Treatment compliance in amblyopia: A mini-review and description of a novel online platform for compliance tracking

Inside Out Medicine's patient flow models increased treatment compliance an d improved outcomes in amblyopia treatment. With no up-front investment on the part of the clinic or costs to families, Inside Out Medicine enables visibility into patient compliance at home and consultative opportunities. The patient flow model included real-time, daily data on patient compliance and improved communication between clinical staff and patients/families. Anecdotally, clinical staff reported that the new flow and platform allowed for greater confidence in management for providers and built a stronger provider-family relationship with parents who embrace its use.

Surv Ophthalmol. 2022 Nov-Dec;67(6):1685-1697. doi: 10.1016/j.survophthal.2022.08.003. Epub 2022 Aug 12.

Tinh Le 1, Faruk Örge 2

• Affiliations

  1. Center for Pediatric Ophthalmology and Adult Strabismus, Rainbow Babies and Children's Hospital and University Hospitals Cleveland Medical Center Eye Institute, Cleveland/Ohio/USA.

  2. Center for Pediatric Ophthalmology and Adult Strabismus, Rainbow Babies and Children's Hospital and University Hospitals Cleveland Medical Center Eye Institute, Cleveland/Ohio/USA. Electronic address: faruk.orge@uhhospitals.org.

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ABSTRACT

• Background

  Patient compliance with amblyopia therapies, including eye patching and atropine drops, is crucial for optimal visual acuity outcomes. Studies utilizing objective measures of compliance measurement have consistently shown that a majority of patients receive significantly less treatment than prescribed. We review the subjective and objective compliance rates reported in the literature, assess possible explanations for poor compliance, and describe studies of interventions to improve compliance. Additionally, we report our experience implementing Inside Out Care, a novel online platform designed to improve monitoring of amblyopia patient compliance, in our clinics. We have found that this platform, which is accessible via both computer and smartphone, has improved monitoring of amblyopia patient patching compliance, as well as allowed for enhanced doctor-patient communication.

• Interventions: Use of Inside Out Care

  Inside Out Care: A novel tool for compliance monitoring

  Inside Out Care (IOC) (Seattle, WA) is an secure, online, HIPAA-compliant platform (website) accessible via computer or smartphone that improves tracking of amblyopia treatment compliance and enhances doctor-patient communication. The platform is accessible to smartphones using both Apple and Android operating systems. The platform's main functionality is allowing patients’ parents to create a virtual “log” in which they record details of daily patching and/or atropine usage (hours patched per day, patches used per day, days of atropine drop usage). Additionally, the platform requests that parents upload a time-stamped photograph of their child's face as soon as they place the patch or as soon as their child's eye dilates following atropine instillation, and a second photo when the patch is removed, introducing a measure of objectivity to the logged treatment. This up-to-date log allows providers to remotely track compliance with treatment in the intervals between visits. Additionally, use of the tracking log over the course of months can provide a detailed record of treatment that, when correlated with changes in VA, could potentially be helpful in altering patching regimens on a patient-by-patient basis.

  Other platform functionalities include allowing patients to send messages to their care team, and providing links to educational materials and free patches. IOC is password-protected and HIPAA compliant, and is responsible for the security of all protected health information (including photographs) stored in the platform.

  The inclusion of timestamped pictures introduces an element of objectivity to the platform's tracking functionality. Although this is admittedly not as robust a method of objectively measuring compliance as ODMs, ODMs are potentially less cost-feasible for use in a large patient population, carry the potential for failure or loss by the patient, and require data download and battery replacement, while IOC requires no investment on the part of the clinic or parent, assuming the parent owns a computer or smartphone. See Figure 1 for a compilation of advantages and disadvantages associated with multiple methods of tracking patching compliance.

  We first implemented IOC in our clinics in July of 2020, and have since enrolled over 100 patients. Since implementation, the real-time tracking of patching compliance has been of use to providers in multiple ways, allowing them to quickly review recent compliance before a follow up, or to check in on a patient as frequently as desired in the time between visits. Additionally, we are in the process of developing a system by which clinic staff review the tracking log data of the patients for compliance and make phone calls for reminders and encouragement if needed. It is possible that this “observer effect” could also encourage compliance.93 Additionally, the photo-sharing element of IOC has allowed clinic staff to review actual patching technique. As has previously been reported, some proportion of families do apply a patch to their child, but either apply the patch incorrectly (i.e., applying the patch in such a way as to allow the child to peek over the patch) or patch the wrong eye.39 Upon reviewing actual pictures of families’ patching, clinic staff have been able to correct multiple parents’ technique.

  Now that IOC has been implemented in our outpatient clinics for over one year, we are beginning the process of collecting compliance and outcome data from patients enrolled in the platform. Of note, our group has presented posters regarding IOC at 2 national conferences, which have since been published in abstract form, including a subjective description of the platform, and description of initial results.49,50 In our initial results abstract, which featured a cohort of 65 patients, we found that the 12 patients who had had a follow up visit at least 60 days after platform enrollment had an average improvement in amblyopic eye visual acuity of 0.055 logMAR units.49

• Conclusions

  Compliance with amblyopia therapy is crucial for treatment success and has been shown to have a direct, dose-response relationship with improvement in visual acuity. Studies of objectively-measured patching compliance consistently reveal that most patients complete significantly less treatment than is prescribed. A variety of interventions to improve patching compliance have been described, often with programs focused on parental education and improving communication between patients’ families and the healthcare system. We describe a novel, online platform designed to improve tracking of compliance with amblyopia treatment by providing real-time, daily data on patient compliance, and to improve communication between clinical staff and patient families. Anecdotally, our experience with the platform is that it allows for greater confidence in management for providers and builds a stronger provider-family relationship for parents who embrace its use. We hope to share these findings at national conferences and in the literature in the coming months.

“We first implemented IOC in our clinics in July of 2020, and have since enrolled over 100 patients. Since implementation, the real-time tracking of patching compliance has been of use to providers in multiple ways, allowing them to quickly review recent compliance before a follow up, or to check in on a patient as frequently as desired in the time between visits.

“Additionally, the photo-sharing element of IOC has allowed clinic staff to review actual patching technique.”