Does outpatient telephone coaching add to hospital quality improvement following hospitalization for acute coronary syndrome?
ABSTRACT Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care.
To test the effectiveness of a six-session outpatient telephone-based counseling intervention to improve secondary prevention (behaviors, medication) in patients with acute coronary syndrome (ACS) following discharge from hospital, and impact on physical functioning and quality of life at 8 months post-discharge.
Patient-level randomized trial of hospital quality improvement (QI-only) versus quality improvement plus brief telephone coaching in three months post-hospitalization (QI-plus). Data: medical record, state vital records, patient surveys (baseline, three and eight months post-hospitalization). Analysis: pooled-time series generalized estimating equations to analyze repeated measures; intention-to-treat analysis.
Seven hundred and nineteen patients admitted to one of five hospitals in two contiguous mid-Michigan communities enrolled; 525 completed baseline surveys.
We measured secondary prevention behaviors, physical functioning, and quality of life.
QI-plus patients showed higher self-reported physical activity (OR = 1.53; p = .01) during the first three months, with decline after active intervention was withdrawn. Smoking cessation and medication use were not different at 3 or 8 months; functional status and quality of life were not different at 8 months.
Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization.
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ABSTRACT: Cardiac rehabilitation is offered to individuals after cardiac events to aid recovery and reduce the likelihood of further cardiac illness. However, patient participation remains suboptimal and the provision of high quality care to an expanding population of patients with chronic heart conditions is becoming increasingly difficult. A systematic review and meta-analysis was conducted to determine the effect of telephone support interventions compared with standard post-discharge care on coronary artery disease patient outcomes. The Cochrane Library, MEDLINE, EMBASE, and CINAHL were searched and randomized controlled trials that directly compared telephone interventions with standard post-discharge care in adults following a myocardial infarction or a revascularization procedure were included. Study selection, data extraction and quality assessment were completed independently by two reviewers. Where appropriate, outcome data were combined and analyzed using a random effects model. For each dichotomous outcome, odds ratios (OR) and 95% confidence intervals (CI) were derived for each outcome. For continuous outcomes, weighted mean differences (WMD) and standardized mean differences (SMD) and 95% CI were calculated. 26 studies met the inclusion criteria. No difference was observed in mortality between the telephone group and the group receiving standard care OR 1.12 (0.71, 1.77). The intervention was significantly associated with fewer hospitalizations than the comparison group OR 0.62 (0.40, 0.97). Significantly more participants in the telephone group stopped smoking OR 1.32 (1.07, 1.62); had lower systolic blood pressure WMD -0.22 (-0.40, -0.04); lower depression scores SMD -0.10 (-0.21, -0.00); and lower anxiety scores SMD -0.14 (-0.24, -0.04). However, no significant difference was observed for low-density lipoprotein levels WMD -0.10 (-0.23, 0.03). Compared to standard post-discharge care, regular telephone support interventions may help reduce feelings of anxiety and depression as well as, improve systolic blood pressure control and the likelihood of smoking cessation.PLoS ONE 05/2014; 9(5):e96581. · 3.53 Impact Factor
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ABSTRACT: /st>(i) To examine the sustainability of an in-hospital quality improvement (QI) intervention, the American College of Cardiology's Guideline Applied to Practice (GAP) in acute myocardial infarction (AMI). (ii) To determine the predictors of physician adherence to AMI guidelines-recommended medication prescribing. /st>Prospective observational study. /st>Five mid-Michigan community hospitals. /st>516 AMI patients admitted consecutively 1 year after the GAP intervention. These patients were compared with 499 post-GAP patients. /st>The main outcome was adherence to medication use guidelines. Predictors of medication use were determined using multivariable logistic regression analysis. /st>1 year after GAP implementation, adherence to most medications remained high. We found a significant increase in beta-blocker (BB) use in-hospital (87.9 vs. 72.1%, P < 0.001) whereas cholesterol assessment within 24 h (79.5 vs. 83.6%, P > 0.225) did not change significantly. However, discharge aspirin (83 vs. 90%, P < 0.018) and BB prescriptions (84 vs. 92%, P < 0.016) dropped to preintervention rates. Discharge angiotensin-converting enzyme inhibitor and treatment of patients with low-density lipoprotein of ≥100 were unchanged. Predictors of receiving appropriate medications were male gender (for aspirin and BBs) and treatment with percutaneous coronary intervention compared with coronary artery bypass graft. Notably, prescription rates for discharge medications differed significantly by hospital. /st>Early benefits of the Mid-Michigan GAP intervention on guideline use were only partially sustained at 1 year. Differences in guideline adherence by treatment modality and hospital demonstrate challenges for follow-up phases of GAP. Additional strategies to improve sustainability of QI efforts are urgently needed.International Journal for Quality in Health Care 05/2014; · 1.79 Impact Factor
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ABSTRACT: Background. Cardiovascular disease (CVD) is a major cause of increased morbidity and mortality globally. Clinical practice guidelines recommend that individuals with CVD are routinely instructed to engage in self-care including diet restrictions, medication adherence, and symptom monitoring. Objectives. To describe the nature of nurse-led CVD self-care interventions, identify limitations in current nurse-led CVD self-care interventions, and make recommendations for addressing them in future research. Design. Integrative review of nurse-led CVD self-care intervention studies from PubMed, MEDLINE, ISI Web of Science, and CINAHL. Primary studies (n = 34) that met the inclusion criteria of nurse-led RCT or quasiexperimental CVD self-care intervention studies (years 2000 to 2012) were retained and appraised. Quality of the review was assured by having at least two reviewers screen and extract all data. Results. A variety of self-care intervention strategies were studied among the male (57%) and Caucasian (67%) dominated samples. Combined interventions were common, and quality of life was the most frequent outcome evaluated. Effectiveness of interventions was inconclusive, and in general results were not sustained over time. Conclusions. Research is needed to develop and test tailored and inclusive CVD self-care interventions. Attention to rigorous study designs and methods including consistent outcomes and measurement is essential.Nursing research and practice. 01/2013; 2013:407608.
Does Outpatient Telephone Coaching Add to Hospital Quality
Improvement Following Hospitalization for Acute Coronary
Margaret Holmes-Rovner, PhD1,2, Manfred Stommel, PhD3, William D. Corser, PhD, RN3,
Adesuwa Olomu, MD, MS2, Jodi Summers Holtrop, PhD4, Azfar Siddiqi, MD, PhD3,
and Susan L. Dunn, PhD, RN5
1Center for Ethics, C203 E. Fee Hall, Michigan State University College of Human Medicine, East Lansing, MI, USA;2Department of Medicine,
College of Human Medicine, East Lansing, MI, USA;3College of Nursing, Michigan State University, East Lansing, MI, USA;4Department of
Family Medicine, College of Human Medicine, East Lansing, MI, USA;5Department of Nursing, Hope College, Holland, MI, USA.
BACKGROUND: Telephone counseling in chronic dis-
ease self-management is increasing, but has not been
tested in studies that control for quality of medical care.
OBJECTIVE: To test the effectiveness of a six-session
outpatient telephone-based counseling intervention to
improve secondary prevention (behaviors, medication)
in patients with acute coronary syndrome (ACS) follow-
ing discharge from hospital, and impact on physical
functioning and quality of life at 8 months post-
DESIGN: Patient-level randomized trial of hospital
quality improvement (QI-only) versus quality improve-
ment plus brief telephone coaching in three months
post-hospitalization (QI-plus). Data: medical record,
state vital records, patient surveys (baseline, three and
eight months post-hospitalization). Analysis: pooled-
time series generalized estimating equations to analyze
repeated measures; intention-to-treat analysis.
PARTICIPANTS: Seven hundred and nineteen patients
admitted to one of five hospitals in two contiguous mid-
Michigan communities enrolled; 525 completed base-
MEASUREMENTS: We measured secondary prevention
behaviors, physical functioning, and quality of life.
RESULTS: QI-plus patients showed higher self-reported
physical activity (OR=1.53; p=.01) during the first three
months, with decline after active intervention was with-
drawn. Smoking cessation and medication use were not
life were not different at 8 months.
for ACS was modestly effective in accomplishing short-
term, but not long-term life-style behavior change. Previ-
to free-standing telephone counseling as an adjunct to
care following hospitalization.
KEY WORDS: clinical trials; disease management; guidelines; chronic
disease; quality improvement; patient-centered care; acute coronary
syndrome; telephone counseling; decision support techniques.
J Gen Intern Med 23(9):1464–70
© Society of General Internal Medicine 2008
efficacy of medical and behavioral secondary prevention.
Accomplishing secondary prevention, however, requires sub-
stantial effort and resources from patients and from clini-
cians.1To realize the benefits of secondary prevention, it is
important to adopt the most effective and efficient set of
interventions that is feasible in routine care. Quality improve-
ment (QI) efforts have been shown to improve guideline
implementation in hospitals.2,3Behavior change interventions
have been shown to be effective in outpatient settings,
especially brief patient advice utilizing a smoking cessation
model.4–8. However, the latter studies frequently fail to estab-
lish the independent contribution of outpatient behavioral
interventions, which are often confounded with the quality of
care the patient has received leading up to the behavior
change. To date, few researchers have addressed the problem
of gauging the independent and cumulative effects on inter-
mediate and long-term outcomes of interventions that link
hospital and outpatient care. Thus, we hypothesized that post-
hospitalization health status and behavior of ACS patients
would be influenced by the intervention, and by patient level
variables, such as illness severity, depressive symptoms and
functioning, socio-economic characteristics and prior smoking
behaviors as well as hospital treatments. We report results of a
trial of a six-session telephone intervention conducted in the
first three months after hospitalization for acute coronary
syndrome (ACS), one year after successful implementation of a
hospital quality improvement (QI) program. All patients re-
ceived care enhanced by the QI program. The hospitals and the
quality improvement program (guidelines applied to practice
[GAP]) have been described previously.9To determine the
independent effects of the outpatient coaching intervention,
we randomized patients to two groups: 1) a six-session
he efficacy of surgical and medical therapies for acute
coronary syndrome (ACS) is well established, as is the
Received July 26, 2007
Revised November 13, 2007
Accepted June 12, 2008
Published online July 10, 2008
telephone coaching intervention in addition to in-hospital QI
(QI-plus) and 2) hospital QI alone (QI-only).
A sample of 719 subjects consented and were enrolled by
trained nurse recruiters from January 14, 2002 through April
13, 2003 at five community hospitals in two geographically
contiguous Michigan communities, with comparable patient
demographics, employment patterns, insurance coverage,
proportions of minority, unemployed and low-income resi-
dents.10–13All five were community teaching hospitals. Based
on peer grouping criteria, three were large hospitals and two
were moderately sized hospitals (none were small volume
hospitals). Four out of five had facilities for coronary artery
bypass graft surgery. Four out of five had greater than 10%
minority patients with ACS discharged per year.
Patient inclusion criteria were a working diagnosis of ACS in
the medical record,a documented serum troponinI levelgreater
than the upper limits of normal, and age greater than 21 years.
Patients were excluded if unable to speak English or complete
study interviews, or discharged to a non-home setting.
Patients who agreed to participate were randomized within
each hospital to QI-only or QI-plus. Randomization was
originally begun at recruitment for the first 98 patients (19%
of baseline interviewed) patients, but was changed to post-
baseline interview for the remaining 427 (81%) to correct an
imbalance in study group sizes. The imbalance in study group
sizes developed not as a result of the initial (blocked) random-
ization, but from unknown factors related to the logistics of
interviewer contacts, which happened to be more successful
among subjects assigned to the intervention than the control
groups. Based on comparison of demographic variables, we
cannot find any introduced bias. The study was approved by
the University Committee on Research Involving Human
Subjects of Michigan State University and by each hospital
IRB before study data were collected.
Participants were recruited from hospitals that participated in
the American College of Cardiology Guidelines Applied to
Practice (GAP) QI program one year prior to the present trial.9
Both intervention and control groups received the QI program
by virtue of having been admitted to GAP hospitals. The added
counseling intervention was provided to the QI-plus interven-
tion group only. The two programs are described in Table 1
according to the American Heart Association Taxonomy for
GAP QI-Only. GAP is a translational program shown to improve
physician adherence toguidelines, but ends atdischarge.3,9GAP
patients received a written discharge contract listing
recommended outpatient medications, cardiac rehabilitation
recommendations, and health behavior changes (smoking
cessation, diet modification, and exercise), as well as numerical
values for ejection fraction and cholesterol. Both discharge
planner and patient signed the contract and the patient
received a copy.
HARP QI-Plus Telephone Coaching. The Heart After-Hospital
Recovery Planner (HARP) intervention was adapted from a
successful smoking cessation program,8and was designed for
multiple risk behaviors. Patients in the QI-plus arm received a
six-session health behavior change telephone counseling
program delivered by a trained health educator (the coach)
during the first three months after discharge. Primary behavior
goals included: reduction or elimination of smoking, increasing
physical activity, and eating a healthier diet. Coaching telephone
sessions averaged 15 to 30 minutes and occurred weekly for six
weeks. Behavior change strategies included behavioral staging,
motivational interviewing, goal setting, relapse prevention, and
obtaining social support.15–18Patients were encouraged to
identify at least one current behavior they intended to improve
and set weekly goal(s). Patients who selected smoking cessation
Table 1. Comparison of QI only* and QI Plus Coaching†
Amer. Heart Assoc.
Hospital QI (GAP)Coaching added to QI (HARP)
Recruited patients with ACS admitted to 5 hospitals
between 14 Jan 2002 and 13 April 2003
Hospital kick off event/Grand Rounds site visit; Guideline
oriented tools to improve adherence to key quality
indicators; Rapid cycle quality improvement;
Identification and assignment of physician and nurse
opinion leader; pre- and post- measurement of
Oversight committee (clinician leaders, community
health coalition, peer review organization)
Implementation teams in each hospital
Physician and nurse leaders in each hospital through
meetings periodically over one year
Added clinician time per patient was minimal
Patient behavior, functional status, quality of life
Random sample of recruited ACS patients from
five hospitals between 14 Jan. 2002 and 13 April 2003
Initial patient contact approximately 2 weeks
post-hospital discharge; 6 weekly sessions,
15- to 30-minutes each (behavioral staging, goal
setting, relapse prevention, and social support),
25-page booklet describing achievable risk reduction,
One health educator (coach) trained in behavior change
and motivational counseling
Method of communication Telephone counseling
Intensity and complexity
Time per patient was 1.5–3.0 hours total for six sessions
Patient behavior, functional status, quality of life
*Full description, see reference3; †Full description, see reference19; ‡ See reference14
Holmes-Rovner et al.: Trial of Outpatient Coaching Post-ACS
were encouraged to use pharmacotherapy for assistance with
cessation. Each patient and his/her family received an
information booklet and goal worksheets, described elsewhere.19
The content of the program was standardized through a
semi-structured counseling program, the adoption of individ-
ual goal sheets, and the use of the same counselor for all
participants. The program was thus tailored to each patient’s
goals. The content of patient goals is described in detail
elsewhere.19Of the 175 patients entering the program, all
completed more than four sessions, with a mean number of
sessions of 5.9 (SD=0.34). Those who did not enter the
program after randomization (n=93) were not different from
those that did complete the program, with the exception of the
non-completers were less likely to have a BMI over 30 (24.5%
versus 9.9%; P=.010). Reasons for non-participation in the
program included: telephone change/disconnected (33%),
changed mind and declined participation (18%), unable to
contact due to privacy manager/caller ID (14%), unspecified
reasons (19%), too ill (13%), and patient moved (5%).
Primary outcomes are secondary prevention behaviors; sec-
ondary outcomes are physical functioning and quality of life.
Predictor variables to control for study baseline health status
include severity of illness, socio-economic status, and hospital
treatment. Race and ethnicity were assessed using the US
Census self-report classification.
Secondary prevention behaviors. Physical activity, weight loss,
and smoking were assessed on a stages-of-change scale.19–21
Self-report physical activity asked whether the patient was
engaging in physical activity for a total of at least 30 minutes a
day at least five days a week. Responses on the five-item scale
were re-coded into two categories: 1 = Engaging in the behavior
(action or maintenance) or 0 = Not Engaging in the behavior
(pre-contemplation, contemplation or preparation). Smoking
status at the time of hospitalization was established by: 1)
medical record (history of current and past smoking), and 2)
the baseline interview. In the three-month and eight-month
interviews, smoking status was divided into three categories:
current smoker, former smoker/quitter, and non-smoker
(never smoked). In-hospital and discharge medications were
obtained from the medical record.
Physical functioning was measured by the Duke Activity
Status Index (DASI), a weighted composite score computed
from answers to questions about 12 activities of daily living of
progressive intensity.22DASI scores range from 0 to 58.2, with
a higher score indicating greater functional capacity.
The quality of life EQ-5D measure evaluates: 1) mobility, 2)
self-care, 3) usual activity, 4) pain/discomfort, and 5) anxiety/
depression.23It produces a score in which full health has a
value of 1 and death has a value of 0.
Health status. ACS case-mix was evaluated by abstracting from
the medical record 1) ejection fraction (EF) and 2) comorbidity
count. Ejection fractions were dichotomized at EF above and
below 35%.22Charlson comorbidity index (CCI) definitions
were used, with the index ACS episode not counted as a
comorbidity.24The distribution of comorbid conditions is
lopsided (Table 2). Since comorbidity effects are often non-
linear, the discrete categorical variable (0–1, 2–3, ≥4) was used
because it captures these effects better than a continuous
Depression was measured by the Centers for Epidemiologic
Studies of Depression (CES-D), a 20-item symptom measure
with a range from 0 (no depressive symptoms) to 60 (highest
level of symptoms). A CES-D score of 16 or greater is highly
correlated with a diagnosis of depression.25
Study data were collected from 1) medical records, 2) post-
discharge patient telephone surveys, and 3) State of Michigan
Vital Records (mortality). Nurse medical record reviewers in
each hospital were supervised by the project field manager.
The nurses developed the code book together, practiced on
pilot charts, and refined the project code book in an iterative
process. The project field manager continued to sample each
reviewer’s charts to maintain quality control. Reliability ≥98%
was maintained throughout.
Telephone surveys lasting approximately 30 to 40 minutes
were conducted by survey researchers from the Michigan State
Table 2. Sample Characteristics at Baseline
Patient age (mean [SD])
Quit before entering
Smoked when entering
# of Co-morbid conditions
Most invasive hospital
Quality of life (EuroQol)*
Functional status (DASI)†
89 (35%) 0.46
82 (31%)70 (27%)
*See reference23; †See reference22; ‡ See reference25
Holmes-Rovner et al.: Trial of Outpatient Coaching Post-ACS
University (MSU) Institute for Public Policy and Social Re-
search. The baseline interview was conducted within four
weeks of discharge (mean=14.1 days, SD=9.6). Telephone
surveys assessed medical care utilization, medication use,
hospital readmissions, emergency department visits, cardiac
rehabilitation program participation, and secondary preven-
tion behaviors, at each interview. Medication use was assessed
in the survey by asking patients to collect the bottles of each of
their currently used prescription medications and read the
names and dosages to the interviewer. Data collectors were
blinded to group membership (QI-only or QI-plus).
Outcome assessments were obtained from the three-month
and eight-month interviews and from State of Michigan Vital
We employed pooled-time series generalized estimating equa-
tions to analyze the survey data. This approach allows for: 1)
regression models with multiple link functions to accommo-
date either categorical or continuous outcome variables (such
as the health status and behavioral variables), 2) the incorpo-
ration of correlated errors to accommodate within-subject
variation between the baseline and follow-up interviews, and
3) regression models with all available observations as well as
intention-to-treat analysis, applying the principle of last
observation carried forward.26,27Overall, we employed five
behavioral outcome variables to test for post-intervention
differences between the intervention and control groups. To
reduce the probability of obtaining significant results due to
multiple tests, we applied a Bonferroni adjustment to the
probability of a Type I error, taking into account that the
outcomes variables were moderately correlated (average corre-
lation 0.24). Consequently, the alpha-level for ‘statistical
significance’ was set at 0.02. Similarly, for the ‘ultimate’
outcomes of the DASI and EQ5D, which correlated highly at
r=0.6, the Bonferroni adjustment led to the adoption of an
alpha value of 0.04.
For all main results, we have adequate power to detect a
difference between groups. For two primary behavioral out-
come measures, weight loss and physical activity, we have
power of approximately 0.89 (Type I error of 0.05, a one-sided
test of a 25% relative improvement). For the secondary out-
comes, the DASI and EQ-5D, standardized effects sizes
translate to 2 point (small ES) and 5 point (moderate ES)
differences on the EQ-5D.28For the DASI, this translates to
mean differences of 3.44 and 8.6, respectively.
Of 719 ACS patients who met eligibility criteria and consented
to participate, 525 (73%) could be re-contacted by phone and
participated in the baseline interview, conducted, on average,
two weeks after discharge. Attrition is shown in Figure 1.
Patients who consented, but did not participate in the baseline
interview differed from the interviewees in that they were older
(63 years vs. 60 years, p<.01) more likely to have received anti-
anxiety medications (OR: 2.58, p<0.01), and were more likely
to be minorities (OR: 2.02, p<0.01). Sample characteristics of
the intervention (N=268) and control groups (N=257) partici-
pating in the baseline interview are shown in Table 2. There
was no difference in attrition by group assignment. Fifteen
post-discharge deaths occurred between baseline and the
eight-month follow-up (intervention=8, control=7, p=0.84)
There were no statistically significant differences in medication
use between the intervention and control groups for beta
blockers, aspirin, angiotensin converting enzyme inhibitors,
angiotensin receptor blockers, and lipid lowering medication at
the three time points.
The intervention increased self-reported physical activity at
3 and 8 months (OR=1.53, p<0.02) (Table 3). Differences in
the odds of smoking cessation and weight loss participation
were not statistically significant, and there were no difference
in functional status or quality of life by intention-to-treat.
The GAP QI intervention was previously shown to be success-
ful in increasing physician adherence to guidelines in-hospital,
and to reduce mortality.3,9,29We evaluated an added telephone
counseling intervention post-discharge. Over a period of
8 months after hospitalization, we found the telephone
counseling intervention to add minimally to self-reported
behavior change during the intervention, with no significant
changes in health status or quality of life. While we found a
small difference in physical activity in the intervention group,
our results are largely negative. We conclude that a telephone
counseling intervention added to hospital QI during the
3-month period post-hospitalization failed to produce a mean-
ingful advantage in terms of health status and quality of life.
What is the explanation for our negative results? One
explanation could be that the intervention approach itself
was not a good match for these patients. While our follow-up
intervals exceeded the usual three-month interval found in
most studies, it is possible that the increased physical activity
reported, if maintained for an even longer time period, could
Figure 1. Patient attrition.
Holmes-Rovner et al.: Trial of Outpatient Coaching Post-ACS
result in health status and quality-of-life benefits. However,
our previous success in smoking cessation in primary care did
not carry over to multiple risk factor intervention post-
hospitalization for ACS.30–32This approach did not produce
gains in physical activity, weight, functional status or quality of
life beyond what patients accomplished spontaneously with
We believe the main explanation for the failure of the
telephone intervention to show additional benefits is that it
came on top of an ongoing QI program in which patients
consistently received standard in-hospital counseling. This
suggests that for the majority of patients, instruction in
hospital appears to have been important and effective, and
that additional counseling outside the context of follow-up
office care added only a little benefit. It may well be that, at
least following ACS, patients largely followed the discharge
advice, including relatively high medication adherence. The QI
protocol required in-hospital counseling and a discharge
patient contract that provided the patient with numerical
values for ejection fraction and cholesterol, and made medica-
tion and behavior change recommendations.
Do we conclude that telephone-delivered health behavior
change is not effective in accomplishing secondary prevention?
In part, the answer is yes. We show that in our study,
telephone counseling for patients added little when the
clinicians were participating in rigorous quality improvement.
In other settings that do not have active QI protocols, telephone
specific issues with a clinician, though we are not aware of
research testing this approach. Putting our results in a broader
context, they are consistent with a recently published Cochrane
review of telephone follow-up following discharge from hospital.
The review included 33 randomized trials or quasi-randomized
trials thatfolloweda total of5,110 patients.33The reviewauthors
found the studies to be of generally low methodological quality
thatvariedwidely interms oftype ofhealthprofessionalinvolved.
However, they concluded that overall, clinically equivalent
Our study is more rigorous, followed patients for eight months
rather than three, and followed a known standardized quality
improvement protocol in the five hospitals. Our findings corrob-
orate the more tentative ones of Mistiaen and Poot in the
Cochrane review33. This suggests that where resource allocation
choices are being made, higher payoff for secondary prevention
post-hospital may be found in consistent delivery of guideline-
What is the impact of other patient-oriented interventions?
Several reviews of related standardized, written patient informa-
tion show clear improvement in patient knowledge.34,35Reviews
of patient-centered care, and coaching show improvements in
patient satisfaction and question asking.36,37Free-standing
patient-oriented behavior change interventions, however, show
limited impact on behavior and health outcomes, including
layperson led chronic disease self-management courses.38,39At
Table 3. Behavioral Outcomes at 3 and 8 Months (GEE Logistic Regression Models: Multivariate Odds-ratios and [95% Confidence Intervals])
VariablesWeight loss attempted†N=434║Quit smoking‡ N=136¶ Phys. activity 150 min/week§ N=432†
Intervention vs. control
Age (in years)
Years of education
Clinical and health status characteristics
Ejection fraction: <35% #
Charlson comorbidity index:
Baseline funct. Status (DASI)
Baseline depression (CESD)
Current smoker #
No invasive procedure #
1.08 [0.45–2.29]2.34 [0.44–12.5] 1.53* [1.09–2.15]
*statistically significant (p≤.05)
†Respondents who engaged (action or maintenance) in a weight loss regimen
‡Respondents who quit (action or maintenance) smoking at time of data collection
§Respondents who engaged (action or maintenance) in physical activity for 30 minutes 5 days a week
║Out of N=440 who participated in the 3-month interview and N=388 who participated in the 8-month interview, due to missing information on predictor
¶Subset of smokers at the time of hospitalization who participated in panel survey
Holmes-Rovner et al.: Trial of Outpatient Coaching Post-ACS
the same time, some disease-specific interventions that provide
information to both clinician and patient at the point of care do
show impact on health outcomes in at least some patient-
oriented chronic disease interventions.40,41
We conclude that patient-oriented interventions, to be both
effective and efficient must be integrated into on-going medical
care. Whether or not brief behavior change interventions can
contribute substantially to clinical care beyond the clear
success of smoking cessation requires further testing. Future
research should investigate both brief and intensive behavior
change interventions that are well-integrated into care delivery
Acknowledgments: Special thanks to Chrystal Price, MS, for data
entry, Camille Proden, RN, BSN, community project manager, for
supervision of field staff, study recruitment and medical record
auditing, and to Cynthia Alderson (deceased) for project manage-
ment. The sponsor had no role in the design and conduct of the
study; collection, management, analysis, or interpretation of the
data; preparation review or approval of the manuscript. Presented in
part at: the Society for General Internal Medicine Annual Meeting,
Funding/Support: Supported in part by an AHRQ R01 grant
(HS10531), “Translating Research: Patient Decision Support/Coach-
ing” (Dr. Margaret Holmes-Rovner, Principal Investigator). None of the
authors receives compensation from any of the hospitals studied. No
consultancies, honoraria, stock ownership, expert testimony, grants
received, grants pending, patients pending, patients received or
royalties or other relationships represent a conflict of interest for any
of the authors.
Corresponding Author: Margaret Holmes-Rovner, PhD; Center for
Ethics, C203 E. Fee Hall, Michigan State University College of Human
Medicine, East Lansing, MI 48824, USA (e-mail: firstname.lastname@example.org).
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