Health Coaching by Medical Assistants to Improve Control of Diabetes, Hypertension, and Hyperlipidemia in Low-Income Patients: A Randomized Controlled Trial

Abstract

PURPOSE Health coaching by medical assistants could be a financially viable model for providing self-management support in primary care if its effectiveness were demonstrated. We investigated whether in-clinic health coaching by medical assistants improves control of cardiovascular and metabolic risk factors when compared with usual care. METHODSWe conducted a 12-month randomized controlled trial of 441 patients at 2 safety net primary care clinics in San Francisco, California. The primary outcome was a composite measure of being at or below goal at 12 months for at least 1 of 3 uncontrolled conditions at baseline as defined by hemoglobin A 1c , systolic blood pressure, and low-density lipoprotein (LDL) cholesterol. Secondary outcomes were meeting all 3 goals and meeting individual goals. Data were analyzed using χ 2 tests and linear regression models.RESULTS Participants in the coaching arm were more likely to achieve both the primary composite measure of 1 of the clinical goals (46.4% vs 34.3%, P = .02) and the secondary composite measure of reaching all clinical goals (34.0% vs 24.7%, P = .05). Almost twice as many coached patients achieved the hemoglobin A 1c goal (48.6% vs 27.6%, P = .01). At the larger study site, coached patients were more likely to achieve the LDL cholesterol goal (41.8% vs 25.4%, P = .04). The proportion of patients meeting the systolic blood pressure goal did not differ significantly.CONCLUSIONS Medical assistants serving as in-clinic health coaches improved control of hemoglobin A 1c and LDL levels, but not blood pressure, compared with usual care. Our results highlight the need to understand the relationship between patients' clinical conditions, interventions, and the contextual features of implementation. 2015;13:130-138. doi: 10.1370/afm.1768. Ann Fam Med INTRODUCTIONC ardiovascular disease is the leading cause of death in the United States, 1 and it accounts for more than $500 billion of health care spending annually.2 Despite the demonstrated effectiveness of pharmaceutical therapies and lifestyle modifications for improving cardiovascular disease outcomes, 50% of people with hypertension, 43% with diabetes, and 80% with hyperlipidemia have not reached their goals for blood pressure, glycemic control, or lipids, respectively. [3][4][5] One-half of patients do not take their chronic disease medications as prescribed, and only 1 in 10 patients follow recommended guidelines for lifestyle changes, such as smoking cessation or weight loss. 6 Minority and low-income communities bear a disproportionate burden of chronic disease and its complications, 7 and they are less likely to engage in effective self-management of their conditions. 8,9 Contributors to this gap in self-management include a lack of patient understanding of, and agreement with, the care plan, and low confidence and motivation to make healthy choices. or were not designed as randomized trials.17-19 They focused on a single condition such as diabetes or hypertension. [16][17][18][19] Medical assistant health coa...

In This Issue: Developing and Amplifying the Effectiveness of the Primary Care Workforce

“…2 Medical assistant health coaches are effective in helping patients to meet goals for diabetes control and cholesterol reduction, but not blood pressure treatment. This article is this issue's Annals Journal Club.…”

“…2 Secondhand smoke exposure is a major cause of sudden infant death syndrome and may cause lung cancer and heart attacks with repeated exposure. 2 No safe level of exposure exists.…”

“…2 Secondhand smoke exposure is a major cause of sudden infant death syndrome and may cause lung cancer and heart attacks with repeated exposure. 2 No safe level of exposure exists. 1,2 Purposefully and recurrently exposing children to secondhand smoke-a known human carcinogendespite repeated warnings, is child abuse.…”

“…2 No safe level of exposure exists. 1,2 Purposefully and recurrently exposing children to secondhand smoke-a known human carcinogendespite repeated warnings, is child abuse. Federal law defines child abuse as "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm."…”

The utilization of behavioural counselling for hypertension within a primary care context

“…Following a critical appraisal of the literature findings, five of the eight studies captured in the review highlight significant decreases in blood pressure related to the MI intervention (Ma et al, 2014;Ogedegbe et al, 2008;Schoenthaler et al, 2015;Svetkey et al, 2009;Woollard et al, 1995) and one study illustrated a non-significant decrease in systolic blood pressure (Miura et al, 2004). The remaining two studies showed no effect on blood pressure but did illustrate other efficacious effects on cholesterol, exercise capacity specifically minutes of walking per week and HbA1c levels (Hardcastle et al, 2013;Willard-Grace et al, 2015). The following section will discuss implications of these findings related to clinical practice, education and research.…”