Methodological quality of the review: Medium confidence

Authors: Newman-Casey PA, Dayno M, Robin AL

Region: USA, UK, Finland, Netherlands, Sweden and China

Sector: Glaucoma

Sub-sector: Educational interventions, treatment  

Equity focus: Adults with glaucoma

Review type: Other review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background:

Although multiple randomized, controlled clinical trials have demonstrated the effectiveness of glaucoma medications, glaucoma medication adherence remains a major public health problem.

Objectives:

To evaluate the current state of the research on educational interventions whose aim is to improve glaucoma medication adherence.

Main findings:

A total of 17 studies were included in the review. These included nine randomized controlled trials (RCTs) and eight observational studies. These studies were conducted in the USA, the UK, Finland, Netherlands, Sweden and China. Of the nine RCTs, four demonstrated an improvement in medication adherence after their intervention. Of the eight observational studies, four demonstrated an improvement in adherence after their intervention.

Among the RCTs that demonstrated a significant improvement in medication adherence after their educational intervention, one was in the USA, two were in the UK and one took place in Sweden. In the study conducted in the USA the intervention group had a significant improvement in adherence over baseline compared to the control group (54%-73% compared to 46% to 51%, p<0.001) at six months using electronic medication monitors. In the UK study, the authors noted that adherence was significantly higher in the intervention group (70% vs. 43%, p=.002) twelve months after the year-long intervention as measured with prescription refill data. There were significant differences in secondary outcomes as well. Intervention patients believed they had more control over influencing their glaucoma (p<.001), had a stronger belief in the necessity of drops (p<.001), and were more knowledgeable about glaucoma (p<.001). An older randomized intervention conducted in Sweden showed the intervention group had 9% ±6.1% fewer missed doses of pilocarpine than the control group (p=0.0004) as measured with custom made electronic medication monitors. The authors note that five RCTs did not show improvement in medication adherence after educational intervention.

Among the observational studies of interventions that demonstrated a significant improvement in adherence, two took place in the USA and one took place in the UK.

Methodology: 

The authors conducted a search on PubMed, Embase and CINAHL for published literature available on June 2, 2015. Search terms used included “glaucoma”, “education”, “compliance” or “adherence”. No language restrictions were used.  The authors generated searches to account for synonyms of these keywords and MESH headings as follows: firstly, “glaucoma” AND (“patient education as topic” OR “health education” OR “consumer health” OR “patient education” or “motivational interviewing” or “instruction”); secondly, “glaucoma” AND (“patient acceptance of healthcare” OR “patient compliance” OR “treatment refusal” OR “self-efficacy” OR “self-care” OR “compliance” OR “adherence” OR “persistence” OR “self-management”).

In addition, the authors reviewed the references of included studies. Primary outcome measure was the impact of the educational intervention on adherence.  Search terms used included “glaucoma” and “education” and “compliance” or “adherence”. They used no language restrictions. They generated searches to account for synonyms of these keywords and MESH headings as follows: firstly,  “glaucoma” AND (“patient education as topic” OR “health education” OR “consumer health” OR “patient education” or “motivational interviewing” or “instruction”); secondly, “glaucoma” AND (“patient acceptance of healthcare” OR “patient compliance” OR “treatment refusal” OR “self-efficacy” OR “self-care” OR “compliance” OR “adherence” OR “persistence” OR “self-management”.

In addition, the authors reviewed the references of included studies. Primary outcome measure was the impact of the educational intervention on adherence. Studies were included if the intervention was described, the outcomes assessed glaucoma medication adherence, and the focus of the research was on adults with glaucoma.

Two authors independently screened studies for inclusion and extracted data of included studies. The researchers assessed the quality of each RCT using a modified Jadad score for the RCTs and a modified Newcastle-Ottowa Score for the observational studies.

Applicability/external validity:

The authors note that a few studies monitored only the prostaglandin analogues or patients on monotherapy could bias the study population and make it less generalizable, as adherence to monotherapy is higher than to a regiment with multiple glaucoma medication.

Geographic focus

Included studies were conducted in high income settings, the authors did not discuss the applicability of findings to low- and middle-income settings.

Summary of quality assessment:

Medium confidence was attributed to this review as the authors did not conduct a thorough search of the literature to ensure that all levant studies were identified for inclusion. The authors did not search grey literature and did not contact authors/experts for further relevant studies. In addition, it is not clear if the authors restricted inclusion of studies written in other languages other than English.