Support for correct eye drop technique and compliance aids is often overlooked outside specialist ophthalmic units compared with other specialist medicines, e.g. inhalers, where dedicated time is usually spent assessing, reviewing and continually supporting technique. Eye drop technique support is as important, since treatment does not always improve sight (often a motivator to use drops correctly) but can prevent disease progression, such as glaucoma.
It is estimated between a third and a half of all medicines prescribed for long-term conditions are not taken as recommended in NICE Guideline CG76, including eye drops. It is reported that up to 50% glaucoma patients are non-compliant with treatment. Given the consequences of treatment failure, it is vital to consider reasons for this non-compliance and help patients overcome these barriers to prevent poor clinical outcomes and potentially unnecessary polypharmacy. Subsequent financial benefits for patients and the NHS may also result.
With recommendations to support compliance in glaucoma [NICE Guideline CG85], and adults receiving social care in the community [NICE Guideline NG67], this campaign was therefore launched.
Aims and objectives
Patients with glaucoma have a significant risk of visual loss and poor clinical outcome if they are not using the prescribed drops correctly. A better understanding of the disease and prescribed eye drop treatment reduces the risk of visual loss and improves clinical outcome. Education has been shown to be successful in the modification of non-compliant behaviours and ultimately related clinical outcomes for patients.
In general, medication adherence support for those receiving ophthalmic medicines to treat glaucoma is not an established part of the patient pathway, despite being recommended by NICE. However it is important to incorporate as a dedicated process of patient review, as by providing patients and/or carers with the correct level of support to overcome compliance barriers, then poor clinical outcomes, unnecessary polypharmacy and/or financial losses can be minimised. This would benefit not only the patient and/or carer but also service provision, the NHS as a whole especially in terms of cost benefits, and also improve quality of life (QoL).
The purpose of the Moorfields Hospital Pharmacy #KnowYourDrops eye drop compliance campaign was to promote best eye drop techniques, help raise awareness of why using eye drops correctly is essential and the barriers to good eye drop compliance, and help educate patients/carers and health professionals on the various compliance aids available, to achieve the overarching aim of medicines optimisation in ophthalmology.
Reasons for implementing your project
Although all patients at Moorfields are reviewed and counselled on eye drops techniques when they receive their medicine(s) and asked about compliance with their medicines at every consultation, given the numerous barriers to compliance, 50% of glaucoma patients were found to be non-compliant with treatment. As a leading eye hospital we decided to review whether we are sufficiently supporting our patients and put forward a campaign to address any identified issues.
Baseline conversations with patients and carers highlighted that patients welcomed extra support and that many were unaware of the various compliance aids available to help them with administration. Feedback from clinicians and nursing staff also highlighted that patients often raised compliance issues and that specific pharmacy-led support for them would be very helpful to support the clinic. In addition, clinicians, optometrists and nursing staff were very positive for training to be given to all staff in the clinic for them to be able to better support patients with compliance-related issues to help improve care and QoL, and that ready access to compliance aids is made available with a clear supply chain.
An initial pilot campaign day was therefore run at one of the 32 Moorfields satellites, within a busy glaucoma clinic due to the expected prevalence of compliance-related issues. Feedback from patients and carers that day was very positive with a queue of patients revealing to the pharmacy team about various compliance issues they experience which they had not indicated to the clinical team. This may have been due to numerous reasons such as not wanting to take staff time up, being afraid to admit a problem to the consultant, prioritising discussing other treatment issues with the time they had with the clinician/nurse, or not realising that there was a problem.
With open and honest discussions with the pharmacy team, the team were able to help educate patients as to why they were prescribed their drops, how to use them with improved techniques and a review of compliance aid appliances - which were supplied if needed. The team were also able to educate about when the drops should be used and why these times were best, and support patients with methods to help remember to use them. This was especially beneficial to newly diagnosed patients starting on drops, as they were able to have a dedicated pharmacy medicines utilisation consultation and learn the correct methods and rationale form the start of treatment.
Through the pharmacist led medicine utilisation consultation, we were able to identify formulation changes and treatment regimen changes for those patients struggling with their current regimen and the clinicians were grateful that this had been highlighted and amendments made to improve care. This may also lead to less frequent visits to the clinic with poor treatment outcomes due to non-compliance, since patients were more likely to use there drops to control their glaucoma. In addition, feedback from nursing time was that the presence of the dedicated pharmacy eye drops compliance team.
How did you implement the project
A presentation was given to the directorate including the clinical director, general manager and matron about how the pilot day went and the feedback received. This led to launching the compliance campaign days across the additional five satellites located in the East of London over the following 2 months. These satellite clinics had some cross-over nursing/clinician staff which made it easier to implement the new initiative, busy glaucoma clinics and a demographic which based on clinicians feedback suggested that extra compliance support would be helpful.
The consultants and nurses in each clinic were very supportive of this extra level of patient care, and based on the feedback from the pilot day we were able to improve the way we ran the campaign. For example, we located our stand away from the reception as feedback was that this could be noisy and busy, and to invest in roll up posters and patient confidentiality screens to carry out consultations which were paid for from the pharmacy budget which covered such apparatus. We also printed more posters and leaflets to advertise the event. Stationary and printing costs for badges, stickers for patient notes were also small and came out of the stationary budget.
We led a heavy media campaign with our communications team with internal advertising and external advertising via social media to raise more awareness and spread the invitation, at no cost to the Trust. We also linked with our 3rd parties and clinic liaison officers, as well as local GPs to invite patients to the event for support on compliance issues and/or medicines questions. With widespread publicity, patients were more engaged and encouraged to speak to us for advice, as the barriers to asking for help were reduced.
One barrier to the campaign running effectively was space, as reception areas were often busy and this limited consultation areas and potentially caused sound issues. We worked with the teams on each site for each clinic however and rearranged furniture ahead of the clinic to best meet the demands of patient’ flow and the compliance reviews and this worked well. Where possible we were given a consultation room to use for the pharmacy medicines reviews which worked more effectively.
Another barrier is funding to support formal research into the clinical effectiveness and patient experience including QoL. This would help embed a pharmacist led eye drop compliance review for every patient as part of their clinical pathway trust-wide and nationally.
We carried out several patient/carer feedback questionnaires at the pilot day and then at subsequent initial days in other clinics, and listened to what patients said and made adjustments.
The survey feedback from the initial pilot generated 44 completed patient surveys. The results of these surveys was that 100% patients/carers found the #knowyourdrops eye drop compliance support day useful to help improve the way they put in eye drops; 100% felt more confident in putting in eye drops than they did before; 89% found the day useful to learn about compliance aids and which ones may be useful to use to improve treatment (7% did not need this advice); and 95% said that they would like more support days like this to help with eye drops to help their care and QoL.
Specific feedback about resources and education material included patients asking for a leaflet with pictures on it about how to use eye drops rather than the Trust format of using a lot of text for the step by step points. We therefore designed more patient-friendly leaflets with approval from our communications team and editorial committee of the layout.
Patients and carers also said that they would like videos of how to use the compliance aids to be available online, so that they can watch them as a reminder once they had left us. Patients said that they found the existing video of using eye drops with no compliance aid helpful (we used this on the day on a laptop to help training, as well as had this rolling on patient TV monitors in the reception area), and without the videos of the compliance aids some patients/carers were filming us themselves to watch back at home to reinforce their learning. We therefore sought approval from our patient experience committee and communications team to fund professional Trust videos, which we wrote scripts for and have been filmed for online videos.
Staff feedback was also very positive reporting that the compliance support days were beneficial to reduce barriers to poor compliance and optimise medicines, with Consultants and Optometrists referring patients to be reviewed by the pharmacy team as part of their pathway on the day we were present.
Feedback from staff about patient outcomes at subsequent patient visits after they had received the pharmacist-led medication utilisation review included: increased compliance, reduced polypharmacy, reduced side effects, avoidance of surgery and reduced need for carers to assist with administration.
Key learning points
- Be patient focused and identify the local/clinical needs for the patients, and then tailor the campaign format according to these needs. Engage with patients/carers and encourage feedback along the way as the campaign evolves.
- Engage with the clinical team, being inclusive of everyone in the team (including non-clinical staff, e.g. ECLOs and volunteers)
- At start of the clinic, a consultant makes an address to encourage and invite everyone attending clinic that day to have a pharmacist led compliance review as part of the standard clinical pathway for that day.
- Identify champions in each clinic, as this makes it easier to encourage patients to open up about any compliance issues, and put them at ease that it is ok to talk about technique challenges or compliance questions if they felt uneasy to do this before. The champions help break barriers and help promote and support your campaign as part of the patient pathway.
- Use promotion and social media activity to raise awareness and work closely with communications team. Display posters advertising clearly and in advance of the event to encourage discussions about compliance and help break barriers even though you are not running the campaign. We had patients coming specifically to the day when they had no appointment because of advertising, and they also spoke to their clinicians that they have problems with drops and admitting they do not use them as they should do because they read the poster and felt able to talk openly about this.
- Coordinate and coincide campaign days with national events (e.g. world glaucoma week, national sight day).
- Having accessible information such as leaflets and videos on the day, and in clinic when we are unavailable for them to read and contact us or speak to the clinic staff.
- Incentives and giveaways, particularly at the start of the campaign when patients were not aware of what it was about was important as we found that this helped encourage patients to come and talk to us. Maintain momentum and enthusiasm. Continue to be visible and innovative as the campaign evolves.
- Share patient stories and pharmacist interventions to help raise awareness of how the campaign has improved care for the patients/carers. Take photos with patients with their consent to help raise awareness and help other patients to relate to the compliance issues they may be experiencing.