Patient Engagement and Coaching for Health: The PEACH study – a cluster randomised controlled trial using the telephone to coach people with type 2 diabetes to engage with their GPs to improve diabetes care: a study protocol

BACKGROUND: The PEACH study is based on an innovative 'telephone coaching' program that has been used effectively in a post cardiac event trial. This intervention will be tested in a General Practice setting in a pragmatic trial using existing Practice Nurses (PN) as coaches for people with type 2 diabetes (T2D). Actual clinical care often fails to achieve standards, that are based on evidence that self-management interventions (educational and psychological) and intensive pharmacotherapy improve diabetes control. Telephone coaching in our study focuses on both. This paper describes our study protocol, which aims to test whether goal focused telephone coaching in T2D can improve diabetes control and reduce the treatment gap between guideline based standards and actual clinical practice. METHODS/DESIGN: In a cluster randomised controlled trial, general practices employing Practice Nurses (PNs) are randomly allocated to an intervention or control group. We aim to recruit 546 patients with poorly controlled T2D (HbA1c >7.5%) from 42 General Practices that employ PNs in Melbourne, Australia. PNs from General Practices allocated to the intervention group will be trained in diabetes telephone coaching focusing on biochemical targets addressing both patient self-management and engaging patients to work with their General Practitioners (GPs) to intensify pharmacological treatment according to the study clinical protocol. Patients of intervention group practices will receive 8 telephone coaching sessions and one face-to-face coaching session from existing PNs over 18 months plus usual care and outcomes will be compared to the control group, who will only receive only usual care from their GPs. The primary outcome is HbA1c levels and secondary outcomes include cardiovascular disease risk factors, behavioral risk factors and process of care measures. DISCUSSION: Understanding how to achieve comprehensive treatment of T2D in a General Practice setting is the focus of the PEACH study. This study explores the potential role for PNs to help reduce the treatment and outcomes gap in people with T2D by using telephone coaching. The intervention, if found to be effective, has potential to be sustained and embedded within real world General Practice

Coaching patients on achieving cardiovascular health: the COACH program a patient targeted strategy for the secondary prevention of coronary heart disease

© 2002 Dr. Margarite Julia ValeIt is well recognised that there is a treatment gap in the management of risk factors in coronary heart disease (CHD) - a gap between what is known from published evidence and what is actually practised. Despite major advances in scientific evidence for aggressive risk factor management, only a minority of patients with CHD are achieving the target levels for their modifiable coronary risk factors. Strategies to address the treatment gap have been usually 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 ('competitive' with usual care) such as secondary prevention clinics or disease management programs, and those where support staff do not have prescribing rights ('cooperative' with usual care). Although intuitively it may appear that any program providing attention to patients would result in improvements in risk factor levels, published work shows that only the competitive programs resulted in significant improvement in coronary risk factor status. All of the cooperative programs failed to effect an improvement in risk factor status. While competitive programs are clearly effective, they risk alienating usual medical care and in a competitive environment may be counterproductive. There is a role for a cooperative program in an environment where primary care is competitive. This has been the rationale for the development of The Coach Program to bridge the treatment gap in CI-ID. The Coach Program was not founded on sociological or psychological theory. It is an empirical technique developed by the PhD Candidate on the basis of the Candidate's experience as a secondary school teacher. Although there is no coherent theory of coaching, coaching has been used in clinical medicine to improve doctor-patient interaction in the consultation process, assist patients to cope with painful procedures, for exercise training of patients to improve medical conditions and in staff teaching. Thus far, coaching has not been applied and evaluated in chronic disease management such as for the achievement of specific secondary prevention goals. 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, know 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 randomised controlled trials. Pilot project carried out at St. Vincent's Hospital only by the PhD Candidate, a qualified dietitian. This study targeted cholesterol levels only, with the aim of achieving a TC < 4.5 mmol/L. At the end of the 6 month intervention, 107 patients who were coached achieved a mean TC (95%CI) of 5.00 (4.82-5.17) mmol/L versus 5.54 (5.36-5.72) mmol/L in 112 usual care patients (P<0.0001). Multivariate analysis showed that being coached was of equal magnitude in its effect on TC as was prescription of lipid-lowering medication. The Coach Program achieved a significantly greater ΔTC than usual care alone: mean ΔTC (95%CI) 0.54 (0.42 to 0.65) mmol/L (n=398) in The Coach Program group versus 0.18 (0.07 to 0.29) mmol/L (n=394) in the usual care group (P<0.0001). Thus, the reduction in TC from baseline to 6 months post-randomisation was 0.36 (95%CI: 0.20 to 0.52) mmol/L greater in The Coach Program group than in the usual care group. Coaching produced substantial improvements in most of the other coronary risk factors and in the patient's quality of life. The results of these two randomised controlled trials prove that coaching, delivered as The Coach Program, is a highly effective strategy in reducing TC and many other coronary risk factors in patients with CHD

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 ($12,707 per person lower; P = .078). The reduction in total cost was significantly greater in those who received 4 or more sessions ($19,418 per person; P = .006) and in males ($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

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.Coronary-artery-disease, Coronary-disorders, Health-education, Medical-education, Patient-education

The roles of ligands proton affinity, π-back donation and metal fragment hardness on the Au-N bond in N-donor heterocycles gold(III) complexes

Cardiac rehabilitation (CR) is the sum of interventions required to ensure the best physical, psychological and social conditions so that patients with cardiac disease may assume their place in society and slow the progression of the disease. Exercise testing (ET) early after MI has been shown to result in earlier return to work than the non-performance of ET. Research quality CR has resulted in lower cardiovascular mortality and lower recurrent hospitalisation and has been shown to be cost-effective. However, the content of cardiac rehabilitation programmes varies considerably. The only randomised trial of CR as usually performed in the ‘real world’ showed that CR had no impact on cardiac death rates or any other outcome. Only 20–50% of eligible patients attend CR programmes and attendance at CR has not improved in the last 20 years despite major attempts to increase participation in CR. Alternative methods for provision of CR have been sought. These include home-based CR, case management approaches, and nurse coordinated prevention programmes. Telephone based programmes, such as The COACH Program, have been introduced to coach patients and improve behavioural and biomedical risk factors. These have been shown to improve risk factors better than usual patient care and to reduce recurrences of cardiac events after discharge from hospital due to MI. Expansion of novel approaches such as The COACH Program may help to counteract the non-attendance at CR