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Editors Selection IGR 12-2

Adherence to Therapy: Role of intensive patient counseling

Comment by David Friedman on:

48688 Individualised patient care as an adjunct to standard care for promoting adherence to ocular hypotensive therapy: an exploratory randomised controlled trial, Gray TA; Fenerty C; Harper R et al., Eye, 2012; 26: 407-417

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Gray and colleagues randomized 127 newly diagnosed ocular hypertensive or open-angle glaucoma patients who were prescribed topical drop therapy to receive usual care or to have a face-to-face assessment focusing on issues that might affect adherence. At the end of the assessment, patients were observed instilling drops and a one-year follow-up care plan was designed and implemented. The exact nature of that plan varied and the number of individuals providing counseling and developing these plans was not stated in the article. The initial meeting lasted a bit more than an hour and about five additional face-to-face or phone meetings were held, but these were shorter. Some patients also received additional contact during the year. Those receiving usual care were informed in the usual fashion about glaucoma and told to follow up as per routine. A previous publication by these authors had documented that most eye doctors provide limited information to their patients about glaucoma and that patients have a relatively poor understanding of their condition. The primary outcome was refill adherence measured by contacting general practitioners and pharmacists for prescription and dispensing information over a one-year period. Patients in the U.K. are expected to refill a new bottle every 28 days and 'poor' adherence was defined as have less than 100% of the necessary prescriptions collected. The intervention was notably effective. In an intention-to-treat analysis, 70% of the intervention arm subjects were fully adherent compared to 43% in the usual care arm. Of note, the intervention arm included ten subjects (out of 64) who did not receive the intervention, nine of whom had poor adherence. As documented previously in other research on adherence, eye pressure was similar in the two arms, which likely indicates better drop taking at the time of the visit. However, IOP fluctuation was lower in the more adherent arm.

This is an exciting paper, but the authors have not provided enough detail on the intervention. It is not clear what exactly was done with each patient and how one could reproduce these findings. Were the outcomes the result of a single exceptional nurse counselor? That said, this study clearly demonstrates that providing intensive counseling can improve patient adherence to therapy and should stimulate interest in identifying how best to integrate this kind of care into routine practice.

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