Willard-Grace Rachel, Chen Ellen H, Hessler Danielle, DeVore Denise, Prado Camille, Bodenheimer Thomas, Thom David H
Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
Department of Family and Community Medicine, University of California San Francisco, San Francisco, California Silver Avenue Family Health Center, San Francisco Department of Public Health, San Francisco, California.
Ann Fam Med. 2015 Mar;13(2):130-8. doi: 10.1370/afm.1768.
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.
We 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 A1c, 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.
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 A1c 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.
Medical assistants serving as in-clinic health coaches improved control of hemoglobin A1c 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.
如果能证明其有效性，由医疗助理进行健康指导可能是一种在初级保健中提供自我管理支持的经济可行模式。我们调查了与常规护理相比，医疗助理在诊所内进行的健康指导是否能改善心血管和代谢危险因素的控制。
我们在加利福尼亚州旧金山的2家安全网初级保健诊所对441名患者进行了为期12个月的随机对照试验。主要结局是根据糖化血红蛋白、收缩压和低密度脂蛋白（LDL）胆固醇定义的，在基线时3种未控制状况中至少1种在12个月时达到或低于目标的综合指标。次要结局是达到所有3个目标以及达到各个目标。使用χ²检验和线性回归模型分析数据。
接受指导组的参与者更有可能实现临床目标之一的主要综合指标（46.4%对34.3%，P = 0.02）以及达到所有临床目标的次要综合指标（34.0%对24.7%，P = 0.05）。接受指导的患者实现糖化血红蛋白目标的人数几乎是未接受指导患者的两倍（48.6%对27.6%，P = 0.01）。在规模较大的研究地点，接受指导的患者更有可能实现低密度脂蛋白胆固醇目标（41.8%对25.4%，P = 0.04）。达到收缩压目标的患者比例没有显著差异。
与常规护理相比，担任诊所内健康指导的医疗助理改善了糖化血红蛋白和低密度脂蛋白水平的控制，但未改善血压控制。我们的结果强调了理解患者临床状况、干预措施以及实施的背景特征之间关系的必要性。
