Dry Eye Dx and Tx
Enhancing Patient Adherence to Dry Eye Therapy, Part 1
BY WILLIAM TOWNSEND, OD, FAAO
Dry eye patients may leave their practitioner’s office with one or more bottles of drops in addition to prescriptions for additional medications. You may assume that patients will adhere perfectly to the treatment regimen, but in reality this is often not the case. Studies show that non-adherence accounts for 30 percent to 50 percent of treatment failures (Gottlieb, 2000).
It is important to understand the terminology regarding provider-patient cooperation. Compliance denotes a situation in which the provider dictates a plan and the patient obeys those instructions (Aronson, 2007). Adherence implies a cooperative relationship in which the provider and patient agree on a treatment plan and the patient follows the agreed-upon disposition (Aronson, 2007). Dyscompliance refers to a situation in which the patient is unable to carry out the recommended therapy due to physical or cognitive deficits (Goldberg 2012).
Relatively few articles address compliance in dry eye therapy, but numerous articles pertain to non-adherence with glaucoma therapy. There are a number of parallels between dry eye and glaucoma. Both are chronic, usually occur in older individuals, rarely cause severe vision, and are usually treated medically rather than by surgery or other procedures. To successfully manage these conditions, providers must convince patients to actually use the medication and then determine whether patients are adhering to the therapy.
Because most individuals do not want to be perceived by providers as “bad patients,” they may deny non-adherence or go to great lengths to conceal it (Hahn et al, 2009). To get an honest assessment of adherence is important to avoid a combative or condemning demeanor in questioning patients.
Hahn et al (2009) described a four-step adherence assessment interview designed to detect non-adherence. It begins with open-ended questions about how and why a patient is using medication. For instance, “Can you tell me how you use Restasis (Allergan) and Systane (Alcon) and how they differ from one another?” This can reveal what a patient understands (or does not understand) about his treatment regimen. In the second step the provider acknowledges that using medications can be difficult and that missing or forgetting doses sometimes happens. In the third step the provider reminds the patient that treatment decisions are based on how the patient takes his medication. An example would be, “I need to know exactly how you are using your drops so that I can determine whether we need to make changes in your treatment plan.” The final step is to ask the patient about the frequency and regularity of taking his medications. This question should be the last one presented to the patient; unfortunately is often is the initial one. It should be open-ended, i.e., “Please tell me how often and the time of day that you use each of your drops,” as opposed to “Do you use your drops twice a day?”
One other factor that influences patient adherence is concern about the impact of medications, especially potential side effects. Rees at al (2010) reported that patients who have concerns about their eye drops are more likely to intentionally break the regimen as opposed to individuals who unintentionally miss dosing because they simply forget. CLS
To obtain references, please visit www.clspectrum.com/references.asp and click on document #206.
Dr. Townsend practices in Canyon, Texas, and is an adjunct professor at the University of Houston College of Optometry. He is president of the Ocular Surface Society of Optometry and conducts research in ocular surface disease, lens care solutions, and medications. He is also an advisor to Alcon, B+L, CooperVision, Tearlab Corporation, and Vistakon. Contact him at firstname.lastname@example.org.