The COACH Program: Closing The “Evidence-Practice Gap” In The Prevention Of Cardiovascular Disease

Reducing coronary risk factors and taking recommended medications is crucial to retard the disease process in cardiovascular disease (CVD) in order to prolong life. There is much documented evidence that clinical practice consistently fails to follow evidence-based guidelines and achieve targets for modifiable disease risk factors. Given the current evidence-based pharmacological treatments on offer, reaching the targets for biomedical risk factors such as LDL-cholesterol, blood pressure, and HbA1c is achievable in nearly all patients.

The reality is that less than half of patients achieve the guideline-recommended risk factor targets. Adjunct systems to improve cardiovascular outcomes have been available for decades, originating with cardiac rehabilitation and, more recently, a proliferation of other systems of disease management, “health coaching,” and telemedicine.

Whilst it’s clear that patients are not being treated according to evidence-based guidelines, other than The COACH Program, none of the adjunct systems aiming to improve outcomes for patients with chronic disease actually address the evidence-practice gap. Most patients are only offered lifestyle strategies in the hope that they will improve cardiovascular risk factors, thereby preventing them from a heart attack, stroke, heart failure, and death. The duration of follow-up for interventions targeting CVD prevention is typically not more than 12 months, whereas the life expectancy of patients with CVD is over 15 years. The European Society of Cardiology (ESC) 2018 sessions highlighted the current state of the art in achieving optimal cardiac risk factor status. Targets for lipids, blood pressure, and HbA1c in people with diabetes are not being achieved in usual clinical practice.

Cardiac rehabilitation has been widely promulgated in Europe and the rest of the world for decades. Most cardiac rehabilitation programs have concentrated on cardiovascular fitness and have ignored the modifiable cardiac risk factor status. Many more recently developed systems designed to mitigate the disease process lack evidence of effectiveness – whilst the programs may claim to be based on evidence, the programs themselves have never been tested. There is currently a “hodgepodge” of different programs – most of which are ineffective and not cost-effective.

An evidence-based solution is needed whereby all eligible patients can participate, irrespective of where they live, their socioeconomic background and their educational background; which achieves risk factor targets; enables patients to be treated as they should be according to the management guidelines; and maintains improvements long-term. The COACH Program ticks all the boxes as a method of closing the “evidence-practice gap”.

The COACH Program is a standardized evidence-based coaching program delivered by telephone and mail to people with a chronic disease over a period of 6 months. Delivered by trained health professionals, it is focused on closing the evidence-practice gap. It does this by identifying the “treatment gaps” in each patient’s management, explicitly informing patients of their specific gaps in treatment and then providing explicit advice on how to close the gaps and achieve national guideline-recommended target levels for their modifiable risk factors while the patients work with their usual doctors. Each verbal coaching session is followed by a structured written report that summarizes the session.

The COACH Program has been previously shown to substantially reduce the treatment gap in the management of patients with CVD in two randomized controlled trials (RCTs), maintain the improvements long term; achieves greater benefit for socioeconomically disadvantaged people than the more affluent; reaches people in remote locations where face-to-face programs are not feasible; and is as effective in indigenous people as it is in nonindigenous people.

The long-term impact of The COACH Program on survival, hospital utilization and costs was evaluated from the perspective of a private health insurer (payor) in patients with CVD. A prospective parallel-group case-control study was conducted 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 pre-program 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. The 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.

The COACH Program achieved a significant reduction in overall mortality of 5.1% over a mean follow-up of 6.35 years (HR 0.70; 95% confidence interval [CI], 0.53-0.93; P = .014).  The impact was greater in those who received 4 or more coaching sessions. Total cost to the health insurer was substantially lower in the intervention group (AUD$12,707 per person lower; P = .078). There was a substantive net reduction in hospital costs of AUD$12,115 per coached patient. The reduction in total cost was significantly greater in those who received 4 or more sessions (AUD$19,418 per person; P = .006) and in males (AUD$18,947 per person; P = .029).

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.

These findings are described in the article entitled Coaching Patients Saves Lives and Money, recently published in The American Journal of Medicine. The economic evaluation was independently conducted by Joshua Byrnes, Thomas Elliott and Paul Scuffham from the Centre for Applied Health Economics & Menzies Health Institute Queensland, Griffith University, Brisbane, Australia.