Interpretation:

There is a need for studies of implementation, particularly those that focus on how to optimize implementation of best practice and new knowledge, how to accelerate adoption of innovation, and how to involve patients in their own care. REACH focused on the issue of LDL cholesterol management, as there are gaps in LDL guideline adherence; specifically, about 80% of CAD patients are not achieving LDL guideline targets. And while there is much current activity to improve care through patient education, the evidence demonstrates that patient knowledge and engagement are not high.

At the REACH presentation during the AHA 2001 annual meeting, discussant Dr. Tom Pearson noted that clinicians often fall short in implementing proven clinical strategies. “Clearly, efficacy does not equal effectiveness,” he said. The underlying hypothesis of a study such as REACH is that a change in patient knowledge will lead not only to a knowledge change but a subsequent chain of events including changes in attitude, behavior, and then risk factors. While a modest change in the proximal target -- knowledge about LDL goal -- was observed, REACH joins other trials that have shown that knowledge change alone – or with reminders – is often not enough to translate into changes in distal target behaviors and risk factor levels.

Other nurse case manager studies have demonstrated that interventions beyond a simple transfer of information and reminders, such as reinforcements and rewards, yield better results. Also, as Dr. Pearson suggested, the nurse case manager model may be an effective but inexpensive intervention that extends post-hospitalization care. Consequently, such patient education deserves continued interest in research and practice.

As with other trials, it is possible that other interventions may have overwhelmed the benefit of nurse case manager educational intervention in REACH. Additionally, the patients in this study may not have been representative of typical patients in the United States. However, as Dr. Pearson also said, “(T)his certainly provides evidence that such a high rate of adherence can be achieved by excellent health care. It reminds me of the MRFIT [Multiple Risk Factor Intervention Trial] Study, and other trials in which the intervention group reached or exceeded their reduction in endpoints, only to find no difference with the usual care group which also showed similar improvement as part of a secular trend.”