Date of publication: June 6, 2014

News & Views

Adherence (Part 7) – Improving adherence through increased patient education

Educational interventions have been found to increase adherence in multiple diseases, although reported effects have been inconsistent and studies have largely been short-term.[1] In this article we review whether patient education can similarly improve adherence to phosphate binder medication.

Educational programmes can improve patient adherence

Several studies have shown that educational sessions or programs regarding phosphate management have led to improved adherence and/or treatment outcomes.

  • In a randomized controlled trial of 56 dialysis patients, those who attended one-to-one teaching sessions, aimed at improving patients’ knowledge of phosphate management, showed a significant reduction in serum phosphorus concentrations compared to control.[2]
  • Gardulf et al. studied 43 CKD patients (most on dialysis) attending a 2-month educational program regarding calcium and phosphate balance, food intake and phosphate binders. The group exhibited significantly reduced plasma phosphate for up to 12 months afterwards.[3]
  • A nurse-led educational and counselling session provided to 41 patients on phosphate binders resulted in an increase in adherence from 83% to 94% after 13 weeks. The control group’s adherence decreased from 86% to 76%.[4]
  • Another nurse-led education program over 12 weeks saw a significant improvement in the proportion of patients who took their phosphate binder correctly, increasing from 44 to 72%, although this did not lead to a statistically significant change in clinical markers.[5]
  • A “Phosphate Education Program” in children with CKD used ‘phosphorus units’ to allow patients to quickly estimate phosphorus content in foods and self-adjust binder dosing. Within 6 weeks after training, the percentage of children with serum phosphate outside of the target range dropped from 63% to 31%.[6]

While these studies suggest benefits from patient education regarding phosphate management, there is a clear need for a randomized controlled trial evaluating educational interventions over an extended period. This is in line with a 2008 Cochrane Review of interventions for enhancing adherence across multiple conditions, which concluded that “high priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.”[1]

Patients would like more information about phosphate management

This need for further research is especially apparent when we consider patients’ current levels of understanding about their treatment goals. In one study, 84% of surveyed patients had heard of phosphate, but 42% were unsure of high phosphate foods and 46% were unaware of consequences of elevated phosphate.[7] This Australian study also revealed an interesting symmetry between patients and nephrologists:

  • 74% of patients wanted to know more about CKD-MBD (40% via written material),
  • 84% of nephrologists believed that their patients wanted to know more about CKD-MBD, but
  • Only 28% provided written patient materials on CKD-MBD.

Adherence to phosphate binders: a quick summary

We have reviewed the topic of adherence over the past few weeks on COMPACT Renal. In summary:

  • Adherence to phosphate binder therapies in dialysis patients is poor, with approximately half of patients non-adherent
  • Non-adherence to phosphate binders is associated with poor control of serum phosphorus which is associated in turn with worse disease outcomes
  • While non-adherence is a complex, multifactorial problem, there are a number of potentially modifiable factors that clinicians could address in order to improve compliance
  • Reducing pill burden and optimizing therapies to improve tolerability are two possible approaches that may bring specific benefits in dialysis patients
  • Simplifying dosing regimens and improving patient education may also lead to improved medication adherence

See also the previous Adherence articles:

March 24th, 2014; Adherence Part 1 – The challenge of non-adherence in hyperphosphatemia

April 11th, 2014; Adherence Part 2 – Is adherence to phosphate binder therapy associated with improved outcomes?

April 24th, 2014; Adherence Part 3 – Why do patients not adhere to therapies?

May 6th, 2014; Adherence Part 4 – Why do patients not adhere to phosphate binders:poor tolerability?

May 16th, 2014; Adherence Part 5 – Why do patients not adhere to phosphate binders:high pill burden?

May 22nd, 2014; Adherence Part 6 – Improving adherence through treatment optimization and simplifying regimens


1. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2008. Available at: Accessed March 19, 2014.

2. Ashurst I de B, Dobbie H. A randomized controlled trial of an educational intervention to improve phosphate levels in hemodialysis patients. J Ren Nutr Off J Counc Ren Nutr Natl Kidney Found. 2003;13(4):267-274.

3. Gardulf A, Pålsson M, Nicolay U, Swedish Renal Nurse Group. Education for dialysis patients lowers long-term phosphate levels and maintains health-related quality of life. Clin Nephrol. 2011;75(4):319-327.

4. Van Camp YP, Huybrechts SA, Van Rompaey B, Elseviers MM. Nurse-led education and counselling to enhance adherence to phosphate binders. J Clin Nurs. 2012;21(9-10):1304-1313. doi:10.1111/j.1365-2702.2011.03967.x.

5. Sandlin K, Bennett PN, Ockerby C, Corradini A-M. The impact of nurse-led education on haemodialysis patients’ phosphate binder medication adherence. J Ren Care. 2013;39(1):12-18. doi:10.1111/j.1755-6686.2013.00343.x.

6. Ahlenstiel T, Pape L, Ehrich JHH, Kuhlmann MK. Self-adjustment of phosphate binder dose to meal phosphorus content improves management of hyperphosphataemia in children with chronic kidney disease. Nephrol Dial Transplant Off Publ Eur Dial Transpl Assoc – Eur Ren Assoc. 2010;25(10):3241-3249. doi:10.1093/ndt/gfq161.

7. Toussaint ND, Pedagogos E, Beavis J, Becker GJ, Polkinghorne KR, Kerr PG. Improving CKD-MBD management in haemodialysis patients: barrier analysis for implementing better practice. Nephrol Dial Transplant. 2010:gfq602. doi:10.1093/ndt/gfq602.

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