Dr. Nicolle Kraenkel
Community health worker-based intervention for adherence to drugs and lifestyle change after acute coronary syndrome: a multicentre, open, randomised controlled trial.
Xavier et al.
Lancet Diabetes Endocrinol 2016; 4: 244–53
Adherence to prescribed drugs and recommended lifestyle changes – physical activity or smoking cessation – are crucial for therapy success. Yet, it is not always easy to adhere to medical advice in everyday life, especially if friends and family still cling to old habits and work leaves little free time and if side effects occur. It is therefore crucial for healthcare providers to understand how to support the patient in maintaining adherence.
In a multi center study, Xavier et al. evaluated the approach to bring counselling support right home to the community of patients, by employing trained community health workers, to support hospital-based medical personnel. They randomly assigned patients with acute coronary syndrome to either a standard care group (n=401) or an intervention group (n=405) receiving an intense counselling programme supported by community-based health workers on top of the standard care.
The programme included an early involvement of the patient in the identification of barriers preventing their compliance with lifestyle changes and pharmacological treatment, as well as in the devising of strategies to overcome those hindrances. Instead on relying solely on a hospital-based team of medical personel, the study also employed community-based health workers, who provided a close contact with the patient, conducting monthly phone interviews about adherence to medication and lifestyle, as well as visits at home or in the hospital.
Adherence to certain drugs, ACE inhibitors, angiotensin receptor blockers and statins was significantly greater in the intervention group, as was smoking and alcohol cessation, physical activity and dietary improvement. This coincided with improvements in systolic blood pressure, body weight, BMI and HDL levels.
Several aspects of this treatment strategy are potentially of importance for the success:
(a) the integration of the patient early on to better integrate treatment in their specific daily life as well as regular feedback,
(b) implementing the person who delivers guidance and support in the community itself, and
(c) including family members in discussions about adherence. Thus, the strategy centers on the individual patient, makes him/her part of the caregiver team and also includes their environment, i.e. family members.
Only 1 year data are available so far, and the study is not intended to be followed up longer. Therefore, no conclusions can be drawn as to whether this apporach would be more successfull in improving long-term adherence than other studies. Moreover, the study was not powered to detect differences in clinical endpoints such as major cardiovascular events. Future studies of longer duration must therefore be awaited to understand whether this very patient-centered approach with frequent interaction between health worker/care giver and patient could help maintain long-term adherence and thus overcome a criticism of other trials, that dwindling adherence over the years jeopardizes initial benefical effects.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology
1 How to keep on going: Editorial comment on The long-term effects of a randomized trial comparing aerobic interval versus continuous training in coronary artery disease patients: one-year data from the SAINTEX-CAD study. Kränkel N. Eur J Prev Cardiol. 2016DOI: 10.1177/20474873166423682 Xavier D, Gupta R, Kamath D, Sigamani A, Devereaux PJ, George N, Joshi R, Pogue J, Pais P, Yusuf S. Community health worker-based intervention for adherence to drugs and lifestyle change after acute coronary syndrome: a multicentre, open, randomised controlled trial. Lancet Diabetes Endocrinol. 2016;4(3):244-53. doi: 10.1016/S2213-8587(15)00480-5.3 Look AHEAD Research Group, Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, Coday M, Crow RS, Curtis JM, Egan CM, Espeland MA, Evans M, Foreyt JP, Ghazarian S, Gregg EW, Harrison B, Hazuda HP, Hill JO, Horton ES, Hubbard VS, Jakicic JM, Jeffery RW, Johnson KC, Kahn SE, Kitabchi AE, Knowler WC, Lewis CE, Maschak-Carey BJ, Montez MG, Murillo A, Nathan DM, Patricio J, Peters A, Pi-Sunyer X, Pownall H, Reboussin D, Regensteiner JG, Rickman AD, Ryan DH, Safford M, Wadden TA, Wagenknecht LE, West DS, Williamson DF, Yanovski SZ. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369(2):145-54. doi: 10.1056/NEJMoa1212914.
Nicolle Kränkel, Charité – Universitätsmedizin Berlin, Berlin Germany
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