Eight-year post-trial follow-up of morbidity and mortality of telephone health coaching.

BACKGROUND: Health coaching is a patient-centred approach to supporting self-management for the chronic conditions. However, long-term evidence of effectiveness of health coaching remains scarce. The object of this study was to evaluate the long-term effect of telephone health coaching (THC) on mortality and morbidity among people with type 2 diabetes (T2D), coronary artery disease (CAD) and congestive heart failure (CHF).. METHODS: 1535 T2D, CAD and CHF patients with unmet treatment targets were randomly allocated into an intervention group (n = 1034) and control group (n = 501). Intervention group received monthly individual strength-based, autonomy supportive THC sessions (average 30 min) for behavior change with a specially trained nurse for 12 months additional to usual health care. Control group received usual health care services. The primary outcome was a composite of death from cardiovascular causes or non-fatal stroke or non-fatal myocardial infarction (AMI) or unstable angina pectoris (UAP) during a follow-up of 8 years Three other composite endpoints with distinct combinations of fatal and non-fatal cardiovascular events and death from any cause were used as secondary outcomes. Other outcomes followed were the most relevant components of the composite endpoints. Randomized controlled trial (RCT) data was linked to Finnish national health and social care registries and electronic health records (EHR). Post-trial eight-year evaluation was conducted using intention-to-treat (ITT) and per-protocol (PP) analysis. RESULTS: The composite primary outcome event rate per 100 person years was lower in the intervention group (3.45) than in control group (3.88) in ITT -analysis, but the difference was not statistically significant (hazard ratio in the intervention group 0.87; 95% CI, 0.71 to 1.07; P = 0.19). In the subgroup (T2D, CAD/CHF) analysis, there were no statistically significant effects. The secondary PP-analysis showed statistically significant benefits for those who participated in the study. CONCLUSIONS: No statistically significant effect of health coaching on mortality and morbidity was found in intention to treat analysis. The per protocol results suggest, however, that the intervention may be effective among patients who are willing and able to participate in health coaching. More research is needed to identify patients most likely to benefit from low-intensity health coaching. TRIAL REGISTRATION: NCT00552903 (registration date: the 1st of November 2007, updated the 3rd of February 2009).

Eight-year post-trial follow-up of health care and long-term care costs of tele-based health coaching.

OBJECTIVE: To evaluate the long-term effect of telephone health coaching on health care and long-term care (LTC) costs in type 2 diabetes (T2D) and coronary artery disease (CAD) patients. DATA SOURCES/STUDY SETTING: Randomized controlled trial (RCT) data were linked to Finnish national health and social care registries and electronic health records (EHR). Post-trial eight-year economic evaluation was conducted. STUDY DESIGN: A total of 1,535 patients (≥45 years) were randomized to the intervention (n = 1034) and control groups (n = 501). The intervention group received monthly telephone health coaching for 12 months. Usual health care and LTC were provided for both groups. PRINCIPAL FINDINGS: Intention-to-treat analysis showed no significant change in total health and long-term care costs (intervention effect €1248 [3 percent relative reduction], CI -6347 to 2217) in the intervention compared to the control group. There were also no significant changes among subgroups of patients with T2D or CAD. CONCLUSIONS: Health coaching had a nonsignificant effect on health care and long-term care costs in the 8-year follow-up among patients with T2D or CAD. More research is needed to study, which patient groups, at which state of the disease trajectory of T2D and cardiovascular disease, would best benefit from health coaching.

Health coaching by telephony to support self-care in chronic diseases: clinical outcomes from The TERVA randomized controlled trial.

BACKGROUND: The aim was to evaluate the effect of a 12-month individualized health coaching intervention by telephony on clinical outcomes. METHODS: An open-label cluster-randomized parallel groups trial. Pre- and post-intervention anthropometric and blood pressure measurements by trained nurses, laboratory measures from electronic medical records (EMR). A total of 2594 patients filling inclusion criteria (age 45 years or older, with type 2 diabetes, coronary artery disease or congestive heart failure, and unmet treatment goals) were identified from EMRs, and 1535 patients (59%) gave consent and were randomized into intervention or control arm. Final analysis included 1221 (80%) participants with data on primary end-points both at entry and at end. Primary outcomes were systolic and diastolic blood pressure, serum total and LDL cholesterol concentration, waist circumference for all patients, glycated hemoglobin (HbA1c) for diabetics and NYHA class in patients with congestive heart failure. The target effect was defined as a 10-percentage point increase in the proportion of patients reaching the treatment goal in the intervention arm. RESULTS: The proportion of patients with diastolic blood pressure initially above the target level decreasing to 85 mmHg or lower was 48% in the intervention arm and 37% in the control arm (difference 10.8%, 95% confidence interval 1.5-19.7%). No significant differences emerged between the arms in the other primary end-points. However, the target levels of systolic blood pressure and waist circumference were reached non-significantly more frequently in the intervention arm. CONCLUSIONS: Individualized health coaching by telephony, as implemented in the trial was unable to achieve majority of the disease management clinical measures. To provide substantial benefits, interventions may need to be more intensive, target specific sub-groups, and/or to be fully integrated into local health care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00552903.

Use of and attitudes toward current care guidelines among primary and secondary care nurses in Finland.

Attitudes toward, familiarity with, and use of clinical guidelines in general and the national Hypertension Guideline were studied. A questionnaire study was conducted before and after an educational program (VALTIT) among primary and secondary care nurses in Päijät-Häme, Finland. The program included centralized training sessions and interactive local workshops. Prior to the program, a majority of nurses had a positive attitude toward guidelines but used guidelines seldom. Primary care nurses were better aware of the Hypertension Guideline than secondary care nurses, but the guideline was poorly used by both groups. At the follow-up, familiarity with the Hypertension Guideline and use of guidelines increased among primary care nurses. In future, primary care nurses will have a more autonomous role in patient care and should participate in clinical guideline development and related research. Our study has shown they are a potential target of such interventions.

The dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians and nurses.

OBJECTIVE: To explore physicians' and nurses' views on patient and professional roles in the management of lifestyle-related diseases and their risk factors. DESIGN: A questionnaire study with a focus on adult obesity, dyslipidemia, high blood pressure, type 2 diabetes, and smoking. SETTING: Healthcare centres in Päijät-Häme hospital district, Finland. SUBJECTS: Physicians and nurses working in primary healthcare (n =220). MAIN OUTCOME MEASURES: Perceptions of barriers to treatment of lifestyle-related conditions, perceptions of patients' responsibilities in self-care, experiences of awkwardness in intervening in obesity and smoking, perceptions of rushed schedules, and perceptions of health professionals' roles and own competence in lifestyle counselling. RESULTS: A majority agreed that a major barrier to the treatment of lifestyle-related conditions is patients' unwillingness to change their habits. Patients' insufficient knowledge was considered as such a barrier less often. Self-care was actively encouraged. Although a majority of both physicians and nurses agreed that providing information, and motivating and supporting patients in lifestyle change are part of their tasks, only slightly more than one half estimated that they have sufficient skills in lifestyle counselling. Among nurses, those with less professional experience more often reported having sufficient skills than those with more experience. Two-thirds of the respondents reported that they had been able to help many patients to change their lifestyles into healthier ones. CONCLUSIONS: The primary care professionals experienced a dilemma in patients' role in the treatment of lifestyle-related diseases: the patient was recognized as central in disease management but also, if reluctant to change, a major potential barrier to treatment.