Learning How to Implement Glaucoma Coaching in Academic Medical Centers from a Successful Clinical Trial using Implementation Science.

Purpose

To evaluate implementation of the Support, Educate, Empower (SEE) personalized glaucoma coaching program.

Design

Prospective, two-site randomized clinical trial with an implementation evaluation using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework and the Consolidated Framework for Implementation Research (CFIR).

Participants

Adults aged ≥40 years with glaucoma, glaucoma suspect, or ocular hypertension and poor self-reported medication adherence who were prescribed ≥1 glaucoma medication (n=236 enrolled; additional screened individuals declined [n=1,750] or were ineligible [n=1,701]). Stakeholders (n=8) and participants (n=32) contributed qualitative data.

Methods

Participants were randomized to a motivational interviewing (MI)-based glaucoma coaching intervention (SEE program) or standard education. Reach was assessed by comparing demographics across recruitment stages. Effectiveness was evaluated by changes in medication adherence, coach autonomy support, and attrition. Implementation fidelity was measured using counselor MI competency scores (passing ≥5). Adoption and maintenance were evaluated through CFIR-guided interviews, post-intervention adherence monitoring, and cost estimates.

Main outcome measures

Glaucoma medication adherence, program reach, implementation fidelity (MI competency scores), qualitative, stakeholder-informed measures of adoption and maintenance, including post-intervention adherence and program cost.

Results

Of 2057 individuals screened, 356 (17.3%) were eligible, of which 236 (66.3%) enrolled; no demographic differences were observed between enrollees and non-enrollees, however those who declined screening (n=1750) were older and more likely to be White (both p<0.0001) . Adherence was better with personalized coaching than standard education (77.6%±19.7% versus 58.0%±25.2%; p<0.001). MI fidelity was high (mean score 5.7). Facilitators of implementation included participant engagement and workflow compatibility, while barriers included limited awareness, resource constraints, and concerns about financial sustainability. Participants reported improved engagement and motivation. 84% of participants continued monitoring after counseling ended; adherence declined by 10.0%±21.1% at 1 month and an additional 3.6%±11.7% by 2 months and remained below intervention levels thereafter. A coach could manage approximately 431 patients per year, with an estimated net revenue of $19,272 annually after costs.

Conclusions

The SEE MI-based program demonstrated high fidelity and improved adherence during the intervention. Post-intervention adherence decline demonstrates the need for continued coaching. Strong uptake, stakeholder support, and projected reimbursement suggest feasibility and organizational sustainability in clinical practice.