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Coaching for lower cholesterol

Study
Results
Comment

The difference between treatments recommended from clinical trials or reviews, and that actually occurring has been called a 'treatment gap', perhaps epitomising the gap between evidence-based medicine and the real world. What happens if more responsibility is given to the patient to achieve important targets? A randomised trial from Australia [1] tells us that they do well.

Study


Patients with coronary heart disease admitted to hospital for revascularisation procedures. Excluded were those over 75 years and others where intensive coaching was not appropriate, often because of other medical conditions. Consecutive recruitment was from hospital discharge lists.

A dietician experienced in working with patients with cardiovascular disease did the coaching by telephone. This involved asking questions to establish patient knowledge and beliefs, followed by explanation and rationale, assertiveness training, goal setting and reassessment at the next coaching session. The goal was to achieve a target cholesterol below 4.5 mmol/L, and patients undergoing coaching were asked to take responsibility for reaching and maintaining the target. Coaching was aimed at the patient, not the treating doctor.

A first telephone session was followed by three further sessions and six week intervals, with a final telephone call at 24 weeks to remind patients to have their blood tested for lipids. Patients not randomised to coaching had two telephone calls, at two weeks after randomisation asking how they were, and at 24 weeks for a reminder about blood tests. All were offered information about a cardiac rehabilitation programme and were encouraged to attend.

Results


The mean cholesterol of coached patients after six months was 5.0 mmol/L, significantly lower than that of those not coached at 5.5 mmol/L. LDL cholesterol was also significantly lower. More coached patients reached the target level (33/107, 31%) than uncoached patients (11/112, 10%). For every five patients coached, one more reached the target level than they would if they had not been coached, with a number needed to treat of 4.8 (3.2 to 9.4).

Use of lipid lowering drugs was not different at about 60% in each group. Coaching had effects in patients prescribed lipid lowering drugs and those not prescribed them (Figure 1).

Figure 1: Effect of coaching and drugs on cholesterol reduction at six months



Comment


This interesting paper comes with a literature review of six nurse-led programmes delivering specific interventions on risk factor status. Two set a therapeutic lipid goal, and were effective. Four focused on behaviour patterns and did not.

Perhaps what this study shows is that the informed (resourceful?) patient is a powerful being. When patients are encouraged to take more responsibility for their own medical management, linked to a specific goal, they seem to get better results and reduce the gap between the ideal of clinical trials and the real world. Why is this not a surprise?

Reference:

  1. MJ Vale et al. 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. Journal of Clinical Epidemiology 2002 55: 245-252.
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