A personalized glaucoma coaching program helped a group of patients to achieve clinically significant improvements in adherence to their eye medication and reductions in disease-related distress, a new study showed.

After 6 months participating in the Support, Educate, Empower (SEE) program — which combines in-person motivational interviewing and personalized disease education, plus phone calls and automated medication reminders — at the University of Michigan and Henry Ford Health System, 77.6% of patients were adherent to medications compared with 58% of those who received mailed information about glaucoma. The results were published online in JAMA Ophthalmology.

“We got a fabulous increase. I was so excited about the results,” said Paula Anne Newman-Casey, MD, MS, Jerome Jacobson Professor of Ophthalmology and Visual Sciences and associate chair for research at the University of Michigan’s Kellogg Eye Center in Ann Arbor, Michigan. “It wasn’t just statistically significant; it was clinically significant as well.”

Newman-Casey and her colleagues enrolled 236 adults with glaucoma taking one or more ocular hypotensive eye drop medications and who reported adherence to the regimen of 85% or lower, from ophthalmology clinics at the University of Michigan (108 adults) and Henry Ford Health System (128 adults). Of those, 235 were randomly assigned to the SEE intervention (n = 117) or a control group (n = 118) that received mailings of educational materials every 2 months from organizations including the Glaucoma Research Foundation and was followed for 6 months. The researchers assessed the severity of glaucoma by visual field testing and medical comorbidities using the Charlson Comorbidity Index at baseline. 

In the intervention arm, trained nonphysician coaches such as health educators and social workers met with participants three times: at baseline for an hour, followed by 30-minute sessions held 2 and 4 months later. During these meetings, coaches offered personalized, multimedia glaucoma education tailored to the patient’s specific subtype of glaucoma, their medications, and doctor recommendations for other treatments. They also demonstrated how to use eye drops and discussed how to integrate glaucoma medications into daily routines.

Between sessions, coaches monitored medication adherence using electronic pill bottles with built-in reminder alerts that transmitted the times and dates the bottles were opened to the study team. They also called participants to discuss their adherence. The coaches provided participants “an accountability partner and also a reason to strive to get better,” Newman-Casey said.

The mean age of participants was 67.3 years, and 124 (53%) were women. Nearly all participants reported having health insurance and prescription drug coverage. Participants self-reported being adherent to their glaucoma medication at a mean percentage of 63.9% at baseline and using between one (38%) and five (0.4%) medications, for a mean of 3.2 drops per day.

At the 6-month follow-up point, medication adherence showed an average difference of 19.7 percentage points (95% CI, 13.7-25.6; P < .001) between the treatment (mean, 77.6%; n = 113) and control (mean, 58%; n = 114) groups. More patients in the intervention group than the control group achieved 80% or greater adherence to their medication regimen (62/113 [54.9%]) vs 27/114 [23.7%], respectively). Glaucoma-related distress among participants in the intervention group decreased from 2.5 to 1.9 compared with the control group, whose distress score decreased from 2.4 to 2.2, according to the researchers.

After adjusting for baseline intraocular pressure, participants in the SEE program experienced a reduction in pressure in their better eye (n = 88; -0.84 mm Hg; 95% CI, -1.56 to -0.11), while those in the control group did not (n = 102; -0.38 mm Hg; 95% CI, -1.06 to 0.30).

“What people really seemed to value was their relationship with the coach,” Newman-Casey said. Participants also reported liking the visual and audible alerts on the monitor, she said. 

“I hope it moves the needle,” Newman-Casey said. “I think self-management support and thinking about delivering chronic disease care in a team has been something that hasn’t really been widely implemented in medicine but seems totally critical to helping people take control of their chronic diseases.”

The most important contribution of this trial may not be the intervention itself but what it revealed about how adherence is elicited and supported in clinical care, wrote Rithambara Ramachandran, MD, MSc, assistant professor of ophthalmology at the Hospital of the University of Pennsylvania, Philadelphia, in an editorial accompanying the journal article. 

“The impact of the SEE program likely stems less from the specific mechanics of coaching and more from its reframing of how adherence is discussed, as well as from its responsiveness to what patients reveal during those conversations,” Ramachandran wrote. 

Clinicians frequently ask questions in ways that suppress truthful responses, but in this program, coaches allowed patients to articulate their own barriers to adherence and potential solutions — an approach that “reinforces autonomy and fosters trust,” she added.

Programs like this are “sorely needed” for patients with glaucoma, said Thomas Johnson III, MD, PhD, the Shelley and Allan Holt Rising Professor of Ophthalmology at Johns Hopkins’ Wilmer Eye Institute in Baltimore. “Lowering their pressure is right now the only intervention that will slow down or stop the disease from getting worse,” he said. “We have lots of good eye drops that work very well, and one of the most salient reasons that they fail for some patients is that they just don’t take them like they’re supposed to.”

Prior studies have used eyedrop monitors or looked at pharmacy refill rates to show that a “huge proportion of patients” do not take eye drops as directed, resulting in higher eye pressures or worse disease, Johnson added. Other interventions studied have included reminders to take eye drops or personalized coaching and education, he said.

Questions that remain to be explored include how durable the response is from an intervention like this, what the costs of establishing such a program are, and if AI could be incorporated, Johnson noted. “We as a field should be thinking about how to employ these sorts of interventions for the benefit of our patients, but we need to also think about the cost-effectiveness of doing this and where the funding would come from.”

The study was supported by the National Eye Institute. Newman-Casey reported having a patent pending for an eyedrop adherence monitoring system and method. Johnson reported having no relevant financial conflicts of interest.

Karen Blum is a freelance medical/science writer in the Baltimore area.