By JeanMarie Davis, OD
You can improve patient compliance to the medical eyecare treatments you prescribe by tailoring regimens to the patient’s lifestyle.
Correctly diagnosing an eye condition or disease is just half the battle to ensuring a good outcome for your patient. The other half of the battle is working with the patient to ensure they are able to follow the regimen you prescribe. ODs who successfully prescribe medical eyecare treatments that can be followed will win long-term patients loyal enough to refer others. We must remember that customary treatment may not be easy or possible for the patient. Taking the time to understand the patient on a more personal level will help identify the patient’s needs and how we can help them, as well as establish a better doctor-patient relationship. Taking extra time to communicate at the time the treatment is prescribed will increase compliance and build trust and credibility.
Think About How You Approach Treatment for Complex Conditions
There are many medical eyecare treatments that follow a regimen, some short-term and some long-term. Examples include: Glaucoma, Dry Eye Syndrome, Meibomian Gland Dysfunction, Blepharitis, Ocular Allergy, Infection, Uveitis, Hordeolum, Macular Degeneration, recovery from corneal foreign body removal, corneal infiltrates, corneal ulcers, corneal epithelial errosion and corneal edema.
Simple Suggestions to Patients Valuable
Frequently, offering a simple suggestion that may seem obvious to us but is not obvious to the patient is a good solution. For example, it is not unusual for a patient to make the assumption that they can only use their medications while at home, particularly if they have jobs where they are in certain environments that make it more difficult to access their medications (i.e.: a cook, construction worker, roofer, mechanic, factory worker, service-oriented professions, truck drivers). If they have an every-four-hour dosing regimen, they may feel as though they have to stick to a strictly timed schedule. The solution? It may be as easy as making the suggestion that the patient dose on a break or at lunchtime and letting them know it does not necessarily have to be exactly every four hours.
Go through the patient’s daily schedule with them to provide guidance. For example: First dose upon waking or at breakfast, second dose at lunch or afternoon break, third dose at dinnertime, fourth dose at bedtime. Sounds simple, but explaining the instructions of dosing in terms that apply to a patient’s specific circumstances allows them to understand that the treatment is manageable. This is especially important if there are multiple steps required in their treatment regimen. For example, a dry eye patient who has blepharitis and MGD (meibomian gland dysfunction) may be required to use prescription eye drops, ocular lubricant eye drops, use warm compresses and lid massage and lid hygiene. This can sound overwhelming to the patient. Understanding the patient’s daily routine and breaking down their treatment regimen into steps taken throughout the day helps the patient see that the regimen is not as hard as it sounds.
You May Have to Try a Different Medication
Another possibility is to change the medication to another medication with less frequent dosing, if available. Often, there are different medications available for the same condition. One medication may require more frequent dosing than another to accomplish the same effect. An easy example would be an ocular allergy medication that must be instilled in a child. Many ocular allergy medications require BID (twice a day)dosing. This may be difficult to instill for a parent who is running frantic in the morning trying to get out the door to get the kids to school on time. Changing to a medication that has QD (once a day)dosing, allowing the drops to be instilled only once a day, in the evening or another time that is more convenient, would be much easier for the parent and the patient, resulting in better compliance.
Ask Patients Key Lifestyle Questions
Understanding a patient’s day-to-day routine and environment is key to helping them with compliance. Ask what they do for a living, what type of environment they work in, what hours they work, when are they home, whether they travel for work, an example of what their typical workday looks like, as well as what their off days look like. From this information it is important to determine if they are able to easily access their medications. Can they carry the medication with them or should they leave it at home? For elderly patients, it is important to determine whether they need assistance in instilling drops, and if so, asking when they have family or friends available to help them.
A lifestyle questionnaire can be very helpful. Questions should be geared to understand the patient’s day-to-day circumstances and schedule. What time do you wake up? What time do you go to bed? What time do you leave the house to go to work or school, etc? What time do you get home from your daily activities? What are your hobbies? What is your occupation? Who do you live with? Do you have assistance at home? What other medications do you take and how often? Many times you can adapt their regimen so they dose their eye medications at the same time they take other medications to make it easier for them.
Have Staff Back You Up in Aiding Compliance
Staff can play a very important role. All patients should be provided with detailed written instructions on their treatment regimen.I strongly recommend that staff members review the written instructions for the treatment regimen again to the patient after the doctor explains it for the first time. Frequently, the patient does not completely understand and does not let the doctor know or even forgets a few minutes later. Having a staff member review the treatment regimen will reinforce the instructions, and often, if there is a question or concern, the patient will use that opportunity to ask questions or make comments. Staff members should be trained in how to handle situations where the patients have difficulty understanding the instructions and in identifying a possible compliance issue. They should know to alert the doctor, before the patient leaves the office, if there is a challenge they are not able to resolve for the patient. It is also highly recommended to actually ask the patient: “Are you able to follow this regimen every day?”
Identify Patients Who Are Not Compliant
Every practitioner has had a case where clinical observation points toward non-compliance. When this happens, explain your findings to the patient and let them know that their lack of progress is not what was expected–if they were following the treatment prescribed. Asking the patient directly about whether they were able to follow through on the treatment regimen often causes the patient to admit that they weren’t “completely” compliant–or they forgot a dose–“or there was that one day when…..” Typically, a compliant patient will tell you upfront if there was a particular day or situation when it was difficult for them to take their medication. When they tell you they are compliant and then start adding to their story after you find clinical evidence to the contrary, indicates non-compliance.
I had a patient I started treating for a uveitis. This was a fairly mild case at the time of diagnosis and should have started to resolve quickly. At follow-up, the patient reported using their medications as directed everyday. However, my clinical examination showed more inflammation. I explained my findings to the patient and probed further as to exactly how they were using their drops. Ultimately the patient admitted that the drops were too expensive so they started using some drops a relative “who had the same thing” had given them.
Remember to Be Respectful When Noticing Non-Compliance
A patient should not be called a liar even when the practitioner feels there is significant evidence that they are not being compliant and truthful. Being clear and direct with the patient as to what you find on clinical examination and explaining that the regimen they are currently following is not working and, therefore, putting them at risk is important. Proper, thorough documentation is a must. Then, you must take action as if the patient is being truthful. If the condition is non-responsive to all reasonable treatment prescribed, you should refer to a specialist.
What Happens When It is Impossible to Follow the Needed Regimen?
If it is simply impossible for a patient to follow-though with a treatment on their own, what a doctor can do is limited and dependent on the situation. If the patient lives alone and is incapable of dosing themselves and has medical coverage, some conditions will allow for a referral to be made for possible surgical intervention, but these circumstances are rare. Trying to get the patient some assistance (free medication if they don’t have insurance and are indigent) or referring the patient to a service that provides home health care are possibilities if the doctor is aware of these services in their area. Most treatment regimens require daily compliance.
If it is short-term and manageable with daily follow-up, the doctor can have the patient return to the office daily to administer the treatment. However, most ocular conditions require much more than what a doctor can provide seeing the patient once a day. If it is a long-term condition, daily office visits are not feasible. For serious conditions, it is important to provide proper documentation to the patient as to the serious nature of the condition and the risk of non-compliance. For the doctor’s legal protection, the patient should sign a document that clearly states that they were not able to comply with the prescribed regimen and have been informed of the possible consequences of their inability to comply. Sometimes reading and signing such a document will prompt the patient to understand how serious the condition is and improve compliance, but not always. Unfortunately, there are times there is nothing more a doctor can do except to make sure the patient clearly understands and document thoroughly for the doctor’s own protection.
Match Treatment Regimen to Patient Lifestyle:
Your Action Plan
Understand the patient’s personal situation as it may relate to their ability to be fully compliant.
Ask the patient to repeat the instructions to you to ensure they fully understand.
Ask the patient directly if they feel they are able to be compliant with the treatment regimen. If they express any hesitancy, probe further to attempt to find a resolution.
Bring the patient back for follow-up within a week (or less depending on the severity of the condition) and ask them if they are having any problems with compliance. Ask specific questions: “Did you fill the prescription? What medication did the pharmacy give you? How often are you using the medication? Are you having any difficulty in using the medication as directed?”
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JeanMarie Davis, OD, is manager, technical, Global Performance Development for Alcon. To contact her: drdavis2020@yahoo.com.
