Article

Financial Implications of Patient Compliance

The association between eye examination frequency and contact lens purchase patterns.

LENS COMPLIANCE & PURCHASING

Financial Implications of Patient Compliance

The association between eye examination frequency and contact lens purchase patterns.

By Sarah Guthrie, PhD; Kathy Dumbleton, PhD, MCOptom, FAAO; & Lyndon Jones, PhD, FCOptom, FAAO

Eyecare practitioners (ECPs) are responsible for their patients and hope that their professional advice is followed. While ECPs recognize that noncompliance is an issue among contact lens wearers, it is human nature to believe that their patients are the exception; even if ECPs realize that patients do not always follow their recommendations for lens wear, care, and replacement, many may not realize the possible financial implications that this causes for their offices.

In 2011, the Centre for Contact Lens Research (CCLR) at the University of Waterloo conducted a survey to investigate the relationship between patients’ compliance with recommendations for lens replacement and the interval between visits to their ECPs’ offices for eye examinations (Dumbleton, Richter et al, 2013). This survey concluded that patients who were compliant with lens replacement frequency were more likely to return for regular eye exams and purchase an annual supply of lenses.

These results suggested that an ECP’s efforts toward increasing overall lens replacement compliance may also be linked to a more successful eyecare practice. However, while this survey provided valuable insights, it included data only from 141 offices and 2,147 questionnaires.

To determine whether this concept held true for a more diverse group of practitioners and lens wearers, a much larger survey was conducted in 2012 to further evaluate the role of patient purchase patterns and demographics on the interval between eye examinations and patient compliance with lens replacement (Dumbleton, Jones et al, 2013). Other information was also considered, such as lens types worn (by replacement frequency), contact lens purchase source, and volume of contact lenses purchased.

Methods

Ethics approval was obtained through a Research Ethics Committee at the University of Waterloo prior to the start of the survey, and the survey was conducted following the tenets of the Declaration of Helsinki. Letters of invitation were sent to ECPs in the United States, who then completed an online registration. An office was considered eligible to participate if it had a minimum of 1,000 contact lens wearing patients and prescribed both daily disposable and silicone hydrogel (SiHy) lenses, with the latter being prescribed for two-week and one-month replacement. Coded survey materials were then mailed to each eligible office.

Each office was asked to invite up to 50 eligible patients who were coming in for a routine eye examination to participate in the survey. Patients were eligible to participate if they were 16 years of age or older, and if they were wearing either two-week or one-month replacement SiHy, or daily disposable hydrogel or SiHy contact lenses. In addition to currently attending the office for a routine full eye examination, they must also have previously had an eye examination at that office (Dumbleton, Jones et al, 2013).

Potential participants were provided with an information letter. If they agreed to participate, they completed the patient portion of a two-part questionnaire. This portion was sealed in an envelope by the patients before they returned it to the ECP. The ECP then completed a separate questionnaire with patient-specific details, including the interval between eye exams and the type of contact lenses prescribed. Both parts of the questionnaire were coded to allow for data matching during analysis.

All completed questionnaires, including an ECP questionnaire regarding office demographics, were sent to an independent data reading center (Datacore Marketing LLC), which generated a report for each ECP office. All reports and data were sent to the CCLR, which then distributed the reports to the individual ECP offices and conducted analysis of the entire data set.

Demographics

The data set eligible for analysis included 9,677 questionnaires (linked responses from ECP and patients) from 457 offices. The mean patient age was 37 ± 13 years (median: 35 years; range: 16 to 92 years) and respondents were 67% women (Dumbleton, Jones et al, 2013), suggesting that patients taking part in this survey were representative of the general contact lens-wearing population (Morgan et al, 2013). The mean age of 37 was somewhat higher (Dumbleton, Jones et al, 2013) than the mean age of 34 reported by Morgan et al (2013) for the United States lens-wearing population in 2012.

The patients were generally established wearers, with a median of 14 years of lens wear, and the majority (75%) wore their lenses every day, with a median wearing time of 14 hours each day (Dumbleton, Jones et al, 2013).

The majority of patients surveyed were wearing spherical contact lenses (70%), with toric and multifocal designs being worn by 22% and 8% of the patients, respectively.

Almost 13% of the patients taking part in the study were wearing daily disposable lenses (Dumbleton, Jones et al, 2013). This value is similar to the 12% reported by Morgan et al (2013) for the U.S. population in 2012, but is higher than that reported in the earlier survey (Dumbleton, Richter et al, 2013).

Overnight Wear

The majority of ECPs caution their patients to avoid sleeping in their lenses. In this data set, 57% of the ECPs surveyed issued this specific advice; however, only 41% of patients followed the recommendation and reported never wearing their lenses while napping or overnight. When patients did respond that they wore their lenses overnight, one-third wore them for seven or more consecutive nights, and just under half reported that they slept while wearing their lenses for only one or two nights in a row. Eleven percent of daily disposable lens wearers, 29% of two-week replacement wearers, and 34% of one-month replacements lens wearers reported sleeping in contact lenses at least “occasionally.”

Lens Supply

Ideally, many ECPs would like to supply their patients with an annual supply of contact lenses, as this would ensure that they could review whether wearers were replacing their lenses as prescribed, and it would be financially rewarding for the practice. When asked where they purchased their supply of contact lenses, 81% of patients reported purchasing their lenses from their ECP, 10% from another store or supplier, and 9% from an Internet supplier. These figures may not, however, be fully representative of the contact lens-wearing population in the United States, because this study was conducted through ECP offices and patients had to be attending the offices to be eligible to participate. When asked how many lenses they purchased at a time, 50% of patients reported purchasing an annual supply of lenses. This proportion did vary according to manufacturer’s recommended replacement frequency (MRRF) of the lenses, with the highest proportion for wearers of lenses with a MRRF of one-month (57%) and the lowest for daily disposable lens wearers (42%).

Compliance with Replacement Frequency

Patient compliance with replacement frequency, or lack thereof, has been previously reported (Dumbleton et al, 2009); in this survey, overall compliance with MRRF was 52% (two-week: 30%; one-month: 65%; daily: 79%; all p<0.001) (Figure 1). Of particular interest here, however, is how a patient’s compliance with replacement frequency is related to the interval between eye exams and lens purchasing patterns.

Figure 1: Compliance with MRRF.

A higher proportion of patients who reported purchasing a one-year supply of lenses were compliant with the MRRF compared with those who purchased less than a one-year supply (57% versus 47%, p<0.001), which supports the belief that having more lenses available may improve compliance with recommendations for lens replacement (Schnider and Jedraszcak, 2012).

The rate of compliance with MRRF of patients who purchased lenses directly from their ECP (52%) was similar to that of patients who purchased their lenses from the Internet (54%, p=0.33) and slightly higher (but statistically different) than that of patients who purchased lenses from a different non-Internet supplier (47%, p=0.005).

Similar to results reported for the smaller survey (Dumbleton, Richter et al, 2013), here patients who were compliant with the MRRF were slightly older compared to noncompliant patients (38.4 ± 14.9 years versus 35.5 ± 12.5 years, p<0.001), but there was no significant difference with respect to gender. Patients with a lower household income had significantly lower rates of compliance with the MRRF compared to patients in the higher income brackets (45% in the lowest income bracket versus 60% in the highest income bracket, p<0.001).

The reasons given for not replacing lenses when recommended varied according to the lens type worn. The primary reason for wearers of lenses with a MRRF of two weeks and one month was forgetting which day to replace the lenses, but for daily disposable wearers it was to save money.

Interval Between Eye Examinations

While ECP recommendations for the interval between routine eye examinations vary considerably, the recommendations for contact lens wearers are usually shorter than for otherwise healthy adult spectacle wearers. In this survey, almost all ECPs (98%) recommended that their patients have an interval of one year between eye examinations. However, the mean reported interval between eye examinations was longer than this at 481 days (16 months), with a median interval of 419 days (14.0 months). This interval once again was found to vary somewhat by modality, with the shortest interval for daily disposable wearers and the longest interval for two-week replacement wearers (431 days (14.4 months) versus 496 days (16.5 months), respectively; p<0.01).

Wearers who were noncompliant with a MRRF of two weeks and one month were found to attend their ECP offices for eye examinations at significantly longer intervals compared to wearers who were compliant with the MRRF (Table 1). Longer intervals between visits were also found for men compared to women (523 days [17.4 months] versus 484 days [16.1 months], p<0.01) and for patients who did not have insurance that covered the costs of an eye examination (477 days [15.9 months] versus 529 days [17.6 months], p<0.001). The interval between eye examinations was also longer in patients reporting a lower household income (537 days [17.9 months] for the $20,000 to $40,000 income bracket versus 479 days [16 months] for the $81,000 to $120,000 income bracket, p<0.01).

TABLE 1 Average Time Between Visits to an Eyecare Practitioner
MRRF NONCOMPLIANT COMPLIANT
Two Weeks (30% compliant) 517 days (17.2 months) 445 days (14.8 months) p<0.01
One Month (65% compliant) 533 days (17.8 months) 445 days (14.8 months) p<0.01
p<0.05 p<0.05

Patients who purchased their lenses directly from their ECP returned for an eye examination more frequently than did patients who purchased their lenses from another source (15.7 months versus 17.3 months, p<0.001); however, patients who purchased more lenses were not found to attend eye examinations at a different interval than those who purchased less than a year’s supply of lenses (p=0.29).

Conclusions

The results from this survey mirrored those of the earlier smaller survey (Dumbleton, Richter et al, 2013) and show that patients who wear contact lenses with a MRRF of two weeks and one month, and who are not compliant with recommendations for lens replacement, attend their ECP offices for eye examinations at significantly longer intervals than do lens wearers who are compliant with the manufacturers’ recommendations for lens replacement. In practice, patients who are more compliant with their lens replacement tend to return for eye examinations at shorter intervals (Figure 2). They are also more likely to be purchasing contact lenses directly from their ECP. Patients who purchase an annual supply of lenses were also more likely to be compliant and return for regular eye exams when recommended.

Figure 2: Compliance with MRRF and interval between eye examinations.

Any efforts an ECP takes to improve patient compliance could result in a more financially successful practice. ECPs will improve patient compliance with replacement by encouraging their patients to purchase an annual supply of lenses, and this will result in shorter intervals between eye examinations. CLS

For references, please visit www.clspectrum.com/references and click on document #229.

Dr. Guthrie is a research associate in the Centre for Contact Lens Research (CCLR) at the University of Waterloo. She can be reached at sarah.guthrie@uwaterloo.ca.

Dr. Dumbleton is director of Clinical Operations for Ocular Technology Group–International. She was formerly head of clinical research at the CCLR and has conducted several studies on compliance with contact lens wear. She has received lecture or authorship honoraria from Alcon.

Dr. Jones is director of the CCLR at the University of Waterloo. He is a consultant or advisor to Johnson & Johnson (J&J), Alcon, and CooperVision and has received research funding from Advanced Vision Research, Alcon, AlgiPharma, Allergan, CooperVision, Essilor, J&J, Oculus, and TearScience, Inc. He can be reached at lyndon.jones@uwaterloo.ca.