TeGeCoach: Telephone Health Coaching and Remote Exercise Monitoring for Peripheral Artery Disease

Sponsor

Universitätsklinikum Hamburg-Eppendorf (Other)

Overall Status

Completed

CT.gov ID

NCT03496948

Collaborator

(none)

1,982

Enrollment

Locations

Arms

33.8

Actual Duration (Months)

660.7

Patients Per Site

19.5

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Peripheral artery disease (PAD) is the third most prevalent cardiovascular disease worldwide, with over 200 million people affected. Most prominent symptom is leg pain while walking known as intermittent claudication. Based on the currently existing gaps in the management of intermittent claudication, the objective of the this study is to explore the clinical effectiveness and cost advantage of TeGeCoach, a 12-month long home-based exercise program, compared to usual care. TeGeCoach consists of telephone health coaching, remote walking exercise monitoring based on wearable activity monitors and intensified primary care. It is hypothesized that TeGeCoach will improve functional outcomes and will reduce total health care costs.

Condition or Disease	Intervention/Treatment	Phase
Peripheral Artery Disease Atherosclerosis Peripheral Arterial Disease Arterial Occlusive Diseases Vascular Diseases Peripheral Vascular Diseases Cardiovascular Diseases	Behavioral: TeGeCoach	N/A

Detailed Description

Peripheral artery disease (PAD) is the third most prevalent cardiovascular disease worldwide and has become a serious public health issue, with over 200 million people affected. Smoking and diabetes are the strongest risk factors for the development of peripheral artery disease, but also high cholesterol, high blood pressure and sedentary lifestyle. The most prominent symptom is leg pain while walking known as intermittent claudication, as the muscles do not get enough blood during exercise to meet the needs. To improve mobility, first line treatment for intermittent claudication are outpatient supervised exercise programs (SEPs); however, their implementation face manifold challenges: low patient adherence, no reimbursement by insurers, high costs of course implementation, and low course availability. These barriers led to the development of home-based exercise programs, which are similarly effective when combined with a structured approach by setting exercise goals, monitoring exercise activity, and regular follow up with a coach. Therefore, this trial aims to determine the clinical effectiveness and cost advantage of TeGeCoach, a 12-month long structured home-based exercise program (HEP), compared with usual care of intermittent claudication. It is hypothesized that TeGeCoach will improve walking impairment and will lower the need of health care resources that are spent on patients with PAD at 24-month follow-up.

The investigators will conduct a prospective, open-label, pragmatic randomized controlled clinical trial in a health insurance setting. 1760 patients with peripheral artery disease at Fontaine stage II will be randomly assigned either to TeGeCoach or Care-as-usual (usual care). TeGeCoach consists of telemonitored walking exercise using wearable activity trackers, telephone health coaching and medical supervision by a physician. The health coaching is a patient-centered approach based on motivational interviewing, shared decision-making and active listening techniques for supporting better patient engagement and activation, disease self-care, treatment adherence and lifestyle management. Depending on the individual functional status and exercise capacity, participants will be asked to walk up to seven times a week. Usual care participants regularly receive information leaflets and can access supervised exercise programs, physical therapy and a variety of programs for promoting a healthy lifestyle. Primary outcomes are functional capacity measured by the Walking Impairment Questionnaire (WIQ). Secondary outcome measures include quality of life, health literacy and health behavior. Claims data is used to collect total health care costs, healthcare resource use and (severe) adverse events. Outcomes will be measured at three time points (0, 12, and 24 months).

Clearly, the current routine care of intermittent claudication in patients with PAD is partly ineffective und insufficient, with the consequence of a poorly served patient population and worsening disease condition. TeGeCoach may provide an effective and feasible alternative in the management of intermittent claudication by improving access to supervised exercise while at the same time potentially reducing health care costs.

Study Design

Study Type:

Interventional

Actual Enrollment :

1982 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Intervention Model Description:

Study arms: TeGeCoach (Intervention); Treatment-as-Usual (TAU)Study arms: TeGeCoach (Intervention); Treatment-as-Usual (TAU)

Masking:

Double (Investigator, Outcomes Assessor)

Primary Purpose:

Treatment

Official Title:

PAD-TeGeCoach: Health Coaching and Telemetry Supported Walking Exercise for Improving Quality of Life

Actual Study Start Date :

Apr 23, 2018

Actual Primary Completion Date :

Feb 15, 2021

Actual Study Completion Date :

Feb 15, 2021

Arms and Interventions

Arm	Intervention/Treatment
Experimental: TeGeCoach Home-based exercise program consisting of telephone health coaching, remote walking exercise monitoring based on wearable monitors and intensified primary care.	Behavioral: TeGeCoach 12-month long telephone health coaching carried out by specially trained coaches. The health coaching is a patient-centered approach based on motivational interviewing, shared decision-making and active listening techniques. Primary care physicians will be constantly involved receiving regular health reports from the coach. The walking exercise is based on the principle of interval training. Patients will continuously wear an activity monitor device to review their exercise performance and for remote exercise monitoring by the coach. This activity information will be regularly reviewed by the coach to ensure that the patient adheres to the individual walking exercise prescription.
No Intervention: Usual care group (TAU) Patients randomized to TAU receive written information about courses offered by their statutory health insurance. Health insurance companies offer a variety of courses to encourage regular exercise and to promote lifestyle changes, including SEPs (vascular and cardio exercise), physical therapy, nutritional assistance programs, smoking cessation programs, weight loss programs, and patient education programs for obesity and diabetes.

Arm

Intervention/Treatment

Experimental: TeGeCoach

Home-based exercise program consisting of telephone health coaching, remote walking exercise monitoring based on wearable monitors and intensified primary care.

Behavioral: TeGeCoach

12-month long telephone health coaching carried out by specially trained coaches. The health coaching is a patient-centered approach based on motivational interviewing, shared decision-making and active listening techniques. Primary care physicians will be constantly involved receiving regular health reports from the coach. The walking exercise is based on the principle of interval training. Patients will continuously wear an activity monitor device to review their exercise performance and for remote exercise monitoring by the coach. This activity information will be regularly reviewed by the coach to ensure that the patient adheres to the individual walking exercise prescription.

No Intervention: Usual care group (TAU)

Patients randomized to TAU receive written information about courses offered by their statutory health insurance. Health insurance companies offer a variety of courses to encourage regular exercise and to promote lifestyle changes, including SEPs (vascular and cardio exercise), physical therapy, nutritional assistance programs, smoking cessation programs, weight loss programs, and patient education programs for obesity and diabetes.

Outcome Measures

Primary Outcome Measures

Change in score on Walking Impairment Questionnaire (WIQ) [baseline, 12-month and 24-month follow-up]
The patient-reported WIQ is a valid clinical tool to classify patient-perceived walking impairment in patients with PAD in terms of pain, walking speed, walking distance and the climbing of stairs. The WIQ has been shown to be responsive to treatment effects and thus can be used as an alternative to treadmill testing for an objective assessment of walking claudication.

Secondary Outcome Measures

Change in score on Walking Estimated Limitation Calculated by History (WELCH) questionnaire [baseline, 12-month and 24-month follow-up]
The WELCH is a four-item questionnaire to estimate walking limitation in patients with suspected peripheral artery disease.
Change in score on EQ5D-5L questionnaire [baseline, 12-month and 24-month follow-up]
The EQ5D-5L is a standardized instrument developed by the EuroQoL Group for the measurement of health-related quality of life. There are five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The EQ5D-5L has been validated for the general German population.
Change in score on Short Form Health Survey (SF-12) [baseline, 12-month and 24-month follow-up]
The SF-12 is a self-report questionnaire for the measurement of generic health status involving multiple health dimensions: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems and mental health. SF-12 is a short version of the SF-36, with good psychometric properties. The German version has been cross-validated with the original English version.
Change in score on Vascular Quality of Life Questionnaire (VascuQoL-25) [baseline, 12-month and 24-month follow-up]
The VascuQol-25 is a highly-responsive validated questionnaire for the measurement of PAD-specific health-related quality of life, with a high level of construct and convergence validity. The questionnaire consists of five domains (Activity, Symptom, Pain, Emotional and Social) and has 25 items in total.
Change in score on Patient Health Questionnaire (PHQ-9) [baseline, 12-month and 24-month follow-up]
The PHQ-9 is a brief valid questionnaire for the diagnosis of depression that can also be used to identify depression outcome measures and changes over time. The German version has been validated twice.
Change in score on Generalized Anxiety Disorder (GAD-7) questionnaire [baseline, 12-month and 24-month follow-up]
The GAD-7 is brief questionnaire for the detection of Generalized Anxiety Disorder, which has been validated in primary care setting and in the general population.
Change in score on Alcohol Use Disorders Identification Test (AUDIT-C) [baseline, 12-month and 24-month follow-up]
The AUDIT-C is a brief screening instrument to identify harmful alcohol consumption, consisting of three questions. Regarding its psychometric properties, the AUDIT-C has been shown to be reliable and valid instrument to screen alcohol misuse in primary care settings.
Change in score on Fagerström Test for Nicotine Dependence (FTND) [baseline, 12-month and 24-month follow-up]
To identify tobacco dependence, the 6-item long Fagerström Test for Nicotine Dependence (FTND) will be used, which has been shown to be validly assessing the physical addiction to nicotine.
Change in score on Health Literacy Questionnaire (HLQ) [baseline, 12-month and 24-month follow-up]
The HLQ is a comprehensive tool with excellent psychometric properties for the measurement of health literacy. The HLQ examines nine dimensions of health literacy.
Change in score on Patient Activation Measure (PAM-13) [baseline, 12-month and 24-month follow-up]
PAM-13 has been shown to be a valuable tool for the measurement of patient activation by dividing people into one of four activation levels. The German version has been validated, with good psychometric properties.
Change in utilization of medical services [baseline, 12-month and 24-month follow-up]
Routine health insurance data: time period until hospitalization; probability of hospitalization; number and duration of inpatient hospitalization; outpatient medical treatment; drug dose (defined daily dose - DDD).
Change in severe (adverse) events [baseline, 12-month and 24-month follow-up]
Routine health insurance data: death, amputation, revascularization, etc.
Change in total health care costs [baseline, 12-month and 24-month follow-up]
Routine health insurance data: hospital billing and insurance reimbursement; inpatient hospital cost; inpatient rehabilitation costs; ambulatory care costs; costs for drugs and other medical supplies; sick pay costs.

Other Outcome Measures

Questionnaire on Satisfaction in Outpatient Care (ZAPA; intervention arm only) [12-month follow-up]
ZAPA is a brief (4 items) and psychometrically valid German questionnaire for measuring the patient's global satisfaction with his or her outpatient care, including the quality and extent of information received and his/her involvement in clinical decisions (i.e. shared-decision making).
Change in exercise adherence (intervention arm only) [baseline and 12-month follow-up]
Activity tracker data: e.g. number of alerts and corresponding phone calls made when step frequency or the duration of exercise sessions fall below an individual threshold range, amount of steps, net walking time (> 50 steps/minute) per day/week
Change in amount of steps/net walking time (intervention arm only) [baseline and 12-month follow-up]
Coaching software data

Eligibility Criteria

Criteria

Ages Eligible for Study:

35 Years to 80 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Insured with one of the three participating health insurance companies
Sufficient German language skills to follow the telephone-based health coaching
Access to a telephone (landline or mobile);
Primary or secondary diagnosis of PAD at Fontaine stage IIa or IIb within the last 36 months, but no primary or secondary diagnosis of PAD at Fontaine stage I within the last 12 months; or at Fontaine stage III or IV within the last 36 months

Inpatient and outpatient diagnoses from routine statutory health insurance data will be used to identify eligible patients.

Exclusion Criteria:

Immobility that goes beyond claudication (inability to carry out intervention and competing risks)
Severe and persistent mental disorders (adherence reasons)
Suicidality (safety reasons)
Life-threatening somatic diseases (e.g., cancer; competing risk)
Active or recent participation in any other PAD intervention trial
Ongoing hospitalization; alcoholism and other drug dependency (adherence reasons)
Heart failure graded New York Heart Association (NYHA) class III and IV (inability to carry out intervention and competing risks)

Ineligible patients are identified based on diagnoses that were made in inpatient settings only, given the considerable number of diagnostic errors in outpatient settings.

Contacts and Locations

Locations

	Site	City	Country	Postal Code
1	TK statutory health insurance	Hamburg	Germany	22305
2	KKH statutory health insurance	Hannover	Germany	30625
3	Mhplus Statutory Health Insurance	Nürnberg	Germany	90411

Sponsors and Collaborators

Universitätsklinikum Hamburg-Eppendorf

Investigators

Principal Investigator: Jörg Dirmaier, PD Dr., Universitätsklinikum Hamburg-Eppendorf
Study Director: Frank Bienert, KKH statutory health insurance
Study Chair: Lutz Herbarth, Dr., KKH statutory health insurance