Sunday, December 29, 2013

Telephone coaching doesn't work for diabetes

A noble effort by the good folks at the General Practice and Primary Health Care Academic Centre at the University of Melbourne to demonstrate the effectiveness of telephone coaching by trained nurses in type 2 diabetes ended in disappointment.

As reported in the British Medical Journal, they randomized 59 primary care practices with 473 adults with A1C above 7.5%. The nurses in the  intervention practices were trained to make structured calls to their patients, engaging them in dealing with their chronic problems, managing stress, improving their lifestyle, self-monitoring their disease, and doing some other good things. The program included seven telephone coaching sessions over 10 months, a face to face coaching session at 12 months, and a final telephone session at 15 months. The nurses were paid to do the calls, overcoming an important barrier in many settings. In other words, this was a well-designed, fairly high-intensity intervention. And, the evaluation is very rigorous and well-designed with little room for random error or bias. These investigators are pros and it shows.

Unfortunately, it didn't work. After 18 months, the A1C in the intervention group was the same as the control group (P=.84). On the plus side, fewer intervention patients were overweight or obese (P=.03). However, some outcomes actually got worse: HDL-cholesterol (P=.05) and systolic blood pressure (P=.07). Given the very large number of secondary outcomes reported, and the lack of any big trends across the outcomes as a group, these apparent effects are probably random error due to multiple comparisons. All in all, there is no evidence that this intervention had important effects on the patients or the health care system.

This isn't the only evidence that high-intensity phone interventions don't work in this setting. Even if they were to generate some improvement, they are so expensive that they can only be used for the sickest patients. So for now, we are left with the proven beneficial effects of less intensive patient engagement techniques that seek to keep patients connected with the practice and activate them when they need to be, rather than educate and prepare them ahead of time. It looks like the "teachable moment" may be more valuable than all the that coaching and preparation.

Blackberry ID, Furler JS, Best JD, Chondros P, Vale M, Walker C, Dunning T, Segal L, Dunbar J, Audehm R, Liew D, Young D. Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement and Coaching for Health (PEACH) pragmatic cluster randomised controlled trial. BMJ. 2013 Sep 18;347:f5272. doi: 10.1136/bmj.f5272.

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