Envisioning a Team-based Approach to Glaucoma Care

Educational Objectives

The goal of this program is to improve medication adherence in glaucoma care. After hearing and assimilating this program, the clinician will be better able to:

1. Identify interventions that improve glaucoma medication adherence.
2. Implement a glaucoma coaching program to improve glaucoma adherence.

Summary

Improving glaucoma medication adherence: Cochrane review — found that evidence- and theory-based interventions, tailored education, motivational interviewing (MI)-based counseling, and reminder systems are effective; several studies indicate that education combined with personalized interventions improved adherence; Ha et al (2022) — performed a network meta-analysis of randomized controlled trials; interventions included standard of care (SOC), enhanced SOC, short messaging service, telephone calls, device reminders, MI, multimedia education, physician education, access to own medical records, providing rebates for adherence, and personalized care with face-to-face needs assessment; outcomes were more favorable when interventions were combined; complex and personalized interventions had the greatest impact

Compassion: tailored care involves compassion; research shows that health care providers’ compassion can increase the likelihood of treatment adherence by 33% to 62%; compassion is demonstrated through eye contact, smiling, leaning toward the patient while speaking, and acknowledging that coping with a chronic illness is difficult; often involves an integrated care team

Physician conversation: patients often receive an overwhelming number of suggestions and are prescribed multiple medications; Sleath et al (2014) videotaped ophthalmologists prescribing new glaucoma medications to patients and found that, in >80% of visits, physicians did not address patient’s concerns; patients were not offered the choice of generics vs brand medications nor were they informed of the need for life-long administration of eye drops; although only 16% of physicians educated patients on administration of eye drops, adherence increased by 337% after patient education; however, physician time is finite; a study found that ophthalmologists typically spend 11.2 min with patients (conversation, 4.7 min; documentation and examination [DE], ≈7 min) and 10 min with patients with glaucoma (conversation, 4 min; DE, 6 min)

Demand for ophthalmologists: availability is worse in rural and underserved areas; better ways to deliver personalized care to all patients should be explored; harnessing health information technology can help deliver standardized but individualized education and improve medication adherence; training paraprofessional workforce to provide personalized education can extend the reach of eye care teams

Aravind eye care: situated in the southern state of Tamilnadu, India; after a diagnosis of cataract, the patient’s encounter with the eye care physician for cataract surgery is brief; however, the patient immediately meets a counselor who explains the procedure, lens choices, and price structure, in addition to addressing any concerns about surgery; the patient is provided with contact details of the counselor and encouraged to contact the counselor to clarify additional concerns; the physician is free to cater to a number of patients and perform surgeries

Glaucoma coaching program: a trained glaucoma coach can educate patients and coordinate with the physician; a prototype of the educational content was created, aiming below eighth-grade level for clear communication; principles of MI include encouraging active listening and helping people identify their own barriers and solutions; user-centered design — the module was modified based on patient’s feedback iteratively; patients preferred in-person to web-based education, and tailored information (eg, test results, recommendations, barriers to adherence) to be discussed; patients had many misconceptions about glaucoma and shared their experience on integrating medications into their daily routine (patients >75 yr of age had more difficulty); a glaucoma coaching program is well-suited to involve caregivers; a glaucoma-specific MI training program was developed to train ophthalmic technicians on coaching to create a credentialing process and allow for reimbursement; Newman-Casey et al (2020) found that trained technicians were better at delivering MI-based coaching, with higher satisfaction scores on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems Survey score; the Support, Educate, Empower (SEE) Personalized Glaucoma Coaching Program was established

SEE program: a 6-mo program; involves 3 in-person coaching sessions (ie, 60, 30, and 30 min); a personalized glaucoma coach is imparted during the first session using test results and health records; medication reminders (eg, cellphone-based audible or visual alerts) are set up; medication adherence is tracked and feedback is provided between sessions; training for coaches — involves 2-day training, with continuous booster sessions; coaches are graded by a MI trainer to maintain quality; coaches use audiovisual content to educate patients (prompts guide the conversation); pilot study — Newman-Casey et al (2020) found that SEE program increased adherence from 60% to 81%; 95% of participants improved on their baseline adherence; patient-centered outcomes — Cho et al (2023) showed that perceived competence, autonomous motivation, and glaucoma-related distress improved with coaching; glaucoma medication self-efficacy and confidence knowing what to ask improved after coaching; randomized controlled trial — Newman-Casey et al (2023) showed improvement in adherence between coaching (SEE; 74%) vs control (education materials by mail; 54%) arms

Improved glaucoma adherence: Muir et al (2022) conducted a coaching trial, with 1-hr personalized session plus daily reminders vs generalized health education plus no reminders; medication adherence improved with personalized coaching, but adherence decreased over time

Current Procedural Terminology (CPT) code: new CPT codes for principal care management services (allow chronic disease-specific self-management support by a trained nonphysician supervised by a physician) were created in 2020; allow between-visit support; adherence programs delivered by paraprofessional staff can be eligible for reimbursement in the future and be sustainable

Identifying beneficiaries: ≈15% of patients do not require adherence support; poor electronically monitored glaucoma medication adherence can be identified with simple questions, with good sensitivity and specificity (eg, “over the past month, what percentage of your drops do you think you took correctly?”; threshold, ≤85%); ask open-ended questions about barriers including cost, difficulty instilling drops, and understanding about glaucoma and its treatment; normalize problems (eg, effectiveness, cost, side effects) before asking open-ended questions

Reflection: restate the key components of what the patient says to indicate comprehension; reflection provides the patient a chance to correct misunderstandings; the coach should acknowledge difficulties faced by patients and request permission to assist or provide advice; provide more than one option (eg, mirror and lying-down techniques for administering eye drops) to offer autonomy and choice for patients

Solicit feedback: ask whether the proposed method will be beneficial; review and practice different methods together with the patient

Documentation: Z codes are not reimbursable (yet); however, documenting difficulties with medication adherence will help justify the need for coaching programs; although institutions can train their own glaucoma coaches, coaching via telemedicine may be possible in places with fewer glaucoma specialists

Readings

Cho J, Song M, Niziol LM, et al. Patient-Centered Outcomes After a Medication Adherence Intervention: a Pilot Study. J Glaucoma. 2023;32(10):891-899. doi:10.1097/IJG.0000000000002228; Ha A, Jang M, Shim SR, et al. Interventions for glaucoma medication adherence improvement: a network meta-analysis of randomized controlled trials. Ophthalmology. 2022;129(11):1294-1304. doi:10.1016/j.ophtha.2022.06.025; Muir KW, Rosdahl JA, Hein AM, et al. Improved Glaucoma Medication Adherence in a Randomized Controlled Trial. Ophthalmol Glaucoma. 2022;5(1):40-46. doi:10.1016/j.ogla.2021.04.006; Newman-Casey PA, Killeen O, Miller S, et al. A Glaucoma-Specific Brief Motivational Interviewing Training Program for Ophthalmology Para-professionals: Assessment of Feasibility and Initial Patient Impact. Health Commun. 2020;35(2):233-241. doi:10.1080/10410236.2018.1557357; Newman-Casey PA, Niziol LM, Lee PP, et al. The Impact of the Support, Educate, Empower Personalized Glaucoma Coaching Pilot Study on Glaucoma Medication Adherence. Ophthalmol Glaucoma. 2020;3(4):228-237. doi:10.1016/j.ogla.2020.04.013; Newman-Casey PA, Resnicow K, Winter S, et al. The Support, Educate, Empower personalized glaucoma coaching trial design. Clin Trials. 2023;20(2):192-200. doi:10.1177/17407745221136571; Read-Brown S, Hribar MR, Reznick LG, et al. Time requirements for electronic health record use in an academic ophthalmology center. JAMA Ophthalmol. 2017;135(11):1250-1257. doi:10.1001/jamaophthalmol.2017.4187; Sleath B, Blalock SJ, Carpenter DM, et al. Provider education about glaucoma and glaucoma medications during videotaped medical visits. J Ophthalmol. 2014;2014:238939. doi:10.1155/2014/238939; Sleath B, Sayner R, Blalock SJ, et al. Patient question-asking about glaucoma and glaucoma medications during videotaped medical visits. Health Commun. 2015;30(7):660-668. doi:10.1080/10410236.2014.888387; Waterman H, Evans JR, Gray TA, et al. Interventions for improving adherence to ocular hypotensive therapy. Cochrane Database Syst Rev. 2013;(4):CD006132. doi:10.1002/14651858.CD006132.pub3.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Newman-Casey was recorded at the 23rd Annual Downeast Ophthalmology Symposium, held September 27-29, 2024, in Bar Harbor, ME, and presented by The Maine Society of Eye Physicians and Surgeons, Manchester, ME. For more information about upcoming CME activities from this presenter, please visit https://maineeyemds.com. Audio Digest thanks Dr. Newman-Casey and The Maine Society of Eye Physicians and Surgeons, Manchester, ME, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

OP630102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.