Durham VAMC Research Improves Medication Adherence
Glaucoma is one of the leading causes of irreversible blindness. Avoiding that often requires lifelong adherence to treatment. An intervention led by the Durham, NC, VAMC helped patients not only improve compliance with their treatment regimen but also was a cost-saver. Now, the goal is to roll out the intervention to more VA facilities across the country.
U.S. Air Force Airman 1st Class Kyle Rudisaile, 18th Logistics Readiness Squadron vehicle maintainer, left, receives eye drops for dilation from Maj. Todd Christiansen, 18th Operational Medical Readiness Squadron human performance flight commander, on Kadena Air Base, Japan, last year. The yearly eye exams look for disorders such as glaucoma. U.S. Air Force photo by Staff Sgt. Rhett Isbell
DURHAM, NC — One of the leading causes of irreversible blindness, glaucoma affects an estimated 4% to 6% of the American population and up to 10%of African Americans. Because the condition is often associated with intraocular pressure (ocular hypertension), treatment to prevent further nerve damage and blindness typically consists of treatments that reduce pressure within the eye, including topical eye drops.
While lifelong adherence to treatment is essential to managing the condition and preventing blindness, research has shown that adherence to glaucoma treatment regimens is often poor. Thus, efforts to understand barriers to compliance and ways to improve or circumvent it are crucial to preventing vision loss.
One such effort led by researchers at Durham VAMC has been shown to improve both compliance with glaucoma treatment and reduce costs. Funded with a VA HSR&D Career Development Award, Kelly W. Muir, MD, MHS, worked with a team of VA researchers to develop a multifaceted intervention to help improve the way patients self-manage their disease. The process involved interviewing veterans concerning their problems with adhering to treatment and watching veterans themselves or their caregivers administer the drops.
“We really feel like there are many reasons why folks may not be able to take their glaucoma medications as prescribed,” said Muir. These might include inadequate education about the importance of the drugs or other medical conditions that make it difficult for patients to administer them. “Actually getting a drop in the eye is not an easy thing to do for anybody, but it is particularly not easy if you have arthritis that makes it hard to grip the bottle, any type of cervical spine issue that makes it difficult to recline the head to put the drops in, or if you have a tremor that makes it hard to aim the bottle or any type of cervical spine issue that makes it difficult to recline the head to put the drops in.” And, of course, she says, it can be challenging just remembering to put them in.
The resulting intervention, which considered all of those factors, consisted of education about glaucoma, aids to help assist with any physical barriers to compliance, a chart laying out when to use each drop and for which eye, and a smart bottle that reminded veterans to take their drops.
In a clinical trial of the intervention, 200 patients were randomized to receive the intervention delivered by an ophthalmic technician delivered or an active control consisting of education about general eye care. The researchers then monitored the use of eye drops in both the intervention and control arm—with an electronic monitor they received relaying how often they took their medicine and of how often they took it on schedule—for six months. “The intervention arm took their medications on schedule on average about 20 percent more frequently than patients in the randomized control arm,” Muir said.1
Implications for Cost, Treatment Intensification
Knowing that the intervention did improve adherence, Muir’s next goal was to determine whether taking drops more regularly was associated with better outcomes and lower costs. Two subsequent studies looked at those issues.
The first compared visual field progression, additional glaucoma medications or a recommendation for surgery or laser due to inadequate intraocular pressure control in the intervention and control arms over the 12 months following randomization. While the study found no significant differences in the two groups, Muir suspects the findings might have been different, if the follow-up had been longer.
“Glaucoma is a really slowly progressing disease,” she said. “Fortunately, it takes about five years to really see a change, so we did not see a difference in the intervention and control arm in terms of how many veterans had to go on to have surgery or more intensive medicine. But not that many in either arm had to have these interventions.”2
A separate study using a decision analytic model to simulate the lifelong costs and quality-adjusted life years QALYs, found that compared to standard of care the intervention dominated resulting in lower life-long costs ($23,339.28 versus $23,504.02) and higher QALYs (11.62 versus 11.58). Muri and her colleagues concluded: “From a VA payer perspective over a lifetime, the glaucoma medication-enhancing behavioral intervention dominated standard of care in terms of generating cost savings and greater QALYs.”3
Muir said her next goal is to get support to expand the intervention—which was tested in a single eye clinic—to other VAs, because the stakes of non-adherence have the potential to affect all areas of life. “Most people in their 70s or 80s aren’t just dealing with glaucoma—it is not the only thing they have to deal with,” she said. “But if you lose vision, caring for everything else in your life becomes difficult. If you have diabetes, seeing your glucometer becomes difficult; your risk of falls goes up significantly, so it is certainly all connected. Treating glaucoma should be a priority because of its potential effect—not just on sight but on virtually every area of life.”
As Muir’s research focusing on improving medication adherence, other research is aimed at circumventing the issue by eliminating the need for daily drops. In March 2020 the FDA approved Durysta, the first biodegradable, intracameral implant for the lowering of intraocular pressure in patients with open-angle glaucoma or ocular hypertension. The implant is inserted into the anterior chamber and provides a sustained release of bimatoprost for several months.
Because glaucoma is a lifelong disease and the benefits of the implant are limited to a relatively short time (each eye can be treated only once), the implant has not been widely adopted by the VA. Muir, however, finds the concept of sustained release medications for glaucoma exciting. “While the therapy has some limitations in its current form, there is a need for sustained release medications, and it is exciting that there is now one FDA approved,” she said.
- Muir KW, Rosdahl JA, Hein AM, Woolson S, Olsen MK, Kirshner M, Sexton M, Bosworth HB. Improved Glaucoma Medication Adherence in a Randomized Controlled Trial. Ophthalmol Glaucoma. 2022 Jan-Feb;5(1):40-46. doi: 10.1016/j.ogla.2021.04.006. Epub 2021 Apr 20. PMID: 33892170.
- Buehne KL, Rosdahl JA, Hein AM, Woolson S, Olsen M, Kirshner M, Sexton M, Bosworth HB, Muir KW. How Medication Adherence Affects Disease Management in Veterans with Glaucoma: Lessons Learned from a Clinical Trial. Ophthalmic Res. 2023 Jan 5. doi: 10.1159/000528857. Epub ahead of print. PMID: 36603568.
- Hung A, Williams AM, Newman-Casey PA, Muir KW, Gatwood J. Cost-Utility Analysis of a Medication Adherence-Enhancing Educational Intervention for Glaucoma. Ophthalmol Glaucoma. 2023 Jan 25:S2589-4196(23)00032-7. doi: 10.1016/j.ogla.2023.01.006. Epub ahead of print. PMID: 36707031.