The relatives of patients who are hospitalized with heart disease may be at greater risk of cardiovascular problems themselves due to shared genes, eating habits and physical activity levels. Yet these relatives may be unaware of their risks, and their loved one's hospitalization could present a unique opportunity to inform and educate them, according to Lori Mosca, ACP Member, director of preventive cardiology at New York-Presbyterian Hospital/ Columbia University Medical Center.
Dr. Mosca recently tested this notion in a trial of 501 patients where relatives were randomly assigned to either a control group, which received a one-page handout message about proper exercise, smoking and diet, or a special intervention group. The latter group received personalized risk factor screening with immediate feedback on measures like lipids, waist circumference, blood pressure, glucose levels, dietary habits and exercise levels, as well as one-on-one education about healthy lifestyle changes. They also received two reinforcement phone calls and got their lipid levels checked at three, six and nine months. Both groups were re-evaluated after a year, when the study ended.
The study found that the LDL levels of both groups declined, but there wasn't a significant difference between groups in the amount of the decline. Blood pressure and waist circumference worsened equally between groups. However, while the control group's HDL levels dropped, the intervention group's levels stayed steady. Individuals in the intervention group also increased their physical activity and improved their diets significantly more than the control group. The study was published online Nov. 12, 2008, in Circulation: Cardiovascular Quality and Outcomes.
Dr. Mosca recently spoke with ACP Hospitalist about the implications of her study, and what hospitalists can do to help relatives of hospitalized patients become aware of their cardiovascular risks.
Q: Why do you think there was no difference in LDL cholesterol change between the groups?
A: It is actually great news because it says to me that people in the control group were highly motivated by having a family member hospitalized. They were able to make enough changes on their own to show a significant benefit, and it lasted a year, which is phenomenal.
Q: The intervention group improved more on the diet and exercise component. Are we to conclude that in addition to education, the reinforcement of regular visits and phone calls was important in getting patients to stick to good habits?
A: Yes. The reinforcement helped not only with education, but patients got their lipids measured regularly, and if they were abnormal we remeasured them. We found that the more times people had lipids testing done, the more they reduced the saturated fat in their diets. So it absolutely is reinforcing to get the numbers along with the educational message.
Q: Why do you think HDL levels went down in the control group and not the intervention group?
A: What people really don't understand about diet is that you can't just reduce saturated fat, because most people will increase carbohydrates when they do that—which is exactly what the control group did. They drove down their HDL by increasing carbohydrates. Our intervention group didn't do that because we educated them not to. Also, our intervention group exercised more, which helped HDL. So I think this shows that motivation plus education really does give you optimal value.
Q: Why did adiposity and blood pressure rise in both groups?
A: Our theory is that it is because it was such a stressful time. There were some people who were not getting as much physical activity because they were taking care of their relative and were afraid to go out of the house. As well, the norm in this country is that everyone gains weight every year. So it could be we blunted a little bit of that weight gain. There was less weight gain or increase in blood pressure in the intervention group.
Q: What good is it that members of the intervention group increased their physical activity and ate better, if doing so didn't improve endpoints like LDL, blood pressure, or adiposity?
A: Physical activity and diet are important for health independent of the numbers we measured. We know exercise increases endothelial function and decreases platelet adhesion. A diet low in saturated fat decreases colon and breast cancer and heart disease risk, independent of its effect on LDL cholesterol and blood pressure. These are direct effects of physical activity and diet on the cardiovascular system which are critically important and which we can't measure in this kind of study.
Q: For the study, you recruited relatives of patients. Did you consider how the severity of the patient's illness might affect the relative's response to the interventions?
A: Actually, one of my predoctoral fellows is looking into that. We are hypothesizing that the earlier the disease strikes, the more severe the disease and the more closely related the patient and relative, the more likely the intervention will have a strong impact. We think that the more susceptible an individual feels to a condition, the more motivated he or she is to take action to reduce risk. This is particularly germane to hospitalists, because they are in a really unique situation to reach out to family members, who can potentially avert themselves from having to be hospitalized.
Q: Should it always be a hospitalist who talks with the relative of a patient, or can a nurse or other staff member do it?
A: It is very important that the discussion be started by the hospitalist/physician. Most research shows that the major impact on patients making lifestyle changes comes from the physician; that is still the primary person they trust.
I work with a lot of hospitalists and residents, and I always make the point that when we work in the hospital we tend to think we are taking care of a patient for just those five or seven days. But to be a good doctor, we should think about what we can do to improve that patient's health 365 days a year. Understand you have tremendous power in preventing new admissions or unnecessary readmissions.
Q: What exactly should a hospitalist say when talking to the family member of the hospitalized patient?
A: She or he would begin with saying that it is important to know that cardiovascular disease runs in families because of both shared genes and shared lifestyle, and that many family members aren't aware of their own risk. It's important to know one's own risk factors and be screened for them, and to know that lifestyle is important to reduce the risk for heart disease, even if you have normal risk factors.
They should know that it's important to eat a diet low in saturated fat and increase intake of fruit and vegetables, and get at least 30 minutes a day of exercise. Of course, they should stop smoking if they smoke. They should learn their waist size. It's just the basic lifestyle messages, but hearing it from a doctor, even in a three-minute intervention, has been shown to improve lifestyle a year later.
Q: What happens after the physician has his or her talk with the patient's relative?
A: Then there needs to be an infrastructure to start the learning process, because the physician doesn't have time to do that. Most hospitals have cardiac education classes that are geared primarily toward the hospitalized patient, but expanding those classes to include changes in family behaviors that contribute to cardiac disease could be a nice benefit.
Q: Does your hospital offer these types of classes for relatives?
A: We have a screening and education room right on the cardiac care floor. So the family members can get screened right then and there. They learn their own blood pressure and waist circumference, etc., and we begin the process of educating them about how to eat better and how to exercise. We refer them if necessary—which many of them need—for stress and depression, because medical crises affect families tremendously. It's worthwhile for hospitals to invest in the infrastructure to initiate the process, and then develop a case management approach, or at least a referral system for when the patient leaves the walls of the hospital.
Q: These programs clearly benefit patients; how do they benefit hospitals?
A: We've shown these programs lead to a significant loyalty to the hospital, so that when a family member of a patient has a problem down the line, he or she is more apt to come back to that hospital. As well, patient satisfaction has significantly improved since we've been providing a comprehensive outreach to family members.
Q: Should this concept of screening family members be adapted to areas outside cardiology?
A: Yes, I think we need to adapt this to all conditions that are related to genetics and lifestyle. One example is family members of colon cancer patients who come in for a colectomy. Wouldn't it be a great opportunity, when you discharge a patient, for the final quality indicator to be “Did you recommend that family members be screened and educated about their potential link between genetics and lifestyle?”
Q: How common is it for hospitals to have programs like this for patients' family members?
A: I think it is uncommon because hospitals don't think outside the box. We have a very strong medical model we've grown up with and we don't tend to think about promoting health as much as we do about treating disease. And we miss the potential marketing opportunity and the opportunity to improve the quality of the care of our patients and their families.