Coaching patients with coronary heart disease to achieve the target cholesterol:

Abstract

Community studies have demonstrated suboptimal achievement of lipid targets in the management of patients with coronary heart disease (CHD). An effective strategy is required for the application of evidence-based prevention therapy for CHD. The objective of this study was to test coaching as a technique to assist patients in achieving the target cholesterol level of <4.5 mmol/L. Patients with established CHD (n = 245) underwent a stratified randomization by cardiac procedure (coronary artery bypass graft surgery or percutaneous coronary intervention) to receive either the coaching intervention (n = 121) or usual medical care (n = 124). The primary outcome measure was fasting serum total cholesterol (TC), serum triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), and calculated low-density lipoprotein cholesterol (LDL-C) level, measured at 6 months postrandomization. At 6 months, the serum TC and LDL-C levels were significantly lower in the coaching intervention group (n = 107) than the usual care group (n = 112): mean TC (95%CI) 5.00 (4.82–5.17) mmol/L versus 5.54 (5.36–5.72) mmol/L (P < .0001); mean LDL-C (95%CI) 3.11 (2.94–3.29) mmol/L versus 3.57 (3.39–3.75) mmol/L (P < .0004), respectively. Coaching had no impact on TG or on HDL-C levels. Multivariate analysis showed that being coached (P < .001) had an effect of equal magnitude to being prescribed lipid-lowering drug therapy (P < .001). The effectiveness of the coaching intervention is best explained by both adherence to drug therapy and to dietary advice given. Coaching may be an appropriate method to reduce the treatment gap in applying evidence-based medicine to the “real world.”

Introduction

During the 1990s it was clearly established that lipid-lowering drug therapy reduced the morbidity and mortality from coronary heart disease (CHD) 1, 2, 3, 4, 5. In particular, the CARE [3] and LIPID [5] studies showed that reductions of total and low-density lipoprotein cholesterol from apparently normal levels in patients with CHD resulted in significant improvements in patient outcomes. However, parallel surveys in the UK 6, 7, 8, Europe [9], and the United States [10] have shown that the results of these studies have been inadequately applied in clinical practice. The difference between the treatment recommended on the basis of clinical trials and the treatment that actually occurs has been referred to as “the treatment gap” [11]. Reasons for this gap include a focus on acute problems in hospitals, reluctance to initiate therapy in the ambulatory care setting, therapy not being titrated to therapeutic level to achieve target lipid levels, and noncompliance or discontinuation of medical therapy 12, 13. These surveys indicate that current systems of health care are delivering suboptimally in the area of secondary prevention of CHD.

Very few programs have been developed specifically aimed at the treatment gap. The reported studies were conducted by nurses 14, 15, 16, 17, 18, 19. Two of these were effective, and a distinguishing feature of the interventions was that they defined the targets for treatment 14, 15. The other four aimed to modify diet and other behaviour according to therapeutic guidelines and were not effective in modifying lipid levels 16, 17, 18, 19.

We propose to solve the treatment gap problem by a program of coaching the patient via the telephone. Coaching has been used in clinical medicine to improve doctor patient interaction [20], to assist patients to cope with painful procedures [21], for exercise training of patients to improve medical conditions 22, 23 and in staff teaching [24]. Thus far, coaching has not been applied and evaluated in chronic disease management such as for the achievement of specific secondary prevention goals. Coaching is a method of training patients to take responsibility for the achievement and maintenance of the target levels for their particular modifiable risk factors. The Heart Foundation of Australia has set a secondary prevention target of <4.5 mmol/L for TC level (http://www.heartfoundation.com.au). In this randomized controlled trial in patients with CHD, we compared the effectiveness of usual care supplemented with coaching to achieve the recommended target TC level, with that of usual medical care alone.