, compliance of the patient, noncompliance of the patient, treatment and eyedrops. In PUBMED, 199 articles were collected, written in English and French languages. No article was found in LILACS. Considering the inclusion and exclusion criteria, 27 articles were selected, with 25 originals and two reviews. Twelve possible intervening factors for noncompliance were raised, as well as estimates for rates of noncompliance. The noncompliance rates varied from 4.6% up to 59%. Two factors, forgetfulness and inadequate between-doses interval, had been associated to noncompliance of the drug therapy. The factors race, adverse effects, treatment cost, number of instilled doses, coexisting illnesses and number of eyedrops used, had resulted contradictory, being impossible to affirm that they have contributed for noncompliance. Age, sex, educational level and loss of visual field, had not been associated with noncompliance. The glaucoma patients tended to disregard the drug treatment. The wide variation in noncompliance rates could be an influence from the authors' difficulty to define the noncompliance and the variety of methodologies used to estimate it. More studies are necessary for a better evaluation of these 12 raised factors.

Methods in assessing drug compliance

Methods and problems in assessing drug compliance are related to the selection of study sample and observation period as well as to methods used to measure patient behaviour in taking medications. Patients under treatment with a certain drug regimen are different from the patients for whom that regimen was originally prescribed. Medication compliance during short periods of time, such as 1-2 weeks before or after a visit to the clinic, is likely to be different from that found over longer periods of time. Several studies indicate that estimates by clinical staff are no more accurate than chance selections in determining medication compliance. Patient interviews have usually identified 25-50% of noncompliant patients, but interview data on spacing between doses seem to be more accurate. Pill counts are useful in assessing drug compliance, although compliance may sometimes be overestimated. Medication monitors provide more detailed information on patient behaviour in taking medications.

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.

Adherence with topical glaucoma medication monitored electronically the Travatan Dosing Aid study

PURPOSE

To assess patient adherence and behaviors with topical once-daily therapy for glaucoma.

DESIGN

Prospective, observational cohort study.

PARTICIPANTS

One hundred ninety-six patients with glaucoma who were being treated with a prostaglandin analog in 1 or both eyes at the Scheie or Wilmer Eye Institutes between August 2006 and June 2007.

METHODS

Detailed medical history was obtained from each patient. All subjects used the Travatan Dosing Aid (DA; Alcon, Fort Worth, TX) to administer travoprost as prescribed. Devices were collected at 3 months and the data of drop usage was downloaded using software provided with the dosing aid. Data were analyzed for the 8-week period starting 2 weeks after the enrollment visit and ending 2 weeks before the 3-month visit.

MAIN OUTCOME MEASURES

Assessment of adherence and patterns of drop usage as indicated by the DA.

RESULTS

A total of 282 subjects consented to be in the study and 86 (30%) withdrew before study completion or had device errors, leaving 196 subjects (70%) with evaluable data at 3 months. The overall mean (+/-standard deviation) adherence rate was 0.71 (+/-0.24), ranging from 0.02 to 0.97. One hundred nine of these patients (55.6%) took greater than 75% of the expected doses. Those with adherence of less than 50% of expected doses showed substantially increased dose taking immediately after the office visit and just before the return visit at 3 months (P = 0.03). The mean adherence rate estimates of the physician and patient self-report were 0.77 and 0.95, respectively. The agreement between the physician assessment and DA-recorded adherence rate showed poor correlation for individual cases (intraclass correlation coefficient, 0.09; 95% confidence interval, 0.00-0.19).

CONCLUSIONS

Nearly 45% of patients using an electronic monitoring device who knew they were being monitored and were provided free medication used their drops less than 75% of the time. Patients reported far higher medication use than their actual behavior. The ability of the physician to identify which persons are poorly adherent from their self-report or from other subjective clues is poor.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Acute bacterial conjunctivitis

Acute bacterial conjunctivitis is the eye disease most commonly seen by general practitioners, and is estimated to represent approximately 1% of all consultations in primary care. This article gives a review of the epidemiology, aetiology, clinical picture, complications, differential diagnoses, in vitro examinations and therapy of acute bacterial conjunctivitis. Until now, topical antibacterial therapy has generally been preferred by both physicians and patients because this will usually shorten the course of the disease slightly and allow the early readmittance of children to their kindergarten or school. Recently, several reports from primary care have confirmed the well-known clinical experience that the disorder has an excellent prognosis with a high frequency of spontaneous remission. In accordance, an expectant attitude or delayed prescription policy are now frequently strongly recommended. However, these reports also emphasize the difficulty in making a correct clinical distinction between bacterial and viral conjunctivitis. The effect of a general non-prescription attitude on transmission rates of pathogens also remains to be clarified. This must be born in mind when deciding how these patients should be handled. The socioeconomic and medical pros and cons of different treatment policies are discussed, and a highly personal view on the optimal handling strategy for these patients is also presented.

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.

Comparison of carteolol plasmatic levels after repeated instillations of long-acting and regular formulations of carteolol 2% in glaucoma patients

BACKGROUND

A new long-acting (LA) formulation of carteolol 2% instilled once daily has been shown to provide a therapeutic effect similar to that of the regular formulation of carteolol 2% instilled twice daily. This study was designed to test whether the new formulation reduces the systemic delivery of carteolol.

METHODS

In this double-masked, randomised, intra-subject comparative study, 23 patients with bilateral primary open-angle glaucoma or bilateral ocular hypertension received sequentially, according to the randomised order of administration, each of the 2 following treatments: carteolol 2% LA once daily for 2 months and carteolol 2% regular twice daily for 2 months. Treatments were instilled in both eyes throughout the study period. At the end of each period of treatment, blood samples were taken immediately before the last morning instillation (residual time), then 30 min, 1 h, 2 h and 4 h after this instillation in order to measure the carteolol plasma concentrations.

RESULTS

The mean values of maximal plasma concentration (C(max)), residual level and area under the curve obtained following carteolol 2% LA treatment were significantly lower than the values obtained after carteolol 2% regular treatment (mean+/-SD): C(max) (ng/ml): 1.72+/-0.85 versus 3.64+/-3.65; residual level (ng/ml): 0.70+/-0.58 versus 1.80+/-0.84; area under the curve (ng/mlxh): 5.50+/-2.66 versus 10.27+/-5.46. Regarding safety, two drug-related, non-serious adverse events were reported in the LA group: one case of moderate, superficial, punctate keratitis and one case of "bitter taste in the throat." Both treatments appeared to be well tolerated.

CONCLUSIONS

The data from this study showed that the systemic delivery of carteolol is lower for the once-daily LA formulation than for the regular twice-daily formulation. Consequently, long-acting carteolol eye-drops should reduce the risk of beta-blocking systemic side effects.

Compliance and persistency in glaucoma follow-up treatment

PURPOSE OF REVIEW

To summarize research published between 1980 and October 2004 regarding compliance (the extent to which patients' behaviors correspond with providers' recommendations) and persistency (total time on therapy) in patients diagnosed with open-angle glaucoma or ocular hypertension; to suggest approaches ophthalmologists might consider to improve compliance and persistency; and to identify areas warranting future research.

RECENT FINDINGS

Medication compliance, the focus of most compliance-related research, has been measured using a variety of methods including patient self-reports, the medication possession ratio, and electronic monitoring. Noncompliance rates of at least 25% commonly have been reported. The primary obstacles to medication compliance appear to be situational/environmental (e.g., being away from home or a change in routine) or related to the medication regimen (e.g., side effects or complexity). Persistency with ocular hypotensive therapies has been found to be poor. Retrospective cohort studies using survival analyses have reported that fewer than 25% of patients are persistent over 12 months.

SUMMARY

Accurately assessing patient compliance and persistency is important to optimizing patient care. Physicians may mistake either medication noncompliance or lack of persistency with poor efficacy. Such errors would likely increase health care costs if they result in unnecessary changes to a patient's therapeutic regimen or in surgery.

Adherence with drug therapy in the rheumatic diseases Part two: measuring and improving adherence

Part one of this review highlighted the problem of high rates of non-adherence with drug therapy in the rheumatic diseases. Part two addresses the problem of assessing adherence to drug therapy, focuses on factors affecting medication taking and discusses interventions that can help to improved adherence.

Design of the PID Evaluation and Clinical Health (PEACH) Study

This paper describes the PID Evaluation and Clinical Health Study (PEACH), a multicenter, randomized clinical trial designed to compare treatment with outpatient and inpatient antimicrobial regimens among women with pelvic inflammatory disease (PID). PEACH is the first trial to evaluate the effectiveness and cost-effectiveness of currently recommended antibiotic combinations in preventing infertility, ectopic pregnancy, chronic pelvic pain, recurrent PID, and other health outcomes. It is also the largest prospective study of PID ever conducted in North America. We describe the PEACH study's specific aims, study organization, patient selection criteria, conditions for exclusion, data collected upon entry, randomization and treatment, adherence measures, follow-up activities, quality-of-life measures, outcomes, and statistical analyses. In the first 11 months of enrollment (March 1996-January 1997), 312 women were randomized. Of eligible women, 59% consented to enroll. Participating women are primarily black (72%) and young (mean age 24 years). After a median of 5.5 months of follow-up, we were in contact with 95% of study participants. The PEACH study will provide a rationale for selecting between inpatient and outpatient antibiotic treatment, the two most common treatment strategies, for PID.

Social pharmacology: unresolved critical issues

This article describes and analyzes decision-making by patients, physicians, and drug information providers about registered medical drugs. Based on a cognitive psychology perspective, cognitive variables (the individual's mediating system) are assumed to be critical factors determining both patient and physician behavior. The individual's psychological functioning is seen as a continuous reciprocal interaction between behavioral, cognitive, and environmental influences; i.e., an interactional paradigm is applied. The importance of research models including cognitive and situation variables to guide the search for appropriate research methods is stressed. An intensive research strategy with a small sample of respondents will often be necessary. Also, respondents should be asked to describe their reactions to specific medical situations. The drug information sender has to select a set of goals for disseminating information to patients. Among the goals most often selected are: message comprehension, receiver satisfaction, changes in knowledge, attitudes, and drug behavior, as well as health effects. More research is needed on how the patient's mediating system, the actual situation, and the perceived situation steer his search for the use of new drug information. A different set of factors influence the patient's decision to start a medicinal or drug treatment than the factors that influence his decision to continue a treatment. The latter factors include forgetfulness, misunderstandings, and the patient's interpretation of physiological signs. More cognitive-oriented research about drug compliance must be undertaken. In such studies the mediating systems of a group of patients could be considered before and after intervention. There are a great number of types of inappropriate (irrational) prescribing. However, a physician may prescribe rationally in one area but irrationally in another. Face-to-face education of physicians has been shown to be effective in reducing inappropriate prescribing in a number of studies. "Overprescribing" of benzodiazepine has been an issue of intensive professional debate during the last decades. The two groups who criticize and defend the existing use of benzodiazepines build their views on different assumptions about the interaction between mind and brain as well as making different value assumptions regarding the use of a psychotropic drug. There is a need for prescription studies where a cognitive and interactional perspective is combined with an information-processing and a normative perspective. The benzodiazepines dependency problem has provoked lively discussion among professionals and the general public. Long-term benzodiazepine use and personality disorders increase the risk of the patient becoming dependent. A great number of research models have been suggested for the analysis of prescription drug dependency and as guides to the treatment of dependency.(ABSTRACT TRUNCATED AT 400 WORDS)

Combined timolol and pilocarpine vs pilocarpine alone and timolol alone in the treatment of glaucoma

We compared the effects of pilocarpine 4% alone, timolol 0.5% alone, and a combination of timolol 0.5% and pilocarpine 4% in the treatment of glaucoma. We treated 43 patients with glaucoma using each drug and then with the combination of drugs for four weeks each. Only patients with a morning intraocular pressure of at least 24 mm Hg without treatment were included. The patients were examined, after one and four weeks of treatment with pilocarpine, timolol, or combined timolol 0.5% and pilocarpine 4%, before the morning dose and at two and five hours after it. At the end of the study, the mean reduction in intraocular pressure from baseline was 9.2 +/- 5.1 mm Hg (28.5% +/- 12.7%) with combined timolol 0.5% and pilocarpine 4%, 5.6 +/- 3.6 mm Hg (17.6% +/- 9.7%) with pilocarpine, and 7.5 +/- 5.0 mm Hg (21.2% +/- 12.6%) with timolol. Intraocular pressure was consistently lower with the combination treatment than with timolol or pilocarpine alone. We believe that this combined solution of timolol-pilocarpine is a valuable contribution to the treatment of open-angle glaucoma.

Actual versus prescribed timing of lovastatin doses assessed by electronic compliance monitoring

The objective of the study was to compare compliance with and the hypocholesterolaemic effect of lovastatin given once daily as a morning or an evening dose. Twenty-four out-patients with familial hypercholesterolaemia were randomly assigned to receive placebo first, then lovastatin 20 mg, to be taken once daily for 4 weeks, either with the breakfast or evening meal, in a single-blind fashion. Drug compliance was assessed by pill counts and continuous electronic monitoring. Two compliance parameters were evaluated, consumption, defined as percentage of prescribed doses taken, and time compliance, the percentage of total dosing events recorded within defined intervals (6.00-10.00 h, and 17.00-21.00 h), for the morning and evening regimes. Both regimes satisfactorily reduced the total and LDL-cholesterol concentrations, and there was no significant difference in the extent of the reductions. Pill counts overestimated compliance, as revealed by the monitoring method. The times of actual consumption of doses by the patients often differed from that prescribed, predominantly in patients who were told to take the evening dose. Partial time compliance may have confounded the efficacy of the drugs. Electronic compliance monitoring appears to be particularly useful in chronopharmacological studies.

Treatment for glaucoma: adherence by the elderly

OBJECTIVES

The purpose of this study was to determine the extent of nonadherence to treatment for glaucoma among elderly patients.

METHODS

This was a retrospective cohort study of 2440 patients older than age 65 who were enrolled in the New Jersey Medicaid Program and who were newly initiated on a topical agent for the treatment of glaucoma. Two patient-specific measures of nonadherence were employed: (1) no filled prescription for any glaucoma medication over a 12-month period after the initiation of therapy and (2) number of days without therapy for glaucoma during this 12-month period.

RESULTS

By the first measure, 569 patients (23%) were found to be nonadherent. The mean number of days without therapy during the study year was 112. Factors associated with nonadherence included the use of glaucoma medication requiring more than 2 administrations per day and the presence of multiple other medications in the patient's drug regimen. Patients started on multiple glaucoma medication were more adherent than those started on a single agent. Age and sex were not found to be predictors of nonadherence.

CONCLUSIONS

Substantial nonadherence was found to be common in this population. More attention to the issue of nonadherence could result in important benefits in the preservation of sight.

Measurement of drug compliance by continuous electronic monitoring: a pilot study in elderly patients discharged from hospital

OBJECTIVE

A pilot study to assess patient compliance with medication by using a new measurement technique, continuous electronic monitoring.

DESIGN

Survey. Compliance monitors were provided to eligible patients at discharge from the hospital to measure drug intake behavior prospectively for a period of 3 weeks.

SETTING

Ambulant patient care after discharge from a geriatric hospital, Krankenhaus Bethanien, which is affiliated with the University Clinic, Heidelberg.

PATIENTS

A consecutive convenience sample of 18 independently living elderly patients (median age 76 years) completed the study. The patients were on maintenance therapy with cardiac glycosides and/or potassium-sparing diuretics prescribed to be taken once daily.

INTERVENTION

The monitoring method provides information about patients' real timing of drug use by continuously recording date and time of openings and closings of the medication containers (monitors). In addition to a standard measure, the percentage of prescribed doses taken, information about regularity of drug use is obtained.

RESULTS

Compliance, percentage of prescribed doses taken, was remarkably variable; it ranged from 24% to 100%, 95% CI: 62%-84%. Mean compliance declined from the first to the third week after discharge, 85% vs 69%, 95% CI: 74%-95% and 56%-81%, respectively (P < 0.05). Omissions of doses, the predominant pattern of non-compliance, were observed in 17 of 18 patients. Regularity of dose timing, as defined by the number of interdose intervals within 24 h +/- 15%, varied from 10% to 100%, 95% CI: 46%-76%.

CONCLUSIONS

Continuous electronic monitoring revealed highly variable compliance in patients prescribed maintenance therapy. Even with a once-daily regimen, persistent and high compliance cannot be assumed. The monitoring technique may be of great value to research and, possibly, to practical therapeutic management.

Twelve-hour IOP control obtained by a single dose of timolol/pilocarpine combination eye drops

The 12 h IOP control achieved by a single application of a newly developed ophthalmic solution containing 0.5% timolol and 2% resp. 4% pilocarpine was compared with that obtained by 1 dose of timolol 0.5% alone in 33 patients with manifest open angle glaucoma or ocular hypertension. The combined solutions gave a significantly better 12 h IOP control, evidenced by both a reduced mean diurnal IOP and a decreased frequency of larger pressure peaks.

Dynamics of drug regimen compliance--its assessment by microprocessor-based monitoring

The utility of a new microprocessor-based method for continuous monitoring of compliance in taking solid medicaments has been evaluated. Medication intake in 31 ambulant patients was assessed in a prospective observational study under the conditions of routine practice. The patients (aged 14-87 y, mean 50 y) were receiving long-term drug treatment for various chronic diseases. There was marked interindividual and intraindividual variation in compliance with different drugs. Deviations from the prescribed dosage regimens were caused by omission of doses (22.7% of prescribed doses) and intake of extra doses (5.6% of prescribed doses). Continuous monitoring revealed that in 19% of the monitoring period no medication was taken, in 13% there was partial intake, and in 8% extra doses were taken. Patient-initiated drug holidays occurred in 50% of patients. They were responsible for 76% of the medication-free time. It is concluded, that continuous compliance monitoring is practicable in ambulatory patients. It provides information about the dynamics of drug intake behaviour that cannot be obtained from medical histories or from clinical or laboratory examination. The information could be used effectively in individual patient care and in clinical drug trials.

Compliance measurement with arthritis regimen

Rheumatoid arthritis affects nearly 6.5 million Americans, causing significant disability and suffering. Improvement of treatment efficacy is of considerable importance. Because adherence moderates treatment effects, efficacy studies need to account for the extent to which the patient complied. This paper reviews the methods of assessing adherence. These methods fall into four categories: (1) clinical measures (therapeutic outcome and clinician judgement); (2) self-report (interviews, questionnaires, and daily records); (3) direct measures (direct observation and biologic assays); and (4) indirect measures (pill counts, pharmacy refills, and electronic monitors). The most commonly used measure is some form of self-report. The clinical measures are problematic as compliance indicators and should not be used in this regard. Selections among the other categories should be made based upon the behavior being studied, the cost and resources available, the capabilities of the patient, the questions being asked, and the level of accuracy and detail desired. There are no perfect measures.

Efficacy and safety of the combination therapy Pilogel/beta-blocker: interim results

The interim results of a multicentered clinical trial with the combination therapy therapy Pilogel/topical beta-blocker (twice daily) in patients with primary open angle glaucoma or ocular hypertension are discussed. Six patients were treated with Pilogel and a topical beta-blocker for one month. Four out of six patients responded well to the combination therapy. Most patients experienced some difficulty in applying the gel and their eyelids stuck together on awakening. In two patients a superficial punctate keratitis was observed. We found an average decrease in intra-ocular pressure (IOP) of 22.5% 22.5 hours after Pilogel administration, but there was some tendency towards higher evening values compared to morning values. In view of the appearance of a corneal haze as described by Johnson et al. during long-term treatment, longer follow-up is necessary.

Timolol-pilocarpine combined vs timolol and pilocarpine given separately

In a controlled, double-observer, multicenter study, we compared the effect of a fixed combination of timolol 0.5%-pilocarpine 4% twice a day with that of timolol 0.5% twice a day plus pilocarpine 4% three times a day in 80 patients with open-angle glaucoma whose intraocular pressure was greater than 21 mm Hg on timolol 0.5% twice a day alone. Administered twice daily, the combination drug lowered intraocular pressure as effectively as concomitant treatment with timolol twice a day and pilocarpine three times a day. No statistically significant differences in reduction of intraocular pressure were found between the two groups nor were any unexpected side effects observed.

Timolol/pilocarpine combination eye drops in open angle glaucoma and in ocular hypertension. A controlled randomized study

The effect of a newly developed ophthalmic solution containing both 0.5% timolol and 2% resp. 4% pilocarpine was compared with that of timolol 0.5% eye drops alone in 93 patients with manifest simple or capsular glaucoma or ocular hypertension. The medications were administered twice daily. The absolute additive effect of pilocarpine was small, although the combined solutions caused a statistically significantly greater reduction of the intraocular pressure than that achieved by timolol alone. This additional effect appeared to last at least 12 h. The effect of the test solutions containing 2% resp. 4% pilocarpine was very similar. Apart from the well-known effects of the pilocarpine-induced miosis, the combined test medications were generally well tolerated.

Compliance with topical pilocarpine treatment

Using an unobtrusive eyedrop medication monitor, we measured compliance with topical pilocarpine treatment in a sample of 184 patients. The eyedrop monitor recorded electronically the date and time of each pilocarpine administration over a four- to six-week period. The subjects administered a mean +/- S.D. of 76.0% +/- 24.3% of the prescribed pilocarpine doses. Eleven patients (6%) took less than one quarter and 28 patients (15.2%) took less than one half of the prescribed administrations. In contrast, when the subjects were interviewed they reported taking a mean +/- S.D. of 97.1% +/- 5.9% of the prescribed pilocarpine doses. As determined by the monitor, 45 patients (24.5%) had at least one day per month with no administrations of pilocarpine; 56 subjects (30.4%) compressed the doses during the daytime hours, leaving an interval between the night dose and the morning dose the next day of 12 hours or more. The rate of compliance was significantly higher (P less than .0001) in the 24-hour period preceding the return appointment than in the entire observation period.

Visual ability and drug regimen: relation to compliance with glaucoma therapy

Compliance with pilocarpine eye drop therapy was studied in relation to different measures of visual ability and different features of the drug regimen. Neither visual ability, nor complexity of the drug regimen nor side effects were significantly related to the patients' compliance with their pilocarpine therapy. Nevertheless, non-compliance was significantly more common among patients who regarded the eye drops as very unpleasant than among patients who did not. This indicates that non-compliance is related to the patient's perception of side effects and/or negative attitudes to the treatment.

Visual field survival: the response to timolol therapy in open-angle glaucoma

A simple method for quantifying visual field survival was devised to assess the progress of chronic simple glaucoma in 36 patients treated with timolol maleate over a 3-year period. Routine tonometric monitoring of the intraocular pressure (IOP) was carried out in conjunction with these Goldmann field studies. Statistical analysis revealed that field survival measurement provided a more consistent clinical guide to the progress of glaucoma under treatment than did IOP (p much less than 0.001). Timolol therapy was associated with sustained IOP reductions of 24.3-34.5%, and 63% of those treated who were monitored for field survival showed no significant field loss. The observed relationships of IOP to field survival are discussed.

Glaucoma patients not compliant with their drug therapy: clinical and behavioural aspects

The pattern of drug self-administration among 15 patients not compliant with their pilocarpine therapy was studied with an electronic medication monitor. Recording the date and the hour every time the medication bottle was opened, the monitor gives detailed information on the medication behaviour. The results indicate different types of medication errors; inadequate spacing of doses during the day with long intervals during the night, frequently missed doses at noon, and long interruptions in the medication, sometimes lasting for several days. Improvement in their compliance was seen in patients who were given instruction and taught to relate their medication to specified events in the day.