LEADING THE WORLD IN COACHING FOR PREVENTION OF CHRONIC DISEASE

LEADING THE WORLD IN COACHING FOR PREVENTION OF CHRONIC DISEASE Dr Margarite Vale, PhD, FCSANZ Clinical Associate Professor The University of Melbourne Department of Medicine Managing Director, The COACH Program The COACH Program

THE COACH PROGRAM Originating in 1995, it is the world s first evidencebased program of coaching for the prevention of chronic disease. First disease management program to reduce risk factors in patients with cardiovascular disease without involving nurses and allied health professionals in prescribing medications directly to patients. The solid evidence-base is the reason The COACH Program has been sought after The most widely used chronic disease management program in Australia.

Why is there a treatment gap? 3 possibilities: Patients may not visit doctor or attend rehab programs Only ~30% of eligible Australian patients enrol in cardiac rehabilitation programs In some areas (e.g., Queensland), <40% of available outpatient cardiac rehabilitation programs places are fully utilised 2,3 Patients my attend the doctor but may not adhere to the treatment recommended Evidence shows people who are prescribed self-administered medications typically take less than half the prescribed doses 4 Even if patients are managed appropriately, many will discontinue their own treatment Adherence to lifestyle measures is very poor Doctors may not make the appropriate checks or tests May not initiate the treatment or titrate therapy to the dose required to achieve the target level. Cardiac rehab often refused by those who need it the most 5 A 2007 study of 208 patients found that patients who agree to attend rehab have better risk factor levels than do those who decline to attend such programs Proportion of patients with various risk factors attending rehab versus those that did not attend rehab Percentage of patients 80 55 TC >4 mmol/l 79 24 Inactive 49 35 BMI >30 kg/m 2 20 7 23 Smoker CDS >100 No rehabilitation (n = 144) Rehabilitation (n = 64) 6 30 8 52 24 DiabetesLipid score >5 1 Vale M et al. J Clin Epidemiol. 2002. 2. Brieger D et al. MJA 2009. 3. Scott I et al. MJA. 2003. 4. Haynes RB et al. Cochrane 2008 5. Redfern et al. MJA 2007

How many patients with cardiovascular disease are achieving their risk factor targets? How are we doing? 1999-2000 (MJA 2002;176:211-15) versus 2008-2011 Risk Factors Percentage at target Public (n=348) 1999-2000 Public (n=577) 2008-2011 Private (n=1221) 2008-2011 TC < 4 mmol/l 26% 39% 43% BP at target 61% 59% 52% HbA1c 7% - 33% 54% FBG at target 65% 45% 63% BMI < 25 kg/m 2 25% 26% 27% Alcohol at target 71% 89% 86% Physical activity at target 74% 45% 49% Not smoking 81% 84% 98% Statin use 87% 84% 93%

The COACH Program looks for treatment gaps and coaches the patient to close these gaps while they work in partnership with their usual doctors Successful improvement of risk factors and adherence to recommended medications are the only proven effective treatments that are known to retard the disease process and prolong life.

What is The COACH Program? The COACH Program is an evidence-based telephone and mailout delivered coaching (disease management) program for patients with chronic disease(s) whereby a health professional trained in The COACH Program, coaches patients to achieve and maintain the target levels for their modifiable risk factors and to take the recommended medications as set by the national evidence-based guidelines for the management of their chronic disease(s) while they work with their usual doctors.

Power to the Patients Know as much as your doctor knows about your medical condition. If you re a person with a chronic disease: Your doctor doesn t have a vested interest in you You have a vested interest in you! Coaches patients to work in close partnership with their doctors to reduce their risk of recurrent disease.

Power to the Patients We have a medical system which is under pressure to deal with people as quickly as possible and get them out of hospital as quickly as possible. Dr Richmond Jeremy, Editor-in-Chief, Heart Lung and Circulation (2011). The COACH Program coaches people to take control of their lives by knowing their risk factors (which influence disease), maximising their risk factor control which reduces their anxiety.

Each phone-delivered coaching session consists of five stages Ask patients questions to find out what they know about their risk factors and treatment for their risk factors 1 Finding out what the patient knows 2 Education Tell patients what they should know Check what action has taken place since the previous coach session and use the information as the basis for the next coach session. Monitoring 5 Closing the loop Action Plan Patient empowerment 4 3 Empower patients to ask their own doctor(s) to measure their risk factors; provide them with their test results; prescribe appropriate medication and alter doses/drugs if appropriate Set an action plan to be achieved by the next coach session

Power to the Patients The COACH Program is a pragmatic intervention that primes the patient to self-manage and to take the initiate with their doctors, leading to more intensive therapy to achieve treatment goals. Coaching emphasises both lifestyle measures and medication treatment. Guides patients step-by-step. Coaches patients to seek more intensive care from their regular doctors for their risk factors

What we do We provide training, software and support for qualified health professionals (employed by healthcare organisations) to deliver coaching via The COACH Program to patients with chronic disease(s) to achieve and maintain the target levels for their modifiable risk factors and to take the recommended medications as set by the national evidence-based guidelines for the management of their chronic disease(s)

History of The COACH Program 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1995 The COACH Program originated in 1995 as a research project 2002/03 Two randomised controlled trials performed in Victoria demonstrated the program s effectiveness 2005 The COACH Program was rolled out as standard care in the Victoria public health system First 10 years research only 2006 The COACH Program Pty Ltd was formed to expand delivery of the program through a researched and tested model 2007 The first private health fund began using The COACH Program. Other private health funds followed 2008 Sought by McKinsey & Company & expanded overseas 2010 Accredited by the Australian Council on Healthcare Standards (ACHS) 2009 Program operating in the public health system in all Australian states, the majority of private health funds; Europe. 2009 Telstra Australian Business of the Year National Winner

The most widely used chronic disease management program in Australia Public health systems that have adopted The COACH Program Nationwide Delivered from major public teaching hospitals for patients with CHD Delivered by the Adelaide Health Service for public hospital patients with: heart failure, type 2 diabetes, COPD, stroke/tia, CHD Western Australia Health SA Health Private health systems Bupa Australia Defence Health nib Health Funds Australian Health Service Alliance Australian Unity Achmea (Netherlands) HBF MLOZ Belgium Queensland Health New South Wales Health Victoria Tasmania Delivered by the Health Contact Centre (13HEALTH) for all of QLD for patients with CHD and/or type 2 diabetes Delivered by NSW Health for public hospital patients with: heart failure, type 2 diabetes, COPD, CHD, HT Delivered from public teaching hospitals for patients with CHD Operating from Diabetes TASMANIA for patients with type 2 diabetes or prediabetes or high risk of type 2 diabetes

Recruitment of patients varies depending on the health system and local needs but The COACH Program experience is the same Patient recruitment in public health systems Patients are recruited face-to-face in hospitals. - For instance, in Queensland, patients are referred by Queensland hospitals to a central Health Contact (Call) Centre using fax or on-line referral form - Thereafter, the Health Contact Centre nurse coaches, contact patients within 1 week of hospital discharge to commence The COACH Program 99% of patients in public health systems choose to participate in the program Patient recruitment in private health systems Claims data is imported into The COACH Program Software Application weekly which includes patient details and ICD (diagnostic) and MBS (procedure) codes The coaches use claims information to identify prospective patients Software allows coaches to sort and prioritise patients Trained coaches based in the private health fund contact members who have recently been hospitalised for chronic diseases; coaches cold call patients to participate ~80% of people in private health systems choose to participate in the program

The COACH Program: available for patients with one or more of the following chronic conditions Patients with multiple conditions: Patients are coached to achieve the target risk factor levels for all of their associated conditions, not just their principal diagnosis. For e.g. a patient with CHD who has diabetes is coached on both their CHD and diabetes risk factors Vascular diseases Diabetes conditions Other chronic conditions

Initial studies validated The COACH Program s effectiveness (1/2) Overview Results Study 1 1 Journal of Clinical Epidemiology. 2002 Single centre randomised controlled trial of 245 patients with CHD who underwent The COACH Program plus usual care vs usual care only. Total cholesterol (TC) levels were measured six months after randomisation Coached patients had significantly lower TC levels (5.00 mmol/l vs 5.54 mmol/l) than did patients who underwent usual medical care only (P<0.0001) Study 2 2 Archives of Internal Medicine. 2003 Multicentre randomised randomised controlled trial of 792 patients who were admitted to six university teaching hospitals for CABG; PCI; AMI or unstable angina (and then discharged on medical therapy); or coronary angiography with later planned elective revascularisation Patients were randomised to The COACH Program plus usual care vs usual care only Patients were coached to achieve the targets for all of their modifiable risk factors 1. Vale M et al. J Clin Epidemiol. 2002 2. Vale M et al. Arch Intern Med. 2003 The COACH Program achieved significantly lower: Total and LDL-cholesterol Blood pressure Dietary intake of total fat, sat fat Anxiety (by questionnaire) Reduced cardiac symptoms The COACH Program achieved significantly higher: Dietary fibre intake Walking for exercise Better self-reported mood, general health, fitness

Initial studies validated The COACH Program s effectiveness (2/2) Study 3 1 Overview Heart Lung and Circulation. 2009 Prospective cohort of 656 patients with CHD who completed the 6 month COACH Program were followed by telephone every 6 months from recruitment (in hospital) for 2 years to assess whether The COACH Program could sustain its favourable impact on coronary risk factors and adherence to recommended medications for 18 months after completion of The COACH Program Results Two-year follow-up of public hospital patients shows that improvements in risk factor status and adherence to medications achieved at 6 months are sustained for more than 18 months after cessation of The COACH Program 1. Jelinek MV et al. Heart, Lung and Circulation. 2009.

and follow-up studies provide additional support 1 THE COACH PROGRAM KEEPS PATIENTS OUT OF HOSPITAL IN THE AUSTRALIAN PUBLIC HEALTH SECTOR 4-YEAR FOLLOW-UP OF THE COACH STUDY MULTICENTRE RCT (20% OF PATIENTS HAD DIABETES IN BOTH GROUPS) Vale MJ, Sundararajan V, Jelinek MV, et al. Circulation 2004; 110: Suppl: III-801 Cardiac Admissions RATE OF EVENTS AT 4-YEAR FOLLOW-UP Rate per 100 person year (99% CI) Coached Usual Care % Reduction P Cardiac hospitalisations 37(32,41) 42(38,47) 12% NS Cardiac beddays 127(119,135) 149(140,157) 15% <0.01 All Cause Admissions All hospitalisations 105(98,112) 125(117,133) 16% <0.01 All beddays 359(346,373) 448(433,463) 20% <0.001 1. Vale MJ, Sundararajan V, Jelinek MV, et al. Circulation 2004; 110: Suppl: III-801

and follow-up studies provide additional support 1 The COACH Program produces significant savings at nib Health Funds The COACH Program commenced at nib Health Funds on 1 st April 2008. After discharge from hospital, 1069 patients with cardiovascular disease underwent The COACH Program for 6 months. METHODS: nib measured the hospital costs paid by nib for coached patients in their first and second year after enrolment in The COACH Program and compared them to a control group matched for age, gender, diagnosis and state of residence. RESULTS: The COACH Program at nib has substantially reduced gross drawing rate costs: with The COACH Program by 27%. without The COACH Program (control) by 10%. The COACH Program at nib resulted in a net saving of $312 per patient over 2 years. For the 3 year follow-up results don t miss Dr Daryl Bull s presentation tomorrow at 2:15PM in the session on Initiatives in the Private Sector (Menzies room) 1. Bull D et al. Oral presentation at National Heart Foundation National Conference, 18 March 2011 Slide 18

The COACH Program at Bupa Australia (incorporating MBF, HBA, Mutual Community) Operating since January 2008 Figures from Bupa Australia (MBF, HBA, Mutual Community) show a net saving in costs between the patients who underwent The COACH Program compared with those who were in the non-coached group as time passed after the intervention. On the strength of this result, Bupa Australia have put on more coaches.

What is the impact of The COACH Program in public and private patients? Presented at National Heart Foundation of Australia Conference 17 March 2011 Background: People at lower socioeconomic status (SES) have a higher incidence and mortality from cardiovascular disease than do the more affluent. Patients with private health insurance are usually of higher SES than those treated in public hospitals. Aim: To compare the risk factor status and adherence to recommended medications in patients at public and private hospitals at entry and at exit from The COACH Program. Methods: The entry and exit status of cardiovascular risk factors and adherence to recommended medications was measured and contrasted in 1935 public hospital cardiovascular patients and 4554 cardiovascular patients from private health funds from 2007.

Baseline characteristics: Comparison of private patients vs public patients with cardiovascular disease (2007-11) Public (n=1953) Private (n=4553) Males (%) 71.1% 76.3% Age (years) 61.6 years 65.6 years Employed 42.7% 40.2% Post secondary education 48.2% 54.3% Prior ACS 22.3% 19.3% Prior PCI 15.6% 23.2% Prior CABG 8.9% 10.5% Prior PVD 5.5% 3.7% Prior CHF 4.7% 2.5% Prior stroke 6.1% 3.7% Prior renal disease 5.0% 3.0%

Comparison of private health results with public health results (2007-11) for patients with cardiovascular disease Risk factors at target Public (n=1953) Private (n=4553) LIPIDS Entry Exit Diff Entry Exit Diff LDL-C < 2 mmol/l 26% 68% 42% 35% 64% 29% TC < 4 mmol/l 31% 70% 39% 40% 67% 27% TG < 1.5 mmol/l 44% 62% 19% 59% 71% 12% BLOOD PRESSURE Entry Exit Diff Entry Exit Diff BP at target (mmhg) 57% 76% 19% 46% 68% 21% DIABETES Entry Exit Diff Entry Exit Diff HbA1c 7% 35% 57% 22% 56% 62% 6% FG (mmol/l) 44% 75% 31% 62% 69% 6%

Comparison of private health results with public health results (2007-11) for patients with cardiovascular disease Risk factors at target Public (n=1953) Private (n=4553) WEIGHT MANAGEMENT Entry Exit Diff Entry Exit Diff Waist (cm) 37% 54% 17% 33% 45% 12% BMI (kg/m 2 ) 28% 37% 9% 29% 33% 5% ALCOHOL Entry Exit Diff Entry Exit Diff Alcohol 83% 95% 11% 86% 95% 9% PHYSICAL ACTIVITY Entry Exit Diff Entry Exit Diff Physical Activity 47% 86% 40% 54% 80% 26% SMOKING Entry Exit Diff Entry Exit Diff Not smoking 80% 91% 11% 98% 98% 0%

Comparison of private health results with public health results (2007-10) cardiovascular disease patients Recommended Medications Public (n=1953) Private (n=4553) Entry Exit Diff Entry Exit Diff Antiplatelets 89% 94% 4% 93% 94% 1% Statins 86% 91% 5% 91% 95% 4% Beta Blockers 73% 76% 3% 53% 52% 1% ACEI/ARA 75% 79% 5% 66% 70% 4%

Conclusion: The impact of The COACH Program in public and private patients RESULTS: The public hospital patients were 5 years younger and had much poorer cardiovascular risk factors than their private counterparts. At the end of The COACH Program the cardiovascular risk factors and adherence to recommended medications was similar for both groups. CONCLUSION: The COACH Program can overcome the worse cardiovascular risk factors in public patients in an equitable fashion.

Comparison of current results (2007-11) with the COACH study results (2003) in patients with cardiovascular disease Risk Factors Mean Entry 2007-2011 (n=6506) Mean Exit Diff COACH Study (2003) (n=792) Mean Entry Mean Exit LDL-C (mmol/l) 2.5 1.8 0.7 3.1 2.5 0.6 TC (mmol/l) 4.5 3.7 0.8 5.0 4.5 0.5 TG (mmol/l) 1.6 1.3 0.3 1.6 1.5 0.1 BP Systolic (mmhg) 126 123 3 130 130 0 BP Diastolic (mmhg) 74 72 2 76 76 0 HbA1c (%) 7.4 7.0 0.4 - - - FG (mmol/l) 5.4 5.1 0.3 5.8 5.7 0.1 Waist Male (cm) 99 97 2 - - - Waist Female (cm) 89 87 2 - - - BMI (kg/m 2 ) 27.5 27.0 0.5 28.2 27.8 0.4 Diff

Why is evidence essential? There is a common misconception that any program that follows up patients with empathetic health professionals and provides education on risk factors and medications will necessarily translate into reduced risk factors and improved outcomes in patients with chronic disease. This cannot be further from the truth. Proof that a disease management program actually works is mandatory. Without rigorous testing it is impossible to know whether it has any positive impact at all in improving patient outcomes. Targeting health behaviours does not work to reduce risk factors in patients with chronic disease. Targeting risk factor levels does work.

A publication in a medical journal is not necessarily evidence A publication in a medical journal is only evidence if it has outcomes. A program which makes intuitive and logical sense will not necessarily improve outcomes in patients with chronic disease as shown by a long list of published programs that did not work.

Cardiovascular disease management programs where dietitians & nurses DID NOT PRESCRIBE DRUGS ALL NEGATIVE NONE were effective in improving the coronary risk factor profile in patients with CHD Heller RF et al. Am J Cardiol. 1993 (RCT): mailout intervention. Kirkman SM et al. Diabetes Care. 1994 (RCT): telephone intervention, research nurse delivered. Cupples & McKnight BMJ. 1994 & 1999 (RCT): clinic-based intervention, nurse conducted. Tooth LR et al. Aust N Z J Public Health. 1998 (Quasi-experiment): clinic-based intervention, occupational therapist conducted. Jolly K et al. BMJ. 1999 (RCT): postal prompt intervention, specialist cardiac liaison nurse delivered Holt et al. Lancet. 1999 (Prospective cohort): mailout Nordmann A et al. Am J Med. 2001 (RCT): case-manager delivered, clinic-based, phone and mailout. Lear SA et al. (ELMI trial) Eur Heart J. 2003 (RCT): group and telephone, case-manager delivered. Southard BH et al. J Cardiopulm Rehabil. 2003 (RCT): internet-based case management Lichtman et al. Am Heart J. 2004 (RCT): telephone delivered.

Cardiovascular disease management programs where dietitians & nurses were permitted to PRESCRIBE DRUGS ALL POSITIVE ALL WORKED - all improved coronary risk factor profile in patients with CHD DeBusk RF et al. MULTIFIT. Ann Intern Med. 1994 (RCT): telephone & mailout intervention, nurse conducted. Robinson JG et al. Am J Cardiol. 2000 (Prospective cohort): telephone & mailout intervention, dietitian delivered. Stagmo et al. J Cardiovasc Risk. 2001 (RCT): clinic-based intervention, nurse conducted. Senaratne MPJ et al. Am Heart J. 2001 (Quasi-experiment): clinicbased intervention, cardiac rehab nurse conducted. Allen JK et al. Am Heart J. 2002 (RCT): clinic-based, nurse practitioner. Koren MJ et al. (ALLIANCE study) J Am Coll Cardiol. 2004 (RCT): disease management in managed-care patients. Straka RJ et al. (ACTION study) Pharmacotherapy. 2005 (RCT): pharmacists implementing physician approved care plans.

CONCLUSION of literature review on chronic disease management programs for cardiovascular disease Until The COACH Program, the only strategies directed at the patient for reducing the treatment gap which were effective allowed the direct prescription of medications. The COACH Program is risk factor outcome focused. The programs which targeted behavioural change did not reduce the treatment gap.

The Transtheoretical Stages of Change Model is published but it is not an evidence-based approach to addressing the treatment gap This model argues that interventions that promote change should be designed so that they are appropriate for an individuals current stage: Pre-contemplation Contemplation Preparation Action Maintenance Termination There is no evidence for stage-matched interventions. There have been a number of detailed critiques of this theory with calls for the abandonment of this model (West R. Addiction 2005; 100: 1036-9). There is no evidence that coaching models based on this theory are effective.

The Transtheoretical Stages of Change Model is published but it is not an evidence-based approach to addressing the treatment gap There is no evidence that coaching models based on this theory are effective. Evidence shows that disease management programs (of coaching) based on this theory do not work. Waste of money Worse than that, patients are not getting the information they need to stop their disease from getting worse.

Don t miss the following sessions at the conference Does The COACH Program work in indigenous patients? Janine Wilson, Queensland Health Today - Thursday 25 th August, 3:00PM, Session: Health Coaching Does The COACH Program work for remote and very remote patients? Dr Umberto Boffa, Head Medical Services, Bupa Australia Tomorrow Friday 26 th August, 2:00PM; Session: Initiatives in the Private Sector Does The COACH Program save money at nib Health Funds? Dr Daryl Bull, Manager Claims, nib Health Funds Tomorrow Friday 26 th August, 2:15PM; Session: Initiatives in the Private Sector

In summary: Evidence-based and cost effective : Unequivocal evidence that The COACH Program works to reduce risk factors in patients with chronic disease (better than usual care), keeps patients out of hospital and reduces costs for the health organisation. Proven track record, underpinned by >16 years of research. Targets risk factors and not just behaviours: Target levels for modifiable risk factors are vigorously pursued in accordance with the national evidence-based guidelines; using a behaviour as a target does not work to reduce the treatment gap. In focussing on reducing risk factors, psychosocial factors are also improved. Patient-led: Empowers patients to drive the process of achieving and maintaining the target levels for their modifiable risk factors. Coaches patients to know as much as their doctor knows about their medical condition. Addresses the reasons for the treatment gap. Very high patient participation in the public and private health systems: 99% in the public health system and ~80% in the private health system. Very high patient satisfaction: Outstanding patient satisfaction as evidenced by patient satisfaction surveys distributed by the health organisations delivering our program.

In summary: Ongoing formal evaluation: Detailed evaluation reports are prepared 6 monthly for all organisations delivering The COACH Program and include a comparison to the national mean. Results are provided for individual coaches and organisations as a whole to assess performance. The COACH Program Software Application provides all KPI data on the effectiveness of the program. The results of the evaluation reports are used to review operations and improve the outcomes within each organisation through a process of CQI. In-expensive: Focus on reducing modifiable risk factors and delivering the program in-house helps keep costs down for the organisation. Research and development: Ongoing commitment to R & D as shown by the other COACH Program papers submitted at this conference and ongoing work in publishing findings of the real world program. Guidelines development: Involvement in developing and implementing the national evidence-based guidelines for chronic diseases. Global applicability: Integrates fully into any existing model of healthcare delivery. Recipient of multiple prestigious awards national and international, academic and business