By Brian Chou, O.D., F.A.A.O.
San Diego, Calif.
Most health care providers will say one-third of patients will follow instructions exactly, one-third will follow some instructions, and one-third will not follow any of your instructions. This may be especially true of contact lens wearers, among whom non-compliance is particularly pervasive; one study shows that 40 to 91% are non-compliant in recommended care and maintenance regimens.1
What"s Behind Non-Compliance
I"ve come across patients who have deliberately "stretched out" the recommended wearing time of their contact lenses because they heard conflicting information about manufacturers" recommended wearing times for different brands of similar lenses. Other patients simply don"t use the solution systems recommended by their doctors. Instead, they"ll buy the cheapest generic brand because they think all solutions are alike. Some patients don"t even know there"s a difference between saline and multi-purpose solutions and use the former to clean and disinfect!
Likewise, unless you make it clear, patients won"t understand that it may be best to use particular types of solution systems with particular types of lenses. For example, a recent study showed that PHMB-containing multipurpose solutions may invoke corneal staining in patients who wear extended-wear silicone hydrogel contact lenses, such as PureVision lenses, on a daily-wear schedule. Switching to non PHMBbased regimens usually eliminates this complication.2
We also need to be aware of some less common reasons for non-compliance. For example, we must keep in mind that a patient may not comply with printed instructions because he or she is unable to read or to completely comprehend them.3 Similarly, elderly patients may have mild cognitive impairments that prevent them from understanding or remembering what they are instructed to do.4
It"s Not Just the Patient. . . .
Before we place all the blame on patient stubbornness, confusion or misinformation, we must look at the broader picture. Much contact lens non-compliance stems from how little most patients value our services. At times, the marketing messages of lens manufacturers imply that patients can purchase contacts as they would appliances or other commodities. Have we made it clear that contact lenses are FDA Class II medical devices? Also, an episode of ABC TV"s 20/20 proved how easily consumers can bypass the eye doctor to buy from unlicensed vendors. Do patients know that contact lenses require a prescription by a licensed practitioner to ensure optimal eye health, vision, and comfort?
To be sure, equal responsibility lies on us as practitioners, for failing to communicate the importance of our expertise. As a whole, optometrists probably don"t fully educate patients about what is involved in the contact lens prescribing process. Mention a "contact lens fitting," for example, and the patient might visualize a session similar to trying on shoes to find the right fit. I prefer to talk to the patient about prescribing contact lenses -- a much more appropriate description of what we do. I do not use the term "trial contact lenses." Because these lenses are diagnostic tools used to finalize a prescription, I refer to them as "diagnostic contact lenses." Being careful about such terminology will create a greater perceived value of contact lens care. This helps correct misguided or misinformed attitudes and enhances compliance.
Creating the Compliant Patient
Even thorough patient education may not be enough to ensure compliance. A 1990 study showed that a "compliance enhancement strategy" including videos, booklets, posters, a checklist, a health care contract and free contact lens supplies had little significant effect on patient compliance levels.5
Encouraging compliance is an exercise in behavior modification. The only time you have to directly influence change is during scheduled appoinments. Therefore, be sure your staff also conveys the importance of compliance. Establish a patient recall system to phone patients who don"t show up for follow-ups and let them know you"re concerned.
Also, talk to your lens reps; many manufacturers have created programs aimed at improving compliance. For example, CIBA offers an electronic messaging service that reminds patients to replace their Night & Day lenses, and there"s a "built-in" compliance mechanism for Focus Dailies (the lenses become uncomfortable with too much wear).
One method my practice uses to raise lens replacement compliance is to prescribe premium monthly disposables such as CooperVision"s Proclear Compatibles. Many patients gravitate toward monthly disposability, perhaps because they associate changing lenses with turning the calendar, paying the mortgage, or other monthly activities. We also offer discounts or incentives, such as free shipping, to encourage the purchase of an annual supply.
Working in concert with your patient"s tendencies and not against them is perhaps the most effective key to assuring contact lens compliance. It may be a difficult and challenging project, but in the end both you and your patient will reap the rewards.
Dr. Chou (chou@refractivesource.com) is in group practice at Carmel Mountain Vision Care in San Diego. A frequent writer on refractive surgery and contact lenses, he completed a fellowship in cornea and external disease at the Jules Stein Eye Institute.
REFERENCES
1. Claydon BE, Efron N. Non-compliance in contact lens wear. Ophthalmic Physiol Opt 1994;14(4):356-64.
2. Jones L, MacDougall N, Sorbara LG. Asymptomatic corneal staining associated with the use of balafilcon silicone-hydrogel contact lenses disinfected with a polyaminopropyl biguanide-preserved care regimen. Optom Vis Sci 2002;79(12):753-61.
3. Mayeaux E, et al. Improving patient education for patients with low literacy skills. Am Fam Physician 1996;53:205-11.
4. Owens NJ, et al. Improving compliance in the older patient. In: Cramer JA, Spilker B, eds. Patient Compliance in Medical Practice and Clinical Trials. New York, NY: Raven Press, Ltd;1991:107-19.
5. Claydon BE, Efron N, Woods CA prospective study of the effect of education on non-compliant behaviour in contact lens wear. Ophthalmic Physiol Opt 1997;17(2):137-46.
