The AGS Patient Care Improvement Project

Executive Summary

In glaucoma care, the issue of noncompliance continues to be a frustrating, seemingly intractable problem. Despite evidence that pressure control is instrumental in protecting against vision loss, a substantial number of patients don’t take their glaucoma medications as prescribed, fail to refill prescriptions and either delay follow-up appointments or miss them altogether. 

In an attempt to develop strategies to address and overcome this problem, the American Glaucoma Society (AGS) initiated the Patient Care Improvement Project. The project, which is the first large-scale patient care initiative conducted by the AGS, is supported by an unrestricted educational grant from Pfizer Ophthalmics

A Look at the Project

The initial goal of the project was to identify “best practice” ideas for enhancing and supporting patient compliance.

To fulfill this objective, the AGS Patient Care Committee began by soliciting ideas from ophthalmologists, allied health personnel (ophthalmic nurses and technicians) and patients themselves regarding perceived barriers to compliance.

A number of print and online sources were used to advertise this project, including the AGS-net, the

American Academy of Ophthalmology’s Academy Express and EyeNet Magazine, and the Glaucoma Research Foundation’s patient information newsletter. The AGS contracted with two experienced investigators at Vanderbilt University to construct an interactive Website, which was used to collect respondents’ descriptions of common reasons for noncompliance and recommended solutions for solving each problem. Initially, many of the responses were overly brief, so the Website was modified to request a longer and more detailed response. The responses were then evaluated and ranked according to their potential impact.

Issues Identified

With 400 registered participants (144 physicians, 120 support personnel and 136 patients), forgetfulness emerged as the leading barrier to compliance, with 31 percent of physicians, 26 percent of support personnel and 24 percent of patients identifying it as a significant barrier. Other common hurdles included patients’ lack of strength or dexterity, which prevents them from being able to open and use eye drop bottles as directed, difficulties with timing and scheduling, medication side effects and the cost of medications. After the grading committee evaluated and ranked ideas, 43 winning ideas were identified from 10 physicians, 10 support personnel and 10 patients. The winners were honored and awarded monetary prizes in November 2006 at Glaucoma Subspecialty Day, held in conjunction with the American Academy of

Ophthalmology’s Annual Meeting.

Future Directions

Now that the winning ideas have been identified, the AGS is in the process of fulfilling the second goal of the project: to develop a compendium of the winning ideas and disseminate this compendium to the ophthalmic community.

The compendium will be featured on the AGS Website,  HYPERLINK "" , as well as in printed educational and patient care materials, including those developed by the AAO.

A third component of the project— to stimulate further research on compliance—is also under way. Under the direction of the AGS Research Committee, a grant of $50,000 has been awarded for research into novel ideas in the area of compliance, adherence and persistence to therapy.

A Look at the Best Ideas

Of the 43 winning suggestions, some clearly require further research and development. But others could easily

be implemented by patients or in ophthalmology practices right away. Overall, the winning ideas fell into three categories:



These ranged from tips for jogging one’s memory to tracking and timing tools.

  • Memory aids. Solutions to the problem of forgetfulness included either developing a habitual way of taking drops (one patient, for instance, takes hers in alphabetical order) or associating the action of putting drops in with other habitual daily routines. Other recommended memory aids included printed forms that patients can consult and either check off or apply stickers to. As one provider noted, “Pictures of the drops have been very helpful to our patients.”
  •  Appointment reminders. Solutions to the perennial problem of getting patients to return for follow-up appointments ranged from the low-tech personal touch (notes and phone calls) to high-tech devices that could remind patients of upcoming appointments. For instance, one physician recommended having patients write themselves a note about their next appointment, which would then be mailed as the appointment date drew nearer. The “novelty of getting a letter from yourself” would remind the patient of how important the visit is, he said. On the high-tech side, a physician recommended a PDA device that could keep track of upcoming appointments and sound an alarm to alert patients and remind them that an appointment is coming up.
  •  Timing and tracking tools. Practical suggestions for how to keep track of drop instillation included using a household clock to time intervals between drops as well as using the alarm on a watch. For instance, one patient reported that she wears a watch that can be programmed with up to 12 daily alarms and text messages. “When the alarm sounds, I can read the text message.” Ideas for tracking tools included simple printed handouts and “white board” dry erase charts that present a drop schedule that can be checked off.



A number of respondents contributed ideas that warrant further consideration by the drug companies. For instance, basic bottle design needs to be reconsidered, they noted. Whether it’s the perpetual problem of getting drops to the eye consistently and accurately or simply knowing how much liquid is left in an individual bottle, eye drop bottles present a significant roadblock to compliance. It might even be time to “lobby for unit-dose medications with the drug companies,” one provider noted. “If they can do it with birth control pills, they can do it with glaucoma drops!”


THE SELF-CARE IMPULSE. The effectiveness of self-care in boosting compliance has been noted time and again in a number of health conditions, notably diabetes care. As numerous studies have found, involved patients who “buy in” to the idea of contributing to their own care tend to be healthier patients. Respondents suggested a number of ways to encourage glaucoma patients’ self-care efforts:

  • Highlight the consequences of not treating the disease. This might include developing tools that simulate vision loss. For instance, one provider created her own “virtual reality glasses,” etching visual field deficits in clear safety glasses. Another suggestion involved the voice of experience: Have patients talk to someone who has experienced vision loss.
  •  Use a team approach. Suggestions included developing a buddy system composed of fellow glaucoma patients who could then support and encourage one another—and even remind one another to keep appointments. At the office end, a patient education and support team could be developed, with one person serving as the point person for any patient questions.
  •  Enlist the patient’s input. Suggestions included sending out questionnaires with appointment reminders that solicit patient input on specific issues such as potential transportation problems that might prevent them from making it to an appointment.
  •  Provide educational materials. Basic information on glaucoma medications, disease progression and the need for follow-up care is always needed, whether it’s a patient compliance sheet or other reading materials.


PHYSICIAN AWARD WINNERS: Nicholas Bell, MD; Peter DeBry, MD; William Haynes, MD; Inci Irak-Dersu, MD; Brian Jacobs, MD; Worldster Lee, MD/ Bradford Lee; Paul A. Sidoti, MD; Joshua Stein, MD; Misha F. Syed, MD; Lisa G. Wohl, MD.


PROVIDER AWARD WINNERS: Carol Anderson; Cindy L. Blachly; Tulay Cakiner-Egilmez; Mona Carpenter; Kelly Cerrada; Wendy Houston; Amanda L. Lee; F. Andres Otalora; Mary Preston; Patricia Weikert.


PATIENT AWARD WINNERS: Sari Aber; Christine Appert; Riva Aidus Hemond; Mary J. King; Ruth Meserve; Lorraine Miller; Naga Narayanaswamy; Mary O’Connor; Elise Tripp; Elizabeth Wolfe.


AMERICAN GLAUCOMA SOCIETY QUALITY OF CARE SUBCOMMITTEE: Paul P. Lee, MD, JD; Richard P. Mills, MD, MPH; Anne L. Coleman, MD, PhD; Henry D. Jampel, MD; James C. Tsai, MD; Ronald L. Fellman, MD; Greg Skuta, MD; Richard P. Wilson, MD.


VANDERBILT RESEARCH TEAM: David G. Schlundt, PhD; James W. Pichert, PhD; Marion Fielder.


GRADING COMMITTEE VOLUNTEERS: Yara Catoira, MD; Richard Grostern, MD; Alan Robin, MD; Bhavna Sheth, MD; Jean Hill, RN, MSN, CRNO; Mary Kay Smit, COT; Patty Fisher; Sherry Holthe.