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Moore SG, Richter G, Modjtahedi BS. Factors Affecting Glaucoma Medication Adherence and Interventions to Improve Adherence: A Narrative Review. Ophthalmol Ther 2023; 12:2863-2880. [PMID: 37698824 PMCID: PMC10640536 DOI: 10.1007/s40123-023-00797-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 08/15/2023] [Indexed: 09/13/2023] Open
Abstract
Glaucoma is a leading cause of vision loss. First line therapy for primary open angle glaucoma (POAG) are topical ocular hypotensive drops. Patient adherence with topical therapy for glaucoma is a significant challenge with a reported adherence of 60%. The purpose of this review is to discuss factors associated with glaucoma adherence (including demographic factors, cost, patient education, health beliefs, treatment burden and regimen, and physical limitations) and to explore potential interventions to improve medication adherence. Articles included in this review were found by searching PubMed and Google Scholar using the key words "Glaucoma Treatment Adherence" and "Glaucoma Treatment Compliance." Data from this review demonstrates that higher medication cost, lower patient education/literacy levels, and being of African and Hispanic descent are associated with lower medication adherence rates. The data is inconclusive on whether medication regimen complexity lowers patient medication adherence rates. Interventions that have successfully improved medication adherence rates for minority patients have focused on building trust and addressing fears and false beliefs. For cost, explicit physician communication to patients regarding medication cost is important and can help the physician determine any patient concerns about cost. Outside the USA, adherence has been improved through adherence-contingent rebate systems and government subsidies. Most interventions that aim to increase adherence target patient education and literacy with the following interventions demonstrating efficacy: written instructions targeting glaucoma-specific health literacy, literacy level appropriate glaucoma education videos, and interactive and personalized educational programs. More clinic infrastructure and programs that utilize patient reminder tools and patient educators could help physicians and patients in support of these personalized action plans.
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Affiliation(s)
- Shannan G Moore
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, 91101, USA
| | - Grace Richter
- Department of Ophthalmology, Southern California Permanente Medical Group, Los Angeles Medical Center, Los Angeles, CA, USA
- Eye Monitoring Center, Kaiser Permanente Southern California, 1011 Baldwin Park Boulevard, Balwin Park, CA, 91706, USA
| | - Bobeck S Modjtahedi
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, 91101, USA.
- Eye Monitoring Center, Kaiser Permanente Southern California, 1011 Baldwin Park Boulevard, Balwin Park, CA, 91706, USA.
- Department of Research and Evaluation, Southern California Permanente Medical Group, N Los Robles Avenue, Pasadena, CA, 91101, USA.
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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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Robinson CG, Schempf T, Williams AM, Muir KW, Woolson S, Olsen M, Rosdahl JA. Glaucoma Knowledge and Disease Severity in a Veteran Population: The Medication Adherence in Glaucoma to Improve Care (MAGIC) Study. Ophthalmol Glaucoma 2023; 6:277-282. [PMID: 36400355 DOI: 10.1016/j.ogla.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/11/2022] [Accepted: 11/01/2022] [Indexed: 05/26/2023]
Abstract
PURPOSE To assess the relationship between glaucoma knowledge and disease severity. DESIGN Substudy of a randomized controlled trial at a single Veterans Affairs (VA) eye clinic. PARTICIPANTS Veterans with medically treated open-angle glaucoma who self-reported poor medication adherence. METHODS Participants completed a glaucoma knowledge assessment using the 10-question National Eye Health Education Program (NEHEP) Eye-Q Test on glaucoma knowledge. Disease severity was determined using visual field criteria. Multiple linear regression was used to assess the association of NEHEP Eye-Q score and disease severity, adjusting for age, number of glaucoma medications, race, sex, and VA Care Assessment Needs (CAN) score. MAIN OUTCOME MEASURES In this cross-sectional, preintervention analysis, the main outcome was glaucoma knowledge as measured by the NEHEP Eye-Q Test. RESULTS Among the 200 study participants, glaucoma severity was mild in 53 (27%), moderate in 56 (28%), severe in 74 (37%), and indeterminant in 17 (9%). The NEHEP Eye-Q scores were low across all severity levels. Scored out of 10, the mean (standard deviation) NEHEP Eye-Q scores were 6.06 (1.57) for mild, 6.21 (1.47) for moderate, 6.28 (1.82) for severe, and 5.88 (1.93) for indeterminate stage. There was no evidence of a significant association between NEHEP scores and disease severity categories (P = 0.78). A regression model did not identify a significant estimated association between NEHEP Eye-Q scores and disease severity after adjusting for age, CAN risk score, number of glaucoma medications, race, and sex. CONCLUSIONS There was no difference in level of glaucoma knowledge based on disease severity. Education-based interventions may benefit patients across all glaucoma stages. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
| | - Tadhg Schempf
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew M Williams
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Kelly W Muir
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Sandra Woolson
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Maren Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Jullia A Rosdahl
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina.
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The case for standalone micro-invasive glaucoma surgery: rethinking the role of surgery in the glaucoma treatment paradigm. Curr Opin Ophthalmol 2023; 34:138-145. [PMID: 36373756 PMCID: PMC9894157 DOI: 10.1097/icu.0000000000000927] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW To highlight progress in glaucoma therapy challenging the traditional medication-first approach and present evidence supporting early standalone surgery in the era of micro-invasive glaucoma surgery (MIGS). RECENT FINDINGS Medical therapy is limited by well documented poor adherence that compromises the quality of intraocular pressure reduction. Results from modern clinical trials demonstrate advantages of selective laser trabeculoplasty and MIGS procedures in terms of both IOP control and progression risk. SUMMARY The MIGS options for pseudophakic or precataractous patients are limited by regulatory rules that require the performance of some procedures only at the time of cataract surgery. These include the iStent/iStent Inject and the Hydrus implants. Nonbleb-forming procedures currently available for standalone use in eyes with mild-moderate primary open-angle glaucoma include gonioscopy-assisted transluminal trabeculotomy (which lowers IOP by 28-61% and medication use by 38-73% in various studies), trabecular ablation with the Trabectome (23-39% and 21-43%, respectively), excisional goniotomy with the Kahook Dual Blade (15-36% and 15-40%, respectively), ab interno canaloplasty (35% and 57%, respectively), and combined canaloplasty and trabeculotomy using the OMNI system (39-40% and 64-73%, respectively). For patients who would benefit from early standalone surgery, these procedures offer meaningful reductions in both IOP and medication burden.
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Erras A, Shahrvini B, Weinreb RN, Baxter SL. Review of glaucoma medication adherence monitoring in the digital health era. Br J Ophthalmol 2023; 107:153-159. [PMID: 33858837 PMCID: PMC8517037 DOI: 10.1136/bjophthalmol-2020-317918] [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: 09/08/2020] [Revised: 02/19/2021] [Accepted: 04/05/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Alaa Erras
- Hamilton Glaucoma Center, Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Bita Shahrvini
- Hamilton Glaucoma Center, Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Robert N Weinreb
- Hamilton Glaucoma Center, Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA
| | - Sally L Baxter
- Hamilton Glaucoma Center, Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, California, USA .,Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California, USA
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Zhao QF, Hirneiss C. Does Diabetes Influence Adherence in Glaucoma Patients? Klin Monbl Augenheilkd 2023; 240:136-141. [PMID: 36351553 DOI: 10.1055/a-1975-2396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
With chronic diseases, patient adherence plays a crucial role in delaying disease progression and in determining the success of therapy. Problems arise not only from low medication adherence, but also non-adherence to recommended follow-up examinations. Obtaining an accurate estimate of adherence is difficult, especially in glaucoma patients, due to the fact that most antihypertensive drugs are administered in the form of eye drops. There is great variability in the published adherence values for glaucoma patients. Most studies report an average medication adherence of approximately 70%, with around 50% of patients having good adherence (at least 80% of medication administered as planned). Furthermore, 6.8 - 31.4% of the eye drops do not end up in the patient's eye, which means there is even less active ingredient to achieve a therapeutic effect. Glaucoma patients also show low persistence and adherence to follow-up appointments. Since diabetes increases the risk for POAG and secondary glaucoma and given that diabetics have particularly low adherence, the question arose whether a diabetes diagnosis is associated with reduced adherence in glaucoma patients. Previous studies found no significant association between diabetes and reduced adherence in glaucoma patients, although a significant impact of elevated HbA1c on adherence in glaucoma patients was found in one study. However, this connection still needs to be examined more closely in studies with larger samples.
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Affiliation(s)
- Qifan Felix Zhao
- Glaukomsprechstunde, Augenklinik und Poliklinik des Klinikums der Universität München, München, Deutschland
| | - Christoph Hirneiss
- Glaukomsprechstunde, Augenklinik und Poliklinik des Klinikums der Universität München, München, Deutschland
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Delavar A, Saseendrakumar BR, Weinreb RN, Baxter SL. Healthcare Access and Utilization Among Glaucoma Patients in a Nationwide Cohort. J Glaucoma 2023; 32:40-47. [PMID: 36223287 PMCID: PMC9805488 DOI: 10.1097/ijg.0000000000002123] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/22/2022] [Indexed: 11/07/2022]
Abstract
PRCIS Despite having lower socioeconomic status on several measures, glaucoma patients do not report more barriers to healthcare access and utilization than non-glaucoma patients. PURPOSE To characterize measures of socioeconomic status and barriers to healthcare access and utilization between patients with and without a diagnosis of glaucoma. METHODS Patients aged 65 years and over who enrolled in the NIH All of Us Research Program, a nationwide longitudinal cohort, were extracted. We analyzed demographic information and several measures of socioeconomic status and healthcare access and utilization. Survey responses were compared by glaucoma status (any type) with Pearson χ 2 tests, univariable logistic regression, and multivariable logistic regression adjusting for age, gender, race/ethnicity, and insurance status. RESULTS Of the 49,487 patients who answered at least 1 question on the All of Us Healthcare Access and Utilization Survey, 4441 (9.0%) had a diagnosis of glaucoma. Majority of the cohort was female (28,162, 56.9%) and nonHispanic White (42,008, 84.9%). Glaucoma patients were observed to have lower rates of education ( P =0.004), employment ( P <0.001), and home ownership ( P <0.001) on χ 2 tests. On multivariable logistic regression models, those with glaucoma were significantly more likely to speak to an eye doctor (Odds ratio: 2.46; 95% confidence interval: 2.16 to 2.81) and significantly less likely to have trouble affording eyeglasses (OR: 0.85 95% CI: 0.72 to 0.99) in the prior year than those without a diagnosis of glaucoma. No significant association was found for other measures of healthcare access and utilization by glaucoma status. CONCLUSION Although glaucoma patients aged 65 years and over fared worse on several measures of socioeconomic status, no significant difference was found in measures of healthcare access and utilization.
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Affiliation(s)
- Arash Delavar
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology, and Shiley Eye Institute, University of California San Diego, La Jolla, CA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA
| | - Bharanidharan Radha Saseendrakumar
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology, and Shiley Eye Institute, University of California San Diego, La Jolla, CA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA
| | - Robert N. Weinreb
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology, and Shiley Eye Institute, University of California San Diego, La Jolla, CA
- Hamilton Glaucoma Center, Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, CA
| | - Sally L. Baxter
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology, and Shiley Eye Institute, University of California San Diego, La Jolla, CA
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA
- Hamilton Glaucoma Center, Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, La Jolla, CA
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Energy Dose-Response in Selective Laser Trabeculoplasty: A Review. J Glaucoma 2022; 31:e49-e68. [PMID: 35701875 PMCID: PMC9362340 DOI: 10.1097/ijg.0000000000002062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/18/2022] [Indexed: 02/04/2023]
Abstract
PRCIS A literature review of selective laser trabeculoplasty (SLT) energy dose-response found no definitive relationship between intraocular pressure (IOP) reduction with respect to total or pulse energy, race, pigmentation, or application pattern. PURPOSE SLT is a safe and effective treatment for lowering IOP. Although evidence is mounting for the advantage of its use as a first-line treatment for IOP reduction, the SLT procedures in use vary widely. The purpose of this literature review was to investigate whether there were any relationships between SLT energy and efficacy for lowering IOP in the published literature. METHODS A literature review was undertaken that included studies in which energy levels required for successful SLT treatment were investigated: in general, with respect to angle pigmentation, race or ethnicity, and treatment arc extent. RESULTS There was no indication that higher (or lower) energy used in the treatment leads to greater (or less) IOP reduction. Similar results were obtained regarding the level of trabecular meshwork pigmentation. Race was not found to be associated with altered dose response in SLT. There were indications that treating the full 360 degrees, as opposed to smaller arcs, could be beneficial for more IOP reduction. IOP reduction from SLT was found to be similar to that provided by topical medications. CONCLUSIONS The optimal energy level of SLT needed for IOP reduction has not yet been definitively established, with all reported pulse energies resulting in similar IOP reduction. Furthermore, similar lack of conclusive findings exists regarding optimal SLT energy dosage for use in different races and degrees of trabecular meshwork pigmentation. This parameter and each of the abovementioned factors requires further research.
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Delavar A, Radha Saseendrakumar B, Weinreb RN, Baxter SL. Racial and Ethnic Disparities in Cost-Related Barriers to Medication Adherence Among Patients With Glaucoma Enrolled in the National Institutes of Health All of Us Research Program. JAMA Ophthalmol 2022; 140:354-361. [PMID: 35238904 PMCID: PMC8895312 DOI: 10.1001/jamaophthalmol.2022.0055] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/21/2021] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Ability to afford medication is a major determinate of medication adherence among patients. OBJECTIVE To determine cost-related barriers to medication adherence by race and ethnicity in a nationwide cohort of patients with glaucoma. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included patients with glaucoma enrolled in the National Institutes of Health All of Us Research Program, a nationwide longitudinal cohort of US adults, with more than 300 000 currently enrolled. Individuals with a diagnosis of glaucoma based on electronic health record diagnosis codes who participated in the Health Care Access and Utilization survey and had complete data on all covariates were studied. Data were collected from June 2016 to March 2021, and data were analyzed from August to November 2021. EXPOSURES Race and ethnicity defined as non-Hispanic African American, non-Hispanic Asian, Hispanic, and non-Hispanic White. MAIN OUTCOMES AND MEASURES Logistic regression was used to evaluate the association between reported cost-related barriers to medication adherence (could not afford prescription medication, skipped medication doses to save money, took less medication to save money, delayed filling a prescription to save money, asked for lower-cost medication to save money, bought prescriptions from another country to save money, and used alternative therapies to save money) and race and ethnicity, adjusting multivariable models by age, gender, health insurance status, education, and income. Odds ratios of these barriers were obtained by race and ethnicity, with non-Hispanic White race as the reference group. RESULTS Of 3826 included patients with glaucoma, 481 (12.6%) were African American, 119 (3.1%) were non-Hispanic Asian, 351 (9.2%) were Hispanic, and 2875 (75.1%) were non-Hispanic White. The median (IQR) age was 69 (60-75) years, and 2307 (60.3%) were female. After adjusting for confounders, non-Hispanic African American individuals (odds ratio, 1.82; 95% CI, 1.34-2.44) and Hispanic individuals (odds ratio, 1.77; 95% CI, 1.25-2.49) were more likely than non-Hispanic White individuals to report not being able to afford medications. Further, despite having the lowest rate of endorsing difficulty affording medications, non-Hispanic White individuals were equally likely to ask for lower-cost medication from their clinicians as individuals of racial and ethnic minority groups. CONCLUSIONS AND RELEVANCE In this study, there was significantly higher odds of self-reported difficulty affording medications among non-Hispanic African American and Hispanic individuals compared with non-Hispanic White individuals. Clinicians should be proactive and initiate discussions about costs in an effort to promote medication adherence and health equity among patients.
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Affiliation(s)
- Arash Delavar
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California, San Diego, La Jolla
- UCSD Health Department of Biomedical Informatics, University of California, San Diego, La Jolla
| | - Bharanidharan Radha Saseendrakumar
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California, San Diego, La Jolla
- UCSD Health Department of Biomedical Informatics, University of California, San Diego, La Jolla
| | - Robert N. Weinreb
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California, San Diego, La Jolla
| | - Sally L. Baxter
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California, San Diego, La Jolla
- UCSD Health Department of Biomedical Informatics, University of California, San Diego, La Jolla
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Kim S, Tong B, Lee J, Borodge D, Kooner K. Lifestyle Counseling for Medication Adherence in Glaucoma. Clin Ophthalmol 2021; 15:3521-3529. [PMID: 34429583 PMCID: PMC8380305 DOI: 10.2147/opth.s321351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/26/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Sandy Kim
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Betty Tong
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jessica Lee
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Darara Borodge
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karanjit Kooner
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Ophthalmology, Veterans Affairs North Texas Health Care System, Dallas, TX, USA
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Realini T, Gazzard G, Latina M, Kass M. Low-energy Selective Laser Trabeculoplasty Repeated Annually: Rationale for the COAST Trial. J Glaucoma 2021; 30:545-551. [PMID: 33428350 PMCID: PMC8238780 DOI: 10.1097/ijg.0000000000001788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/20/2020] [Indexed: 11/25/2022]
Abstract
The recent Laser in Glaucoma and Ocular Hypertension Trial provided the evidentiary basis for a paradigm shift away from the historical medication-first approach to glaucoma--which has numerous limitations, the most important of which is poor adherence to therapy --and toward a laser-first approach. Now 20 years after its commercialization, selective laser trabeculoplasty (SLT) is routinely performed consistently with its initial description, with energy titrated to the appearance of fine, champagne-like cavitation bubbles. A recent data set suggested that lower energy SLT, applied as primary therapy and repeated annually irrespective of intraocular pressure--rather than pro re nata when its effect wanes and irrespective of intraocular pressure rises --yields longer medication-free survival than standard energy SLT repeated pro re nata. A new study--Clarifying the Optimal Application of SLT Therapy --has been initiated to explore this preliminary finding in a pair of consecutive randomized trials. Herein, we provide an evidence-based rationale for the use of low-energy SLT repeated annually as primary therapy for mild to moderate primary open-angle glaucoma or high-risk ocular hypertension.
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Affiliation(s)
- Tony Realini
- Department of Ophthalmology and Visual Sciences, West Virginia University, Morgantown, WV
| | - Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; University College London, UK
| | - Mark Latina
- Department of Ophthalmology, Tufts University, Boston, MA
| | - Michael Kass
- Department of Ophthalmology and Visual Sciences, Washington University, St. Louis, MO
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Aihara M, Aung T, Bacharach J, Cantor L, Kook M, Nakazawa T, Park KH, Lu DW. Omidenepag isopropyl ophthalmic solution for open-angle glaucoma and ocular hypertension: an update. EXPERT REVIEW OF OPHTHALMOLOGY 2021. [DOI: 10.1080/17469899.2021.1935241] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Makoto Aihara
- Department of Ophthalmology, The University of Tokyo, Tokyo, Japan
| | - Tin Aung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Center, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jason Bacharach
- Medical Director and Director of Research, North Bay Eye Associates, Inc., Sonoma County, CA, USA
- Chief of Glaucoma Service, California Pacific Medical Center, San Francisco, CA, USA
| | - Louis Cantor
- Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael Kook
- Department of Ophthalmology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Toru Nakazawa
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Ki Ho Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Da-Wen Lu
- Department of Ophthalmology, Tri-Service General Hospital, Taipei, Taiwan
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Assil KK, Greenwood MD, Gibson A, Vantipalli S, Metzinger JL, Goldstein MH. Dropless cataract surgery: modernizing perioperative medical therapy to improve outcomes and patient satisfaction. Curr Opin Ophthalmol 2021; 32 Suppl 1:S1-S12. [PMID: 33273209 DOI: 10.1097/icu.0000000000000708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW Advances in pharmacology offer freedom from topical medical therapy without compromise of anti-inflammatory and antimicrobial coverage in the perioperative period. In this review, we describe the basis for dropless cataract surgery with the goal of improving outcomes and the patient experience. RECENT FINDINGS Phacoemulsification outcomes depend largely on surgeon skill but also on adherence to a complex multidrug regimen of perioperative anti-inflammatory and antimicrobial therapy to prevent sight-threatening complications such as cystoid macular edema or endophthalmitis. Successful administration of this regimen can be limited by noncompliance, difficulty administering eye drops, bioavailability, and side effects, among others. The recent development of sustained-release formulations of dexamethasone - one an intracanalicular insert and the other an intraocular suspension - can provide sustained tapering doses of dexamethasone while reducing or eliminating the need for anti-inflammatory eye drop therapy. Similarly, mounting evidence compellingly demonstrates that intracameral antibiotic use intraoperatively is at least as effective as topical antibiotics in preventing endophthalmitis. SUMMARY Sustained-release dexamethasone coupled with intracameral antibiotics at the time of phacoemulsification can provide antimicrobial and anti-inflammatory prophylaxis without the need for topical eye drop medications. This approach has the potential to improve compliance with therapy, visual acuity outcomes, and the overall patient experience.
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Affiliation(s)
| | | | - Andrea Gibson
- Ocular Therapeutix, Inc., Bedford, Massachusetts, USA
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Ramakrishnan MS, Yu Y, VanderBeek BL. Association of Visit Adherence and Visual Acuity in Patients With Neovascular Age-Related Macular Degeneration: Secondary Analysis of the Comparison of Age-Related Macular Degeneration Treatment Trial. JAMA Ophthalmol 2020; 138:237-242. [PMID: 32027349 DOI: 10.1001/jamaophthalmol.2019.4577] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Visit adherence has been shown to play a significant role in patient health outcomes. The effect of missing visits on visual acuity (VA) in individuals with neovascular age-related macular degeneration has yet to be characterized. Objective To quantify the association between patients' adherence to randomized clinical trial visits and VA in individuals with neovascular age-related macular degeneration based on 4 visit adherence metrics. Design, Setting, and Participants This is a secondary analysis of the Comparison of Age-Related Macular Degeneration Treatment Trial randomized clinical trial. Individuals with age-related macular degeneration were recruited from 44 clinical centers in the United States between February 2008 and December 2009. The 2-year study protocol required 1 visit every 4 weeks (every 21-35 days for a total of 26 visits) for monthly vs pro re nata treatments of bevacizumab vs ranibizumab. Analysis took place from November 2018 through May 2019. Exposures Visit adherence was measured in 4 ways: total number of missed visits, average number of days (avg days) between each visit, longest duration in days (max days) between visits, and visit constancy (the tally of 3-month periods with at least 1 visit attended). Average and max days were also categorized as on time (28-35 days), late (36-60 days), and very late (>60 days). Main Outcomes and Measures Change in Early Treatment Diabetic Retinopathy Study VA between the baseline and the last visit. Linear multivariate regression models were applied to analyze the association between visit adherence and change in VA, controlling for age, sex, baseline VA, anti-vascular endothelial growth factor drug, number of injections, and dosing regimen. Results Of 1178 patients, the mean (SD) age was 79.1 (7.3) years, and 727 (61.7%) were women. The mean (SD) number of missed visits was 2.4 (3.1). Overall, 1091 patients (92.6%) had complete visit constancy during the entire study period. Average days were categorized with 1060 patients (90.0%) classified as on time, 108 (9.2%) were late, and 10 (0.8%) were very late. For max days between visits, 197 patients (16.7%) were on time, 773 (65.6%) were late, and 208 (17.7%) were very late. After controlling for covariates, the late (avg days = -6.1; max days = -2.0) and very late (avg days = -12.5; max days = -5.9) groups saw fewer letters in both the avg and max days categories than patients in the on-time group (P < .001). Conclusions and Relevance These results provide evidence to support the concept that visit adherence contributes to VA outcomes in neovascular age-related macular degeneration. The magnitude of the association of visit adherence with VA outcomes in this clinical scenario suggests that substantial effort should be expended to strive for visit adherence or therapeutic strategies that reduce the visit burden without compromising VA outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT00593450.
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Affiliation(s)
- Meera S Ramakrishnan
- Scheie Eye Institute, Perelman School of Medicine, Department of Ophthalmology, University of Pennsylvania, Philadelphia
| | - Yinxi Yu
- Center for Preventative Ophthalmology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L VanderBeek
- Scheie Eye Institute, Perelman School of Medicine, Department of Ophthalmology, University of Pennsylvania, Philadelphia.,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Leonard Davis Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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15
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Kashaf MS, Jampel HD. Adherence Studies with Short Follow-up Do Not Suffice for a Chronic Disease Like Open-Angle Glaucoma. Ophthalmol Glaucoma 2020; 3:225-227. [PMID: 33008555 DOI: 10.1016/j.ogla.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 05/29/2020] [Indexed: 06/11/2023]
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16
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Munayco-Guillén F, Noriega-Cerdán JF, Cámara-Reyes RR, Niño-García R, Mezones-Holguin E. Knowledge of open angle glaucoma questionnaire: Design and validation in Spanish-speaking patients of Peru. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2020; 95:57-63. [PMID: 31892482 DOI: 10.1016/j.oftal.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To design and validate a questionnaire on the knowledge of primary open-angle glaucoma (POAG) in Spanish-speaking patients. METHODS An observational study was conducted on adults with diagnosis of POAG and who received outpatient medical care in a national reference health care institute of Peru. The questionnaire was based on a literature review and expert judgment. A pilot study was carried out on 60 patients. The items were classified and weighted according to the expert judgment. The final questionnaire was completed by 314 patients and its overall score was scaled by tertiles. RESULTS A total of 72 items were found by primary searching. The initial questionnaire was made up of 20 items, which was tested in a pilot study. A total of 14 items were selected that were then classified into 3weighted domains: risk factors (10%), clinical aspects (36%), and treatment (54%). The questionnaire has a score range from 0 to 100 points (lowest to highest level). In patients, the mean score was 62.6±14.1. The overall score was classified into 3categories of knowledge level: low (0 to 55 points), medium (56 to 69 points), and high (70 to 100 points). CONCLUSIONS The questionnaire provides evidence of validity to assess knowledge of POAG in Peruvian Spanish-speaking patients.
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Affiliation(s)
- F Munayco-Guillén
- Departamento de Glaucoma, Instituto Nacional de Oftalmología, Lima, Perú; Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Perú
| | - J F Noriega-Cerdán
- Departamento de Glaucoma, Instituto Nacional de Oftalmología, Lima, Perú; Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - R R Cámara-Reyes
- Facultad de Medicina, Universidad Nacional San Luis Gonzaga, Ica, Perú
| | - R Niño-García
- Facultad de Ciencias de la Salud, Universidad Nacional de Piura, Sociedad Científica de Estudiantes de Medicina de la Universidad Nacional de Piura (SOCIEMUNP), Piura, Perú; Epi-gnosis Solutions, Piura, Perú
| | - E Mezones-Holguin
- Universidad San Ignacio de Loyola (USIL), Centro de Excelencia en Investigaciones Económicas y Sociales en Salud. Lima, Perú; Epi-gnosis Solutions, Piura, Perú.
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Javidi H, Poonit N, Patel RP, Barry RJ, Rauz S, Murray PI. Adherence to Topical Medication in Patients with Inflammatory Eye Disease. Ocul Immunol Inflamm 2020; 29:890-895. [PMID: 31944132 DOI: 10.1080/09273948.2019.1699122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Hedayat Javidi
- Inflammatory Eye Disease Service, Birmingham & Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Nat Poonit
- Inflammatory Eye Disease Service, Birmingham & Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Radhika P. Patel
- Inflammatory Eye Disease Service, Birmingham & Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Robert J. Barry
- Inflammatory Eye Disease Service, Birmingham & Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing University of Birmingham, Birmingham, UK
| | - Saaeha Rauz
- Inflammatory Eye Disease Service, Birmingham & Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing University of Birmingham, Birmingham, UK
| | - Philip I. Murray
- Inflammatory Eye Disease Service, Birmingham & Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing University of Birmingham, Birmingham, UK
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18
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Bilger M, Wong TT, Lee JY, Howard KL, Bundoc FG, Lamoureux EL, Finkelstein EA. Using Adherence-Contingent Rebates on Chronic Disease Treatment Costs to Promote Medication Adherence: Results from a Randomized Controlled Trial. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:841-855. [PMID: 31317511 PMCID: PMC6885505 DOI: 10.1007/s40258-019-00497-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
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.
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Affiliation(s)
- Marcel Bilger
- Health Economics and Policy, Vienna University of Business and Economics, Welthandelsplatz 1, Building D4, 1020, Vienna, Austria.
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore.
| | - Tina T Wong
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Jia Yi Lee
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Kaye L Howard
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Filipinas G Bundoc
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Ecosse L Lamoureux
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Eric A Finkelstein
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, NC, USA
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Miraldi Utz V, Bulas S, Lopper S, Fenchel M, Sa T, Mehta M, Ash D, Lovell DJ, Kaufman AH. Effectiveness of long-term infliximab use and impact of treatment adherence on disease control in refractory, non-infectious pediatric uveitis. Pediatr Rheumatol Online J 2019; 17:79. [PMID: 31783768 PMCID: PMC6884783 DOI: 10.1186/s12969-019-0383-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Refractory non-infectious uveitis is a serious condition that leads to ocular complications and vision loss and requires effective systemic treatment to control disease. The effectiveness of long-term infliximab [IFX] in refractory non-infectious childhood uveitis and the impact of treatment adherence on disease control were evaluated. METHODS Retrospective, single-center study between December 2002 and April 2016 of 27 children with refractory non-infectious uveitis [17 with juvenile idiopathic arthritis, JIA] treated with long-term IFX [9+ months]. Disease activity was assessed prior to and while on IFX using the Standardization of Uveitis Nomenclature [SUN]. Number of visits per year with active uveitis was analyzed by repeated measures logistic regression analysis from 2 years prior to IFX initiation or from onset of uveitis until most recent visit on IFX. Incomplete treatment adherence was assessed for each visit and defined as any deviance in corticosteroid use, prescribed infusion frequency, and/or follow-up examination frequency. RESULTS Primary outcomes were sustained uveitic and systemic disease control prior to and during IFX treatment and the impact of incomplete adherence on uveitic disease control while on IFX. Secondary outcomes included corticosteroid and glaucoma medication requirement, ocular complications and need for surgical intervention. Mean age at IFX initiation was 10.4 ± 4.5 years; initial mean dose was 6.6 ± 2.2 mg/kg [and given at weeks 0, 2, 4 and q4 weeks thereafter for 93%]. Median duration on IFX was 35 [range 9-128] months. Prior to IFX, 14/27 patients had failed adalimumab ± methotrexate [MTX]; 21/27 failed MTX. IFX led to uveitis control in 89% and arthritis control in 76% (13/17). The odds ratio of having controlled disease after IFX was 4.1 (2.6, 6.4) compared to pre-treatment visits. Topical corticosteroids and glaucoma medications were statistically decreased (p = 0.007 right eye [OD], 0.003 left eye [OS] and p = 0.001 OD, p = 0.028 OS respectively). Incomplete adherence to treatment showed 10.3 times greater odds (7.1, 15.0) of having disease activity than full adherence. CONCLUSIONS This study adds significantly to the IFX literature by documenting outstanding uveitis control with long-term IFX treatment in non-infectious pediatric uveitis patients. Higher dosage and shorter interval were utilized without adverse effects. Importantly, this is the first study, to our knowledge, to document the significant impact of treatment adherence on uveitis control.
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Affiliation(s)
- Virginia Miraldi Utz
- Abrahamson Pediatric Eye Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Ophthalmology, University of Cincinnati, Cincinnati, OH, USA.
| | - Sabrina Bulas
- 0000 0000 9025 8099grid.239573.9Abrahamson Pediatric Eye Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,0000 0001 2179 9593grid.24827.3bDepartment of Ophthalmology, University of Cincinnati, Cincinnati, OH USA
| | - Sarah Lopper
- 0000 0000 9025 8099grid.239573.9Abrahamson Pediatric Eye Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,0000 0001 2179 9593grid.24827.3bDepartment of Ophthalmology, University of Cincinnati, Cincinnati, OH USA
| | - Matthew Fenchel
- 0000 0000 9025 8099grid.239573.9Department of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Ting Sa
- 0000 0000 9025 8099grid.239573.9Department of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Mitul Mehta
- 0000 0001 0668 7243grid.266093.8Gavin Herbert Eye Institute, University of California, Irvine, CA USA
| | - Daniel Ash
- 0000 0004 1936 7822grid.170205.1Department of Medicine, University of Chicago, Chicago, IL USA
| | - Daniel J. Lovell
- 0000 0000 9025 8099grid.239573.9Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Adam H. Kaufman
- 0000 0000 9025 8099grid.239573.9Abrahamson Pediatric Eye Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,0000 0001 2179 9593grid.24827.3bDepartment of Ophthalmology, University of Cincinnati, Cincinnati, OH USA ,grid.418609.2Cincinnati Eye Institute, Cincinnati, OH USA
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Newman-Casey PA, Salman M, Lee PP, Gatwood JD. Cost-Utility Analysis of Glaucoma Medication Adherence. Ophthalmology 2019; 127:589-598. [PMID: 31767436 DOI: 10.1016/j.ophtha.2019.09.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/10/2019] [Accepted: 09/27/2019] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The majority of patients with glaucoma do not take their medications as prescribed. Estimates of the cost-utility value of adherence to prescribed glaucoma medication are vital to implement potentially effective interventions. DESIGN Cost-utility analysis using Monte Carlo microsimulations incorporating a series of Markov cycles (10 000 iterations per strategy). PARTICIPANTS Patients with glaucoma aged ≥40 years with a full lifetime horizon (up to 60 years). METHODS The analysis estimated glaucomatous progression on the basis of data from the United Kingdom Glaucoma Treatment Study. Participants with glaucoma entered the model at age 40 years with a mean deviation in the better-seeing eye of -1.4±-1.9 decibels (dB) and -4.3±-3.4 dB in the worse-seeing eye. Participants whose glaucoma worsened each year accumulate -0.8 dB loss compared with -0.1 dB loss for those who remained stable. Data from the Glaucoma Laser Trial and the Tube versus Trabeculectomy Studies were used to assign probabilities of worsening disease among treated patients. Claims data estimating rates of glaucoma medication adherence over 4 years were used to assign probability of adherence. Those with poor adherence were modeled as having outcomes similar to the placebo arm of the clinical trials. As patients' mean deviation deteriorated, they transitioned between health states from mild (≥-6 dB), to moderate (<-6 to ≥-12 dB), to severe glaucoma (<-12 to ≥23 dB), to unilateral (<-20 dB) and bilateral blindness. At each health state, patients incurred the costs of treatment and established health utilities; ultimately, societal costs of low vision and blindness were included. MAIN OUTCOME MEASURES Cost and quality-adjusted life year (QALY) of glaucoma medication adherence. RESULTS Beginning at an initial glaucoma diagnosis at age 40 years, patients proceeded to single-eye blindness as early as 19 years among those who were nonadherent and 23 years for those remaining adherent. Total healthcare costs for adherent patients averaged $62 782 (standard deviation [SD], 34 107), and those for nonadherent patients averaged $52 722 (SD, 38 868). Nonadherent patients had a mean loss of 0.34 QALYs, resulting in a cost-effectiveness ratio of $29 600 per QALY gained. CONCLUSION At a conservative willingness to pay of $50 000/QALY, there is room to expand services to improve patient adherence.
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Affiliation(s)
- Paula Anne Newman-Casey
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan.
| | - Mariam Salman
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Paul P Lee
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Justin D Gatwood
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, Tennessee
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Spencer SKR, Shulruf B, McPherson ZE, Zhang H, Lee MB, Francis IC, Bank A, Coroneo MT, Agar A. Factors Affecting Adherence to Topical Glaucoma Therapy: A Quantitative and Qualitative Pilot Study Analysis in Sydney, Australia. Ophthalmol Glaucoma 2019; 2:86-93. [PMID: 32672609 DOI: 10.1016/j.ogla.2019.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 01/13/2019] [Accepted: 01/16/2019] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Sascha K R Spencer
- The University of New South Wales, Sydney, NSW, Australia; Prince of Wales Hospital, Sydney, NSW, Australia
| | - Boaz Shulruf
- The University of New South Wales, Sydney, NSW, Australia
| | | | - Helen Zhang
- The University of New South Wales, Sydney, NSW, Australia; Prince of Wales Hospital, Sydney, NSW, Australia
| | - Mitchell B Lee
- Prince of Wales Hospital, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Ian C Francis
- The University of New South Wales, Sydney, NSW, Australia; Prince of Wales Hospital, Sydney, NSW, Australia; Chatswood Eye Specialists, Sydney, NSW, Australia
| | - Allan Bank
- The University of New South Wales, Sydney, NSW, Australia; Prince of Wales Hospital, Sydney, NSW, Australia; Chatswood Eye Specialists, Sydney, NSW, Australia
| | - Minas T Coroneo
- The University of New South Wales, Sydney, NSW, Australia; Prince of Wales Hospital, Sydney, NSW, Australia
| | - Ashish Agar
- The University of New South Wales, Sydney, NSW, Australia; Prince of Wales Hospital, Sydney, NSW, Australia; Marsden Eye Specialists, Sydney, NSW, Australia.
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Dai WW, Gao JM, He P, Ma Z, Tian XX, Zheng XY. The association between socioeconomic status and visual disability among older adults in China. Int J Ophthalmol 2019; 12:106-113. [PMID: 30662849 DOI: 10.18240/ijo.2019.01.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/07/2018] [Indexed: 10/27/2022] Open
Abstract
AIM To investigate the association between socioeconomic status (SES) and visual disability (VD) among older Chinese adults. METHODS We obtained data from the Second National Sample Survey on Disability, conducted in China in 2006. A total number of 192 375 older adults (aged≥65y) were screened for suspected VD via interviews with trained examiners. Those who screened positively for VD were referred to ophthalmologists to obtain a final diagnosis. RESULTS VD was prevalent among 7.29% of Chinese adults aged 65 and older, and was higher in rural areas (8.71%) than in urban areas (4.82%). After adjusting for SES indicators and covariates, we found that less-educated older adults were more likely to suffer from VD, with an odds ratio (OR) of 2.50 (95%CI: 2.26-2.82) for illiterates, compared with those who graduated from senior high school or above. Older adults who were in the lowest income quintile were more at risk of VD, with an OR of 1.81 (95%CI: 1.68-2.95), compared with adults in the highest income quintile. In urban areas, when compared with adults who graduated from senior high school or above, those who did not continue their education after junior high school, primary school, or those who were illiterate, were more likely to suffer from VD, with an OR of 1.35 (95%CI: 1.51-1.59), 1.84 (95%CI: 1.60-2.12), and 2.63 (95%CI: 2.27-3.04), respectively. Lower levels of income were statistically significant when associated with VD. In rural areas, adults who were illiterate had an OR of 2.21 (95%CI: 1.75-2.79) when compared to adults with senior high school or above education level. Per capita, household income remained significantly associated with VD. Older adults who were ≥85, female, single, and residing in rural areas were associated with higher risks of VD. CONCLUSION Individual-level SES among the elderly, in the form of education and income, is associated with VD among elderly Chinese adults in both urban and rural areas; however, the association is stronger in rural areas. Further studies are still required to explore the mechanism behind the relationships.
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Affiliation(s)
- Wan-Wei Dai
- Institute of Population Research, APEC Health Science Academy (HeSAY), Peking University, Beijing 100891, China.,The Third Hospital, Peking University, Beijing 100191, China
| | - Jia-Min Gao
- Institute of Population Research, APEC Health Science Academy (HeSAY), Peking University, Beijing 100891, China.,Guanghua School of Management, Institute of Strategic Research, Peking University, Beijing 100891, China
| | - Ping He
- Institute of Population Research, APEC Health Science Academy (HeSAY), Peking University, Beijing 100891, China.,China Center for Health Development Studies, Peking University, Beijing 100891, China
| | - Zheng Ma
- Institute of Population Research, APEC Health Science Academy (HeSAY), Peking University, Beijing 100891, China
| | - Xiao-Xiao Tian
- Institute of Population Research, APEC Health Science Academy (HeSAY), Peking University, Beijing 100891, China
| | - Xiao-Ying Zheng
- Institute of Population Research, APEC Health Science Academy (HeSAY), Peking University, Beijing 100891, China
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Garrido M, Turco M, Formentin C, Corrias M, De Rui M, Montagnese S, Amodio P. An educational tool for the prophylaxis of hepatic encephalopathy. BMJ Open Gastroenterol 2017; 4:e000161. [PMID: 28944074 PMCID: PMC5596837 DOI: 10.1136/bmjgast-2017-000161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/16/2017] [Accepted: 07/25/2017] [Indexed: 01/25/2023] Open
Abstract
Background Providing structured information for the understanding of hepatic encephalopathy (HE) might be relevant to the prevention and management of the syndrome. The aim of our study was to design a brief, structured educational intervention and evaluate its usefulness in preventing HE-related hospitalisation over time. Methods Thirty-nine cirrhotic outpatients with a history of HE were enrolled and randomly assigned to an intervention (group A; n=20) or control group (group B; n=19). All of them underwent evaluation of HE (clinical and quantitative neuropsychiatric assessment) and completed the Questionnaire on the Awareness of Encephalopathy. A 15 min educational session was then provided to patients in group A, including basic information on the pathophysiology, hygienic and medical management of HE. Results No demographic/clinical differences were observed at baseline between the two groups. Similarly, there were no significant differences in HE-related information available at baseline between the two groups; knowledge of HE was limited in both. The intervention was highly effective in increasing patients’ understanding of treatment of the condition (from 5% to 80%). The educational intervention also reduced the risk of developing an episode of HE over a period of 12 months. Conclusion The educational intervention confirmed the poor knowledge of patients with previous HE about their condition, served as a tool to increase patients’ awareness, and minimised HE-related readmission rates over a period of 1 year.
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Affiliation(s)
- Maria Garrido
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Matteo Turco
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Chiara Formentin
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Michela Corrias
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Michele De Rui
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Sara Montagnese
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Piero Amodio
- Department of Medicine, DIMED, University of Padova, Padova, Italy
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Skalicky SE, D'Mellow G, House P, Fenwick E. Glaucoma Australia educational impact study: a randomized short-term clinical trial evaluating the association between glaucoma education and patient knowledge, anxiety and treatment satisfaction. Clin Exp Ophthalmol 2017; 46:222-231. [DOI: 10.1111/ceo.13016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/24/2017] [Accepted: 06/19/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Simon E Skalicky
- Discipline of Ophthalmology; University of Sydney; Sydney New South Wales Australia
- Departments of Ophthalmology and Surgery, Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital; University of Melbourne; Melbourne Victoria Australia
| | - Guy D'Mellow
- Terrace Eye Centre; Brisbane Queensland Australia
- Greenslopes Hospital; Brisbane Queensland Australia
| | - Philip House
- Centre for Ophthalmology and Visual Science; The University of Western Australia; Perth Western Australia Australia
| | - Eva Fenwick
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital; University of Melbourne; Melbourne Victoria Australia
- Singapore Eye Research Institute; Singapore National Eye Centre; Singapore
- Duke-NUS Medical School, Singapore; National University of Singapore; Singapore
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Feehan M, Munger MA, Cooper DK, Hess KT, Durante R, Jones GJ, Montuoro J, Morrison MA, Clegg D, Crandall AS, DeAngelis MM. Adherence to Glaucoma Medications Over 12 Months in Two US Community Pharmacy Chains. J Clin Med 2016; 5:jcm5090079. [PMID: 27618115 PMCID: PMC5039482 DOI: 10.3390/jcm5090079] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/25/2016] [Accepted: 08/29/2016] [Indexed: 12/11/2022] Open
Abstract
This study determined the degree of adherence to medications for glaucoma among patients refilling prescriptions in community pharmacies. Methods: Data abstracted from the dispensing records for 3615 adult patients (18 years or older, predominantly over 45) receiving glaucoma medications from two retail pharmacy chains (64 stores in total) were analyzed. From a 24-month historic data capture period, the 12-month levels of adherence were determined using standard metrics, the proportion of days covered (PDC) and the medication possession ratio (MPR). The overall 12-month mean PDC was only 57%, and the mean MPR was 71%. Using a criterion by which 80% coverage was considered satisfactory adherence, only 30% had satisfactory overall 12-month PDC coverage, and only 37% had satisfactory overall 12-month MPR coverage. Refill adherence increased with age and was highest in the 65-and-older age group (p < 0.001). Differential adherence was found across medication classes, with the highest satisfactory coverage seen for those taking alpha2-adrenergic agonists (PDC = 36.0%; MPR = 47.6%) down to those taking direct cholinergic agonists (PDC = 25.0%; MPR = 31.2%) and combination products (PDC = 22.7%; MPR = 31.0%). Adherence to glaucoma medications in the community setting, as measured by pharmacy refill data, is very poor and represents a critical target for intervention. Community pharmacists are well positioned to monitor and reinforce adherence in this population.
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Affiliation(s)
- Michael Feehan
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA.
- Department of Ophthalmology & Visual Sciences, Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
| | - Mark A Munger
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA.
| | | | | | - Richard Durante
- Marketing and Planning Systems (MaPS), a Division of Millward Brown Analytics, Boston, MA 02116, USA.
| | | | - Jaime Montuoro
- Smith's Food & Drug Centers, Inc., Salt Lake City, UT 84104, USA.
| | - Margaux A Morrison
- Department of Ophthalmology & Visual Sciences, Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
| | - Daniel Clegg
- Department of Ophthalmology & Visual Sciences, Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
| | - Alan S Crandall
- Department of Ophthalmology & Visual Sciences, Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
| | - Margaret M DeAngelis
- Department of Ophthalmology & Visual Sciences, Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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Study on Incentives for Glaucoma Medication Adherence (SIGMA): study protocol for a randomized controlled trial to increase glaucoma medication adherence using value pricing. Trials 2016; 17:316. [PMID: 27422389 PMCID: PMC4947326 DOI: 10.1186/s13063-016-1459-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background Many glaucoma patients do not adhere to their medication regimens because they fail to internalize the (health) costs of non-adherence, which may not occur until years or decades later. Behavioural economic theory suggests that adherence rates can be improved by offering patients a near-term benefit. Our proposed strategy is to offer adherence-contingent rebates on medication and check-up costs. This form of value pricing (VP) ensures that rebates are granted only to those most likely to benefit. Moreover, by leveraging loss aversion, rebates are expected to generate a stronger behavioural response than equivalent financial rewards. Methods/Design The main objective of the Study on Incentives for Glaucoma Medication Adherence (SIGMA) is to test the VP approach relative to usual care (UC) in improving medication adherence. SIGMA is a randomized, controlled, open-label, single-centre superiority trial with two parallel arms. A total of 100 non-adherent (Morisky Medication Adherence Scale ≤6) glaucoma patients from the Singapore National Eye Centre are block-randomized (blocking factor: single versus multiple medications users) into the VP and UC arms in a 1:1 ratio. The treatment received by VP patients will be strictly identical to that received by UC patients, with the only exception being that VP patients can earn either a 50 % or 25 % rebate on their glaucoma-related healthcare costs conditional on being adherent on at least 90 % or 75 % of days as measured by a medication event monitoring system. Masking the arm allocation will be precluded by the behavioural nature of the intervention but blocking size will not be disclosed to protect concealment. The primary outcome is the mean change from baseline in percentage of adherent days at month 6. A day will be counted as adherent when the patients take all their medication(s) within the appropriate dosing windows. Discussion This trial will provide evidence on whether adherence-contingent rebates can improve medication adherence among non-adherent glaucoma patients, and more generally whether this approach represents a promising strategy to cost-effectively improve chronic disease management. Trial registration NCT02271269. Registered on 19 October 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1459-1) contains supplementary material, which is available to authorized users.
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