Patient Centred Treatment Management

Patients value clinicians who listen to their concerns and fears, counsel them about their disease and its treatment options, and establish a quality long-term therapeutic relationship. Good clinician-patient interaction can enhance the therapeutic value of administered treatments.¹ Providing patients with the skills, knowledge and confidence to make informed decisions leads to optimal long-term successful participation in their management.

True – this approach is not for all patients, many of whom simply expect (and want) to follow whatever plan the doctor sets. However increasingly, patients are better informed and want detailed explanations, as well as clear strategies and treatment options from which to choose with guidance, if their alliance with their clinician is strong.

Achieving Management Success

In glaucoma, the crucial predictors for management success are medication adherence and participation in regular clinical monitoring. Increasingly, patient-focused educational interventions are used in the management of glaucoma.² Education about the nature of glaucoma, its prognosis, the need for ongoing monitoring and treatment improve the patient’s knowledge and experience.³ Patient education has been shown to improve adherence^4,5 and better adherence has been linked to a better prognosis in glaucoma.⁶

She was grateful to have been offered these options and felt empowered to make the best possible treatment decision for herself

There may be unspoken fears for the future; allowing patients the opportunities to express these, and addressing them appropriately can be beneficial; often multiple sessions are required.⁷ Counselling to improve glaucoma knowledge and providing patients with opportunities to discuss their concerns have a significant impact on patients’ treatment satisfaction, wellbeing and anxiety level.^{7, 8}

Although we generally take the time to counsel patients during clinical practice, patients should be encouraged to seek further information from a third party or reputable website. There is only so much time in a day for busy clinicians, and only so much a patient can absorb in one consultation, in which stress from a recent diagnosis might impair their comprehension and their retention. This approach can improve treatment success: Friedman et al found that glaucoma patients who acquire information from sources external to their doctor have the best medication adherence.⁹

Advantages of Third Party Counsel

Glaucoma Australia is a not-for-profit organisation that for many years has provided free patient services. These include counselling, leaflets, support groups, regular glaucoma newsletters and options to ask questions directed to an Expert Advisory Medical panel. The impact of these services has recently been evaluated. A short-term randomised clinical trial was published measuring the impact of glaucoma-specific counselling on glaucoma knowledge and disease-related anxiety.¹⁰ One hundred and one newly diagnosed open angle glaucoma patients from 13 centres across Australia were randomised 1:1 into the intervention arm (usual clinical care from ophthalmologist and counselling from Glaucoma Australia) and control arm (usual care from ophthalmologist). After four weeks the intervention arm, but not controls, had improved knowledge levels (p=0.02); and intergroup analysis revealed a significant reduction in anxiety from the intervention (p=0.02).

So, third party counselling and external information is not only linked to better medication adherence, it also improves glaucoma knowledge and anxiety, at least in the short term.

Referring to Glaucoma Australia

The traditional GA model has been to encourage clinicians to refer patients by mail or phone to GA at the time of glaucoma diagnosis. However, there are a variety of barriers to this, and despite much encouragement over the years, the service is only used for a small proportion of newly diagnosed glaucoma patients in Australia.

Technology provides new solutions for old problems; realising the limitations of the traditional referral model, GA is exploring IT solutions to better connect with glaucoma patients and their families. Today GA is modernising for the digital age, building a sophisticated, informative and interactive website, with tailored entry portals for patients, optometrists, ophthalmologists and pharmacists. One exciting opportunity is via new software interface platforms. When an optometrist or ophthalmologist refers a glaucoma patient or suspect using Oculo for example, upon their consent, an electronic contact with GA is generated. The patient is then electronically invited to the GA webpage, and social media and email for subsequent patient contact becomes possible. This approach requires an interface between clinicians and IT experts to be fine-tuned to ensure we are capturing the right patients – work is underway.

More work is also needed to further evaluate the kind of counselling that are appropriate – what media should be used, what constitutes sufficient information, and how many counselling sessions are required. When training ourselves and junior clinicians, more emphasis should be placed on the art of clinical interaction and education, not just the science and skills of clinical optometry and ophthalmology. We should embrace new technology to improve patient screening, education and communication, harnessing the opportunities provided by personalised devices, digital media and sophisticated networking.

Building bridges with advocacy groups and other healthcare professionals, and strengthening the bonds of the glaucoma health team can only be beneficial to our patients.

Empowering Patients in the Decision Making Process

Fifty-eight year old Mrs. K, with intraocular pressures (IOPs) of 15/27 mm Hg OD/OS, was diagnosed with left primary open angle glaucoma. She has asthma. She was provided limited explanation and opportunities to ask questions, and told to administer an alpha agonist twice daily in the left eye. The treatment reduced IOP to 15/18 mm Hg OD/OS, but provoked a left watery, red and irritated eye with occasional blurred vision. She asked her GP for a second opinion and was referred to another ophthalmologist. At her second opinion, she was noted to have a left follicular conjunctivitis (Figure 1). Her anterior chamber angles were found to be open on gonioscopy and anterior chambers unremarkable. Cup-disc ratio was 0.55 on the right and 0.75 on the left; left inferior rim loss was noted. An optical coherence tomography (OCT) scan of the retinal nerve fibre layer and macular ganglion cell complex was normal on the right; inferior damage was noted on the left (Figure 2). A left superior nasal step was noted on visual field testing (Figure 3). Figure 1 Figure 2 Figure 3 Mrs. K was explained the following: Raised intraocular pressure occurs when outflow drainage of fluid from the eye is impaired. This can lead to damage to the optic nerve in a process called glaucoma. The optic nerve is the crucial link that transmits all visual information from the eye to the brain. There is currently a small amount of damage to her left optic nerve affecting her left peripheral vision – thankfully this is early and is unlikely to cause a major impact on her daily life. Untreated raised IOP can lead to further loss of peripheral vision in a process that is cumulative, generally slow, but irreversible. It does not cause symptoms until very late in the disease course; the idea is to intervene to protect the current sight well before the onset of symptoms. Fortunately, the disease process can be halted or significantly slowed by IOP lowering. There is no cure – the IOP needs to be managed over the long term, and a treatment that works today might not be effective in six months’ time. Equally important is long-term monitoring – she should have her IOP checked every six months by either her optometrist or ophthalmologist, who can work together in collaboration. She would benefit from regular optic nerve tests – both structural (OCT) and functional (visual field) – to serially monitor the degree of glaucomatous damage. She has developed a topical allergy to the medicine she was using – this is why her eye is sore, watery and red. Other eye drop medications can be considered, each with their own safety and side effect profile. Alternatively, selective laser trabeculoplasty (SLT) can be considered – the process and efficacy of SLT was explained. Glaucoma can run in families: she was advised to ask her first degree relatives to be screened from their late thirties. Mrs. K was invited to ask further questions, given a leaflet about glaucoma and advised that further resources were available – she might benefit from contacting Glaucoma Australia for information and resources. She was grateful to have been offered these options and felt empowered to make the best possible treatment decision for herself. She decided to consider her options for now and return soon – while she decides she will cease the topical alpha agonist. Eye drop instillation and the importance of long-term adherence and persistence to the treatment were discussed.

Dr. Simon Skalicky, FRANZCO, PhD, BSc (Med), MPhil, MMed, MBBS (Hons 1) is a Clinical Senior Lecturer at the University of Sydney and University of Melbourne. He is a federal Councillor for Glaucoma Australia and Associate Advisory Board member for the World Glaucoma Association. Based in Melbourne, Dr. Skalicky specialises in glaucoma and cataract surgery.

References

1. Neumann M, Edelhauser F, Kreps GL, et al. Can patient-provider interaction increase the effectiveness of medical treatment or even substitute it?–an exploration on why and how to study the specific effect of the provider. Patient education and counseling. 2010; 80: 307-14.

2. Cate H, Bhattacharya D, Clark A, Fordham R, Notley C and Broadway DC. Protocol for a randomised controlled trial to estimate the effects and costs of a patient centred educational intervention in glaucoma management. BMC ophthalmology. 2012; 12: 57.

3. Do AT, Pillai MR, Balakrishnan V, et al. Effectiveness of Glaucoma Counseling on Rates of Follow-up and Glaucoma Knowledge in a South Indian Population. Am J Ophthalmol. 2016; 163: 180-9 e4.

4. Sleath B, Blalock SJ, Carpenter DM, et al. Ophthalmologist-patient communication, self-efficacy, and glaucoma medication adherence. Ophthalmology. 2015; 122: 748-54.

5. Newman-Casey PA, Dayno M and Robin AL. Systematic Review of Educational Interventions to Improve Glaucoma Medication Adherence: an update in 2015. Expert Rev Ophthalmol. 2016; 11: 5-20.

6. Sleath B, Blalock S, Covert D, et al. The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity. Ophthalmology. 2011; 118: 2398-402.

7. Kong XM, Zhu WQ, Hong JX and Sun XH. Is glaucoma comprehension associated with psychological disturbance and vision-related quality of life for patients with glaucoma? A cross-sectional study. BMJ open. 2014; 4: e004632.

8. Rhodes LA, Huisingh CE, McGwin G, Jr., et al. Eye Care Quality and Accessibility Improvement in the Community (EQUALITY): impact of an eye health education program on patient knowledge about glaucoma and attitudes about eye care. Patient Relat Outcome Meas. 2016; 7: 37-48.

9. Friedman DS, Hahn SR, Gelb L, et al. Doctor-patient communication, health-related beliefs, and adherence in glaucoma results from the Glaucoma Adherence and Persistency Study. Ophthalmology. 2008; 115: 1320-7, 7 e1-3.

10. Skalicky SE, D’Mellow G, House P, Fenwick E and Glaucoma Australia Educational Impact Study C. Glaucoma Australia educational impact study: a randomised short-term clinical trial evaluating the association between glaucoma education and patient knowledge, anxiety and treatment satisfaction. Clin Exp Ophthalmol. 2017.