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Quaranta L, Novella A, Tettamanti M, Pasina L, Weinreb RN, Nobili A. Adherence and Persistence to Medical Therapy in Glaucoma: An Overview. Ophthalmol Ther 2023; 12:2227-2240. [PMID: 37311908 PMCID: PMC10441906 DOI: 10.1007/s40123-023-00730-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
Glaucoma is a group of progressive optic neuropathies characterized by loss of retinal ganglion cells and visual field deterioration. Despite the fact that the underlying pathophysiology of glaucoma remains unknown, elevated intraocular pressure (IOP) is a well-established risk factor, and the only factor that can be modified. Robust evidence from epidemiological studies and clinical trials has clearly demonstrated the benefits of IOP control in reducing the risk of glaucoma progression. IOP-lowering therapy by the means of eye drops remains a first-line treatment option. However, like other chronic and asymptomatic conditions, many patients with glaucoma have difficulties in maintaining high rates of adherence persistence to prescribed medications. On average, patients with chronic medical conditions take 30-70% of the prescribed medication doses, and on average 50% discontinue medications in the first months of therapy. The ophthalmic literature shows similarly low rates of adherence to treatment. Indeed, poor adherence is associated with disease progression and increased complication rates, as well as healthcare costs. The present review analyzes and discusses the causes of variability of the adherence to the prescribed drugs. The education of patients about glaucoma and the potential consequences of insufficient adherence and persistence seems fundamental to maximize the probability of treatment success and therefore prevent visual disability to avoid unnecessary healthcare costs.
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Affiliation(s)
| | - Alessio Novella
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Mauro Tettamanti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Robert N Weinreb
- Viterbi Family Department of Ophthalmology, and Shiley Eye Institute, Hamilton Glaucoma Center, University of California San Diego, La Jolla, CA, USA
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Kinast RM, Sanchez FG, Rees JP, Yeh K, Gardiner SK, Dawes J, Johnston ML, Porter JD, Klei V, Mansberger SL. Eye Drop Adherence With an Eye Drop Bottle Cap Monitor. J Glaucoma 2023; 32:369-373. [PMID: 37053080 PMCID: PMC10132997 DOI: 10.1097/ijg.0000000000002166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/21/2022] [Indexed: 04/14/2023]
Abstract
PRCIS An eye drop bottle cap monitor with audio and visual alarms measured eye drop adherence in 50 subjects with glaucoma. Baseline adherence rates were too high to test if the alarms could improve adherence. PURPOSE To determine if an eye drop bottle cap monitor can measure and improve adherence. MATERIALS AND METHODS The Devers Drop Device (D3, Universal Adherence LLC) was designed to measure eye drop adherence by detecting bottle cap removal and replacement, and it can provide text, visual and audio alerts when a medication is due. In Stage 1, we determined baseline adherence for 50 subjects using a nightly eye drop over a 25-day period. Subjects with less than 90% baseline adherence were eligible for Stage 2. In Stage 2, we randomized subjects to receive either no reminder or automated D3 alerts for their nightly eye drop over a subsequent 25-day period. We defined adherence as the proportion of drops administered within 3 hours of the subjects' scheduled dosing time. Subjects completed 3 questions regarding satisfaction with the device and willingness to pay. RESULTS The D3 monitor remained attached to the eye drop bottle cap for the duration of the study and collected adherence data in all 50 patients. In Stage 1, the mean adherence rate was 90 ± 18% (range 32-100%). Forty (80%) subjects had an adherence rate greater than 90%. Adherence rates were too high in Stage 1 to adequately test the effects of reminders in Stage 2. Ninety-eight percent (49/50) and 96% (48/50) of subjects agreed "the device always stayed attached to the bottle cap" and "I was able to use the device to take the drops", respectively. Patients would pay $61±83 (range $0-400) for a similar device to improve adherence. CONCLUSIONS The D3 can measure eye drop adherence. Research subjects reported high satisfaction and willingness to pay for an eye drop bottle cap monitor. Glaucoma patients have high adherence when they are being monitored, and future studies with research subjects screened for poor adherence may further determine the benefit of electronic monitoring of adherence with and without electronic reminders.
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Affiliation(s)
| | | | | | | | | | - Jacob Dawes
- Oregon State University, School of Electrical Engineering and Computer Science
| | - Matthew L Johnston
- Oregon State University, School of Electrical Engineering and Computer Science
| | - J David Porter
- Oregon State University, School of Mechanical Industrial and Manufacturing Engineering, Corvallis, OR
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Ju B, Kim I, Li BM, Knowles CG, Mills A, Grace L, Jur JS. Inkjet Printed Textile Force Sensitive Resistors for Wearable and Healthcare Devices. Adv Healthc Mater 2021; 10:e2100893. [PMID: 34212513 PMCID: PMC8542615 DOI: 10.1002/adhm.202100893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/02/2021] [Indexed: 01/21/2023]
Abstract
Pressure sensors for wearable healthcare devices, particularly force sensitive resistors (FSRs) are widely used to monitor physiological signals and human motions. However, current FSRs are not suitable for integration into wearable platforms. This work presents a novel technique for developing textile FSRs (TFSRs) using a combination of inkjet printing of metal-organic decomposition silver inks and heat pressing for facile integration into textiles. The insulating void by a thermoplastic polyurethane (TPU) membrane between the top and bottom textile electrodes creates an architectured piezoresistive structure. The structure functions as a simple logic switch where under a threshold pressure the electrodes make contact to create conductive paths (on-state) and without pressure return to the prior insulated condition (off-state). The TFSR can be controlled by arranging the number of layers and hole diameters of the TPU spacer to specify a wide range of activation pressures from 4.9 kPa to 7.1 MPa. For a use-case scenario in wearable healthcare technologies, the TFSR connected with a readout circuit and a mobile app shows highly stable signal acquisition from finger movement. According to the on/off state of the TFSR with LED bulbs by different weights, it can be utilized as a textile switch showing tactile feedback.
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Affiliation(s)
- Beomjun Ju
- Department of Textile Engineering, Chemistry and Science, North Carolina State University, Raleigh, NC, 27606, USA
| | - Inhwan Kim
- Department of Textile Engineering, Chemistry and Science, North Carolina State University, Raleigh, NC, 27606, USA
| | - Braden M Li
- Department of Textile Engineering, Chemistry and Science, North Carolina State University, Raleigh, NC, 27606, USA
| | - Caitlin G Knowles
- Department of Textile Engineering, Chemistry and Science, North Carolina State University, Raleigh, NC, 27606, USA
| | - Amanda Mills
- Department of Textile Engineering, Chemistry and Science, North Carolina State University, Raleigh, NC, 27606, USA
| | - Landon Grace
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, 27695, USA
| | - Jesse S Jur
- Department of Textile Engineering, Chemistry and Science, North Carolina State University, Raleigh, NC, 27606, USA
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Affiliation(s)
- Alan L. Robin
- Department of Ophthalmology, Johns Hopkins School of Medicine and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Department of Ophthalmology, The University of Michigan, Ann Arbor, MI, USA
| | - Kelly W. Muir
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, USA
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Waterman H, Evans JR, Gray TA, Henson D, Harper R. Interventions for improving adherence to ocular hypotensive therapy. Cochrane Database Syst Rev 2013:CD006132. [PMID: 23633333 DOI: 10.1002/14651858.cd006132.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence. OBJECTIVES To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. DATA COLLECTION AND ANALYSIS At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity. MAIN RESULTS Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive. AUTHORS' CONCLUSIONS Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.
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Affiliation(s)
- Heather Waterman
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
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Lanzl I, Kaercher T. [Preservative-containing eye drops and adherence in ophthalmological practice]. Ophthalmologe 2012. [PMID: 23179814 DOI: 10.1007/s00347-012-2641-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronic eye diseases, such as glaucoma or dry eye syndrome, require long-term drug application to the eyes. Good adherence is required to achieve the therapeutic goal and patient needs and requirements have to be taken into account. This distinguishes adherence to drug therapy from the former compliance which implies only following medical instructions. Adherence is influenced by socioeconomic, health system-related, disease-related, treatment-related and patient-related factors. It can be measured by tedious procedures, such as electronic monitoring, self-assessment, drop counting and laboratory findings of systemic drug levels. Non-adherence is a growing medical problem worldwide. An increase in adherence means an increased degree of therapeutic safety for the patient and long-term cost savings for the individual as well as society. Non-adherence in chronic diseases, such as glaucoma and dry eye syndrome is increased by eye drops that cause side effects. Often these side effects are caused by agents such as the preservative benzalkonium chloride. To achieve a good adherence preservative-free eye drops are advised.
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Affiliation(s)
- I Lanzl
- Augenklinik, TU München, Ismaninger Str. 22, 81675, München, Deutschland.
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Abstract
PURPOSE To assess the patient adherence and behavior with brimonidine twice daily (bid) or 3 times daily (tid) in patients used to topical glaucoma medication. PATIENTS AND METHODS Seventy-five patients with glaucoma or ocular hypertension were enrolled in a prospective, observational cohort study. Consenting patients were randomly assigned to brimonidine bid or tid and received conventional brimonidine eye drops with attached electronic monitoring devices for 4 weeks. Patients were not explicitly informed on the compliance monitoring. RESULTS The study was completed by 67 patients (89%). In 65 patients (97%), at least 1 dosing interval exceeded 24 hours. The mean adherence rates were better in the brimonidine bid group (72 ± 19% vs. 62 ± 16%, P=0.04), although dosing frequency was higher in the tid group (1.9 ± 0.5 vs. 1.4 ± 0.4 per day; P<0.001). On average medication coverage was 70% for the bid group and 67% for the tid group; 19 patients (28%) had a coverage rate above 75%, 42 patients (63%) 50% to 75%, and 6 (9%) below 50%. Patients with normal-tension glaucoma had lower coverage rates than patients with primary open-angle glaucoma and ocular hypertension (P<0.05). Data also showed that on average 20% of the glaucoma medication was wasted owing to inefficient drug delivery by using more than 1 drop per dosing. CONCLUSIONS Individual adherence with brimonidine was highly variable and pharmacologically insufficient for more than two-third of the patients. Special attention should be paid to compliance of patients with normal-tension glaucoma. Our findings underline the need to improve individual adherence and drug delivery in topical glaucoma therapy.
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Prevalence and correlates of self-reported nonadherence with eye drop treatment: the Belgian Compliance Study in Ophthalmology (BCSO). J Glaucoma 2012; 20:414-21. [PMID: 21048510 DOI: 10.1097/ijg.0b013e3181f7b10e] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to investigate (1) the prevalence of nonadherence with eye drop treatment; (2) selected correlates of nonadherence at the patient and health-care organization level; and (3) the diagnostic value of the ophthalmologists' ratings, using patients' self-reports as standard. METHODS This cross-sectional multicenter survey used questionnaires for ophthalmologists and their patients to assess self-reported nonadherence and its correlates. One item, using a 4-point scale [never (ie, adherent) to daily], asked the patients whether they had forgotten to administer eye drops during the past 2 weeks. Ophthalmologists rated their patients as adherent or nonadherent. Nonadherence was also determined by combined methods, whereby either could indicate nonadherence. Given the nested structure of the data, multilevel modeling was used to investigate self-reported nonadherence-correlates. Diagnostic values of ophthalmologists' report were calculated. RESULTS Of 663 patients (48% female, 44% >69 years), nonadherence was indicated in 39.2% (n=260) through self-reporting, 2.1% (n=14) through ophthalmologists' ratings, and 40% (n=266) through combined measures. The multivariable, multilevel model showed following significant nonadherence-correlates: Male sex (P=0.01), younger age (P=0.027), and higher-dose frequency (P=0.001). No significant correlation with treating ophthalmologist (P=0.21) could be seen. Yet, the patients visiting their ophthalmologists at least every 3 months were less nonadherent than patients with fewer consultations (P=0.01). The ophthalmologists' report showed a sensitivity and specificity of 3% and 98.5%, respectively. CONCLUSIONS The prevalence of self-reported nonadherence was congruent with literature. The patients visiting their ophthalmologists at least every 3 months have a lower risk of nonadherence. Ophthalmologist report is an insensitive method for detecting nonadherence.
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Hermann MM, Papaconstantinou D, Muether PS, Georgopoulos G, Diestelhorst M. Adherence with brimonidine in patients with glaucoma aware and not aware of electronic monitoring. Acta Ophthalmol 2011; 89:e300-5. [PMID: 21106046 DOI: 10.1111/j.1755-3768.2010.02050.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess the impact of open versus masked adherence monitoring on adherence with topical brimonidine using two different dosing schedules. METHODS Thirty-seven patients with glaucoma or ocular hypertension were enrolled in a prospective, observational cohort study. Patients were randomly assigned to open or masked adherence monitoring and to brimonidine twice daily (BID) or three times daily (TID). Patients received conventional brimonidine eye drops with attached electronic monitoring devices for 4 weeks with weekly intraocular pressure measurements. Adherence calculations comprised dosing intervals, adherence rate and time covered. Subgroup analysis with anova included the factors masking, regimen, diagnosis and age. RESULTS Among 36 individually analysed patients, 12 (33%) had adherence rates above 75%, therein two (5%)>90%. The mean adherence rate in 19 patients aware of adherence measurements was 70 ± 17% for brimonidine BID and 65 ± 14% for TID, not significantly different to the rates of 17 patients not informed about adherence measurements (77 ± 6% BID, 62 ± 9% TID, p = 0.24). On average, patients with brimonidine TID achieved significantly lower adherence rates (64 ± 12%) than patients on BID (73 ± 13%, p = 0.02). Still, patients on TID applied brimonidine more often (TID 1.9 ± 0.3, BID 1.5 ± 0.1 mean applications per day). The median coverage was 70% and showed no statistically significant difference between patients on BID and TID (p = 0.36). CONCLUSION The study findings suggest that adherence measurements are not significantly altered by open adherence monitoring, which may simplify future adherence studies. Adherence with brimonidine eye drops was insufficient for most patients. These results demonstrate the necessity to develop new strategies to improve compliance in glaucoma therapy.
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Electronic compliance monitoring of topical treatment after ophthalmic surgery. Int Ophthalmol 2010; 30:385-90. [DOI: 10.1007/s10792-010-9362-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 03/22/2010] [Indexed: 10/19/2022]
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Gray TA, Orton LC, Henson D, Harper R, Waterman H. Interventions for improving adherence to ocular hypotensive therapy. Cochrane Database Syst Rev 2009:CD006132. [PMID: 19370627 DOI: 10.1002/14651858.cd006132.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information and ongoing support according to patient need, may have a positive effect on improving adherence. OBJECTIVES To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma. SEARCH STRATEGY We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, ZETOC and OpenSIGLE. In addition, we searched research registers of ongoing studies. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 15 January 2009. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma. DATA COLLECTION AND ANALYSIS At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We calculated the mean difference for continuous data and relative risks for dichotomous data. Where appropriate, we pooled data using a fixed-effect model. MAIN RESULTS Eight trials met the inclusion criteria. There was considerable heterogeneity of interventions and reported outcome measures and therefore, meta-analysis was limited to two studies. Overall, studies were not of high quality due to small sample sizes, missing data and short term follow-up. Three of five drug comparison studies provided evidence that reducing the frequency of drops can improve adherence. However, the study that compared the least frequent regime with one of the most complicated, showed no difference in reported adherence. A small study of thirteen patients found a reminder device beneficial to adherence levels yet only one of two studies involving education and individualised care planning was found to be successful. AUTHORS' CONCLUSIONS Interventions involving simplified dosing regimes, reminder devices, education and individualised care planning, did show improvements in adherence rates. However, due to inadequate methodological quality and heterogeneity of study design we are unable to advocate any particular interventions at this time.
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Affiliation(s)
- Trish A Gray
- Academic Department of Ophthalmology, Manchester Royal Eye Hospital, Oxford Road, Manchester, UK, M13 9WH.
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Abstract
Glaucoma is a relatively common ocular disease among adults aged >65 years. However, knowledge about glaucoma, the physical capacity to perform self-application of antiglaucomatous drops, and general compliance may be massively restricted in the older population owing to significantly increasing comorbidity and other factors (e.g. their social and financial situation). Additional efforts by ophthalmologists, the pharmaceutical industry and health politics are required to improve knowledge and compliance among elderly glaucoma patients.
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Affiliation(s)
- T S Dietlein
- Zentrum für Augenheilkunde, Universität Köln, Joseph-Stelzmann-Strasse 9, 50931 Köln, Germany.
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Diestelhorst M. The State of Being Noninferior. Ophthalmology 2006; 113:2108. [PMID: 17074570 DOI: 10.1016/j.ophtha.2006.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 07/27/2006] [Indexed: 10/24/2022] Open
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