Medicine (St Vincent's) - Theses
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ItemCoaching patients on achieving cardiovascular health: the COACH program a patient targeted strategy for the secondary prevention of coronary heart diseaseVale, Margarite Julia ( 2002)It 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.