Survey highlights factors influencing glaucoma medication use

Issue: April 2009

About half of patients participating in a survey conducted in southern India reported one or more problems in using their glaucoma medications.

The results also showed less than 10% of patients reporting imperfect medication adherence during the week before the survey.

In interviews with Ocular Surgery News, study authors Betsy L. Sleath, PhD, RPh, and Alan L. Robin, MD, discussed the survey results and factors that affect compliance with glaucoma medications.

Alan L. Robin

“I think those problems are pretty universal,” Dr. Robin said. “They show that people really overestimate their ability to adhere to medications. Most published studies that actually observe patients taking medications find that most patients don’t have any concept of how bad they are at remembering to take medications.”

A lower percentage of Indians, however, reported problems taking glaucoma medication than patients in the United States.

“In India, the results were much better than in the U.S., but there were still a lot of factors, which were in themselves problems,” he said. “In this study, it was opening up a bottle, grasping the bottle. The utilization issues were major factors.”

Indian patients tended to have trouble using eye drops, whereas American patients participating in a survey reported difficulty remembering to take their medications, Dr. Sleath said.

“It seems to be that in India, they’re reporting more that the problems are opening the bottle and squeezing the bottle compared to in the U.S., where the biggest thing that impacted self-reported adherence was them saying they had trouble remembering,” she said.

Survey results were published in the Indian Journal of Ophthalmology.

Younger and unmarried patients at risk

The survey included 243 patients who sought care at a large glaucoma clinic in that region. Trained clinical staff distributed the questions to patients taking glaucoma medications during a 1-month period in 2006, the study authors said.

“One of the first take-home points is that 42% of the patients reported that they had one or more problems in using their glaucoma medications,” Dr. Sleath said.

Younger patients were significantly more likely to report difficulty paying for medications (P = .04) and getting drops into their eyes (P = .02).

“One of the key things from this article and some other articles is that eye drops, although they sound good because you get all the benefits to the eye, are bad as a compliance aid,” Dr. Robin said. “They are hard for people to use. That is one message.”

Also, about 6% of patients reported being less than 100% compliant with glaucoma medication dosing instructions during the 1 week before the survey. Difficulty squeezing the bottle (P = .04), difficulty opening the bottle (P = .02) and being unmarried (P = .016) were significantly correlated with patient-reported medication compliance of less than 100%, the authors reported.

Dr. Sleath said unmarried patients’ lack of social support systems contributes to lower adherence.

“They may not have someone that can help them get it in their eye, in which case a provider could try to work with them to have a friend or someone, maybe even a co-worker, help them get it in their eye,” she said.

A partner will often remind a glaucoma patient to take his or her medication, Dr. Robin said.

“If you have a husband, wife or significant other, the other person if they get involved will say, ‘Don’t forget your medicine,’” he said. “A lot of people use the team approach. I think people who are single, divorced or widowed have more problems remembering.”

Additionally, occupational demands may further reduce an unmarried patient’s medication adherence, Dr. Robin said.

“If you’re in rural India and you’re a farm person, you’ve got to get out there early in the morning and do the fields. In the evening, you’re tired. So there’s nobody there to help you remember to take the medicine,” he said, noting that many of the patients had monthly incomes of $30 to $50.

“In India, adherence is important, just like it is anywhere but especially in India because the Aravind Institute, where we did this study, has a great video on how if you live in India and lose your sight, it can almost be like a death sentence because then you’re not a contributing member to the family or the economy,” Dr. Sleath said.

In a survey conducted in the United States, 60% of patients reported having one or more problems taking glaucoma medications; 14% reported being less than 100% compliant, she said.

Patient education and outreach

Survey results did not show a correlation between patients’ education level and medication adherence or reported problems. However, Dr. Robin noted a study by Kelly Muir, MD, of Duke University, Durham, U.S.A., on the impact of health literacy, or the capacity to understand and retain basic medical terms, on glaucoma medication compliance.

“We’re doing a similar study in the same [Indian] population now,” Dr. Robin said. “I can tell you that most individuals have no concept or knowledge of common words. Educating them on the importance of therapy and the consequences of not taking medications are extremely important, and we do a bad job of that.”

When patient education and outreach efforts fail, glaucoma specialists may be able to improve treatment and enhance outcomes by taking medication adherence out of patients’ hands, he said.

“There are some major issues involved with the ability to take eye drops,” Dr. Robin said. “If you could get the drop out of the patient’s hands and make it part of a visit where you give an injection or put a punctal plug in … then perhaps people will do better therapeutically.” — by Matt Hasson

Reference:

Sleath BL, Krishnadas R, Cho M, et al. Patient-reported barriers to glaucoma medication access, use and adherence in southern India. Indian J Ophthalmol. 2009;57(1):63-68.

Alan L. Robin, MD, can be reached at 6115 Falls Road, Suite 333, Baltimore, MD 21209, U.S.A.; +1-410-377-2422; fax: +1-410-377-7960; e-mail: arobin@glaucomaexpert.com.

Betsy L. Sleath, PhD, RPh, can be reached at Division of Pharmaceutical Outcomes and Policy, University of North Carolina School of Pharmacy, Kerr Hall, Room 2214 CB #7360, Chapel Hill, NC 27599-7360, U.S.A.; +1-919-962-0079; fax: +1-919-966-8486; e-mail: betsy_sleath@unc.edu.