Margarite J. Vale

Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement And Coaching for Health (PEACH) pragmatic cluster randomised controlled trial

Objective To evaluate the effectiveness of goal focused telephone coaching by practice nurses in improving glycaemic control in patients with type 2 diabetes in Australia. Design Prospective, cluster randomised controlled trial, with general practices as the unit of randomisation. Setting General practices in Victoria, Australia. Participants 59 of 69 general practices that agreed to participate recruited sufficient patients and were randomised. Of 829 patients with type 2 diabetes (glycated haemoglobin (HbA1c) >7.5% in the past 12 months) who were assessed for eligibility, 473 (236 from 30 intervention practices and 237 from 29 control practices) agreed to participate. Intervention Practice nurses from intervention practices received two days of training in a telephone coaching programme, which aimed to deliver eight telephone and one face to face coaching episodes per patient. Main outcome measures The primary end point was mean absolute change in HbA1c between baseline and 18 months in the intervention group compared with the control group. Results The intervention and control patients were similar at baseline. None of the practices dropped out over the study period; however, patient attrition rates were 5% in each group (11/236 and 11/237 in the intervention and control group, respectively). The median number of coaching sessions received by the 236 intervention patients was 3 (interquartile range 1-5), of which 25% (58/236) did not receive any coaching sessions. At 18 months’ follow-up the effect on glycaemic control did not differ significantly (mean difference 0.02, 95% confidence interval −0.20 to 0.24, P=0.84) between the intervention and control groups, adjusted for HbA1c measured at baseline and the clustering. Other biochemical and clinical outcomes were similar in both groups. Conclusions A practice nurse led telephone coaching intervention implemented in the real world primary care setting produced comparable outcomes to usual primary care in Australia. The addition of a goal focused coaching role onto the ongoing generalist role of a practice nurse without prescribing rights was found to be ineffective. Trial registration Current Controlled Trials ISRCTN50662837.

The COACH Program Produces Sustained Improvements in Cardiovascular Risk Factors and Adherence to Recommended Medications—Two Years Follow-up

PURPOSE To assess whether The COACH Program could sustain its favourable impact on coronary risk factors (CRFs) and adherence to recommended medication for 18 months after the completion of The COACH Program. METHOD A clinical audit of a secondary prevention program performed in three teaching hospitals in Melbourne, Victoria for patients with coronary heart disease (CHD). The CRF targets were based on recommendations from the National Heart Foundation of Australia between 2003 and 2007. RESULTS 656 patients were followed by telephone every 6 months from recruitment in hospital for 2 years. There was a substantial improvement in all CRF from discharge from hospital to the completion of active coaching 6 months after hospital discharge. There was also a significant increase in the proportion of patients taking statins and renin-angiotensin system antagonists in the same period of time. There was a small deterioration in CRF status in the 6 months after exit from The COACH Program but thereafter CRF status was maintained and substantially better than that on entry to The COACH Program. The use of the recommended cardio-protective medications remained at the levels achieved at exit from The COACH Program. CONCLUSION The changes in CRF status and adherence to cardiac medications achieved at 6 months in The COACH Program are sustained for at least 18 months after cessation of The COACH Program.

Impact of Coaching Patients on Coronary Risk Factors: Lessons from The COACH Program

It is well recognized that there is a treatment gap in the management of risk factors in patients with coronary heart disease (CHD) — a gap between what is known from published evidence and what is actually practiced.Strategies to address the treatment gap have usually been aimed at the physician and these have often been ineffective. Few strategies have been directed at the patient. Patient-targeted strategies can be subdivided into those that permit the prescribing of medication by allied health professionals and those where allied health staff do not have prescribing rights. Although intuitively it may appear that any program providing attention to patients would result in improvements in risk-factor levels, published work shows that the programs that allow the prescription of drugs have all resulted in significant improvement in coronary risk factor status. By contrast, all but one of the non-drug prescribing programs failed to improve the risk factor status. The COACH (Coaching patients On Achieving Cardiovascular Health) Program is a novel program using non-drug prescribing health professionals to achieve the target levels for all of the modifiable risk factors in patients with CHD.The COACH Program is a training program for patients with CHD in which a health professional coach trains patients to aggressively pursue the target levels for their particular coronary risk factors. The coach is hospital-based and uses the telephone and mailouts to provide regular coaching sessions to patients after discharge from hospital. Coaching is directed at the patient and not at the treating doctor. Patients are coached to know their risk-factor levels, the target levels for their risk factors, and how to achieve the target levels for their risk factors. Patients are persuaded to go to their own doctor(s) and ask for appropriate prescription of medication(s). Coaching also trains patients to follow appropriate lifestyle measures.The COACH Program has been validated by two randomized controlled trials. The first was a pilot, single-center study in which one coach targeted serum cholesterol as an outcome. Having established the success of the method, a definitive multicenter study was performed in six hospitals, each with its own trained coach, which aimed to improve lipid and other risk factors. This study confirmed that coaching was an independent and significant factor in lowering total and low-density lipoprotein cholesterol. In addition, coaching resulted in a lower blood pressure, lower intake of dietary saturated fat, lower bodyweight, less anxiety, improved self-perception of health, and lesser symptoms of chest pain and breathlessness at 6-month follow-up. The COACH Program is a proven, highly effective method of using health professionals, who do not have the authority to prescribe medication, to improve risk status in patients with CHD.

Reversing social disadvantage in secondary prevention of coronary heart disease

BACKGROUND To compare and contrast the coronary heart disease (CHD) risk factors of lower socio-economic status public hospital patients with those of privately insured CHD patients before and after six months of telephone delivered coaching using The COACH Program. METHODS A retrospective observational study which contrasts the lifestyle and biomedical coronary risk factor status of 2256 public hospital patients with the same risk factors of 3278 patients who had private health insurance. All patients received an average of 5 coach sessions over 6 months. RESULTS The public hospital patients were four years younger and had multiple measures confirming their lower socio-economic status than their private hospital counterparts. At entry to the program, the public hospital patients had worse risk factor levels than the privately insured patients for total and LDL-cholesterol, triglycerides, fasting glucose, smoking and physical activity levels (P<0.0001) but better status for systolic and diastolic blood pressures and alcohol intake. At exit from the program, many of these differences had diminished or disappeared. The public hospital patients had greater improvements in their risk factor status for total and LDL-cholesterol, fasting glucose, body weight, smoking status and physical activity level than did the privately insured patients (P<0.05). CONCLUSIONS This paper demonstrates that a program of initiating contact with patients with CHD, identifying treatment gaps in their management and coaching to achieve guideline recommended risk factor targets can help reduce health inequalities in such patients and thus benefit all patients in the context of ongoing secondary prevention.

‘FIT FOR PURPOSE’. The COACH program improves lifestyle and biomedical cardiac risk factors

The ‘Rehabilitation after Myocardial Infarction Trial’ (RAMIT) showed that cardiac rehabilitation in the UK failed to impact on total mortality, cardiac morbidity, health related quality of life and behavioural risk factors.1 These results were met with indignation. David Wood actually questioned whether cardiac rehabilitation as performed in the UK was ‘fit for purpose’.2 Which raises the question: what is the purpose of cardiac rehabilitation? We believe that the immediate objectives of cardiac rehabilitation are to improve the physical fitness of cardiac patients after acute illness or cardiac procedures and to initiate secondary prevention by improving lifestyle and biomedical risk factors. Nowadays, patients spend 2–4 days in hospital after an acute coronary syndrome. They are not deconditioned. They are fit to return to work 2–4 weeks after the acute event. They are unlikely to attend a cardiac rehabilitation …

Coaching Patients Saves Lives and Money

BACKGROUND The Coaching On Achieving Cardiovascular Health (COACH) Program has been proven to improve biomedical and lifestyle cardiovascular disease (CVD) risk factors. The objective of this study was to evaluate the long-term impact of The COACH Program on overall survival, hospital utilization, and costs from the perspective of a private health insurer (payor), in patients with CVD. METHODS A prospective parallel-group case-control study design with controls randomly matched to patients based on propensity score. There were 512 participants with CVD engaged in a structured disease management program of 6 months duration (The COACH Program) who were matched to 512 patients with CVD who were allocated to the control group. The independent variables that estimated the propensity score were preprogram hospital admissions, age, and sex. The primary outcome was overall survival with secondary outcomes, including hospital utilization and cost incurred by the private health insurer. Mean follow-up was 6.35 years. Difference in overall survival between the 2 groups was estimated using a Cox proportional hazard ratio (HR) with difference in total cost estimated using a generalized linear model. RESULTS The COACH Program achieved a significant reduction in overall mortality (HR 0.70; 95% confidence interval [CI], 0.53-0.93; P = .014). There was an apparent dose-response effect: those who received up to 3 coaching sessions had no decrease in mortality (HR 1.02; 95% CI, 0.69-1.49; P = .926); those who received 4 or more coaching sessions had a substantial decrease in mortality (HR 0.58; 95% CI, 0.42-0.81; P = .001). Total cost to the health insurer was substantially lower in the intervention group (

A packaged secondary prevention program outside primary care

12,707 per person lower; P = .078). The reduction in total cost was significantly greater in those who received 4 or more sessions (

Improving access and equity in reducing cardiovascular risk: Coaching patients On Achieving Cardiovascular Health (COACH)

19,418 per person; P = .006) and in males (

Coaching patients On Achieving Cardiovascular Health (COACH): A Multicenter Randomized Trial in Patients With Coronary Heart Disease

18,947 per person; P = .029). CONCLUSIONS Those enrolled in The COACH program achieved a statistically significant decrease in overall mortality compared with usual care at 6.35 years. A substantive reduction in hospital costs was also observed among those who received The COACH program compared with those who did not, particularly in those who received 4 or more sessions and in males.

Coaching patients with coronary heart disease to achieve the target cholesterol: A method to bridge the gap between evidence-based medicine and the real world: randomized controlled trial

[1] Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H. Coronary artery stenting and non-cardiac surgery–a prospective outcome study. Br J Anaesth 2006;96(6):686–93. [2] Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005;293 (17):2126–30. [3] Grines CL, Bonow RO, Casey Jr DE, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol 2007;49(6):734–9. [4] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.