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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Enhancing Adherence with Glaucoma Therapy: Practical Strategies for Superior Outcomes


GOAL
To provide ophthalmologists with up-to-date information on the treatment and management of patients with glaucoma.

TARGET AUDIENCE
This activity is designed for ophthalmologists. No prerequisites required.

LEARNING OBJECTIVES
At the conclusion of this activity, the participant should be able to:

  • Assess the magnitude of nonadherence issues as they apply to glaucoma medication.
  • Identify the barriers to adherence in patients with glaucoma and glaucoma suspects.
  • Recognize strategies to maximize adherence and persistence.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity:  2 hours.

After reading this monograph, participants may receive credit by completing the CME test, evaluation, and receiving a score of 70% or higher.

Release date: April 15, 2008. Expiration date: April 15, 2010.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Pfizer Inc.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

David S. Friedman, MD, MPH, PhD
Associate Professor,
The Wilmer Eye Institute
The Johns Hopkins University
School of Medicine
Baltimore, Maryland
Dr Friedman reports receiving grants/research support and honoraria from Alcon Laboratories, Inc and Pfizer Inc; and serving as a consultant for Pfizer Inc.

Gail F. Schwartz, MD
Glaucoma Consultants
Greater Baltimore Medical Center
Assistant Professor
The Wilmer Eye Institute
The Johns Hopkins University
School of Medicine
Baltimore, Maryland
Dr Schwartz reports receiving grants/ research support and research funding from Allergan Inc and Pfizer Inc; and serving as a consultant for, receiving honoraria from, and serving on the speakers' bureau for Pfizer Inc.

PARTICIPATING FACULTY

Donald L. Budenz, MD, MPH
Professor of Ophthalmology
Bascom Palmer Eye Institute
Miller School of Medicine
University of Miami
Miami, Florida
Dr Budenz reports receiving grants/research support from Allergan Inc, Carl Zeiss Meditec, New World Medical, Inc, and Pfizer Inc; and serving as a consultant for, receiving honoraria from, and serving on the speakers' bureau for Alcon Laboratories, Inc and Pfizer Inc.

Steven R. Hahn, MD
Professor of Clinical Medicine
Instructor of Psychiatry
Albert Einstein College of Medicine of Yeshiva University
Bronx, New York
Dr Hahn reports serving as a consultant for GlaxoSmithKline, Ortho-McNeil Pharmaceuticals, and Pfizer Inc; and receiving honoraria from and serving on the speakers' bureau for Ortho-McNeil Pharmaceuticals and Pfizer Inc.

Notice: All faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Ophthalmology provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Ophthalmology does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Enhancing Adherence with Glaucoma Therapy: Practical Strategies for Superior Outcomes
David S. Friedman, MD, MPH, PhD,* and Gail F. Schwartz, MD 

Glaucoma is a chronic and asymptomatic disease. It requires long-term treatment by patients already facing many daily life difficulties (in addition to impending visual impairment), including frequent use of other medications for other long-term conditions. Adhering with prescribed glaucoma treatments can be particularly challenging for these patients.

Several studies have addressed adherence issues with glaucoma medications, and the results show that factors associated with lower adherence are both obvious (eg, patients prefer once-daily dosing for eye drops) and surprising.1 For example, a prospective case series of 48 patients who participated in structured interviews revealed 71 unique situational barriers to adherence.2 Another report showed that "forgetfulness"–not side effects or costs–was the most common reason for nonadherence.3

Poor adherence is not unique to glaucoma or even ophthalmology. Physicians who treat other chronic diseases are faced with the same challenge of ensuring that patients take their medications as prescribed every day, over the course of the disease, even when the disease may be asymptomatic and/or the medications have side effects. Of course, "getting patients to take their medication" is not simply a matter of convincing them, and factors that make medication taking unattractive are not simply side effects. There are many barriers to adherence.

This issue of  Johns Hopkins Advanced Studies in Ophthalmology is a summary of presentations from a satellite symposium held during the American Academy of Ophthalmology Annual Meeting in New Orleans, Louisiana, on November 12, 2007. The objective of this monograph is to educate ophthalmologists and glaucoma specialists on the gravity of this public health issue and devise new strategies to address it.

The monograph is divided into 3 parts–detecting, identifying, and addressing adherence barriers–and uses example of dialogue from the educational program to illustrate how the physician can better detect, identify, and address adherence issues in their patients with glaucoma. The case studies presented in this monograph and in the educational program are based on actual patients of the faculty.

One aspect that makes this monograph so unique is the participation of Steven R. Hahn, MD, an internal medicine physician with an interest and fellowship training in behavioral medicine and psychiatry. His research and teaching activities focus on the behavioral, communication, and psychologic aspects of medical care across therapeutic areas, including glaucoma. In fact, he is an investigator in the Glaucoma Adherence and Persistency Study, the data from which are presented in this monograph. In addition to the case studies and discussion, we include an interview between Dr Hahn and Dr Friedman, to capitalize on Dr Hahn's unique expertise and further explore some of the challenges of implementing the academic theories of adherence psychology into an ophthalmology clinical practice.

March 6 was World Glaucoma Day. It is estimated that, worldwide, approximately 66.8 million people have visual impairment from glaucoma, with 6.7 million suffering from blindness.4 How many of those cases of blindness could have been avoided with a simple discussion about adherence issues? As you read this monograph, you may be surprised to learn how easy it is to implement these strategies.

REFERENCES

1. Buller AJ, Morgan LH, Hercules BL. Patients prefer once-daily glaucoma drops. Graefes Arch Clin Exp Ophthalmol. 2006;245:293-294.
2. Tsai JC, McClure CA, Ramos SE, et al. Compliance barriers in glaucoma: a systematic classification. J Glaucoma. 2003;12:393-398.
3. Taylor SA, Galbraith SM, Mills RP. Causes of non-compliance with drug regimens in glaucoma patients: a qualitative study. J Ocul Pharmacol Ther. 2002;18:401-409.
4. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90:262-267.

*Associate Professor, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Glaucoma Consultants, Greater Baltimore Medical Center; Assistant Professor, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: David S. Friedman, MD, MPH, PhD, Associate Professor, The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Wilmer 120, Baltimore, MD 21287. E-mail: Friedman@jhu.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.





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