Methods: This study consisted of two phases. Phase I: Identifying intervention targets. A cross-sectional preliminary investigation on phosphorus intake, binder prescription and adherence, and dialysis adequacy was carried out to identify intervention targets for phosphorus management. All foods in the duplicate portions as eaten by 36 patients for three days were collected and analyzed. Patients’ adherence to phosphate binders were evaluated by the Morisky Medication Adherence Scale. Clinical parameters and demographic information were collected. Phase II: Development of the TIPS intervention.
Results: Results from Phase I study revealed that non-adherence to prescribed diet remained the major explanation for uncontrolled phosphorus levels. Insufficient phosphate binder prescriptions and medication non-adherence pose significant challenges to phosphate control for patients achieving restricted dietary phosphorus intake.The TIPS intervention is based on Chronic Care Model (CCM) (Wagner et al., 2001) and Health Promotion Model (HPM) (Pender, Murdaugh, & Parsons, 2011), targeting to balance phosphorus intake and binder use for patients receiving standard hemodialysis treatment. The CCM emphasizes the importance of ongoing interactions and adjustments between patients and health-care system during chronic disease management. Health Promotion Model was additionally used to guide the development of behavior change strategies. The TIPS intervention will be delivered within 3 months through eight face-to-face behavior change sessions provided by trained clinical nurses. Session 1 will provide an overall assessment of the participant’s diet quality, medication use, and adherence behavior. An education handbook for increasing patients’ awareness of phosphorus control will be provided to each participant after Session 1. In Session 2, each participant will received a tailed diet and medication suggestions based on the initial assessment. Nurses will develop an individualized phosphorus intake and pills plan with each patient. They will then explore potential barriers to implement the plan, and discuss the available support and resources to motivate patients to initiate behavior change. Session 3-8 focuses on facilitating behavior change. Nurses will review participants’ dietary intake and pills logs with them, discuss positive experiences, and provide encouragement. Depending on the progress participants being made, TIPS goals and plans will be renewed or revised as needed. Referrals will be also made as needed. The behavior change intervention was designed to improve self-efficacy of phosphorus management by supporting patients to appropriate modify their diets and binder use through self-monitoring, problem solving, and goal setting.
Conclusion: The CCM and HPM provided a framework for development of TIPS intervention to encourage and facilitate dietary and medication behavior changes for dialysis patients with hyperphosphatemia. The next step is to evaluate the feasibility, acceptability, and preliminary results of TIPS intervention using an experimental design.