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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">The issue of adherence to phosphate binders</span><p id="par0005" class="elsevierStylePara elsevierViewall">Treatment adherence is one of the greatest challenges for medicine in general and Nephrology in particular&#46; Lack of adherence is especially important in those patients with chronic diseases and in those diseases in which a clear association is not observed between taking the drug and the benefit that is obtained&#46; Phosphate &#40;P&#41; binders would be part of this latter drug group&#44; with the added inconvenience that they must be taken with food or immediately after eating&#44; which <span class="elsevierStyleItalic">interferes considerable with the individual&#39;s lifestyle and habits</span>&#46; This&#44; along with other reasons we shall discuss&#44; explains how the percentage of non-compliance for P binders exceeds 50&#37; in most studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2</span></a> which has a clear repercussion on morbidity and mortality in patients who do not achieve the therapeutic objectives recommended by the clinical practice guidelines&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">What are the causes of non-adherence to phosphate binders&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Traditionally both <span class="elsevierStyleItalic">treatment regimen complexity</span> &#40;for example&#44; the frequency or amount of tablets to take&#41;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> as well as <span class="elsevierStyleItalic">lack of information and lack of knowledge</span> about the use of the drug have been identified as negatively influencing adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> In this sense&#44; P binders account for more than half of the daily tablets taken by the dialysis patient&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> Patients find it difficult to understand the true importance of high P levels on their survival and morbidity&#44; since there is no direct repercussion between taking the P binder and symptoms&#46; Simplifying the administration regimen and increasing the patient&#39;s information are fundamental elements&#44; but only offer a partial solution to the problem&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> One study conducted in a haemodialysis unit showed that patients with high P levels were the ones who best knew the importance of controlling it and the utility of the P binders&#44; which demonstrated that&#44; despite the information&#44; there are other causes of non-adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are two types of non-adherence<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a>&#58; 1&#41; <span class="elsevierStyleItalic">Unintentional</span>&#58; the patients do not comply with the treatment because they are unable or do not have the resources to do so&#46; They may forget to take the drug&#59; be unable to buy the prescriptions or go to the hospital to obtain the medication&#59; they may not know how to take it properly &#40;for example&#58; always with food&#44; including &#8220;snacks&#8221; and not just with the main meals&#41; or how to take it effectively &#40;for example lanthanum carbonate chewed or well ground&#41;&#46; These are <span class="elsevierStyleItalic">practical barriers</span> to adherence&#46; 2&#41; <span class="elsevierStyleItalic">Intentional&#58;</span> the patients do not comply because they consciously decided not to do so because of their own beliefs or preferences&#46; These are <span class="elsevierStyleItalic">perceived barriers</span> to adherence&#46; In this case&#44; motivation becomes essential to obtaining appropriate adherence results&#46; This is one of the most difficult challenges to overcome&#44; but we as doctors&#44; are capable to act on it&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In a study conducted on haemodialysis&#44; nearly 25&#37; of patients did not take the medication when they left the house or were with friends&#44; and among the highest risk patient groups were those who had a more active &#8220;social life&#8221; who were embarrassed or uncomfortable of taking medication when going out&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> Another factor that influenced treatment adherence were the patient <span class="elsevierStyleItalic">preferences</span>&#46; More than 50&#37; of the patients on haemodialysis did not like the P binder that had been prescribed to them&#44; and those who took P binders they did not like had a higher risk of presenting uncontrolled P levels&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> The main reasons they did not like the drug were&#58; gastrointestinal intolerance &#40;stomach upset&#44; diarrhoea&#44; constipation&#44; etc&#46;&#41;&#59; bad taste&#44; tablets were too big&#44; difficult to swallow&#44; or chew&#59; preferences for dosage forms different from what was administered to them&#44; etc&#46; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">How to improve adherence to phosphate binders</span><p id="par0025" class="elsevierStylePara elsevierViewall">Lack of treatment adherence&#44; as deduced from the above&#44; is a problem with a multifactorial origin&#46; Therefore being able to provide an adequate solution in each case requires a certain knowledge about the patient personality and habits&#58; it is essential to personalise the strategies and different professionals have to be involved &#40;physicians&#44; nurses&#44; nutritionists&#44; psychologists&#44; social workers&#41; as a multidisciplinary team that approaches this problem from all the necessary angles&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">First&#44; the healthcare profession should approach and investigate the practice of non-adherence&#46; In clinical practice it is common to evaluate the non-adherence directly and subjectively&#46; However&#44; this approach&#44; when compared with other methods&#44; considerably underestimates non-adherence in patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">10&#44;11</span></a> This prevents the identification of many non-adherent patients&#44; with no opportunity to intervene in their behaviour and&#46; In addition&#44; therapeutic approaches with a high degree of empiricism may lead us to unnecessary increase of the drug dosage&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Once non-adherence is identified&#44; the next step is to detect the type of non-adherence&#44; i&#46;e&#46; whether it has to do with practical barriers or perceived barriers&#46; Practical barriers may be relatively easy to identify and resolved&#46; However&#44; the true challenge for professionals comes from those patients who do not comply because they consciously decided not to&#44; due to their own beliefs or preferences&#46; The relationship established between the healthcare professionals and the patients is essential in this type of non-adherence&#46; We have already observed that&#44; although important&#44; it is not sufficient to simplify the treatment regimen or to give scientific information about the drug&#39;s utility&#46; It is not enough to repeat to the patient after every blood test that they should take the medication and continue increasing the P-binder dose to obtain the desired therapeutic effect&#46; A higher number of tablets is associated with a worse health-related quality of life &#40;HRQOL&#41; and increasing the number of binder tablets does not seem to improve control and can have the cost of worsening HRQOL&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> Better adherence&#44; better HRQOL&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The relationship between physicians and their patients is something more than a mere technical act&#46; It is a true human interaction&#44; with the emotional content that goes along with it&#46; To achieve adequate treatment adherence&#44; especially for P binders&#44; the physician should not be limited to the patient&#39;s biological aspects &#40;for examples elevated serum P levels&#41;&#44; but should also know the environment the patient is in&#44; their habits&#44; their motivations&#44; the way they experience their disease&#44; what are their concerns&#44; the difficulties they face&#59; in short&#44; their values&#44; opinions&#44; expectations&#44; beliefs and preferences&#58; a patient-centred model of communication&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> This creates a climate that encourages them to participate in generating and pursuing a treatment strategy&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The manner how healthcare professionals communicate with patients may encourage motivation&#44; or do the opposite&#46; It is not uncommon to hear patients claiming that they want an &#8220;&#224; la carte&#8221; treatment&#46; A change is needed&#44; since the professional approaching the patient as an individual with the ability to make decisions may result in improvement of long-term adherence&#44; especially with P binders that interfere significantly with the individual&#39;s lifestyle and habits&#46; This personalised &#8220;&#224; la carte&#8221; treatment&#44; adjusted to the patient&#39;s preferences may facilitate the achievement of treatment objectives that may not be accomplished by increasing the dose&#44; simplifying the treatment or educating the patient about the risks of having a poor control of P&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Professionals&#8217; attitudes must be directed to increase patient&#39;s motivation to take the medication on their own and helping them to overcome the barriers that the patient may be facing&#46; Education on diets to increase the patient&#39;s knowledge about the P content of foods and the &#8220;hidden sources&#8221; of phosphorus is part of the strategy&#46; Teaching them which foods have a high P content and providing alternatives foods with lower inorganic P content<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> will not only encourage treatment compliance&#44; by decreasing the needs for P binders&#44; but will also help to motivate and involve the patient in self care&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore it is important to change our physician&#8211;patient communication model&#46; A discussion with the patient on the convenience to patient&#39;s change should be avoided&#44; because this leads to rejection&#59; arguments and attempts to convince the patient tend to cause opposition to the indications&#44; suggestions&#44; or orders needed to achieve a change&#46; This opposition frequently arises if the patient has the perception that his ability to choose is limited and&#44; in general&#44; when his sense of freedom is constrained&#46; Certain attitudes should be avoided&#44; such as&#58; trying to impose a change for &#8220;their own good&#8221;&#59; implicitly or explicitly suggesting that the healthcare relationship brings an obligation to change&#59; arguing with the patients about not changing&#59; etc&#46; Furthermore&#44; believing in the possibility of changing is an important motivational factor&#44; influencing the ability to initiate and maintain new habits&#46; Having previous satisfactory results reinforces the patient&#39;s self confidence in his ability to achieve targets&#46; We will help the patient by analysing with him the results obtained which will enhance their positivity &#40;&#8220;It is difficult to take the P binders&#44; but you have done it&#8221;&#41;&#46; We cannot forget that the patients are responsible for choosing and making the change and we help them if they wish&#46; All these elements are part of the &#8220;motivational interview&#8221; that has been demonstrated to be effective in improving treatment adherence&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">16&#8211;18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our haemodialysis unit&#44; we have observed an improvement in treatment adherence versus the prior results in which other measures were used &#40;arguing&#44; insisting&#44; convincing&#44; increasing medication&#41;&#44; by taking into account the patients&#8217; preferences&#46; &#8220;Intentional&#8221; non-adherence fell&#44; going from 38&#46;4&#37; to 23&#46;3&#37;&#44; and it was especially significant in the patient group with the worst P control &#40;P<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; which went from 63&#46;6&#37; &#8220;intentional&#8221; non-adherence to 36&#46;3&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; after 24 months&#44; with a significant decrease in the serum P levels &#91;6&#46;63<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;0&#46;98&#41; to 4&#46;45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;10&#46;12&#41;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#93; with a significantly lower number of phosphate-binder tablets &#91;7&#46;76 &#40;3&#46;60&#41; to 5&#46;92 &#40;2&#46;7&#41;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#93;&#46; &#8220;Unintentional&#8221; non-adherence did not show any change&#44; as was also observed in other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> since forgetting occasionally to take a tablet requires other strategies as an approach and likely has a smaller repercussion on P levels&#46; Measuring adherence through questionnaires &#40;SMAQ&#41;&#44; with those that also measure &#8220;unintentional&#8221; non-adherence may explain the differences in results found between non-adherence measured by high P levels and non-adherence measured by specific questionnaires&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Lack of treatment adherence in chronic kidney disease patients is a problem of great clinical significance with repercussions on morbidity and mortality&#59; therefore healthcare professionals who care for these patients should pay appropriate attention to detect it&#46; It is necessary to implement a strategy to improve treatment compliance&#44; acting on the clinical and psychosocial factors that interfere in each specific case on treatment adherence&#46; As for improving adherence with P binders&#44; we should act specifically on the treatment complexity&#44; on the patients&#8217; knowledge about the utility of these drugs and dietary P content&#44; but essentially&#44; we should establish adequate physician-patient communication that allows us to learn about the patients&#8217; difficulties&#44; their preferences&#44; their lifestyle and habits&#46; This helps us to choose with the patient the treatment that is best suited to their needs and encourages adherence&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arenas Jimenez MD&#44; Alvarez-Ude Cotera F&#46; Estrategias para mejorar la adherencia a los captores del f&#243;sforo&#58; un reto en la relaci&#243;n m&#233;dico paciente&#46; Nefrologia&#46; 2016&#59;36&#58;583&#8211;586&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#46; Regimen complexity in quantity and frequency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Lack of knowledge about the drug&#39;s utility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Lack of association between phosphate binders with the symptom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; Practical barriers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; High interference with the patient&#39;s lifestyle and habits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&#46; Preferences&#58; flavour&#44; digestive upset&#44; uncomfortable to take&#44; size&#44; dosage form&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46; Beliefs&nbsp;\t\t\t\t\t\t\n
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Editorial
Strategies to improve adherence to phosphate binder therapy. A challenge to the relationship doctor–patient
Estrategias para mejorar la adherencia a los captores del fósforo: un reto en la relación médico paciente
M. Dolores Arenas Jimeneza,
Corresponding author
lola@olemiswebs.net

Corresponding author.
, Fernando Alvarez-Ude Coterab
a Vithas Hospital Perpetuo Internacional, Alicante, Spain
b Hospital General de Segovia, Segovia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">The issue of adherence to phosphate binders</span><p id="par0005" class="elsevierStylePara elsevierViewall">Treatment adherence is one of the greatest challenges for medicine in general and Nephrology in particular&#46; Lack of adherence is especially important in those patients with chronic diseases and in those diseases in which a clear association is not observed between taking the drug and the benefit that is obtained&#46; Phosphate &#40;P&#41; binders would be part of this latter drug group&#44; with the added inconvenience that they must be taken with food or immediately after eating&#44; which <span class="elsevierStyleItalic">interferes considerable with the individual&#39;s lifestyle and habits</span>&#46; This&#44; along with other reasons we shall discuss&#44; explains how the percentage of non-compliance for P binders exceeds 50&#37; in most studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2</span></a> which has a clear repercussion on morbidity and mortality in patients who do not achieve the therapeutic objectives recommended by the clinical practice guidelines&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">What are the causes of non-adherence to phosphate binders&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Traditionally both <span class="elsevierStyleItalic">treatment regimen complexity</span> &#40;for example&#44; the frequency or amount of tablets to take&#41;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> as well as <span class="elsevierStyleItalic">lack of information and lack of knowledge</span> about the use of the drug have been identified as negatively influencing adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> In this sense&#44; P binders account for more than half of the daily tablets taken by the dialysis patient&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> Patients find it difficult to understand the true importance of high P levels on their survival and morbidity&#44; since there is no direct repercussion between taking the P binder and symptoms&#46; Simplifying the administration regimen and increasing the patient&#39;s information are fundamental elements&#44; but only offer a partial solution to the problem&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> One study conducted in a haemodialysis unit showed that patients with high P levels were the ones who best knew the importance of controlling it and the utility of the P binders&#44; which demonstrated that&#44; despite the information&#44; there are other causes of non-adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are two types of non-adherence<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a>&#58; 1&#41; <span class="elsevierStyleItalic">Unintentional</span>&#58; the patients do not comply with the treatment because they are unable or do not have the resources to do so&#46; They may forget to take the drug&#59; be unable to buy the prescriptions or go to the hospital to obtain the medication&#59; they may not know how to take it properly &#40;for example&#58; always with food&#44; including &#8220;snacks&#8221; and not just with the main meals&#41; or how to take it effectively &#40;for example lanthanum carbonate chewed or well ground&#41;&#46; These are <span class="elsevierStyleItalic">practical barriers</span> to adherence&#46; 2&#41; <span class="elsevierStyleItalic">Intentional&#58;</span> the patients do not comply because they consciously decided not to do so because of their own beliefs or preferences&#46; These are <span class="elsevierStyleItalic">perceived barriers</span> to adherence&#46; In this case&#44; motivation becomes essential to obtaining appropriate adherence results&#46; This is one of the most difficult challenges to overcome&#44; but we as doctors&#44; are capable to act on it&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In a study conducted on haemodialysis&#44; nearly 25&#37; of patients did not take the medication when they left the house or were with friends&#44; and among the highest risk patient groups were those who had a more active &#8220;social life&#8221; who were embarrassed or uncomfortable of taking medication when going out&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> Another factor that influenced treatment adherence were the patient <span class="elsevierStyleItalic">preferences</span>&#46; More than 50&#37; of the patients on haemodialysis did not like the P binder that had been prescribed to them&#44; and those who took P binders they did not like had a higher risk of presenting uncontrolled P levels&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> The main reasons they did not like the drug were&#58; gastrointestinal intolerance &#40;stomach upset&#44; diarrhoea&#44; constipation&#44; etc&#46;&#41;&#59; bad taste&#44; tablets were too big&#44; difficult to swallow&#44; or chew&#59; preferences for dosage forms different from what was administered to them&#44; etc&#46; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">How to improve adherence to phosphate binders</span><p id="par0025" class="elsevierStylePara elsevierViewall">Lack of treatment adherence&#44; as deduced from the above&#44; is a problem with a multifactorial origin&#46; Therefore being able to provide an adequate solution in each case requires a certain knowledge about the patient personality and habits&#58; it is essential to personalise the strategies and different professionals have to be involved &#40;physicians&#44; nurses&#44; nutritionists&#44; psychologists&#44; social workers&#41; as a multidisciplinary team that approaches this problem from all the necessary angles&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">First&#44; the healthcare profession should approach and investigate the practice of non-adherence&#46; In clinical practice it is common to evaluate the non-adherence directly and subjectively&#46; However&#44; this approach&#44; when compared with other methods&#44; considerably underestimates non-adherence in patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">10&#44;11</span></a> This prevents the identification of many non-adherent patients&#44; with no opportunity to intervene in their behaviour and&#46; In addition&#44; therapeutic approaches with a high degree of empiricism may lead us to unnecessary increase of the drug dosage&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Once non-adherence is identified&#44; the next step is to detect the type of non-adherence&#44; i&#46;e&#46; whether it has to do with practical barriers or perceived barriers&#46; Practical barriers may be relatively easy to identify and resolved&#46; However&#44; the true challenge for professionals comes from those patients who do not comply because they consciously decided not to&#44; due to their own beliefs or preferences&#46; The relationship established between the healthcare professionals and the patients is essential in this type of non-adherence&#46; We have already observed that&#44; although important&#44; it is not sufficient to simplify the treatment regimen or to give scientific information about the drug&#39;s utility&#46; It is not enough to repeat to the patient after every blood test that they should take the medication and continue increasing the P-binder dose to obtain the desired therapeutic effect&#46; A higher number of tablets is associated with a worse health-related quality of life &#40;HRQOL&#41; and increasing the number of binder tablets does not seem to improve control and can have the cost of worsening HRQOL&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> Better adherence&#44; better HRQOL&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The relationship between physicians and their patients is something more than a mere technical act&#46; It is a true human interaction&#44; with the emotional content that goes along with it&#46; To achieve adequate treatment adherence&#44; especially for P binders&#44; the physician should not be limited to the patient&#39;s biological aspects &#40;for examples elevated serum P levels&#41;&#44; but should also know the environment the patient is in&#44; their habits&#44; their motivations&#44; the way they experience their disease&#44; what are their concerns&#44; the difficulties they face&#59; in short&#44; their values&#44; opinions&#44; expectations&#44; beliefs and preferences&#58; a patient-centred model of communication&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> This creates a climate that encourages them to participate in generating and pursuing a treatment strategy&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The manner how healthcare professionals communicate with patients may encourage motivation&#44; or do the opposite&#46; It is not uncommon to hear patients claiming that they want an &#8220;&#224; la carte&#8221; treatment&#46; A change is needed&#44; since the professional approaching the patient as an individual with the ability to make decisions may result in improvement of long-term adherence&#44; especially with P binders that interfere significantly with the individual&#39;s lifestyle and habits&#46; This personalised &#8220;&#224; la carte&#8221; treatment&#44; adjusted to the patient&#39;s preferences may facilitate the achievement of treatment objectives that may not be accomplished by increasing the dose&#44; simplifying the treatment or educating the patient about the risks of having a poor control of P&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Professionals&#8217; attitudes must be directed to increase patient&#39;s motivation to take the medication on their own and helping them to overcome the barriers that the patient may be facing&#46; Education on diets to increase the patient&#39;s knowledge about the P content of foods and the &#8220;hidden sources&#8221; of phosphorus is part of the strategy&#46; Teaching them which foods have a high P content and providing alternatives foods with lower inorganic P content<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> will not only encourage treatment compliance&#44; by decreasing the needs for P binders&#44; but will also help to motivate and involve the patient in self care&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore it is important to change our physician&#8211;patient communication model&#46; A discussion with the patient on the convenience to patient&#39;s change should be avoided&#44; because this leads to rejection&#59; arguments and attempts to convince the patient tend to cause opposition to the indications&#44; suggestions&#44; or orders needed to achieve a change&#46; This opposition frequently arises if the patient has the perception that his ability to choose is limited and&#44; in general&#44; when his sense of freedom is constrained&#46; Certain attitudes should be avoided&#44; such as&#58; trying to impose a change for &#8220;their own good&#8221;&#59; implicitly or explicitly suggesting that the healthcare relationship brings an obligation to change&#59; arguing with the patients about not changing&#59; etc&#46; Furthermore&#44; believing in the possibility of changing is an important motivational factor&#44; influencing the ability to initiate and maintain new habits&#46; Having previous satisfactory results reinforces the patient&#39;s self confidence in his ability to achieve targets&#46; We will help the patient by analysing with him the results obtained which will enhance their positivity &#40;&#8220;It is difficult to take the P binders&#44; but you have done it&#8221;&#41;&#46; We cannot forget that the patients are responsible for choosing and making the change and we help them if they wish&#46; All these elements are part of the &#8220;motivational interview&#8221; that has been demonstrated to be effective in improving treatment adherence&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">16&#8211;18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our haemodialysis unit&#44; we have observed an improvement in treatment adherence versus the prior results in which other measures were used &#40;arguing&#44; insisting&#44; convincing&#44; increasing medication&#41;&#44; by taking into account the patients&#8217; preferences&#46; &#8220;Intentional&#8221; non-adherence fell&#44; going from 38&#46;4&#37; to 23&#46;3&#37;&#44; and it was especially significant in the patient group with the worst P control &#40;P<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; which went from 63&#46;6&#37; &#8220;intentional&#8221; non-adherence to 36&#46;3&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; after 24 months&#44; with a significant decrease in the serum P levels &#91;6&#46;63<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;0&#46;98&#41; to 4&#46;45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;10&#46;12&#41;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#93; with a significantly lower number of phosphate-binder tablets &#91;7&#46;76 &#40;3&#46;60&#41; to 5&#46;92 &#40;2&#46;7&#41;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#93;&#46; &#8220;Unintentional&#8221; non-adherence did not show any change&#44; as was also observed in other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> since forgetting occasionally to take a tablet requires other strategies as an approach and likely has a smaller repercussion on P levels&#46; Measuring adherence through questionnaires &#40;SMAQ&#41;&#44; with those that also measure &#8220;unintentional&#8221; non-adherence may explain the differences in results found between non-adherence measured by high P levels and non-adherence measured by specific questionnaires&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Lack of treatment adherence in chronic kidney disease patients is a problem of great clinical significance with repercussions on morbidity and mortality&#59; therefore healthcare professionals who care for these patients should pay appropriate attention to detect it&#46; It is necessary to implement a strategy to improve treatment compliance&#44; acting on the clinical and psychosocial factors that interfere in each specific case on treatment adherence&#46; As for improving adherence with P binders&#44; we should act specifically on the treatment complexity&#44; on the patients&#8217; knowledge about the utility of these drugs and dietary P content&#44; but essentially&#44; we should establish adequate physician-patient communication that allows us to learn about the patients&#8217; difficulties&#44; their preferences&#44; their lifestyle and habits&#46; This helps us to choose with the patient the treatment that is best suited to their needs and encourages adherence&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arenas Jimenez MD&#44; Alvarez-Ude Cotera F&#46; Estrategias para mejorar la adherencia a los captores del f&#243;sforo&#58; un reto en la relaci&#243;n m&#233;dico paciente&#46; Nefrologia&#46; 2016&#59;36&#58;583&#8211;586&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#46; Regimen complexity in quantity and frequency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Lack of knowledge about the drug&#39;s utility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Lack of association between phosphate binders with the symptom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; Practical barriers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; High interference with the patient&#39;s lifestyle and habits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&#46; Preferences&#58; flavour&#44; digestive upset&#44; uncomfortable to take&#44; size&#44; dosage form&nbsp;\t\t\t\t\t\t\n
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Idiomas
Nefrología (English Edition)
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?