Glaucoma medication compliance in inpatient settings: The Holy Grail

Author(s):

Glaucoma medication compliance in an inpatient setting is poor, with more than one-third of patients not receiving their anti-glaucoma drugs.

Ironically, though IOP drugs are markedly effective at decreasing the development and progression of open-angle glaucoma, compliance is “notoriously poor” among aging patients for a few reasons, said Tavish Nanda, MD, and colleagues.

Among the factors are reliance on staff in nursing homes and subacute rehabilitation centers as well as transfer of care from inpatient hospitals, according to Dr. Nanda, from the Harkness Eye Center of Columbia University Irving Medical Center and Northwell Health of Lenox Hill Hospital, both in New York.

About 2.2 million U.S. adults have glaucoma, and by as early as next year that number is expected to increase unbelievably to 3.36 million.

“Medication reconciliation is the process by which a patient’s outpatient medication regimen is documented and converted to synonymous medications in the hospital formulary. The intention of this process is to continue all outpatient medications during a patient’s hospital stay, unless otherwise contraindicated,” the authors explained.

However, while this process is primarily an electronic one, “…medication reconciliation on hospital admission and discharge is fraught with discrepancies, with errors occurring as often as 70% to 85% of the time,” they noted and explained that the frequency of these error rates associated with anti-glaucoma medications is unknown.

In addition, glaucoma is not considered to be as important as other chronic conditions such as diabetes and hypertension. The authors theorized that reconciliation of glaucoma drugs is suboptimal in inpatient hospitals, resulting in noncompliance.

The study

In light of this, they conducted a retrospective, cross-sectional, hospital-based study that included 475 patients (46.3% women; average age, 80.2 years) who had been admitted to a general medicine regional hospital service (average stay, 4.61 ± 3.7 days).

The investigators reviewed the administrative database and cross-referenced patient charts and the following information was collected: demographic data, past medical problems, inpatient orders, intake history and physical, length of stay, and admitting diagnosis.

The main outcome measures were twofold: the effect of outpatient glaucoma drop reconciliation and recognition of glaucoma as a pertinent past medical problem in a patient’s intake history and physical on inpatient eye-drop administration, they recounted.

Analysis of the database and charts found that “in total, 63.8% achieved successful reconciliation of medication on the hospital floor, resulting in a 36.2% eye-drop abstinence rate during the hospital stay,” the authors reported.

Regarding this, the investigators commented that while the reconciliation occurred, successful administration did not necessarily occur because the practitioners had to convert each reconciled medication intentionally to an active inpatient order.

Of 386 (81.3%) patients who had successful reconciliation of their anti-glaucoma medications, these patients achieved significantly different rates of eye-drop administration, i.e., 283 (73.3%) of the 386 patients received anti-glaucoma medications on the floor compared with 19 (21.0%) of 89 patients without successful reconciliation who received their medications, a difference that reached significance (p < 0.001).

Another important finding was that the presence of glaucoma was recognized in the history and physical in less than half of patients, 42.5%.

“Recognition of glaucoma as a pertinent medical problem was poor,” the investigators commented, “with only 202 of 475 (42.5%) patients having glaucoma listed in their intake history and physical. Among those with glaucoma listed, 153 of 202 patients (75.7%) received glaucoma medications. In comparison, in those without glaucoma listed (150/273), 55.0% received glaucoma medications (p < 0.001).

These results were reported in Ophthalmology Glaucoma (2019;2:188-191).

Considerations

The study emphasized the importance of accurate recording of the patients’ medication regimen before admission to a hospital in order to improve eye-drop administration. This could be improved, they suggested, by using teaching rounds or morning case presentations as opportunities for residents and staff to become familiar with the various types of anti-glaucoma drops and administration regimens that are frequently prescribed.

“This ideally would include a table or chart providing the generic medications that are available in the hospital formulary and their synonyms in the outpatient setting. It is imperative that these teachings also emphasize the chronic nature of this disease and the vision-threatening consequences of prolonged noncompliance,” the authors stated.

They also suggested that small cards listing basic medication information, such as the name, dose, side effects, and regimen, be provided with the goal of improving quality as well as serving as a reminder to inquire about glaucoma as a patient’s chronic medical problem.

The study concluded, “Glaucoma treatment incurs a high rate of medication noncompliance, especially in the elderly. The present study demonstrates that more than one third of patients admitted to an academic medical center do not receive their glaucoma medications. Patients discharged to nursing homes, subacute rehabilitation, and assisted living facilities rely on appropriate discharge medication reconciliations, resulting in forced abstinence during transition of care. An emphasis on appropriate medical reconciliation and recognition of glaucoma as a pertinent past medical problem will improve rates of eye-drop administration on inpatient admission significantly.”