User-centered Design of the eyeGuide: A Tailored Glaucoma Behavior Change Program

The Support, Educate, Empower personalized glaucoma coaching trial design

BACKGROUND

Glaucoma is a chronic disease that affects 3 million Americans. Glaucoma is most often asymptomatic until very late in its course when treatment is more difficult and extensive peripheral vision loss has already occurred. Taking daily medications can mitigate this vision loss, but at least half of people with glaucoma do not take their prescribed medications regularly. The purpose of this study is to improve glaucoma medication adherence among those with medically treated glaucoma and poor self-reported adherence using the Support, Educate, Empower personalized coaching program.

METHODS/DESIGN

This study is a two-site randomized controlled trial enrolling 230 participants with poor self-reported glaucoma medication adherence. The trial has two arms, an intervention arm and a control arm. Participants in the intervention arm receive personalized glaucoma education and motivational interviewing-based coaching over 6 months from a trained non-physician interventionist for three in-person sessions with between visit phone calls for check-ins where current adherence level is reported to participants. Participants also can elect to have visual, audio, text or automated phone call medication dose reminders. Participants in the control arm continue usual care with their physician and receive non-personalized glaucoma educational materials via mail in parallel to the three in-person coaching sessions to control for glaucoma knowledge content. All participants receive a medication adherence monitor. The primary outcome is the proportion of prescribed doses taken on schedule during the 6-month period. The secondary outcome is glaucoma related distress. The exploratory outcome is intraocular pressure.

DISCUSSION

The personalized education and motivational-interviewing-based intervention that we are testing is comprehensive in that it addresses the wide range of barriers to adherence that people with glaucoma encounter. Leveraging a custom-built web-based application to generate the personalized content and the motivational-interviewing-based prompts to guide the coaching sessions will make this program both replicable and scalable and can be integrated into clinical care utilizing trained non-physician providers. Although this type of self-management support is not currently reimbursed for glaucoma as it is for diabetes, this trial could help shape future policy change should the intervention be found effective.

Loss to Follow up in Patients with Neovascular Age Related Macular Degeneration treated with Anti-VEGF therapy in the United States in the IRIS® Registry

OBJECTIVE

To determine the incidence of loss to follow up (LTFU) and nonpersistence in patients with neovascular age related macular degeneration (AMD) treated with anti-vascular endothelial growth factor (VEGF) injections in the United States.

DESIGN

Retrospective cohort study using IRIS (Intelligent Research in Sight) Registry data.

SUBJECTS

156,327 treatment-naïve neovascular AMD patients who were subsequently treated with anti-VEGF therapy from 2013 to 2015 and followed through 2019.

METHODS

Multivariable logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) MAIN OUTCOME MEASURES: LTFU was defined as no follow up within 12 months from last intravitreal injection. Nonpersistence was defined as no follow up within 6 months from last intravitreal injection.

RESULTS

For neovascular AMD, 11.6% (95% CI, 11.4-11.7) of patients were LTFU and 88.4% of patients had a follow up within 12 months. The rate of LTFU is generally higher with increasing age, with odds of LTFU greatest for patients between 81-84 years of age (OR, 2.51; 95% CI, 2.31-2.74; p<0.001) compared with patients 70 years of age and younger. Odds of LTFU for Black or African-American patients (OR, 1.32; 95% CI, 1.08-1.61; p=0.007) were greater than for white patients. Odds of LTFU were higher for patients with Medicaid insurance (OR, 1.27; 95% CI, 1.01-1.60; p=0.04) and lower for patients with Medicare Fee-for-Service insurance (OR, 0.69; 95% CI, 0.64-0.74; p<0.001) compared to patients with Private insurance. 14.3% (95% CI, 14.1-14.4) of patients were nonpersistent and 85.7% of patients had a follow up within 6 months. Odds of nonpersistence were also greatest among patients between 81-84 years of age (OR, 2.13; 95% CI, 1.98-2.29; p<0.001) compared with patients 70 years of age or younger. Odds of nonpersistence for Black or African American patients (OR, 1.38; 95% CI, 1.15-1.65; p<0.001) and Hispanic patients (OR, 1.13; 95% CI, 1.03-1.24; p=0.009) were greater than odds for white patients.

CONCLUSIONS

Nearly one out of nine neovascular AMD patients treated with anti-VEGF injections are LTFU while one out of seven patients are nonpersistent. Risk factors identified included increasing age, male sex, unilateral involvement, diabetes, Medicaid insurance and race/ethnicity.

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.

Facilitators and Barriers to Glaucoma Medication Adherence

PRCIS

Patient education and dosing self-efficacy are important factors related to ongoing adherence to glaucoma topical treatment, and patients view their disease management as a shared effort with their provider.

PURPOSE

Glaucoma affects nearly 3 million Americans, and medication adherence has been reported to be as low as 20% in this patient population; however, key limitations to our understanding of this behavior in adults with glaucoma exist.

PATIENTS AND METHODS

This research used an electronic survey including validated concepts related to topical medication use and an in-person interview to investigate the influencers of and solutions for challenges to medication adherence in adults with glaucoma. Patient eligibility was determined upon arrival to a regularly-scheduled visit to the Vanderbilt Eye Institute, during which they were asked for consent to complete the survey. Responses were captured by tablet and assessed using descriptive and inferential statistics. The primary focus was instrument correlations with the Adherence to Refills and Medications Scale score and were run between Adherence to Refills and Medications Scale, and the totaled score for each individual questionnaire as well as individual items. Recorded interviews were thematically assessed by multiple study team members.

RESULTS

Survey results of adults with glaucoma suggested that self-efficacy, forgetfulness, fear of side effects, and dosing ability were all related to self-reported medication adherence. Despite most having glaucoma for several years, discrepancies in disease knowledge were observed. Patient interviews uncovered 3 overall themes related to glaucoma treatment: (1) glaucoma management as a shared responsibility; (2) the importance of patient education; and (3) specific adherence facilitators and barriers.

CONCLUSION

Glaucoma medication adherence interventions may benefit from focusing on developing patient medication-taking self-efficacy, disease-related education, and engagement with their provider.

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.

Facilitators and Barriers to Glaucoma Screening Identified by Key Stakeholders in Underserved Communities: A Community-engaged Research Approach

PRCIS

Community-engaged research (CER) enables researchers to identify community-specific barriers and facilitators to program implementation. Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust, and community-specific barriers, such as Language and Convenience/Access, were identified.

PURPOSE

The aim was to identify the facilitators and barriers to implementing glaucoma screening programs in 2 community clinics.

METHODS

A concurrent mixed-methods process analysis using CER. Key stakeholders-including patients, providers, and staff members-from 2 community clinics were interviewed using a semistructured interview guide. Interviews had 2 parts: (1) asking patients about community-based facilitators and barriers to implementing glaucoma screening and care and (2) eliciting feedback about a personalized coaching program. The transcripts were coded using Grounded Theory. Number of participants and number of representative citations were counted per theme. The qualitative analysis was coded using Dedoose 8.3.17 (Los Angeles, CA).

RESULTS

Thematic saturation was reached after coding 12 interviews. 30 participants were interviewed, 13 from Hamilton Clinic (Flint, MI; 8 patients, 5 providers and staff members) and 17 from Hope Clinic (Ypsilanti, MI; 6 patients, 11 providers and staff members). The most commonly cited themes were: Priorities (98 citations, 30 participants), Knowledge (73, 26) Transportation (63, 26), Cost (60, 23), and Convenience/Access (63, 22). Broadly applicable barriers to glaucoma care, such as Cost, Transportation, and Trust were identified alongside community-specific barriers such as Language and Convenience/Access. Participants rated their likelihood to follow up with an ophthalmologist after participating in the personalized coaching program at a mean of 8.83 (on a scale of 1 to 10 with 10 being the most confident).

CONCLUSIONS

CER enables researchers to identify community-specific barriers and facilitators, allowing more effective program implementation.

Patterns and Facilitators for the Promotion of Glaucoma Medication Adherence-A Qualitative Study

Primary open-angle glaucoma (POAG) is a chronic optic neuropathy causing irreversible nerve fiber damage. Initially asymptomatic, it progresses slowly without any notable sign of vision loss, thus early detection and treatment is essential. The standard treatment being non-invasive topical administration of eye drops harbors the problem of patients not being adherent. This study aimed to explore the experiences and thoughts of glaucoma patients about their medication management to improve our knowledge on how adherence works for the individual patient. Narrative interviews were conducted with 21 glaucoma patients. Data were analyzed using inductive content analysis and the documentary method. Different patterns of adherence were identified which depended on personal biographies, living conditions, or the patient's knowledge about the disease. Interpreting eye drop medication as a ritual, a task, or routine was helpful for some patients, whereas other patients, who were aware of the consequences of not taking the drops, were motivated by intrinsic or extrinsic factors. The patterns identified here represent strategies for managing and adhering to daily glaucoma medication at an individual level. Linking daily drop application or medication intake to these patterns may help to promote correct medication management of patients with chronic diseases who lack a regular medication regimen.

A novel EyePhone© App for improving adherence to glaucoma therapy

PURPOSE

Despite advances in glaucoma treatment options, patient adherence and compliance remain very low. The EyePhone© App is a free non-commercial reminder application designed specifically for the needs of glaucoma patients. In this study, we evaluated its usefulness in improving adherence to medical treatment among glaucoma patients.

METHODS

This is a prospective multicenter interventional study. Glaucoma patients were recruited from a tertiary center and a large community glaucoma service center. After a short explanation, the EyePhone© App was installed on their smartphone device, and the notifications for the current medical treatment were entered. After enrollment and at 1-month follow-up, subjects completed the Morisky Medication Adherence Scale (MMAS-8) and the Quality of Life and Glaucoma 17-item (GlauQOL-17) questionnaires for evaluation of adherence and QOL, respectively.

RESULTS

In the study, 133 patients (71 men and 62 women) aged 62±15.5 years and using 2.0±0.9 IOP-lowering drugs participated. The proportion of highly adherent subjects improved from 29.3% (39/133) at baseline to 42.1% (56/133) at follow-up (P < 0.001), and the proportion of poorly adherent subjects decreased from 29.3 (39/133) to 20.3% (27/133) at follow-up (P = 0.012). QOL also improved, as evidenced by a significant increase in the GlauQOL-17 score (P < 0.05). In a subgroup of patients for whom IOP measurements were available, IOP reduced by 0.92 mmHg (P = 0.069).

CONCLUSIONS

Significant improvements in glaucoma adherence and QOL were achieved among poorly adherent glaucoma patients after 1 month of using the EyePhone© App.

A Glaucoma-Specific Brief Motivational Interviewing Training Program for Ophthalmology Para-professionals: Assessment of Feasibility and Initial Patient Impact

Our objective was to test the feasibility of, fidelity to, and initial impact of a brief, glaucoma-specific motivational interviewing (MI) training program for ophthalmic para-professionals. This prospective, mixed-methods study had two components, one for staff and one for patients. Staff fidelity to MI principles was graded through audio-recorded encounters after initial and final training sessions. After training, patients graded staff for adherence to autonomy supportive care. Semi-structured interviews with para-professionals elicited feedback about the training and about their ability to implement MI in the clinic. The impact on patient satisfaction with staff communication, eye drop instillation self-efficacy, and overall health activation was assessed using a survey pre- and post-training. Para-professionals met two of three program goals for MI skills and improved in their overall scores for MI fidelity. Para-professionals noted lack of time in the clinic as a significant barrier to implementing counseling. Patient satisfaction with staff communication increased after the training (p = 0.04) among patients who rated their staff above the mean for providing autonomy supportive care. The intervention did not improve patients' eye drop instillation self-efficacy or overall health activation. Training para-professional staff in brief, glaucoma-specific MI techniques is feasible and may improve patient satisfaction, though dedicated time in clinic is needed to implement MI counseling into glaucoma practice.

Integrating Patient Education Into the Glaucoma Clinical Encounter: A Lean Analysis

PURPOSE

The main purpose of this study was to use Lean analysis to identify how often and when wait times occur during a glaucoma visit to identify opportunities for additional patient engagement.

METHODS

This prospective observational time-motion study measured process and wait times for 77 patient visits from 12 ophthalmologists at an academic glaucoma clinic over a 3-month period. Value stream maps visually diagramed the process of a clinical visit from the patient's perspective. Descriptive statistics were calculated for process times, wait times, and the frequency of 10+ minute wait times during each part of the visit. Key stakeholders participated in a root cause analysis to identify reasons for long wait times. The main outcome measure was average times (hours: minutes: seconds) for process times and wait times.

RESULTS

Twenty-nine new visit (NV) patients and 48 return visit (RV) patients were included. Total time in clinic was 187.1±44.5 (mean±SD) minutes for NV patients and 102.0±44.7 minutes for RV patients. Wait time for NV patients was 63.7±33.4 minutes (33.1% of total appointment time) and for RV patients was 52.6±31.6 minutes (49.4% of the total appointment time). All NV patients and 87.5% of RV patients had at least one 10+ minute wait time during their clinic visit and the majority (75.9% NV, 60.4% RV) had >1.

CONCLUSIONS

Currently, sufficient wait time exists during the visit for key portions of glaucoma education such as teaching eye drop instillation.

Personalized behavior change program for glaucoma patients with poor adherence: a pilot interventional cohort study with a pre-post design

Background

About half of people with glaucoma do not adhere to their recommended medications. Interventions for other chronic conditions have successfully utilized reminder systems and motivational interviewing (MI)-based counseling. This study was designed to pilot a personalized intervention that leverages these strategies to assess their impact on medication adherence in glaucoma patients.

Methods

Glaucoma patients taking ≥ 1 medication will be pre-screened by telephone survey for adherence to their medication(s). Those who self-report poor adherence will be enrolled in a 3-month monitoring period to measure medication adherence using electronic medication monitors. Participants who are non-adherent (take </=80% of their medication doses) over the 3-month run in phase will be eligible for the study. We plan to enroll 57 participants who are non-adherent to their medications. Participants' adherence will then be continuously measured with electronic medication monitors, by self-report, and via pharmacy refill data over 2 years, during which two successively more resource-intensive components of an intervention aimed to improve medication adherence will be administered. The first component is a 3-month period of reminders (audio and/or visual) and text message or automated phone call if a dose of medication is not taken within a pre-specified time frame. The second component is a 6-month MI-based counseling program with a trained glaucoma counselor. This component uses the eyeGuide, a computer-based personalized behavior change program that enables para-professional staff to provide personalized education and counseling for glaucoma. The primary outcome is change in medication adherence. The secondary outcomes include changes in clinical outcomes (intraocular pressure, IOP, and IOP fluctuation) and psychosocial mediators of adherence (e.g., competence, energy for change and satisfaction). Participants will undergo semi-structured interviews at 12 months to give feedback about the counseling program in order to improve it.

Discussion

This pilot study will provide insight into ways to deliver more personalized health care to non-adherent glaucoma patients in order to better support them in managing their chronic disease.

Trial registration

Retrospectively registered with ClinicalTrials.gov (NCT03159247).

Access to and Experiences with, e-Health Technology Among Glaucoma Patients and Their Relationship with Medication Adherence

Background: As online health information becomes common, it is important to assess patients' access to and experiences with online resources. Introduction: We examined whether glaucoma patients' technology usage differs by medication adherence and whether adherence is associated with online education experiences. Materials and Methods: We included 164 adults with glaucoma taking ≥1 glaucoma medication. Participants completed a survey including demographic and health information, the Morisky Adherence Scale, and questions about online glaucoma resource usage. Differences in technology access, adherence, and age were compared with chi-squared, Fisher exact, and two-sample t-tests. Results: Mean age was 66 years. Twenty-six percent reported poor adherence. Eighty percent had good technology access. Seventy-three percent of subjects with greater technology access wanted online glaucoma information and yet only 14% of patients had been directed to online resources by physicians. There was no relationship between technological connectivity and adherence (p = 0.51). Nonadherent patients were younger (mean age 58 years vs. 66 years for adherent patients, p = 0.002). Nonadherence was associated with negative feelings about online searches (68% vs. 42%, p = 0.06). Discussion: Younger, poorly adherent patients navigate online glaucoma resources without physician input. These online searches are often unsatisfying. Technology should be leveraged to create high quality, online glaucoma resources that physicians can recommend to provide guidance for disease self-management.

Patient satisfaction with care in an urban tertiary referral academic glaucoma clinic in the US

BACKGROUND

The purpose of this study was to determine the factors associated with glaucoma patients' satisfaction with their medical care by fellowship-trained glaucoma specialists in an urban tertiary referral clinic in the US.

METHODS

A total of 110 established patients aged ≥60 years with a diagnosis of either primary open angle glaucoma, glaucoma suspect, or ocular hypertension monitored by an ophthalmologist with fellowship training in glaucoma were enrolled at an academic, urban, tertiary referral eye clinic. Enrolled patients were administered a general demographics questionnaire along with a Patient Satisfaction Questionnaire-18 (PSQ-18), a Likert scale validated tool. The seven dimensions of patient satisfaction from the PSQ-18 were summarized for the sample overall and by the patients' age, race, employment status, education level, distance travelled from home address to clinic, and glaucoma therapy type. Two-sample t-tests were used to compare group means. Spearman correlation coefficients were used to correlate satisfaction scores with peripheral vision and visual acuity function.

RESULTS

Overall, the general satisfaction scores were high (mean 4.62). Patients ≥70 years of age had lower general satisfaction with their care (mean 4.5 vs 4.8, p=0.03), the interpersonal manner of their appointment (mean 4.7 vs 4.9, p=0.009), and with their time spent with their doctor (mean 4.4 vs 4.7, p=0.03) than patients aged 60-69 years. Non-European descent patients (47% African descent and 1% other of sample) were more satisfied with the time they spent with the doctor (mean 4.7 vs 4.4, p=0.04) and with the communication during the appointment (mean 4.8 vs 4.6, p=0.04) than European descent patients (52% of sample). Patients with a higher level of education (>high school degree) were less satisfied with the accessibility and convenience of the appointment (mean 4.3 vs ≤ high school, 4.6, p=0.02). There were no statistically significant differences in patient satisfaction based upon employment status, distance travelled to clinic, prior glaucoma therapy, or visual function.

CONCLUSION

Overall, across all dimensions of the PSQ-18, patients were highly satisfied with the care they received at the urban tertiary care glaucoma clinic.