Glaucoma: Automated Calls May Up Compliance With Eye Drops

Larry Hand

June 04, 2014

Electronic monitoring of patients prescribed eye drops for glaucoma shows that a "sizable" number of patients do not take their medications as prescribed, according to an article published online May 15 in JAMA Ophthalmology.

In a companion article, however, the researchers report that automated telecommunication-based reminders linked to an online personal health record can be an effective tool in improving medication adherence with minimum effort and expense by a practitioner or a patient.

Michael V. Boland, MD, PhD, assistant professor at the Wilmer Eye Institute at Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues conducted a prospective cohort study involving patients recruited from the Glaucoma Center of Excellence at Wilmer Eye Institute.

After identifying nonadherent patients through electronic monitoring, they conducted another study involving those same patients. They randomly assigned the patients either to receive automated text or telephone messages or to a nonintervention control group.

The researchers enrolled 491 adult participants for the electronic monitoring study, 407 (83%) of whom successfully completed a 3-month adherence assessment. They gave participants a 100-mL clear plastic bottle to keep their prescribed prostaglandin eyedrop bottles in, along with an electronic cap for the clear bottle to record when the medication was removed.

During study visits, researchers extracted the usage data from the electronic bottle caps. The patients returned the bottle caps after the 3-month intervention period, and a study coordinator downloaded the dosing data.

Researchers analyzed the adherence data in 3 ways: percentage of days on which participants took their medication within 4 hours of mean dosing time prescribed, percentage of total number of prescribed doses taken, and percentage of days on which the participants took the correct number of doses.

High Levels of Adherence

Of the 407 participants who completed the study, 83% adhered to their prescribed medication dosing at least 75% of the time. Factors associated with the remaining, nonadherent participants compared with adherent participants include younger age, more likely to be black, receiving medications for a shorter period of time, lower education levels, and worse scores on health assessments administered at baseline.

Those who were nonadherent were less likely than other patients to be able to name their glaucoma medication, to agree that remembering their eyedrops is easy, and to strongly agree that they followed physicians' orders.

The mean adherence rate for the adherent group was 95% compared with 50% for the nonadherent group. Researchers found no significant differences between groups regarding sex, glaucoma diagnosis, previous surgery, cup–disc ratio, intraocular pressure, or self-assessment of health.

The electronic monitoring "provided us with a cohort of nonadherent participants who could be randomized to an intervention designed to improve adherence," the researchers write. "It also demonstrated risk factors that could be used to develop a quantitative tool for identifying patients likely to be nonadherent."

Automated Reminders Improved Adherence

In the follow-up study involving the 70 nonadherent participants, 38 were randomly assigned to receive automated reminders by telephone or text as to when to take their medicine, and 32 were assigned to a nonintervention control group. All but 2 in the intervention group chose telephone message reminders. Researchers again monitored all participants' medication adherence, using electronic bottle cap data.

The median adherence rate for the intervention group increased from 53% to 64% (P < .05), but the researchers observed no statistical change in the control group.

"We found that a telecommunication-based reminder linked to a personal health record can increase adherence with once daily glaucoma medications," the researchers write. "This finding is important because it supports an intervention that is feasible in terms of time and cost for a typical ophthalmology practice."

They estimate that the intervention would cost about $20 a year per patient.

Dr. Boland told Medscape Medical News that his institution is already working on this in a practical way, using electronic health records and personal health portals. Such a system "relies on technology that all of us now have in reach," he added. He said he was unaware of any efforts by others to use any similar systems on a widespread basis.

One caveat, he said, is that the factors associated with nonadherence still need to be studied further for many patients and that a risk calculator still needs to be developed based on those factors.

Shuchi Patel, MD, a glaucoma specialist and assistant professor of ophthalmology at Loyola Stritch School of Medicine in Maywood, Illinois, told Medscape Medical News that the automated reminder system could be good tool, especially for addressing one of those risk factors: younger age of nonadherents.

"It makes sense that nonadherents are younger. They have more going on. But it's concerning that they have a lot longer to deal with their disease and are much more likely to go blind in their lifetime," she said.

"Everybody has technology today," Dr. Patel added, and a reminder system could be "a great application of our technology and our resources and perfectly geared to younger patients."

This research was supported by the Microsoft Be Well Fund. The authors and Dr. Patel have disclosed no relevant financial relationships.

JAMA Ophthalmol. Published online May 15, 2014. Electronic monitoring abstract, Automated telecommunication abstract

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