Health Coaches for Lower Risk of CVD, Diabetes: A Newsmaker Interview With Eugene Oddone, MD

October 02, 2002

Oct. 3, 2002 — Editor's Note: Duke University Medical Center and the federal Centers for Medicare and Medicaid Services (CMS) have launched a one-year pilot study aimed at helping middle-aged people identify and change health behaviors that could lead to diabetes or cardiovascular disease later in life.

Testing the efficacy of an intervention called "strategic health planning," the randomized controlled trial of 200 patients older than 45 years will use healthcare coaches to educate and provide reinforcement to help patients make key behavior changes, such as weight loss, exercise, or stress management.

The research team, headed co-investigators Tracy Gaudet, MD, director of the Duke Center for Integrative Medicine, and Eugene Oddone, MD, chief of Duke's general internal medicine division, hopes to learn how to integrate the knowledge about risk-reducing behavior change into an individual's ongoing relationship with his or her primary care physician.

Medscape's Cathy Tokarski spoke with Dr. Oddone, who designed the study. He also directs the Center for Health Services Research in Primary Care at the Durham Veterans' Administration in North Carolina.

Medscape: Why is it so difficult for people to practice preventive health behaviors when we know so much about our ability to prevent many chronic diseases?

Dr. Oddone: The problem for a lot of patients is that they don't get a lot of reinforcement for it. People don't get a lot of information about how to go about this, because we're asking them to change their behavior, and behaviors are hard to change. Patients will go to their doctors intermittently, and they may have the best intention to change behaviors that their doctor has identified to them as not being good for them. But doctors don't have a lot of tools to help get this done; they don't really know how to motivate people to change.

[Dr.] Tracy Gaudet believes this other layer of care [health coaches] can help people identify what their barriers are for changing behavior. We don't know if this is going to be the answer, but we are going to study it in a rigorous way.

Medscape: What does the term "strategic health planning" mean?

Dr. Oddone: The term has a business orientation, in that you set goals that you work on each day to achieve. Individuals don't do this with their health. We all go through our lives, and often the focus isn't on our health until later. The concept of mindfulness tries to get you to consider that more often.

In healthcare, you have a medical record that describes all the bad things about your health, but no plan about what you need to work on, whether it's lowering your anxiety or cutting down on your drinking. Identifying and acting on those goals is the kernel of uniqueness of this intervention.

Medscape: How specifically will the health coaches interact with patients?

Dr. Oddone: As the ones who will motivate patients, health coaches will serve as an interface between a psychologist and a physician. Most of the interaction [with patients] will take place with the coaches. We envision that 90% of the time, the patient in the study will be in contact with the coach, both face-to-face and over the phone.

In the study we are recruiting people with identified risk factors for cardiovascular disease and diabetes, such as obesity, hypertension, or smoking. Our theory is that of the 100 patients [who are using health coaches] a certain number of them will want to work on weight control, change their eating patterns, or start an exercise program, and that specific groups will get formed around those goals. The coaches will work with these groups to identify and work on behavior changes.

Medscape: How will this process become a part of a patient's routine care?

Dr. Oddone: Right now, [doctors] talk about prevention, but we'll need to design an intervention that would be more effective, recognizing that we are not doing a good job now. We also have to recognize that patients have a relationship with their primary care physician that needs to be sustained, so we have to integrate the information from the coaches with the primary health providers. We still have to do further study to figure out how to do that.

Medscape: Why was CMS interested in funding this study, since the age of the average Medicare patient is 20 years older than the patients in the study?

Dr. Oddone: We're trying to convince them that they need to start younger, since CMS feels the downstream risk of chronic diseases. Patients with cardiovascular disease often have the onset of symptoms by middle age, and by the time they are in their early 60s, they have their first MI. When the patient turns 65, CMS is paying for all of their care.

We see the study as a step in a sequence, to see if it works to create change in a year. We tried to pick an outcome variable that would resonate, and would give us the information to say, 'This is working.' We settled on Know Your Number, which is a proprietary statistical model that assesses an individual's risk for heart attack. It also measures things like stress, anxiety, depression symptoms, quality of life, and satisfaction.

Our next step would be a larger study to see how the intervention influences longer-term outcomes.

Medscape: Do you think this approach can eventually reduce the amount of money that we spend treating diseases that could be prevented?

Dr. Oddone: There have not been extensive economic studies comparing the cost of prevention versus the cost of dialysis or coronary artery bypass graft. Part of that is defining what intervention is — is a lipid-lowering drug a preventive agent? But overall, there is not much data about prevention strategies.

I am pessimistic in believing that dollars spent in intensive intervention in the long run will save money. We are not good enough at identifying who needs these interventions, so we give it to everyone. That's not cost-effective. In this study, health coaches are another layer, and they need a paycheck. Who downstream is going to pay these folks for their time and expertise? That's an important policy issue, but until we have better data on how it works, it's a little too early to talk about it.

In the long term, we need to figure out if this strategy works, and then we can work on better targeting the more intensive aspects to those who need it.

Reviewed by Gary D. Vogin, MD

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