Summary
Cardiovascular mortality has decreased over the past 25 years, largely because of acute coronary syndrome care and preventive actions. Nevertheless, the rate of coronary heart disease remains high, with an annual risk of 4.7% (cardiac mortality, myocardial infarction, stroke). Cardiovascular risk factor management must be a priority in primary and secondary prevention, to improve the prognosis of this severe disease, in which absence of symptoms does not mean benignity. The current goals of therapeutic patient education are smoking cessation, regular physical activity, a cardioprotective (Mediterranean) diet, management of stress, good treatment adherence (which improves compliance), judicious use of the care system and help with occupational reintegration. Current and future programmes must be in accordance with the Haute Autorité de Santé recommendations published in 2007.
Résumé
La mortalité cardiovasculaire a diminué de moitié en 25 ans, en raison des progrès de la prise en charge des syndromes coronaires aigus et des actions de prévention. Néanmoins, l’incidence de la maladie coronarienne stable reste élevée, avec un risque annuel de 4,7 % (mort cardiaque, infarctus du myocarde, accident cérébral). La prise en charge des facteurs de risque modifiables reste une priorité, tant en prévention primaire que secondaire, afin d’améliorer le pronostic de cette affection redoutable dont le caractère asymptomatique n’est pas synonyme de bénignité. L’aide au sevrage du tabac, une activité physique régulière, une alimentation cardioprotectrice (régime « méditerranéen »), la gestion du stress, une bonne adhésion au traitement médicamenteux qui améliore son observance, un recours judicieux au système de santé, l’aide à la réinsertion professionnelle sont les enjeux actuels de l’éducation thérapeutique du patient coronarien. À partir des recommandations de la Haute Autorité de santé publiées en 2007, les programmes (existants et futurs) doivent se mettre en conformité avec la législation actuelle.
Background
The reduction of cardiovascular mortality is explained mainly by prevention . Consequently, cardiovascular risk factor management is widely recognized as a priority in primary and secondary prevention programmes . In this way, education programmes provide a unique opportunity to improve compliance to healthy lifestyle .
The value of therapeutic patient education (TPE) for the coronary patient has been highlighted by several strategies. The European programme EUROACTION showed the efficacy of a comprehensive approach that included the patient’s family, in terms of optimizing medical treatment and controlling cardiovascular risk . The Italian study GOSPEL evaluated the benefit of a 3-year educational programme after cardiac rehabilitation on cardiovascular risk factor control and non-fatal myocardial infarction rate . In France, the PEGASE TPE programme improved the Framingham risk score in hypercholesterolaemic patients in primary or secondary prevention compared with in a control group; however, this improvement was not statistically significant, partly due to the short follow-up . A TPE programme for patients with hypertension, coronary heart disease (CHD) or heart failure was tested in patients who were beneficiaries of an agricultural mutual insurance company near their home. The programme improved their knowledge of treatment, diet and physical activity . Studies published in recent years by health networks and educational and rehabilitation units have reported similar findings . This list of TPE strategies is not comprehensive.
TPE for patients with heart failure has been developed over a number of years and its efficiency is now established; it has been published as a recommendation of the French Society of Cardiology (FSC) .
Issues
The therapeutic education that must form part of the care package for coronary patients cannot be limited to simple information. Indeed, information targets the disease while education is a patient-centered learning process . There is no recommendation regarding TPE for coronary patients. The purpose of this article is to propose a reference framework and a structured method to facilitate the development of TPE for the benefit of all coronary patients. The consistency of messages is also an objective to facilitate exchanges between the centers that use the TPE programme.
Any TPE programme must be authorized according to the recent legislation . TPE must fulfill quality criteria, and be feasible to be implemented and assessed by the educational team, in order to benefit most patients and ensure equality of access to health care.
Target population: coronary patients and their families
TPE could be offered to patients in different situations by any of the relevant health professionals to a patient at the time of an acute coronary syndrome (ACS), to a revascularized coronary patient (percutaneous coronary intervention or coronary artery bypass graft), and to a coronary patient with angina or silent ischaemia.
The coronary patient is often taken into care just after an acute event or a revascularization. It may be difficult to introduce TPE during this period because of the somatic, psychological and social difficulties connected with being given the disease diagnosis. However, if the cardiologist trivializes the seriousness of a speedily revascularized ACS (especially using radial access), this could increase the risk of disease denial by the patient, who will be unaware of the value of long-term care of their atheromatous disease. These circumstances should be taken into account in the organization of the TPE programme modalities.
In case of refusal of TPE by the patient, their decision must be respected, but the reasons for refusal should be understood and the concept of TPE re-explained. This prepares the ground for a new proposal to be made at a later date, in more favorable conditions.
Training and qualifications for health professional participants
TPE should be offered by professionals trained in this discipline and in coronary pathology; the involvement of cardiologists in coordinating the programme and leading the sessions is essential.
Most medical and paramedical professionals are not currently trained in TPE at university; continuous training must be organized. Every care provider required to deliver TPE in the field of coronary disease must undertake two training courses: validated training in TPE (by any approved structure), and specific training relating to coronary heart disease (pathology, treatments, risk factors).
The participants must learn to use a common language and to give consistent messages in different educational sessions, according to a reference guide based on current recommendations .
Practical experience is essential and must form part of any training course. Experience acquired by staff who have already delivered TPE will be recognized as validated training, according to the current decrees.
Steps in a TPE programme for the coronary patient
Identification of patient needs
The programme starts with an educational diagnosis (also called shared educational assessment), during one or several conversations with different participants from the multidisciplinary team (doctor, dietician, physiotherapist, nurse, psychologist, pharmacist, etc.). This step is essential to identify the needs and expectations of the patient; it serves to identify obstacles and resources to ensure the success of the TPE; it also enables the compilation, with the patient, of a list of skills that they must acquire or use. The educational diagnosis takes into account various aspects of the patient’s life, personality, potential and future plans; it identifies the patient’s support network, their psychological, social and occupational vulnerabilities, and their receptiveness to the TPE proposal.
The educational diagnosis tries to include adequate patient and care provider priorities using negotiated educational objectives. It begins with the collection of the patient’s consent, which is obtained during an individual interview; data from this are transcribed into the TPE file, which must be accessible to all participants. Each participant can complete the educational diagnosis according to the programme. As with any medical record data, all TPE file information is subject to strict confidentiality. It is recommended that an interview guide is used for the educational diagnosis to facilitate the collection of information. This document, specific to coronary disease, must focus on the patient’s knowledge, their own description of their health, illness and treatment, and their psychosocial context. The guide can be complied by the educational team using information in Tables 1 and 2 , in accordance with publications by Simon et al. and d’Ivernois and Gagnayre .
| Interview methods | Interview in a friendly atmosphere |
| Ask the patient to reiterate facts back to you (reformulation) | |
| Use open questions | |
| Aim for mutual understanding (avoid mistakes, empathic attitude) | |
| Present the educational programme | |
| Estimate the degree of motivation | |
| Negotiate an educational contract | |
| Obtain the patient’s informed consent (document written according to the legislation in force) | |
| Identification of the patient’s needs and expectations | |
| What he (she) has | Identify health problems (handicaps, co-morbidity) |
| What he (she) does | Professional activity (constraints) |
| Social activities (constraints, benefits) | |
| Family life (circle of acquaintances, solitude, living conditions) | |
| What he (she) knows | How does he (she) describe his (her) disease? |
| Does he (she) attribute the disease to a particular cause? | |
| What does he (she) think of his (her) treatment? | |
| How he (she) is | Attitude (denial, revolt, bargaining, depression, acceptance, resignation) |
| Profile (passive, resigned, active, dynamic) | |
| His (her) plan | What is his (her) plan? (occupation, sport at risk, etc.) |
| Secondary prevention objectives | |
| Smoking | Current weaning? Envisaged? Difficulties? In need of help? Not relevant? |
| Physical activity | Sufficient? Possibility of increase? Questions? |
| Diet | Well-balanced? Desired modifications? Possible? Questions? |
| Treatment | Easy follow-up? Difficult? Questions? |
| Return to work | Easy? Difficult? Impossible? Questions? Not relevant? |
| Other | Personal needs not taken into account by the standard programme |
| I know my treatment | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | (from “not at all” to “perfectly”) |
| I know the beneficial diet for my health | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | (from “not at all” to “perfectly”) |
| I know what physical activity I can do | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | (from “not at all” to “perfectly”) |
| I feel that I am able to make the necessary changes | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | (from “not at all” to “perfectly”) |
| I feel motivated to carry out these changes | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | (from “not at all” to “perfectly”) |
| I consider my health care to be… | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | (from “very bad” to “excellent”) |
| Item at end of programme | ||||||||||||
| I am satisfied with this programme | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | (from “not at all” to “completely”) |
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