Juliette G. M. M. Hoevenaars|Jan S.A.G. Schouten|Bart van den Borne|Henny J. M. Beckers|Carroll A.B. Webers
Will improvement of knowledge lead to improvement of compliance with glaucoma medication? Authors' reply
Maastricht University|Maastricht University|Maastricht University|Maastricht University|Maastricht University
editor would like thank mansouri shaarawy 2009 comments paper improvement knowledge lead improvement compliance glaucoma medication hoevenaars et al 2008 article suggest patient education population level remains important unlikely improving knowledge beyond current level greatly improve compliance glaucoma medication dutch patients mansouri shaarawy 2009 write findings contradiction positive correlation better understanding glaucoma compliance described three articles mackean elkington 1983 zimmerman zalta 1983 khandekar et al 2005 however study khandekar et al investigating noncompliance medical treatment among glaucoma patients oman comparable study firstly 676 khandekar et als study population illiterate small minority dutch population illiterate patient study population illiterate moreover khandekar et al explain development questionnaire used five questions investigate knowledge compared 37 items used stated adequate knowledge negatively associated noncompliance showed risk ratio 205 khandekar et al 2005 however apply correction confounding study presented unadjusted odds ratios well adjusted odds ratios item odds ratios adjusted age gender length time since diagnosis glaucoma educational level prescribed medication history laser therapy surgery zimmerman zalta described showing patients 10min video presenting basic information glaucoma treatment film reinforced booklet patients outlined daily schedules recorded medications dosages instillation times documented problems encountered patients also noted physicians medications booklet office personnel trained question instruct review reinforce patients also reviewed booklets praised compliance identified reasons noncompliance solved problems zimmerman zalta mentioned reinforcement programme patient education tailoring may efficient way help patient compliance provide safety sideeffects however investigate programme report results intervention article zimmerman zalta 1983 mackean elkington investigated knowledge glaucoma patients asking patients knew name eye condition patients knew glaucoma asked whether heard diagnosed much knew interviewers asked patients knew would happen treatment results showed patients knew name disease knew possible effect treatment compliant knowledge disease mechanism prediagnostic knowledge glaucoma found affect compliance however method measuring knowledge comparable method used systematically developed questionnaire based focusgroup interviews expert opinions pilot test used 37 items investigate knowledge glaucoma treatment mackean elkington 1983 mansouri shaarawy also refer unpublished data course judge unpublished data mansouri shaarawy 2009 state definition noncompliance unusual defined noncompliance missing one eyedrops last 4 weeks unusual definition different studies used varying definitions compliance different assessment methods several studies used strict definition amon et al 1990 chang et al 1991 bour et al 1993 patel spaeth 1995 laster et al 1996 tsai et al 2003 result 273 noncompliant patients corresponds findings reports used questionnaires bloch et al 1977 winfield et al 1990 pharmacy refill records gurwitz et al 1993 1998 electronic medication monitors kass et al 1986 assess compliance using definition noncompliance risk socially acceptable behaviour overestimation compliance diminished reports used less strict definition noncompliance definitions also arbitrary nobody tell correct cutoff value relevant noncompliance probably continuum relation outcome treatments agree mansouri shaarawy 2009 total level knowledge necessarily reflect useful knowledge patients however useful definition assess relation overall level knowledge compliance moreover limit definition also described correlation improved knowledge compliance per individual item questionnaire two 37 items showed statistically significant correlation knowledge compliance one item showed positive statistically significant correlation third comment mansouri shaarawy 2009 miscalculated statement effective response rate 595 incorrect study 60 ophthalmologists asked select four consecutive glaucoma patients fortyfour ophthalmologists participated thirtyfour returned four questionnaires two returned five five returned three two returned two one returned one therefore 166 questionnaires included study 44 ophthalmologists returned four questionnaires 176 questionnaires would included study performed preliminary statistical sample size calculations based response rate 50 target number 100 patients planned ask 200 patients participate study 95 confidence interval frequency one certain item would freq 196 freq 1 freq n12 event 100 responding patients frequency 10 95 confidence interval would 416 event 100 responding patients frequency 50 95 confidence interval would 4060 however 166 patients participated study 95 confidence interval 54146 event frequency 10 424576 event frequency 50 moreover statement 12 patients excluded various reasons alongside 11 patients provide compliance information correct indeed 11 patients fill often missed eyedrop according answers seven patients could classified compliant noncompliant four patients could determined compliant noncompliant eight patients use eyedrops glaucoma treatment excluded analysis total 12 patients excluded contrary 23 patients stated mansouri shaarawy 2009 cannot exclude possibility selection bias chance selection patients present time selection difficult assess case order however selection bias minimized asking ophthalmologists invite four consecutive patients participate selecting one patient ophthalmologist selecting patients one hospital nonrandomly selected hospitals pharmacy visits members glaucoma patient society would certainly led selection bias moreover asking ophthalmologists invite four consecutive patients workload minimized therefore best method reducing selection bias compared alternative methods addressed issue dyscompliance paper addressed important point another article olthoff et al 2008 however scope paper investigate issue mansouri shaarawy 2009 state recommendation contradiction earlier report socioeconomic determinants previous article defined socioeconomic classes based educational level found patients lower socioeconomic classes lower level knowledge glaucoma treatment investigate relationship lower socioeconomic class compliance therefore made suggestion suggestion better provision information specific items mentioned article patients lower socioeconomic groups could reduce risk becoming blind contribute earlier presentation glaucoma improve quality life adjust expectations reduce incidence adverse effects improve compliance hoevenaars et al 2006 contradiction study discussed mansouri shaarawy 2009 fully appreciate design study development questionnaire based systematic item selection focusgroup interviews consultation several experts questionnaire extensive contained 37 items knowledge glaucoma treatment interestingly enough mansouri shaarawy refer studies describe development questionnaires used questions knowledge compared alternative methods patient selection selection patients best method minimize selection bias improve participation levels ophthalmologists patients ophthalmologists patients received incentive participated moreover presented results adjusted confounding factors article state effect found study proven rather unlikely improving knowledge dutch glaucoma patients greatly improve compliance possible general level knowledge dutch glaucoma patients higher found countries example oman higher literacy levels easy solutions improve compliance compliance glaucoma medication based knowledge also behavioural aspects several reviews demonstrated successful compliance interventions complex include combinations educational behavioural affective components roter et al 1998 mcdonald et al 2002 kripalani et al 2007 sixteen 37 trials reported consistent improvement adherence interventions affected clinical outcomes significantly lot successful interventions contained multiple elements delivered time kripalani et al 2007 review reviews van dulmen et al 2007 showed positive effect patient education knowledge adherence effects knowledge appeared diminish time also showed technical interventions less frequent dosage resulted better adherence behavioural interventions relevant improving adherence roter et al 1998 found interventions combining cognitive behavioural affective components effective interventions focused one element alone therefore follow suggestion mansouri shaarawy 2009 improved knowledge greatly improve compliance outcome opinion important achieve general level knowledge glaucoma patients however high expectations improvement knowledge dutch population enhance compliance greatly knowledge items even correlated negatively compliance example knowing glaucoma condition progresses slowly without treatment correlated worse compliance intervention studies needed examine dimensions think complianceenhancing interventions focused reducing forgetfulness increasing usage dosing aids may benefit intervention based improvement knowledge thank mansouri shaarawy reading article carefully