Optimising Secondary Prevention and Cardiac Rehabilitation for Atherosclerotic Cardiovascular Disease During the COVID-19 Pandemic: A Position Statement From the Cardiac Society of Australia and New Zealand (CSANZ).

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has introduced a major disruption to the delivery of routine health care across the world. This provides challenges for the use of secondary prevention measures in patients with established atherosclerotic cardiovascular disease (CVD). The aim of this Position Statement is to review the implications for effective delivery of secondary prevention strategies during the COVID-19 pandemic. CHALLENGES: The COVID-19 pandemic has introduced limitations for many patients to access standard health services such as visits to health care professionals, medications, imaging and blood tests as well as attendance at cardiac rehabilitation. In addition, the pandemic is having an impact on lifestyle habits and mental health. Taken together, this has the potential to adversely impact the ability of practitioners and patients to adhere to treatment guidelines for the prevention of recurrent cardiovascular events. RECOMMENDATIONS: Every effort should be made to deliver safe, ongoing access to health care professionals and the use of evidenced based therapies in individuals with CVD. An increase in use of a range of electronic health platforms has the potential to transform secondary prevention. Integrating research programs that evaluate the utility of these approaches may provide important insights into how to develop more optimal approaches to secondary prevention beyond the pandemic.

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.

Improving access and equity in reducing cardiovascular risk: the Queensland Health model.

OBJECTIVES: To measure changes in cardiovascular risk factors among patients with coronary heart disease (CHD) and/or type 2 diabetes enrolled in a centralised statewide coaching program delivered by telephone and mail-out in the public health sector in Queensland. DESIGN: A population-based audit of cardiovascular risk factor data collected prospectively as part of The COACH (Coaching Patients On Achieving Cardiovascular Health) Program (TCP) delivered through Queensland Health's Health Contact Centre. SETTING AND PARTICIPANTS: 1962 patients with CHD and 707 patients with type 2 diabetes who completed TCP from 20 February 2009 to 20 June 2013, of whom 145 were Indigenous Australians. MAIN OUTCOME MEASURES: Changes in fasting lipids, fasting glucose, glycosylated haemoglobin levels, blood pressure, body weight, body mass index, smoking, alcohol consumption and physical activity, as measured at entry to and completion of the program. RESULTS: Statistically significant improvements in cardiovascular risk factor status, from entry to completion of the program, were found across all biomedical and lifestyle factors in patients with CHD and/or type 2 diabetes. For both diseases, improvements in serum lipids, blood glucose, smoking habit and alcohol consumption combined with increases in physical activity were the most notable findings. Similar differences were found in mean change scores in cardiovascular risk factors between Indigenous and non-Indigenous Queenslanders. CONCLUSION: A centralised statewide coaching program delivered by telephone and mail-out overcomes obstacles of distance and limited access to health services and facilitates a guideline-concordant decrease in cardiovascular risk.

40 years of cardiac rehabilitation and secondary prevention in post-cardiac ischaemic patients. Are we still in the wilderness?

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.

Reversing social disadvantage in secondary prevention of coronary heart disease.

BACKGROUND: To compare and contrast the coronary heart disease (CHD) risk factors of lower socio-economic status public hospital patients with those of privately insured CHD patients before and after six months of telephone delivered coaching using The COACH Program. METHODS: A retrospective observational study which contrasts the lifestyle and biomedical coronary risk factor status of 2256 public hospital patients with the same risk factors of 3278 patients who had private health insurance. All patients received an average of 5 coach sessions over 6 months. RESULTS: The public hospital patients were four years younger and had multiple measures confirming their lower socio-economic status than their private hospital counterparts. At entry to the program, the public hospital patients had worse risk factor levels than the privately insured patients for total and LDL-cholesterol, triglycerides, fasting glucose, smoking and physical activity levels (P<0.0001) but better status for systolic and diastolic blood pressures and alcohol intake. At exit from the program, many of these differences had diminished or disappeared. The public hospital patients had greater improvements in their risk factor status for total and LDL-cholesterol, fasting glucose, body weight, smoking status and physical activity level than did the privately insured patients (P<0.05). CONCLUSIONS: This paper demonstrates that a program of initiating contact with patients with CHD, identifying treatment gaps in their management and coaching to achieve guideline recommended risk factor targets can help reduce health inequalities in such patients and thus benefit all patients in the context of ongoing secondary prevention.

Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement and Coaching for Health (PEACH) pragmatic cluster randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness of goal focused telephone coaching by practice nurses in improving glycaemic control in patients with type 2 diabetes in Australia. DESIGN: Prospective, cluster randomised controlled trial, with general practices as the unit of randomisation. SETTING: General practices in Victoria, Australia. PARTICIPANTS: 59 of 69 general practices that agreed to participate recruited sufficient patients and were randomised. Of 829 patients with type 2 diabetes (glycated haemoglobin (HbA1c) >7.5% in the past 12 months) who were assessed for eligibility, 473 (236 from 30 intervention practices and 237 from 29 control practices) agreed to participate. INTERVENTION: Practice nurses from intervention practices received two days of training in a telephone coaching programme, which aimed to deliver eight telephone and one face to face coaching episodes per patient. MAIN OUTCOME MEASURES: The primary end point was mean absolute change in HbA1c between baseline and 18 months in the intervention group compared with the control group. RESULTS: The intervention and control patients were similar at baseline. None of the practices dropped out over the study period; however, patient attrition rates were 5% in each group (11/236 and 11/237 in the intervention and control group, respectively). The median number of coaching sessions received by the 236 intervention patients was 3 (interquartile range 1-5), of which 25% (58/236) did not receive any coaching sessions. At 18 months' follow-up the effect on glycaemic control did not differ significantly (mean difference 0.02, 95% confidence interval -0.20 to 0.24, P=0.84) between the intervention and control groups, adjusted for HbA1c measured at baseline and the clustering. Other biochemical and clinical outcomes were similar in both groups. CONCLUSIONS: A practice nurse led telephone coaching intervention implemented in the real world primary care setting produced comparable outcomes to usual primary care in Australia. The addition of a goal focused coaching role onto the ongoing generalist role of a practice nurse without prescribing rights was found to be ineffective. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50662837.

Cost-effectiveness of optimizing use of statins in Australia: using outpatient data from the REACH Registry.

BACKGROUND: Although few cardiovascular registries report the costs of illness or cost-effectiveness of health interventions, such information is critical to inform the effective and cost-effective management of cardiovascular disease, particularly if drawn from population-based registries, which more accurately reflect clinical practice and follow up patients for much longer than clinical trials. OBJECTIVE: The goal of this study was to estimate the cost-effectiveness of closing the statin "treatment gap" in the secondary prevention of coronary artery disease (CAD) in Australia. METHODS: A decision analysis Markov model was developed with yearly cycles and the health states of alive or dead. Using data from the Australian Reduction of Atherothrombosis for Continued Health Registry, the model compared current statin coverage (82%) in the secondary prevention of CAD (the current group) with a hypothetical situation of 100% coverage (the improved group). The 18% gap was filled with use of generic statins. Data from a recent meta-analysis were used to estimate the benefits of statin use in terms of reducing recurrent cardiovascular events and death. Government reimbursement data from 2011 were used to calculate direct health care costs. The cost of the intervention to improve statin coverage was assumed to be $250 per person. Years of life lived and costs were discounted at 5% annually. All values are given in Australian dollars. RESULTS: Among the 2058 subjects in the current group, the model estimated that there would be 106 nonfatal myocardial infractions, 68 nonfatal strokes, and 275 deaths over 5 years. In the improved group, all of whom took statins, the corresponding numbers were 101, 65, and 259, equating to numbers needed to treat of 426, 639, and 127, respectively. Over the 5 years, there would be 0.018 life-years gained (discounted) at a net cost of $546 (discounted) per person. These equated to an incremental cost-effectiveness ratio of $29,717 per life-year gained. CONCLUSION: The results suggest that for patients with CAD, maximizing coverage with statins, in line with evidence-based recommendations, represents a cost-effective means of secondary prevention.

The COACH program produces sustained improvements in cardiovascular risk factors and adherence to recommended medications-two years follow-up.

PURPOSE: To assess whether The COACH Program could sustain its favourable impact on coronary risk factors (CRFs) and adherence to recommended medication for 18 months after the completion of The COACH Program. METHOD: A clinical audit of a secondary prevention program performed in three teaching hospitals in Melbourne, Victoria for patients with coronary heart disease (CHD). The CRF targets were based on recommendations from the National Heart Foundation of Australia between 2003 and 2007. RESULTS: 656 patients were followed by telephone every 6 months from recruitment in hospital for 2 years. There was a substantial improvement in all CRF from discharge from hospital to the completion of active coaching 6 months after hospital discharge. There was also a significant increase in the proportion of patients taking statins and renin-angiotensin system antagonists in the same period of time. There was a small deterioration in CRF status in the 6 months after exit from The COACH Program but thereafter CRF status was maintained and substantially better than that on entry to The COACH Program. The use of the recommended cardio-protective medications remained at the levels achieved at exit from The COACH Program. CONCLUSION: The changes in CRF status and adherence to cardiac medications achieved at 6 months in The COACH Program are sustained for at least 18 months after cessation of The COACH Program.

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 (COACH): a multicenter randomized trial in patients with coronary heart disease.

BACKGROUND: Disease management programs in which drugs are prescribed by dietitians or nurses have been shown to improve the coronary risk factor profile in patients with coronary heart disease. However, those disease management programs in which drugs are not prescribed by allied health professionals have not improved coronary risk factor status. The objective of the Coaching patients On Achieving Cardiovascular Health (COACH) study was to determine whether dietitians or nurses who did not prescribe medications could coach patients with coronary heart disease to work with their physicians to achieve the target levels for their total cholesterol (TC) and other risk factors. METHODS: Multicenter randomized controlled trial in which 792 patients from 6 university teaching hospitals underwent a stratified randomization by cardiac diagnosis within each hospital: 398 were assigned to usual care plus The COACH Program and 394 to usual care alone. Patients in The COACH Program group received regular personal coaching via telephone and mailings to achieve the target levels for their particular coronary risk factors. There was one coach per hospital. The primary outcome was the change in TC (DeltaTC) from baseline (in hospital) to 6 months after randomization. Secondary outcomes included measurement of a wide range of physical, nutritional, and psychological factors. The analysis was performed by intention to treat. RESULTS: The COACH Program achieved a significantly greater DeltaTC than usual care alone: the mean DeltaTC was 21 mg/dL (0.54 mmol/L) (95% confidence interval [CI], 16-25 mg/dL [0.42-0.65 mmol/L]) in The COACH Program vs 7 mg/dL (0.18 mmol/L) (95% CI, 3-11 mg/dL [0.07-0.29 mmol/L]) in the usual care group (P<.0001). Thus, the reduction in TC from baseline to 6 months after randomization was 14 mg/dL (0.36 mmol/L) (95% CI, 8-20 mg/dL [0.20-0.52 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 patient quality of life. CONCLUSIONS: Coaching, delivered as The COACH Program, is a highly effective strategy in reducing TC and many other coronary risk factors in patients with coronary heart disease. Coaching has potential effectiveness in the whole area of chronic disease management.

How many patients with coronary heart disease are not achieving their risk-factor targets? Experience in Victoria 1996-1998 versus 1999-2000.

OBJECTIVES: To determine the proportion of patients with established coronary heart disease (CHD) in two Australian studies (VIC-I in 1996-1998, and VIC-II in 1999-2000) who achieved their risk-factor targets as recommended by the National Heart Foundation of Australia, and to compare this proportion with those in studies from the United Kingdom (ASPIRE), Europe (EUROASPIRE I and II) and the United States (L-TAP). DESIGN AND SETTING: Prospective cohort study with VIC-I set in a single Melbourne university teaching hospital and VIC-II set in six university teaching hospitals in Melbourne, Victoria. PARTICIPANTS: 460 patients (112 in VIC-I, 348 in VIC-II) who completed follow-up in the control groups of two randomised controlled trials of a coaching intervention in patients with established CHD. MAIN OUTCOME MEASURES: The treatment gap (100%, minus the percentage of patients achieving the target level for a particular modifiable risk factor) at six months after hospitalisation. RESULTS: The treatment gap declined from 96.4% (95% CI, 91%-99%) to 74.1% (95% CI, 69%-79%) for total cholesterol concentration (TC) < 4.0 mmol/L (P = 0.0001) and from 90.2% (95% CI, 83%-95%) to 54.0% (95% CI, 49%-59%) for TC < 4.5 mmol/L (P = 0.0001). This reduction in the treatment gap between VIC-I and VIC-II appears to be entirely explained by an increase in the number of patients prescribed lipid-lowering drugs. The treatment gaps in the UK and two European studies were substantially greater. The treatment gap for blood pressure (systolic > or = 140 mmHg and/or diastolic > or = 90 mmHg) in VIC-II was 39.5%, again less than corresponding European data. There were 8.1% of patients who had unrecognised diabetes in VIC-II (fasting glucose level > or = 7 mmol/L), making a total of 25.6% of VIC-II patients with diabetes, self-reported or unrecognised. The proportion of patients in VIC-II who were obese (body mass index > or = 30 kg/m2) was similar to the overseas studies, while fewer patients in VIC-II smoked compared with those in the UK and European studies. CONCLUSIONS: A substantial treatment gap exists in Victorian patients with established CHD. The treatment gap compares well with international surveys and, at least in the lipid area, is diminishing.

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.

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 post-randomization. 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."