Reinforcing Education About Cholesterol - REACH

Description:

Reinforcing Education About Cholesterol.

Hypothesis:

Educational intervention, focused on consensus targets and patients partnering with their physicians, will improve compliance with National Cholesterol Education Program (NCEP) low-density lipoprotein (LDL) cholesterol targets (

Study Design

Study Design:

Patients Screened: 2,657
Patients Enrolled: 756
Mean Follow Up: 1 year
Mean Patient Age: 30-80 years old
Female: 30

Patient Populations:

Men and women aged 30-80 years; consecutive patients hospitalized for one of the following reasons: myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft surgery, or suspected CAD plus history of any of the above or a known coronary stenosis >70%.

Exclusions:

Out-of-state residence; terminal illness; contraindications to lipid lowering; transfer to long-term care facility; condition precluding ability to give informed consent or to be interviewed (of 1,188 eligible patients, most of those not enrolled in the study either refused inclusion or were discharged prior to consent).

Primary Endpoints:

Percentage of patients with LDL <100 mg/dL 1 year after discharge.

Secondary Endpoints:

Percentage of CAD patients with knowledge about LDL cholesterol target levels 1 year after discharge.

Drug/Procedures Used:

Educational intervention vs. standard care to teach cholesterol post-hospitalization for coronary artery disease (CAD).

Concomitant Medications:

HMG CoA reductase inhibitors.

Principal Findings:

One year follow-up was 89.6% for the intervention group and 87.4% for the usual care cohort. At 1 year, 70.2% of the intervention group and 67.4% of the usual care group had LDL cholesterol levels <100 mg/dL. Knowledge of LDL target, which was 5% of each group at baseline, had risen to 19.6% in the intervention group but only 6.7% in the usual care group (p<0.001). Across the arms, 70.1% of patients who knew the LDL target reached goal; 69.0% of those who did not know the target also reached goal. At follow-up, 70.2% of intervention patients and 67.8% of usual care patients were on hyperlipidemic medication, almost exclusively statins. The investigators found that educational intervention did not improve guideline compliance although intervention was modestly successful in increasing the knowledge of the LDL target. Investigators acknowledged that possible explanations for the results were: compliance rates high in both groups so the researchers may have encountered a ceiling effect; the intensive educational efforts were inadequate; patient knowledge was not related to reaching the target; and that patient education is ineffective unless integrated within the system of care. Educational efforts such as those studied are unlikely to be effective alone in raising compliance; thus there remains a clear need to develop innovative strategies to enhance implementation of effective therapies.

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.”

References:

1. Risk factor changes and mortality results from MRFIT. JAMA 1982;248:1465-77.
2. Clinical evaluation and patient teaching in the ACCEPT trial. Clin Ther 1994;16:838-53.
3. Reaching NCEP target LDL levels in L-TAP. Arch Intern Med 2000;160:459-67.
4. Practice patterns and missed opportunities. Am J Cardiol 2000;86:62L-5L. 5. Collaborative educational intervention in lipid evaluation. Arch Intern Med 2001;161:839-44.
6. Educational interventions. Am J Med 2001;110:12S-16S.
7. Teaching patients about lipid levels. Nursing 2001;31:68.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Homozygous Familial Hypercholesterolemia, Lipid Metabolism, Nonstatins, Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Myocardial Infarction, Follow-Up Studies, Coronary Stenosis, Cholesterol, LDL, Research Personnel, Guideline Adherence, Hypercholesterolemia, Coronary Artery Bypass, Reward, Consensus, Percutaneous Coronary Intervention


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