Russell Cynthia L
University of Missouri, Columbia, MO 65211, USA.
Clin Nurse Spec. 2010 Mar-Apr;24(2):69-75. doi: 10.1097/NUR.0b013e3181cf554d.
A clinical nurse specialist-led intervention to improve medication adherence in chronically ill adults using renal transplant recipients as an exemplar population is proposed.
BACKGROUND/RATIONALE: Meta-analyses and systematic reviews of chronically ill and transplant patients indicate that patient-specific characteristics not only are poor and inconsistent predictors for medication nonadherence but also are not amenable to intervention. Adherence has not meaningfully improved, despite meta-analyses and systematic narrative reviews of randomized controlled trials (RCTs) dealing with medication nonadherence in acutely and chronically ill persons and RCTs dealing with transplant patients. Interventions with a superior potential to enhance medication adherence must be developed.
Use of a clinical nurse specialist-led continuous self-improvement intervention with adult renal transplant recipients is proposed. Continuous self-improvement focuses on improving personal systems thinking and behavior using the plan-do-check-act process. Electronic medication monitoring reports, one of several objective measures of medication adherence, are used by the clinician to provide patient feedback during the check process on medication-taking patterns.
Continuous self-improvement as an intervention holds promise in supporting patient self-management and diminishing the blame that clinicians place on patients for medication nonadherence. Using an objective measure of medication adherence such as an electronic monitoring report fosters collaborative patient-clinician discussions of daily medication-taking patterns. Through collaboration, ideas for improving medication taking can be explored. Changes can be followed and evaluated for effectiveness through the continuous self-improvement process.
Future studies should include RCTs comparing educational and/or behavioral interventions to improve medication adherence.
提出一项由临床护理专家主导的干预措施，以提高慢性病成年人的用药依从性，以肾移植受者作为示例人群。
背景/理论依据：对慢性病患者和移植患者的荟萃分析及系统评价表明，患者的个体特征不仅是用药不依从性的不良且不一致的预测指标，而且无法通过干预改善。尽管对急性和慢性病患者用药不依从性的随机对照试验（RCT）以及针对移植患者的RCT进行了荟萃分析和系统叙述性综述，但依从性并未得到显著改善。必须开发具有更大潜力提高用药依从性的干预措施。
建议对成年肾移植受者采用由临床护理专家主导的持续自我改进干预措施。持续自我改进注重利用计划-执行-检查-行动流程来改善个人系统思维和行为。临床医生使用电子用药监测报告（用药依从性的几种客观测量指标之一）在检查过程中就用药模式向患者提供反馈。
持续自我改进作为一种干预措施有望支持患者自我管理，并减少临床医生因患者用药不依从而产生的指责。使用电子监测报告等用药依从性的客观测量指标有助于促进医患就日常用药模式进行协作讨论。通过协作，可以探索改善用药的方法。可以通过持续自我改进过程跟踪并评估变化的有效性。
未来的研究应包括比较教育和/或行为干预措施以提高用药依从性的随机对照试验。
