Patient-Centered Outcomes After a Medication Adherence Intervention: a Pilot Study.

PRCIS: Self-determination theory (SDT) guided behavioral interventions are effective in improving several patient-centered metrics, including glaucoma-related distress. However, whether improvement in patient-centered metrics can drive an improvement in medication-taking behavior remains to be seen. OBJECTIVE: The 7-month Support, Educate, Empower (SEE) personalized glaucoma coaching program was previously shown to improve glaucoma medication adherence by 21 percent points. This study's goal was to assess the impact of the SEE program on self-determination theory (SDT) metrics and other patient-centered outcome measures. PARTICIPANTS AND METHODS: Glaucoma patients (≥40 y old, taking ≥1 medication) self-reporting poor medication adherence were recruited at the University of Michigan. Eight surveys (with 10 subscales) were completed before and after the 7-month SEE program. Three surveys assessed changes in SDT (Treatment Self-regulation Questionnaire, Healthcare-Climate Questionnaire, Perceived Competence) while the others assessed participants' Glaucoma Knowledge, Glaucoma Medication Self-efficacy, Glaucoma-related distress, Perceived benefits, confidence asking and getting questions answered. RESULTS: Thirty-nine participants completed the SEE program. Significant improvements were in 7 subscales, including all three SDT tenets of competence (mean change =0.9, SD =±1.2, adjusted P =0.0002), autonomy (0.5, ±0.9, 0.044), and relatedness ( P =0.002). Glaucoma-related distress (-2.0, ±3.2, 0.004), confidence in asking questions (1.1, ±2.0, 0.008), and confidence in getting questions answered (1.0, ±2.0, 0.009) also improved. Glaucoma-related distress was correlated with perceived competence ( r =-0.56, adjusted P =0.005), and an increase in perceived competence was associated with a decrease in glaucoma-related distress (ß=-0.43, 95% CI -0.67 - -0.20, adjusted P =0.007). CONCLUSIONS: The SEE program improved participants' autonomous motivation, perceived support, perceived competence, glaucoma-related distress, and competence. These results point to the promising potential of SDT-guided behavioral interventions in improving patient-centered metrics.

The Support, Educate, Empower personalized glaucoma coaching trial design.

BACKGROUND: Glaucoma is a chronic disease that affects 3 million Americans. Glaucoma is most often asymptomatic until very late in its course when treatment is more difficult and extensive peripheral vision loss has already occurred. Taking daily medications can mitigate this vision loss, but at least half of people with glaucoma do not take their prescribed medications regularly. The purpose of this study is to improve glaucoma medication adherence among those with medically treated glaucoma and poor self-reported adherence using the Support, Educate, Empower personalized coaching program. METHODS/DESIGN: This study is a two-site randomized controlled trial enrolling 230 participants with poor self-reported glaucoma medication adherence. The trial has two arms, an intervention arm and a control arm. Participants in the intervention arm receive personalized glaucoma education and motivational interviewing-based coaching over 6 months from a trained non-physician interventionist for three in-person sessions with between visit phone calls for check-ins where current adherence level is reported to participants. Participants also can elect to have visual, audio, text or automated phone call medication dose reminders. Participants in the control arm continue usual care with their physician and receive non-personalized glaucoma educational materials via mail in parallel to the three in-person coaching sessions to control for glaucoma knowledge content. All participants receive a medication adherence monitor. The primary outcome is the proportion of prescribed doses taken on schedule during the 6-month period. The secondary outcome is glaucoma related distress. The exploratory outcome is intraocular pressure. DISCUSSION: The personalized education and motivational-interviewing-based intervention that we are testing is comprehensive in that it addresses the wide range of barriers to adherence that people with glaucoma encounter. Leveraging a custom-built web-based application to generate the personalized content and the motivational-interviewing-based prompts to guide the coaching sessions will make this program both replicable and scalable and can be integrated into clinical care utilizing trained non-physician providers. Although this type of self-management support is not currently reimbursed for glaucoma as it is for diabetes, this trial could help shape future policy change should the intervention be found effective.

Glaucoma Medication Adherence 1 Year after the Support, Educate, Empower Personalized Glaucoma Coaching Program.

PURPOSE: To assess the efficacy of the Support, Educate, Empower (SEE) glaucoma coaching program on medication adherence among poorly adherent patients with glaucoma for 12 months after cessation of the intervention. DESIGN: Uncontrolled intervention study with a pre-post design. PARTICIPANTS: The SEE cohort was recruited from the University of Michigan and included patients with glaucoma aged ≥ 40 years, taking ≥ 1 medication, who self-reported poor adherence. Electronic medication monitoring of those who completed the program continued for up to 1 year after the coaching intervention. METHODS: Adherence was monitored electronically (AdhereTech) during the 7-month program and 12-month follow-up period. Adherence was the percentage of doses taken on time. Participants were censored for surgery, change in glaucoma medications, or adherence monitor disuse. The SEE program included automated medication reminders, 3 in-person motivational interviewing-based counseling sessions with a glaucoma coach, and 5 phone calls with the coach for between-session support. There was no contact between the study team and participants during the 12-month follow-up after program cessation. Baseline participant characteristics were summarized with descriptive statistics. Paired t tests and Wilcoxon signed rank tests were used to investigate significant changes in monthly adherence during follow-up. MAIN OUTCOME MEASURES: Change in electronically monitored medication adherence over the 12 months following the conclusion of the SEE program. RESULTS: Of 48 participants, 39 (81%) completed the SEE program and continued electronic medication monitoring for up to 1 year after program cessation. The mean age of the participants was 64 years (standard deviation [SD], 10); of the 39 participants, 56% were male, 49% were Black, and 44% were White. The mean length of follow-up was 284 days (SD, 110; range, 41-365 days). Censoring occurred in 18 (56%) participants. The mean adherence during the follow-up period was 67% (SD, 22%). This was significantly lower than the adherence during the SEE program (mean, 81%; SD, 18%; P < 0.0001) but significantly higher than the baseline preprogram adherence (mean, 60%; SD, 18%; P = 0.0393). The largest monthly losses occurred at months 1 (mean, 7%; P = 0.0001) and 4 (mean, 6%; P = 0.0077). CONCLUSIONS: Glaucoma medication adherence decreased significantly in the year after cessation of the SEE coaching program but remained significantly higher than baseline adherence. To maintain excellent long-term medication adherence, intermittent reinforcement sessions may be necessary.

Demographic, Clinical, and Psychosocial Predictors of Change in Medication Adherence in the Support, Educate, Empower Program.

PURPOSE: To investigate whether demographic, clinical, or psychosocial factors act as moderators of change in medication adherence in the Support, Educate, Empower (SEE) program. DESIGN: Prospective, single-arm pilot study with a pre-post design. PARTICIPANTS: Patients with glaucoma aged ≥ 40 years and taking ≥ 1 glaucoma medication were recruited from the University of Michigan Kellogg Eye Center. Those who had electronically measured adherence ≤ 80% in the 3-month eligibility monitoring period were enrolled in the SEE program. METHODS: Medication adherence was monitored electronically during the 7-month intervention and calculated as the percentage of doses taken correctly. Change in adherence at different points in the SEE program and cumulative change in adherence were modeled with linear regression, and baseline demographic, clinical, and psychosocial factors were investigated for significant associations. MAIN OUTCOME MEASURES: Demographic, clinical, and psychosocial variables associated with change in medication adherence in the SEE program. RESULTS: Thirty-nine participants completed the SEE program. These participants were on average 63.9 years old (standard deviation [SD], 10.7 years), 56% (n = 22) were male, 44% (n = 17) were White, and 49% (n = 19) were Black. Medication adherence improved from an average of 59.9% (SD, 18.5%) at baseline to 83.6% (SD, 17.5%) after the final SEE session, for an increase of 23.7% (SD, 17.5%). Although participants with lower income (< $25 000 and $25 000-50 000 vs. >$50 000) had lower baseline adherence (48.4% and 64.1% vs. 70.4%), these individuals had greater increases in adherence during the first month of medication reminders (19.6% and 21.6% vs. 10.2%; P = 0.05 and P = 0.007, respectively). Participants taking fewer glaucoma medications also had significantly greater increases in adherence with medication reminders (P < 0.001). Those with higher levels of glaucoma-related distress (GD) had lower baseline adherence and greater increases in adherence with glaucoma coaching (P = 0.06). CONCLUSIONS: Patient-level factors associated with relatively greater improvements in medication adherence through the SEE Program included lower income, fewer glaucoma medications, and increased GD. These findings demonstrate that the SEE program can improve glaucoma self-management even among participants with social and psychological barriers to medication adherence.

Psychosocial Predictors of Glaucoma Medication Adherence Among the Support, Educate, Empower (SEE) Personalized Glaucoma Coaching Pilot Study Participants.

PURPOSE: To evaluate the association between baseline psychosocial milieu and subsequent glaucoma medication adherence among participants in the Support, Educate, Empower (SEE) personalized glaucoma coaching program pilot study. DESIGN: Prospective cohort study. METHODS: Participants (University of Michigan glaucoma patients aged ≥40 years, taking ≥1 glaucoma medication, who self-reported poor adherence) completed a baseline survey that assessed the following: (1) demographics; (2) social network; (3) perceived stress; (4) consideration of future consequences; (5) glaucoma-related distress; and (6) social support. Medication adherence was then monitored electronically for 3 months and the percentage of prescribed doses taken was calculated. The relationship between baseline factors and medication adherence was assessed using univariate and multivariate analysis. Main outcome measure was median percent adherence over 3 months. RESULTS: Of the 95 study participants, 63% had graduated from college, 55% were white, 35% were African-American, and 97% had insurance. Median adherence over 3 months was 74% ± 21% (±standard deviation, SD). Higher income and more education were significantly associated with better adherence (P < .0001, P = .03). Glaucoma-related distress (mean score 5.6, SD = 3.0) was inversely associated with medication adherence on univariate (P < .0001) and multivariate analysis (P = .0002). Every 1-point increase in glaucoma-related distress score predicted a 2.4-percentage-point decrease in medication adherence. CONCLUSIONS: Lower income, lower educational attainment, and a higher level of glaucoma-related distress all predicted lower adherence to glaucoma medications. Additional glaucoma self-management support resources should be directed toward patients with such risk factors for poor adherence.

Leadership of United States Academic Departments of Ophthalmology: Chairperson Characteristics, Accomplishments, and Personal Insights.

PURPOSE: To report on the characteristics, accomplishments, and past experiences of current academic ophthalmology department chairs. DESIGN: Cross-sectional study. METHODS: Setting: A confidential online survey. STUDY POPULATION: Total of 111 chairs of US academic ophthalmology departments. MAIN OUTCOME MEASURES: Chairs' general characteristics, training/former positions held, academic accomplishments, previous organization/committee involvement, motivation/insight, and overall work satisfaction. RESULTS: Fifty-five chair responses were received (96% male, mean age 57 years, mean term 7 years). The majority were American medical graduates (93%), full professors of ophthalmology (93%), and permanent chairs (96%). All completed their residency in the US and 96% completed a fellowship (25% vitreoretinal surgery, 22% cornea and external disease, and 20% glaucoma). On average, chairs authored 98 peer-reviewed articles, 2 books, and 11 book chapters. They were also significantly involved in peer-reviewed journal literature, serving as editors (20%), associate editors (18%), or editorial board members (60%). The majority of chairs indicated they decided to seek their position late in their career, having already become a full (33%) or associate professor (26%), primarily owing to a desire to build and promote an academic ophthalmology department (61%). Chairs regarded their experience as head of service as most important for their current performance as department heads. Their principal advice to aspiring ophthalmology chairs was to focus on developing skills as a clinician, researcher, and educator ("triple threat"). CONCLUSIONS: Overall, academic department chairs are accomplished leaders in ophthalmology and prolific authors with an established academic record. Chairs regarded their previous leadership roles within the department as invaluable to their effectiveness as chair.

First Described Case of Anterior and Posterior Segment Crystals in Phacolytic Glaucoma.

Phacolytic glaucoma is an open-angle glaucoma that occurs when lens proteins from hypermature cataracts seep through an intact anterior capsule and induce obstruction of the trabecular meshwork by inflammatory cells. We review the case of a 66-year-old man who presented with acute pain, a hypermature cataract, prominent anterior chamber crystals, and elevated intraocular pressure. After cataract surgery was performed, iridescent crystals were noted in the posterior chamber. Anterior chamber crystals have been associated with phacolytic glaucoma, but this is the first case demonstrating crystals in the posterior chamber as well.

Mapping Direct Observations From Objective Structured Clinical Examinations to the Milestones Across Specialties.

BACKGROUND: Little is known about residents' performance on the milestones at the institutional level. Our institution formed a work group to explore this using an institutional-level curriculum and residents' evaluation of the milestones. OBJECTIVE: We assessed whether beginner-level milestones for interpersonal and communication skills (ICS) related to observable behaviors in ICS-focused objective structured clinical examinations (OSCEs) for postgraduate year (PGY) 1 residents across specialties. METHODS: The work group compared ICS subcompetencies across 12 programs to identify common beginner-level physician-patient communication milestones. The selected ICS milestone sets were compared for common language with the ICS-OSCE assessment tool-the Kalamazoo Essential Elements of Communication Checklist-Adapted (KEECC-A). To assess whether OSCE scores related to ICS milestone scores, all PGY-1 residents from programs that were part of Next Accreditation System Phase 1 were identified; their OSCE scores from July 2013 to June 2014 and ICS subcompetency scores from December 2014 were compared. RESULTS: The milestones for 10 specialties and the transitional year had at least 1 ICS subcompetency that related to physician-patient communication. The language of the ICS beginner-level milestones appears similar to behaviors outlined in the KEECC-A. All 60 residents with complete data received at least a beginner-level ICS subcompetency score and at least a satisfactory score on all 3 OSCEs. CONCLUSIONS: The ICS-OSCE scores for PGY-1 residents appear to relate to beginner-level milestones for physician-patient communication across multiple specialties.

IOP Elevation After Cataract Surgery: Results for Residents and Senior Staff at Henry Ford Health System.

PURPOSE: To determine the incidence of intraocular pressure (IOP) elevation on postoperative day 1 (POD1) after cataract surgery performed by resident surgeons compared with attending surgeons and to examine the influence of associated variables on the incidence of postoperative IOP elevation. PATIENTS AND METHODS: Retrospective review of 2472 consecutive 2.2 to 2.8 mm temporal clear corneal cataract extractions by phacoemulsification performed by either residents or attending surgeons at Henry Ford Health System. Fellow eyes were excluded, resulting in 1847 eyes. IOP measurements of >40, >30, and >23 mm Hg were noted along with incremental IOP elevations of ≥10 and 20 mm Hg over preoperative/baseline IOP. Associated variables included: age, sex, diabetes mellitus, hypertension, glaucoma, glaucoma suspect, uveitis, prior ocular trauma, and vitreous loss at surgery. RESULTS: Resident-performed cataract surgery was associated with statistically significant higher rates of IOP elevation in all categories and in all clinical situations known to be associated with postoperative IOP spike, that is, vitreous loss at surgery, prior ocular trauma, and preexisting glaucoma. CONCLUSIONS: The incidence of postoperative day 1 IOP elevation after phacoemulsification performed by resident surgeons was 2 to 5 times that of experienced cataract surgeons. Variables including vitreous loss at surgery, prior ocular trauma, preexisting glaucoma, glaucoma suspect status, and male sex were significant contributors. Consideration for prophylactic IOP lowering is advised in high-risk patients.

First Reported Case of Proliferative Retinopathy in Hemoglobin SE Disease.

We report the first case of proliferative sickle cell retinopathy in a patient with hemoglobin SE (Hb SE) disease. Only a few dozen cases of Hb SE disease have been reported previously, and none had evidence of proliferative retinopathy. A 56-year-old African American man presented to our clinic for routine examination and was found to have sea-fan peripheral neovascularization bilaterally without maculopathy. Hemoglobin analysis revealed Hb SE heterozygosity. Sector laser photocoagulation to areas of nonperfusion in both eyes resulted in regression of the peripheral neovascularization over a period of 6 months. Although Hb SE disease is rare, the incidence of Hb SE disease is postulated to rise in the future. Awareness of its potential ocular complications is needed to appropriately refer these patients for screening.

Interstitial keratitis secondary to severe hidradenitis suppurativa: a case report and literature review.

PURPOSE: To report a patient who presented with bilateral interstitial keratitis in association with severe hidradenitis suppurativa. METHODS: Case report. RESULTS: An 18-year-old African American woman with severe active hidradenitis suppurativa of the axillae and groin presented with a 2-week history of bilateral blurry vision. On examination, best-corrected visual acuity was counting fingers in the right eye and 20/70 in the left eye. Slit-lamp examination revealed diffuse vascularization of the corneal stroma with surrounding infiltrates bilaterally. In the left eye, corneal thinning and an epithelial defect were present in an area of infiltrate. Our clinical impression at that time was bilateral interstitial keratitis with secondary bacterial keratitis in the left eye. Topical therapy, prednisolone acetate 1% in the right eye, and ofloxacin in the left eye, was instituted. A systemic workup, including antinuclear antibody, rheumatoid factor, Lyme titer, cytoplasmatic staining antineutrophil cytoplasmic antibodies, perinuclear staining antineutrophil cytoplasmic antibodies, erythrocyte sedimentation rate, Venereal Disease Research Laboratory, rapid plasma reagin, basic metabolic panel, angiotensin-converting enzyme level, and a chest x-ray was negative. Topical steroids were used in the left eye after resolution of the bacterial keratitis. The interstitial keratitis responded to topical steroids and remained in remission after steroid taper. However, bilateral interstitial keratitis recurred coincident with a severe flare of hidradenitis suppurativa within 1 month of discontinuing the topical steroids. A course of subcutaneous adalimumab injections (40 mg/mL every 2 weeks) for hidradenitis suppurativa was implemented. Both her dermatological and ocular conditions responded to this therapy and have remained in remission through 7 months of follow-up. CONCLUSIONS: Hidradenitis suppurativa is a rare cause of bilateral interstitial keratitis. Patients may experience simultaneous exacerbations of both dermatological and ocular manifestations. Systemic treatment with adalimumab can improve both dermatological and ocular conditions.