Dear Readers,
The quotation from Hippocrates warns physicians to Keep watch also on the faults of the patients which often make them lie about the taking of things prescribed. and it is occasionally replaced by or supplemented by C. Everett Koops observation that Drugs dont work in patients who dont take them.

The problem of poor patient adherence has been extensively researched. Healthcare providers play a unique and important role in assisting patients' healthy behavior changes. Adherence is a complex behavior that depends on a patient's decision-making process in response to health care advice and results in the patient taking none, some, or all of the advice. A variety of factors influence the patient's decision as to the burden versus the benefit of the recommendation. Adherence reflects the type of disease, its severity, the recommended treatment regimen, and the obstacles to care, as well as the characteristics of the patient and the provider. For patients to successfully integrate health care advice into their daily life, impediments to adherence and negative influences should be identified and minimized.

This issue of site news dedicates its focus on introduction to compliance,perceived and recognized barriers to compliance , strategies for enhancing patient compliance ,role of management in enhancing patient compliance, and successful strategies from other sectors of healthcare such as HIV, OSA, Bronchial Asthma and hypertension. The data in this issue can help shape a perspective for pragmatically conceptualizing and thinking about patient noncompliance.

The issue features www.alignmap.com website and podcast by Dr. Kim (Chief of Retina Clinic), Aravind Eye Hospital, Madurai.

Happy Reading!


Vision 2020 e-resource team
The Issue Features...
Vol. 6 No. 12 December 2009
•   Introduction to compliance
•   Barriers to compliance
•   Strategies for enhancing patient compliance
•   Role of management in enhancing patient compliance
•   Improving compliance - lesson to be learnt from other sectors
•  History of Ophthalmology
•   Featured personality
•   Featured Organisation
•   Talk to Us
•   Past Issues


The term compliance (or adherence) is a medical term that means the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication, or drug compliance, but may also mean use of medical appliances such as compression stockings, chronic wound care, self-directed physiotherapy exercises, or attending counseling or other courses of therapy.

An estimated half of those for whom medicines are prescribed do not take them correctly. Until recently, this was termed "non-compliance", and was sometimes regarded as irrational behavior or willful ignoring of instructions, although forgetfulness is probably a more common reason. Today, health care professionals prefer to talk about "adherence" to a regimen rather than "compliance".

This section provides a detailed overview of prevalence and incidence of noncompliance, myths surrounding adherence, need for compliance assessment and enhancement.


  • The article concludes that medical noncompliance is, by any measure and from any perspective, pervasive and that healthcares failure to successfully address such a problem comes at the cost of diminished outcomes, unnecessary expense, and avoidable patient morbidity and mortality.


  • This article talks about patient compliance myths and contradictions.


  • This report provides a critical review of what is known about adherence to long-term therapies. This is achieved by looking beyond individual diseases. By including communicable diseases such as tuberculosis and human immunodeficiency virus/acquired immunodeficiency syndrome; mental and neurological conditions such as depression and epilepsy; substance dependence (exemplified by smoking cessation);as well as hypertension, asthma and palliative care for cancer, a broad range of policy options emerges. Furthermore, this broader focus highlights certain common issues that need to be addressed with respect to all chronic conditions regardless of their cause. These are primarily related to the way in which health systems are structured, financed and operated.


  • It talks about the definition and impact of medication adherence in the elderly, Identifies factors affecting medication adherence in the elderly, Utilization of helpful assessment tools for medication adherence and apply intervention strategies to enhance medication adherence.


Noncompliance is potentially deleterious to pharmaceutical manufacturers, prescribers, dispensers, and most importantly patient and society as a whole. Barriers to compliance may be patient, therapy or clinician related. This section talks about various perceived and recognized barriers to cataract surgeries and other ocular therapies. It also presents a book that captures current issues and challenges in patient compliance to medications


The problem of patient non-adherence persists and a solution appears hard to be found, it continues to be important to look for new ways to further the issue. For enhancing adherence, the development of simple interventions originating from a multidisciplinary perspective including patients input, appears most promising. Disclosing patients perspectives requires open communication about patients expectations, needs and experiences in taking medication and about what might help them to become and remain adherent. This section captures many new innovative and successful compliance enhancing strategies.

Current Follow-Up Trend At Aravind Eye Hospital, Madurai
Glaucoma 48 61
  • Follow up card given to patient with time and date of next appointment written on it
  • Follow up date is given according to patient convenience.
  • Patient phone number is collected to remind regarding appointment.
  • Counseling staff writes postcard to patients who are not regular for follow up.
  • SMS alert is being planned
Uvea 72 84
Paediatric 53 76
Cataract 87 82
Neuro 62 70
Retina 54 63
Orbit 80 85
Cornea NA 85

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This section provides an in depth reading on managerial aspects of compliance. It talks about cost of noncompliance to healthcare provider. Different compliance models and programs followed currently and their relative effectiveness and ineffectiveness. It also provides strategy of Healthcare Alignment that focuses on infusing engagement model into every aspect of organization.


  • This article talks about direct consequences and costs of noncompliance.


  • It talks about current compliance models that implicitly require patients to behave rationally for the models to operate properly. The requirement that patients behave rationally severely restricts the clinical utility of these models and theories. Three of the most influential models, The Health Belief Model, The Transtheoretical Model, and Learning Theory, provide illuminating examples of this notion.


  • It talks about multitudes of programs and devices designed to enhance compliance. Most of these programs and devices are never scientifically tested. For the overwhelming majority of these devices and single-premise programs, there is little evidence of effective compliance enhancement for more than a small fraction of the patient population. The programs that show the most promise for effective compliance enhancement are typically multifaceted, well-staffed and resource-rich.


  • It talks about infusing the principles of the Engagement Model into every aspect of the organization. Focusing on implementing the best workable treatment plan for the patient rather than the patients compliance with an ideal treatment plan. Alignment of all stakeholders starts with explicit conversations between those stakeholders.


  • This article talks about Compliance models and programs where Some compliance enhancement programs and models work with some patients some of the time, but none work with all patients all the time.

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Despite the abundance of patient education information and advances in medical technology, there are large numbers of people who become incapacitated or debilitated by the conditions that could be treated or controlled effectively. This section talks about compliance improvement strategies applied in various diseases such as OSA, HIV, hypertension and Bronchial Asthma. It also captures different innovations implemented by pharmaceutical companies to increase patient adherence to medications.

* OSA- Obstructive Sleep Apnea
* HIV-Human Immunodeficiency Virus
* CPAP- Continuous Positive Airway Pressure


Do you know that

     ophthalmologist those days didnt know whether it was cataract or glaucoma?


SINCE the invention of the ophthalmoscope, improvements in diagnostic technology have provided an increasingly more refined definition of glaucoma. But in the centuries prior to that, the term glaucoma had been applied to a wide range of disparate conditions, according to Georgios Balanikas MD PhD, Katerini, Pieria, Greece.

At the 6th International Symposium of Glaucoma, Dr Balanikas provided an historical perspective on the study of glaucomatous pathology and its changing definitions from antiquity to the modern era.

He noted that the word glaucoma derives from the Greek 'glaukos' a word appearing in the works of Homer where it seems to mean a sparkling silver glare. Later the word was used for colours such as sky-blue or green. The word entered ophthalmology when Hippocrates, in his Aphorisms, lists among the infirmities of the aged a condition he called glaucosis which he associated with dimness of vision.

Aristotle did not mention any diseases called glaucoma although he helped create the foundation for research into the pathology of the disease. In his work On sense and sensible objects, he clearly refers to the aqueous humour, Dr Balanikas pointed out.

By the Roman era, most authors used the term glaucoma for what is now known as cataract. For example, Oribasius (325-400 AD) quotes Ruphus from Ephesus (1st century AD) as using the term for that condition of the crystalline body in which the same loses its original colour and instead becomes blue-grey. However, Archigenes, who practised at Rome in the time of Trajan (98-117 AD), used the term ophthalmos glaucos for a curable blindness that was not caused by cataract. Archigenes records that he used the juice of the deadly nightshade, a mydriatic, in the treatment of this condition, adding, the instilled juice of nightshade makes black the grey eyes. Around the same era, Galen (129-216 AD) defined glaucoma as a condition in which changes in fluids of the eye caused the pupil to become grey. He also refers to the mydriatic effect of nightshade. Aetius, the physician of the emperor Justinian (482-565) AD, and a great ophthalmologist, identified two forms of glaucoma, one a curable condition of the lens and the other an incurable condition that involved an effusion in which the pupil.


Dr. Carl Camras, M.D., Dr. Carl Camras, M.D., the University of Nebraska Medical Center physician whose research led to the discovery of the most effective drug for treating glaucoma. A native of Chicago, Dr. Camras devoted more than 20 years of his career to looking for a better drug to treat glaucoma. His quest began as an undergraduate student at Yale University and continued in medical school at Columbia University College of Physicians and Surgery. At Columbia, he studied under Laszlo Bito, Ph.D., a legendary researcher-novelist from Hungary who worked at Columbia from 1966 to 1998.

As a biochemistry major at Yale, Dr. Camras first conceived the idea that prostaglandins, a type of hormone found in virtually all tissues and organs, could lower the increased intraocular pressure that occurs with glaucoma. In 1996, using prostaglandins, Drs. Bito and Camras were the lead investigators in developing a new drug latanoprost for treatment of glaucoma.

The drug, sold under the trade name of Xalatan, was first marketed by Pharmacia. In short order, it became the most effective drug for the treatment of glaucoma. Since Xalatan was created, two additional glaucoma drugs using prostaglandins Travatan and Lumigan have reached the market place. With annual sales exceeding $2 billion, the three glaucoma drugs are by far the most lucrative ophthalmic pharmaceutical products in history.

Dr. Camras incredible research portfolio includes more than 280 published articles in scientific journals.

He served as chairman of the UNMC Department of Ophthalmology and Visual Sciences since 2000. He came to UNMC in 1991 as a tenured professor of ophthalmology. . Dr. Camras, was 55 when he died on 16 April, 2009.

Reference: http://app1.unmc.edu/publicaffairs/newsarchive/view_art.cfm?article_id=1878



Beyond Compliance, Adherence, and Concordance Supporting the Patients Implementation of Optimal Treatment

AlignMap.com is a workshop for developing an alternative approach to improving treatment implementation. The initial version of a pragmatic, readily operational procedure has been constructed by identifying effective strategies that offer utility to everyday healthcare practices from the patient compliance research and work in non-medical fields, adapting these ideas to the politics, economics, and ethics affecting contemporary healthcare, and organizing them into a logical and practical process. The essential catalyst to this Best Practices paradigm, however, has been the task of bringing the patient, the clinicians, and other stakeholders into alignment with a single, shared objective: to implement the best workable treatment plan for the patient. While further formatting, evaluation, and revision is ongoing, it may well be that this step is the key to improving outcomes, saving lives, decreasing costs, and revitalizing healthcare.


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Lions Aravind Institute of Community Ophthalmology,
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