Adherence to Glaucoma Medication

Gender Disparities in Depression, Stress, and Social Support Among Glaucoma Patients

Purpose

To understand differences in measures of depression, stress, and social support by gender among those diagnosed with glaucoma.

Methods

We obtained a cohort of glaucoma patients (any type) ages 18 years and over who answered the COVID-19 Participant Experience (COPE) survey of the NIH All of Us Research Program. We analyzed several measures of depression, stress, and social support by gender. Logistic regression was used to evaluate the association among reported stress associated with social distancing, depression (using Patient Health Questionnaire-9 [PHQ-9] scores), and measures of social support by self-reported gender, with men as the reference group. Multivariable models were adjusted for age, race and ethnicity, health insurance status, education, and income.

Results

Of 3633 glaucoma patients, 56.8% were women. Many patients had a PHQ-9 score > 4 (33.3%), indicating mild, moderate, or severe depression. In multivariable models, women were significantly more likely to report a PHQ-9 score > 4 (odds ratio [OR] = 1.40; 95% confidence interval [CI], 1.20-1.62; P < 0.001) and some or a lot of stress (OR = 1.34; 95% CI, 1.14-1.57; P < 0.001) compared with men. Further, women were significantly less likely to report having help all or most of the time if they needed someone to prepare meals (OR = 0.78; 95% CI, 0.67-0.92; P = 0.002) or perform daily chores (OR = 0.79; 95% CI, 0.67-0.91; P = 0.003) than men.

Conclusions

Women with glaucoma were more likely to experience depression and stress and were less likely to have social support on some measures than men.

Translational Relevance

The disproportionate burden of psychosocial factors among women may complicate glaucoma management.

Personality Traits Associated with Treatment Choice with an Explicit Statistical Prediction After an Explanation in a Negative Context: A Study in Patients with Glaucoma

Purpose

Over 50% of patients with early-stage glaucoma discontinue topical therapy within the first 6 months of treatment initiation. This risk of discontinuation could be reduced by how the ophthalmologist explains the treatment plan. Ophthalmologists can explain the treatment plan to patients in either positive or negative contexts. Although explanations in a negative context can be selected depending on the medical situation, identification of patients who will choose the treatment with explicit statistical prediction after an explanation in a negative context is important; personality traits are related to these emotional decisions. Therefore, in the present study, we examined the personality traits associated with choice of treatment with explicit statistical prediction after an explanation in a negative context.

Patients and Methods

A total of 147 patients with glaucoma were recruited for this study. The questionnaire booklets used contained positively framed or negatively framed versions of an "Asian disease problem" to enable examination of the influence of the way in which a problem is framed (framing effect) on the participants' decision-making. The Japanese version of the Ten-Item Personality Inventory was used to estimate the personality traits of the participants.

Results

Low conscientiousness was identified as the only variable that was strongly predictive of the choice of treatment with explicit statistical prediction (β = -0.44, z = 2.19, p = 0.03). In addition, while the association was not statistically significant, low neuroticism was found to be weakly predictive of the choice of uncertain treatment (β = -0.37, z = 1.73, p = 0.08).

Conclusion

In conclusion, we showed that low levels of conscientiousness predict the choice of treatment with explicit statistical prediction (ie, topical treatment) for glaucoma after an explanation in a negative context.

Positive feedback loop between vision-related anxiety and self-reported visual difficulty

BACKGROUND

Patients with Inherited Retinal Diseases typically experience progressive, irreversible vision loss resulting in low vision and blindness. As a result, these patients are at high risk for vision-related disability and psychological distress, including depression and anxiety. Historically, the relationship between self-reported visual difficulty (encompassing metrics of vision-related disability and quality of life, among others) and vision-related anxiety has been regarded as an association and not a causal relationship. As a result, there are limited interventions available that address vision-related anxiety and the psychological and behavioral components of self-reported visual difficulty.

MATERIALS AND METHODS

We applied the Bradford Hill criteria to evaluate the case for a bidirectional causal relationship between vision-related anxiety and self-reported visual difficulty.

RESULTS

There is sufficient evidence to satisfy all nine of the Bradford Hill criteria of causality (strength of association, consistency, biological gradient, temporality, experimental evidence, analogy, specificity, plausibility, and coherence) for the relationship between vision-related anxiety and self-reported visual difficulty.

CONCLUSIONS

The evidence suggests that there is a direct positive feedback loop-a bidirectional causal relationship-between vision-related anxiety and self-reported visual difficulty. More longitudinal research on the relationship between objectively-measured vision impairment, self-reported visual difficulty, and vision-related psychological distress is needed. Additionally, more investigation of potential interventions for vision-related anxiety and visual difficulty is needed.

Interventions for Glaucoma Medication Adherence Improvement: A Network Meta-analysis of Randomized Controlled Trials

TOPIC

Comparative effectiveness of interventions to improve glaucoma medication adherence.

CLINICAL RELEVANCE

High adherence to ocular hypotensive therapy is essential for prevention of visual impairment in glaucoma patients. Various types of intervention for adherence enhancement have been proposed, although there is still no firm evidence of their relative efficacies.

METHODS

We searched PubMed, EMBASE, Scopus, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov on November 30, 2021. Randomized controlled trials (RCTs) entailing interventions for improved adherence to ocular hypotensive therapy were identified. A network meta-analysis (NMA) was performed, and the following 11 interventions (single category or combinations of categories) were compared: (1) standard of care ([SOC] control), (2) short message service, (3) telephone call, (4) device reminder, (5) motivational interview, (6) multimedia education, (7) physician education, (8) provision of own medical records, (9) incentives, (10) tailored care, and (11) enhanced SOC. The primary outcome was the postintervention mean adherence score. The standardized mean differences (SMDs) were analyzed, and the effectiveness was ranked by P-score (probability of being best treatment). We appraised trials using the Cochrane risk-of-bias tool for RCTs. Confidence of results was assessed by Confidence in Network Meta-analysis.

RESULTS

We obtained data for 19 RCTs (4981 participants). Tailored care, as inclusive of face-to-face needs assessment and a personalized care plan, was superior to SOC in improving adherence (SMD, 1.28; 95% confidence interval [CI], 0.08-2.48; P-score, 0.810). Multifaceted interventions that included tailored care showed further adherence improvement: tailored care + multimedia education (SMD, 1.44; 95% CI, 0.20-2.67; 0.850) and tailored care + multimedia education + device reminder (SMD, 1.61; 95% CI, 0.75-2.47; 0.914). The ranking of the remaining interventions by P-scores was as follows: incentives (0.606), short message service (0.535), enhanced SOC (0.458), multimedia education (0.430), device reminder (0.429), telephone call (0.401), provision of own medical records (0.391), physician education (0.281), SOC (0.230), and motivational interview (0.165).

CONCLUSIONS

The NMA indicated that tailored care can improve adherence to glaucoma medication compared with SOC. A multifaceted approach might yield additional improvements.

Impact of anxiety and depression on progression to glaucoma among glaucoma suspects

AIMS

To assess the impact of anxiety and depression in the risk of converting to glaucoma in a cohort of glaucoma suspects followed over time.

METHODS

The study included a retrospective cohort of subjects with diagnosis of glaucoma suspect at baseline, extracted from the Duke Glaucoma Registry. The presence of anxiety and depression was defined based on electronic health records billing codes, medical history and problem list. Univariable and multivariable Cox proportional hazards models were used to obtain HRs for the risk of converting to glaucoma over time. Multivariable models were adjusted for age, gender, race, intraocular pressure measurements over time and disease severity at baseline.

RESULTS

A total of 3259 glaucoma suspects followed for an average of 3.60 (2.05) years were included in our cohort, of which 911 (28%) were diagnosed with glaucoma during follow-up. Prevalence of anxiety and depression were 32% and 33%, respectively. Diagnoses of anxiety, or concomitant anxiety and depression were significantly associated with risk of converting to glaucoma over time, with adjusted HRs (95% CI) of 1.16 (1.01, 1.33) and 1.27 (1.07, 1.50), respectively.

CONCLUSION

A history of anxiety or both anxiety and depression in glaucoma suspects was associated with developing glaucoma during follow-up.

Lifestyle Counseling for Medication Adherence in Glaucoma

Background

Medication adherence in glaucoma patients remains sub-par despite proven benefits of regular administration. The objective was to analyze medication adherence before and after lifestyle counseling in patients with ocular hypertension (OHT) or primary open-angle glaucoma (POAG) (mild, moderate, severe).

Methods

Prospective cohort study from May to July 2018 at a single academic center. From 391 consecutive records, 247 were excluded based on exclusion criteria with 28 patients not meeting inclusion criteria resulting in the final sample of 116 patients (33 had OHT, 83 had POAG – 28 mild, 39 moderate, 16 severe). Scripted lifestyle counseling focusing on diet, exercise, vitamin intake, stress management, and medication adherence was administered by a team of trained medical students. Primary outcome measure was self-reported medication adherence, defined as not missing an eye drop administration in the past month. A 2–3 week follow-up with scripted telephone survey assessing medication adherence, diet, and exercise was collected.

Results

At baseline, in 116 patients, 59.5% were adherent to their medication with a breakdown of 42.4% OHT, 64.3% mild, 66.7% moderate, and 68.7% severe and an increasing trend in medication adherence was found across increasing disease severity (p=0.055). Of the 76 (65.5%) patients reached for follow-up, 17 (22.4%) became adherent following lifestyle counseling (p=0.02) increasing overall adherence to 78.9% from 62.5%.

Conclusion

In our study, comprehensive lifestyle counseling succeeded in increasing medication adherence in patients with OHT and POAG.

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.

Impact of COVID-19 on follow-up and medication adherence in patients with glaucoma in a tertiary eye care centre in south India

Purpose:

COVID-19 pandemic has affected the healthcare system worldwide hindering the continuum of treatment of chronic disease patients. The objective of the study is to analyze the barriers encountered by the glaucoma patients for the follow-up visit and medication adherence during the pandemic.

Methods:

This cross-sectional study included glaucoma patients who did not attend the scheduled appointment from April 1, 2020 to July 31, 2020 in a tertiary eye care center (88.21%). Eligible patients of age >18 years and advised antiglaucoma medication in Madurai Zone were interviewed with validated questionnaire through telephonic call.

Results:

363 patients answered the questionnaire through telephonic interview. 57.3% of the patients were found to be non-adherent to medication. The main barriers for glaucoma follow-up visit during the pandemic were lockdown restriction, transport problem, and financial difficulties. The top barriers for medication adherence were non availability of medication (54.81%), financial difficulties (30.29%), did not feel much improvement with eye drops (20.19%). On multiple regression analysis, longer distance to hospital, low socioeconomic status, more than one antiglaucoma medication use, lack of awareness of glaucoma, non-complaint before COVID-19 and stress due to the pandemic were found to be significant factors for medication non adherence.

Conclusion:

COVID-19 pandemic has emphasized the need for reformation in health care system for accessibility of medical care to patients in rural areas. Decentralization of health system to primary care level and utilization of teleophthalmology should be considered by health care planners in future.

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.

Patient Experience during the Support, Educate, Empower Glaucoma Coaching Program to Improve Medication Adherence: A Pilot Study

PURPOSE

To understand patients' qualitative experiences with the Support, Educate, Empower (SEE) personalized glaucoma coaching program, provide a richer understanding of the components of the intervention that were useful in eliciting behavior change, and understand how to improve the SEE Program.

DESIGN

A concurrent mixed-methods process analysis.

PARTICIPANTS

Thirty-nine patients with a diagnosis of any kind of glaucoma or ocular hypertension who were aged ≥40 years, were taking ≥1 glaucoma medication, spoke English, self-administered their eye drops, and had poor glaucoma medication adherence (defined as taking ≤80% of prescribed medication doses assessed via electronic medication adherence monitors) who completed the 7-month SEE Program.

METHODS

All participants who completed the study were interviewed in-person using a semistructured interview guide after the intervention. Coders conducted qualitative analysis of transcribed interviews using Grounded Theory. Participants were then stratified into groups based on change in adherence, and thematic differences between groups were examined.

MAIN OUTCOME MEASURES

Themes that emerged from interviews categorized by the number of participants who expressed a theme and the number of representative citations.

RESULTS

Participants expressed positive views toward the program overall (95%, n = 37/39). They perceived program components as working together to improve their medication adherence. Interactions with the glaucoma coach (38 participants, 184 citations), motivation to aid personal change (38 participants, 157 citations), personalized glaucoma education (38 participants, 149 citations), electronic reminders, and hearing their adherence score (37 participants, 90 citations) were most commonly cited by participants as helpful program elements contributing to improved adherence. Patients expressed a desire for personalized education to be a standard part of glaucoma care. Participants who demonstrated more improvement in adherence had a more trusting attitude toward the adherence score and a greater magnitude of perceived personal need to improve adherence.

CONCLUSIONS

Participants reported a highly positive response to the in-person glaucoma education and motivational interviewing intervention used in conjunction with automated adherence reminders.

The Association between Medication Adherence and Visual Field Progression in the Collaborative Initial Glaucoma Treatment Study

PURPOSE

To evaluate the relationship between medication adherence and visual field progression in participants randomized to the medication arm of the Collaborative Initial Glaucoma Treatment Study (CIGTS).

DESIGN

The CIGTS was a randomized, multicenter clinical trial comparing initial treatment with topical medications to trabeculectomy for 607 participants with newly diagnosed glaucoma.

PARTICIPANTS

Three hundred seven participants randomized to the medication arm of the CIGTS.

METHODS

Participants were followed up at 6-month intervals for up to 10 years. Self-reported medication adherence and visual fields were measured. Medication adherence was assessed by telephone from responses to the question, "Did you happen to miss any dose of your medication yesterday?" The impact of medication adherence on mean deviation (MD) over time was assessed with a linear mixed regression model adjusting for the effects of baseline MD and age, cataract extraction, interactions, and time (through year 8, excluding time after crossover to surgery). Medication adherence was modeled as a cumulative sum of the number of prior visits where a missed dose of medication was reported.

MAIN OUTCOME MEASURE

Mean deviation over time.

RESULTS

Three hundred seven subjects (306 with adherence data) were randomized to treatment with topical medications and followed up for an average of 7.3 years (standard deviation, 2.3 years). One hundred forty-two subjects (46%) reported never missing a dose of medication over all available follow-up, 112 patients (37%) reported missing medication at up to one third of visits, 31 patients (10%) reported missing medication at one third to two thirds of visits, and 21 patients (7%) reported missing medication at more than two thirds of visits. Worse medication adherence was associated with loss of MD over time (P = 0.005). For subjects who reported never missing a dose of medication, the average predicted MD loss over 8 years was 0.62 dB, consistent with age-related loss (95% confidence interval [CI], 0.17-1.06; P = 0.007); subjects who reported missing medication doses at one third of visits had a loss of 1.42 dB (95% CI, 0.86-1.98; P < 0.0001); and subjects who reported missing medication doses at two thirds of visits showed a loss of 2.23 dB (95% CI, 1.19-3.26; P < 0.0001).

CONCLUSIONS

This longitudinal assessment demonstrated a statistically and clinically significant association between medication nonadherence and glaucomatous vision loss.

Using Adherence-Contingent Rebates on Chronic Disease Treatment Costs to Promote Medication Adherence: Results from a Randomized Controlled Trial

BACKGROUND

Poor adherence to medications is a global public health concern with substantial health and cost implications, especially for chronic conditions. In the USA, poor adherence is estimated to cause 125,000 deaths and cost $US100 billion annually. The most successful adherence-promoting strategies that have been identified so far have moderate effect, are relatively costly, and raise availability, feasibility, and/or scalability issues.

OBJECTIVE

The main objective of SIGMA (Study on Incentives for Glaucoma Medication Adherence) was to measure the effectiveness on medication adherence of a novel incentive strategy based on behavioral economics that we refer to as adherence-contingent rebates. These rebates offered patients a near-term benefit while leveraging loss aversion and regret and increasing the salience of adherence.

METHODS

SIGMA is a 6-month randomized, controlled, open-label, single-center superiority trial with two parallel arms. A total of 100 non-adherent glaucoma patients from the Singapore National Eye Centre were randomized into intervention (adherence-contingent rebates) and usual care (no rebates) arms in a 1:1 ratio. The primary outcome was the mean change from baseline in percentage of adherent days at Month 6. The trial registration number is NCT02271269 and a detailed study protocol has been published elsewhere.

FINDINGS

We found that participants who were offered adherence-contingent rebates were adherent to all their medications on 73.1% of the days after 6 months, which is 12.2 percentage points (p = 0.027) higher than in those not receiving the rebates after controlling for baseline differences. This better behavioral outcome was achieved by rebates averaging 8.07 Singapore dollars ($US5.94 as of 2 November 2017) per month during the intervention period.

CONCLUSION

This study shows that simultaneously leveraging several insights from behavioral economics can significantly improve medication adherence rates. The relatively low cost of the rebates and significant health and cost implications of medication non-adherence suggest that this strategy has the potential to cost-effectively improve health outcomes for many conditions.

Factors Affecting Adherence to Topical Glaucoma Therapy: A Quantitative and Qualitative Pilot Study Analysis in Sydney, Australia

PURPOSE

To assess which factors in the lives and disease of patients with glaucoma affect their adherence to topical glaucoma therapy and the quantitative significance of this effect. To assess qualitatively the most influential barriers to adherence from the perspective of the patient.

DESIGN

Multicenter, prospective, cross-sectional pilot study.

PARTICIPANTS

A total of 145 patients, attending outpatient metropolitan glaucoma clinics in Sydney, Australia, who were prescribed topical glaucoma medications.

METHODS

A structured interview-based questionnaire was conducted with 145 individuals using glaucoma eye drops that had been prescribed at least 2 weeks previously. The questionnaire involved 2 novel questions on adherence, 29 questions on factors identified or postulated in the literature as affecting adherence for quantitative analysis, and 1 open-response question on patient-identified causes of nonadherence for qualitative analysis. This questionnaire represents the broadest coverage of factors hypothesized to affect adherence in a single study in the glaucoma medication adherence literature to date.

MAIN OUTCOME MEASURES

Adherence rate, risk factors for poor adherence, and patient-identified barriers to adherence.

RESULTS

In response to the question "How many days have you missed a drop in the last 2 weeks," 69.7% of patients reported total adherence. Four factors were significantly related to an increased likelihood of reporting having missed drops in the last 2 weeks. These were difficulty applying drops (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.02-5.44; P < 0.05), a past or current diagnosis of depression (OR, 3.61; 95% CI, 1.53-8.52; P < 0.01), patient self-rating of own memory ≤ 7 of 10 (OR, 3.15; 95% CI, 1.36-7.30; P < 0.01), and self-reported motivation score ≤ 6 of 10 (OR, 10.94; 95% CI, 3.00-39.81; P < 0.01). Patient understanding of glaucoma, ethnicity, and socioeconomic status were among the 25 factors found not to have a statistically significant correlation with adherence.

CONCLUSIONS

There is a significant proportion of patients taking their topical glaucoma medications less often than prescribed. Adherence to topical glaucoma therapies is negatively correlated to several factors: difficulty applying drops, a past or current diagnosis of depression, poor self-rating of own memory, and poor self-rating of own motivation. These may prove useful in designing interventions to improve adherence in these patients.

Trends in and Predictors of Depression Among Participants in the Collaborative Initial Glaucoma Treatment Study (CIGTS)

PURPOSE

To characterize longitudinal trends and factors predictive of depressive symptoms following glaucoma diagnosis in Collaborative Initial Glaucoma Treatment Study (CIGTS) participants.

DESIGN

Cohort study using follow-up data from a clinical trial.

METHODS

A total of 607 participants with newly diagnosed open-angle glaucoma were enrolled at 14 clinical centers in the United States from October 1993 through April 1997, randomized to treatment with medication or surgery, and followed every 6 months through 2004. The 8-item Center for Epidemiologic Studies Depression Scale (CES-D) was administered at baseline and follow-up visits. Three outcome measures were investigated: overall CES-D depression score, presence of mild or worse depression (CES-D score ≥ 7), and number of depressive symptoms endorsed.

RESULTS

The average baseline CES-D score was 2.4 (SD = 3.8), 12.5% of subjects reported symptoms associated with mild or worse depression, and 55.3% reported at least 1 depressive symptom. By 1 year posttreatment, depression measures decreased (1.5, 6.7%, and 38.4%, respectively), with modest decreases thereafter. Baseline factors predictive of mild or worse depression included worse vision-related quality of life (VRQOL) (odds ratio [OR] = 2.41), female sex (OR = 1.42), younger age (OR per 10 years younger = 1.24), and less than high school education (OR = 2.93); other outcomes showed similar results.

CONCLUSIONS

Depressive symptoms decreased considerably during the first year after treatment initiation, but were elevated in those with impaired VRQOL. Given the potential of depression to reduce treatment adherence and thus increase the risk of glaucoma progression, eye care providers should ask patients about depressive symptoms, provide reassurance when appropriate, and make referrals as necessary.

The Effect of an Educational Intervention on Adherence to Intraocular Pressure-Lowering Medications in a Large Cohort of Older Adults with Glaucoma

BACKGROUND

Glaucoma is a progressive, irreversible disease that can lead to vision loss and lower quality of life if treatment is not optimized. Effective glaucoma therapies are available to lower intraocular pressure (IOP) and minimize or delay disease progression. Nonetheless, adherence to treatment remains suboptimal for many patients.

OBJECTIVE

To identify potentially nonadherent patients and evaluate the effect of patient- and physician-centric educational interventions on adherence by using a validated predictive model of nonadherence to glaucoma medication.

METHODS

This prospective, randomized, controlled, and interventional study included Humana Medicare Advantage Prescription Drug plan patients with a glaucoma diagnosis between May and October 2014, ≥ 1 pharmacy claim for glaucoma medication, and ≥ 50% likelihood of nonadherence. Patients and physicians were randomized to cohorts A (no interventions), B (physician intervention), or C (patient and physician interventions). Physicians in cohorts B and C received information on the model, adherence, and patient profiles at baseline and months 3, 6, and 9. Patients in cohort C received educational materials on glaucoma and adherence (same schedule). The primary outcome was the proportion of days covered (PDC) with medication over 12 months. Adherence was defined as PDC ≥ 0.80.

RESULTS

Overall, 23,306 patients and 2,955 physicians were eligible. After excluding physicians with < 3 nonadherent patients, each cohort included 200 physicians and 600 patients. Mean PDC was 0.54-0.56 across cohorts. At 12 months, ≥ 90.5% of physicians and ≥ 75.5% of patients remained in the study; mean PDC was 0.53-0.54 across cohorts. No statistically significant between-cohort differences in PDC and adherence were observed.

CONCLUSIONS

Intensive educational mailings to patients and their physicians did not improve PDC or adherence in this large population of potentially nonadherent patients with glaucoma. Findings highlight the difficulty of improving adherence in a disease that requires lifelong therapy despite being largely asymptomatic and can inform development of future interventions aimed at improving adherence to glaucoma therapy.

DISCLOSURES

This study was sponsored by Allergan plc (Dublin, Ireland). Fiscella and Chandwani are employees of Allergan plc. Caplan, Kamble, Bunniran, and Uribe are employees of Comprehensive Health Insights, a Humana company. The authors did not receive honoraria or other payments for authorship.

Pigment dispersion syndrome and pigmentary glaucoma: a review and update

INTRODUCTION

Pigment dispersion syndrome (PDS) is a condition where anomalous iridozonular contact leads to pigment dispersion throughout the anterior segment and the released pigment is abnormally deposited on various ocular structures.

CLINICAL PRESENTATION

The clinical presentation of PDS is defined by the presence of pigmented cells on the corneal endothelium, an increase of pigmentation of the trabecular meshwork, and mid-periphery transillumination defects of the iris. This syndrome, more common in myopes, is usually bilateral and can be associated with ocular hypertension or glaucoma. Secondary open-angle pigmentary glaucoma (PG) can develop due to reduction of the outflow of aqueous humour and consequent increase in intraocular pressure leading to glaucomatous optic neuropathy. Diagnosis of PG is commonly between 40 and 50 years of age, occurring more frequently in men. The advent of ultrasound biomicroscopy and anterior segment optical coherence tomography has contributed to enhancing our knowledge on the condition. Typical alterations of the anterior segment are the posterior insertion of the iris and iris concavity. Treatment of PG should be initiated early to hinder disease progression, glaucomatous damage, and vision loss. Management is based on medical therapy, laser iridotomy, selective laser trabeculoplasty, and filtration procedures.

CONCLUSIONS

The differential diagnosis of PDS with other disorders can be challenging and awareness of the condition together with meticulous ophthalmologic examination allows early diagnosis followed by appropriate management strategies. The present review is a comprehensive report on the clinical characteristics, pathogenesis, current management, and status quo of PDS and PG.

Overcoming Barriers to Eye Care: Patient Response to a Medical Social Worker in a Glaucoma Service

This paper investigates the patient response to a medical social worker in a glaucoma clinic. The literature suggests that medical social workers are effective in a variety of health care settings, yet the efficacy of a medical social worker in an adult ophthalmic setting has not been studied. We present the results of a retrospective chart review of 50 patients with glaucoma referred to a medical social worker between January 5, 2015 and June 31, 2015 in an outpatient clinic of an urban eye hospital. Clinical and demographic data, as well as the data from a quality of care questionnaire, were collected for each patient. Patients rated their interaction with the medical social worker as highly positive (mean = 4.75, 5-point Likert scale), and nearly 90 % of patients expressed interest in future contact with the social worker. Additionally, most patients reported that the social worker resolved the issues they were facing (61.1 %), supported them in seeing their ophthalmologist (70.6 %), and helped them to manage their glaucoma (69.7 %). Reported barriers to glaucoma care were emotional distress; cost of office visits and medications; lack of medical insurance; transportation; poor medication adherence; impairment of daily activities; follow-up adherence; and language. As vision loss from glaucoma is irreversible, it is important to detect and treat patients at early stages of the disease. Therefore, it is imperative for patients to regularly visit their eye care providers and adhere to treatment and follow-up recommendations. This study suggests that a medical social worker could play a pivotal role in helping patients with glaucoma overcome barriers to treatment and facilitate disease management.

Update on pigment dispersion syndrome and pigmentary glaucoma

PURPOSE OF REVIEW

The present article reviews the clinical features and pathogenesis of pigment dispersion syndrome and pigmentary glaucoma and provides an update regarding their diagnosis and management.

RECENT FINDINGS

Newer imaging modalities including ultrasound biomicroscopy and anterior segment optical coherence tomography facilitate visualization of the iris concavity characteristic of eyes with pigment dispersion syndrome and pigmentary glaucoma. Patients with pigmentary glaucoma may be distinguished from those with other glaucoma types by the presence of typical symptoms, personality type, and patterns of diurnal intraocular pressure fluctuation. Although laser iridotomy has been shown to alter iris anatomy in pigmentary glaucoma, it is not proven to slow visual field progression. Multiple trials have validated the safety and efficacy of filtering surgery in treating pigmentary glaucoma, with fewer studies published on the role of micro-invasive glaucoma surgery.

SUMMARY

Literature from the review period has further defined the unique clinical characteristics of pigment dispersion syndrome and pigmentary glaucoma. Laser surgery has a limited role in the management of these entities, whereas trabeculectomy remains an acceptable first-line surgical treatment. Further studies are needed to define the potential application of the newer micro-invasive glaucoma procedures in pigmentary glaucoma.

Automated telephone communication systems for preventive healthcare and management of long-term conditions

BACKGROUND

Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

OBJECTIVES

To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.

SELECTION CRITERIA

Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to select and extract data and to appraise eligible studies.

MAIN RESULTS

We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.

AUTHORS' CONCLUSIONS

ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.

Effectiveness and Cost of a Personalized Reminder Intervention to Improve Adherence to Glaucoma Care

BACKGROUND

Glaucoma is the leadi ng cause of irreversible blindness in the USA. Glaucomatous vision loss is preventable with proper eye care, including appointment adherence. Therefore, interventions that improve appointment adherence can reduce the number of patients with more severe glaucoma.

OBJECTIVES

The primary study aim was to determine the efficacy and cost-effectiveness of a multifaceted personal reminder intervention, which included a customized letter and personal telephone outreach, in improving appointment adherence of patients with glaucoma. A secondary study aim was to identify patient characteristics that were associated with non-adherence.

METHODS

This prospective, randomized, controlled study included a cost-effectiveness analysis completed using a decision analytic model. The subjects included 256 patients with glaucoma. Study measures included appointment adherence and incremental cost effectiveness ratios.

RESULTS

Patients in the intervention group were more likely to adhere to appointments (82.31 vs. 69.05 %; RR 1.23; 95 % CI 1.04-1.37, p < 0.012) than patients in the usual care group. Patients in the intervention group were 23 % more likely to adhere to appointments (RR 1.23; 95 % CI 1.08-1.41, p < 0.0021) than patients in the usual care group, when adjusting for age, secondary insurance, primary open angle glaucoma diagnosis, number of previous visits at Wills Eye Hospital, and follow-up recommendation using Poisson regression. Per-patient cost of the program was US$11.32, and cost per follow-up attended within the adherence window was US$73.56.

CONCLUSIONS

A low cost reminder intervention consisting of a personalized letter and telephone outreach significantly improved appointment adherence of patients with glaucoma.

Psychological Aspects of Glaucoma

Glaucoma is a group of optic neuropathies that is more prevalent among the elderly population and commonly associates with comorbidities, including mental disorders in that population. This article reviews the relationship between glaucoma and mental disorders. In it, we discuss the coexistence of glaucoma and mental illnesses, including Alzheimer's disease, depression, and personality disorder. We also focus on the proper treatment approaches for glaucoma patients with mental comorbidity and poor treatment adherence. We summarize some cautiously recommended psychotherapeutic medications, while also discussing the psychologically adverse effects of antiglaucoma medications.

Systematic Review of Educational Interventions to Improve Glaucoma Medication Adherence: an update in 2015

PURPOSE

To evaluate the current state of the research on educational interventions whose aim is to improve glaucoma medication adherence.

METHODS

A systematic review of Pubmed, Embase and CINAHL was conducted to identify research studies evaluating educational interventions to improve glaucoma medication adherence. Studies were included if the intervention was described, the outcomes assessed glaucoma medication adherence, and the focus of the research was on adults with glaucoma. The search was conducted on June 2, 2015.

RESULTS

Seventeen studies were identified that met the inclusion criteria. These included nine randomized controlled trials and eight observational studies. Eight of the studies demonstrated an impact on glaucoma medication adherence, though their outcome measures were too heterogeneous to estimate a pooled effect size..

CONCLUSION

The interventions that successfully improved glaucoma medication adherence used an adequate dose of face-to-face counseling to overcome barriers to health behavior change alongside education about glaucoma.

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.

Finding the best glaucoma questionnaire: a qualitative and quantitative evaluation of glaucoma knowledge assessments

Objective

The goal of the study was to determine which glaucoma quiz provides the best information about patient glaucoma knowledge to clinicians in clinical practice settings.

Methods

Four glaucoma quizzes were identified from the literature and national eye education programs and were qualitatively analyzed to categorize questions by topic. Quizzes were assessed by 64 glaucoma specialists using an online survey, with descriptive statistics. Comments about the quizzes were analyzed qualitatively using themes and representative quotations.

Results

Quizzes covered content that was important for glaucoma diagnosis and management. The National Eye Health Education Program (NEHEP) and Prevent Blindness America quizzes covered primarily diagnosis, screening, and risk factors, and the quizzes from the literature primarily covered causes of glaucoma, vision loss, eye drops, and systemic disease. Overall, the NEHEP quiz was ranked best for clinical practice, ranked first by 38%. Ranked second overall, the Gray quiz was ranked first by 34% and last by 34%.

Conclusion

The NEHEP quiz was rated most useful for assessing baseline general glaucoma knowledge for a busy clinical practice. The Gray quiz appears to be more useful as part of a comprehensive education program, perhaps in combination with an ophthalmic educator.

Adherence and Persistence: The Challenges for Glaucoma Medical Therapy

Suboptimal adherence and persistence to therapy are major challenges for patients treated with ocular hypotensive medications. The problem affects 5% to 80% of glaucoma patients from all nations, ethnicities, socioeconomic backgrounds, and education levels. Although health care providers are generally poor at detecting suboptimal or poor adherence in the clinical setting, several strategies to systematically assess adherence and persistence rates are available. One strategy involves electronic monitoring of patient dosing, which provides useful insights into specific patterns of adherence behavior among glaucoma patients. Adherence behavior is complex with multiple interrelated determinants; these can be broadly grouped into provider factors, environmental factors, medication factors, and patient factors. Targeted patient education strategies, counseling, electronic monitors, alarms, and reminders have all been used in efforts to improve adherence. These interventions probably work best in combination. Identifying tangible barriers to adherence and simple strategies to overcome these through an open, discursive relationship between clinician and patient is key to optimizing adherence.