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Open communication essential to patient-centered comanagement
Here’s an example of how open communication between comanaging doctors is essential to the best patient outcomes.
A patient who had cataract surgery a few weeks ago recently came back to see me with a classic case of cystoid macular edema (CME). CME has become a rare event in recent years because of the routine use of a topical nonsteroidal anti-inflammatory drug (NSAID) after surgery.
I asked this patient about her eye drop regimen and learned that she had not taken her NSAID, Bromday (bromfenac ophthalmic solution 0.09%, Ista Pharmaceuticals), as recommended. Apparently, her pharmacy had substituted a generic version of ketorolac to save the patient $12 in out-of-pocket costs. Not surprisingly, this generic substitution led to corneal toxicity that is well described with generic ketorolac.
 Generic ketorolac has become a well-known cause of corneal toxicity, as evidenced in this case by infiltration and permanent loss of corneal stromal tissue. Image: Devgan U |
When she saw her comanaging optometrist after 2 weeks of this medication, he recognized the corneal toxicity and the source of her symptoms of blurred vision, and asked her to stop the generic ketorolac. He did not instruct her to start another NSAID.
Unfortunately, a few weeks later the patient developed CME, reducing her best corrected vision to 20/70.
In the end, this patient will do very well. She will return to normal vision and will likely be no worse for this episode. However, there are a few important lessons to be learned:
1. Pharmacies may make medication switches without a doctor’s permission. This practice is illegal but quite common, and it can meaningfully affect outcomes. We should never assume our patients are taking the medications we have prescribed them.
2. Many medication substitutions are a perfectly reasonable way to save the patient money, and some are not. Communication between optometrist and ophthalmologist is essential in understanding which medications can and can’t be safely substituted.
3. It’s never a bother to answer a colleague’s questions about postoperative treatment. My optometrist colleague, a trusted friend and very capable clinician, simply “didn’t want to be a bother” by calling to ask about this medication substitution. In retrospect, I wish he had done so.
I blame myself for the gap in communication in this case. Had we had more open lines of communication to share concerns, give feedback and relay outcomes data to each other, we might have known about the pharmacy’s action to switch the patient’s medication, and we might have taken an even more appropriate next step. In an age in which an increasing number of our patients choose premium options for their cataract surgery, we can’t afford to allow gaps in communication or care.
I welcome comments on how comanaging doctors can communicate for the betterment of our patients’ care.
- Disclosure: Dr. Hovanesian is a consultant to Ista.