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Non-compliance can be subdivided into voluntary and involuntary types. Voluntary non-compliance is patients deciding not to use their medication. Involuntary non-compliance refers to situations where medications are used incorrectly, such as eye drops missing the conjunctival sac, using incorrect medication, or following an incorrect regime. The impact of non-compliance is particularly important for patients with chronic diseases such as glaucoma.1
We collected data from patients in our clinic to try to ascertain the frequency and nature of any discrepancies between the drop regimes patients were using and what their notes said their current regimes should be.
One hundred consecutive patients using topical medication to lower intraocular pressure attending a UK teaching hospital’s glaucoma service clinics were asked which drops they were using and how often they put them in. Each patient was only entered into the study once. If any deviation from the drop regime described in their notes was identified then further questioning was used to identify the cause of that discrepancy.
In total, 30 of the 100 patients were not using the antiglaucoma medication as described in their notes. Eighteen cases were caused by ophthalmologists either changing a regime without informing the general practitioner or not giving clear instructions to the patient. Examples include transcription errors by the ophthalmologist when dictating the letter to the general practitioner (four cases), patients stopping treatments because of side effects without contacting clinic (four cases), patients stopping their glaucoma drops after cataract surgery (three cases), and ambiguity between Xalatan and Xalacom (one case).
Patient error can be attributed to nine cases. Examples include patient using drops less frequently than prescribed (three cases), patient using drops in the wrong eye or one eye only (two cases), patients changing the dose frequency of their own accord (one case), and using drops too frequently (one case).
The other three cases were the result of “unreliable” nursing home staff (two cases), and failure to prescribe eye drops on admission to a general medical ward.
Ophthalmologists communicating poorly with patients or with general practitioners caused nearly one in five patients to use the wrong regime. The responsibility for ensuring that all communication between the ophthalmologist and patients or general practitioners is intelligible and unambiguous lies with the ophthalmologist.
One frequent cause of non-compliance is newly diagnosed patients thinking that the initially prescribed bottle is the full course of treatment, and ceasing treatment when this bottle expires. This is a well recognised phenomenon on the literature on persistency with treatment for glaucoma.2
We were alarmed that 30% of the sample were using an incorrect drop regime. Involuntary non-compliance merits further research and poses a considerable threat to the control of patients’ disease. Furthermore, failure to identify compliance as the cause of a patient’s apparent lack of response to treatment may result in prescription of more toxic medication, and increasingly complex drop regimes, which can lead to further compliance problems.3