CHOICE (Choice of Health Options In reducing Cardiovascular Events) program for secondary prevention
The CHOICE program is a brief and patient-centered method for reducing cardiovascular risk factors. The program is packaged as risk factor modules via a clinic visit plus telephone support. Patients participate in a mandatory cholesterol-lowering module and tailored modules for other major risk factors based on their individual need and preference.
Cardiovascular disease is a major cause of morbidity and mortality in Australia and is associated with significant cost.
Patients with a previous cardiac event have a markedly higher risk of further events than the general population and thus identify themselves as being an extremely high return target for risk prevention strategies.
Consequently, it is recommended that all acute coronary syndrome (ACS) survivors participate in a secondary prevention program. However, despite the potential benefits of cardiac rehabilitation programs only the minority (10-30%) participate representing a significant evidence-practice gap in Australian healthcare.
To add to the problem, heart event survivors who do not access existing rehabilitation have higher levels of individual risk factors and poorer knowledge of their risk factors than those who access a rehabilitation program.
Given that cardiovascular disease is a chronic condition, life-long lifestyle changes and adherence to pharmacotherapy are required. It is also important to establish an ongoing therapeutic alliance with health professionals where patients are partners in managing their disease. The CHOICE program provides a clinically tested method for closing the current evidence practice gap.
The CHOICE program includes a one-hour initial consultation and a few follow-up phone calls over three months.
The program is an individualized, structured, case-management approach and is overseen by treating physicians.
Stage one of the program involves development of modules and tailoring of leaflets according to locally available programs and resources. Management options for each risk factor are broadly summarized as physician-directed, hospital program , individual program or self-help.
Stage two is a face-to-face risk factor assessment, generating a list of each patient’s relevant risk factors.
In stage three, usually commenced in the same session as stage 2, patients make guided choices about which risk factors they will aim to lower, participate in goal-setting informed by current national targets for the chosen risk factors, and select management option(s) they will undertake to lower risk.
All CHOICE patients participate in the core module for lowering cholesterol (including healthy eating advice and pharmacotherapy) given its major impact on reducing recurrent events. Choice modules are also offered for other major risk factors including blood pressure-lowering, smoking cessation, increased physical activity and nutrition depending on individual patient need and preference.
Stage four, is telephone follow-up, during which each patient’s risk factor(s) goals and strategies are re-evaluated and mutually changed if necessary to enhance success. Patients also have the opportunity to add another module they had not previously elected to undertake.
The CHOICE program has diverse and important applications. It provides an effective option for large numbers of Australians who experience a heart event but do not access the existing rehabilitation model. It is likely that narrowing this significant evidence-practice gap will reduce recurrent cardiovascular events in those with established disease and significantly lower the cardiac disease burden. In a broader sense the CHOICE program could form the basis of both primary and secondary prevention clinics that reduce the disease burden across a range of cardiovascular and chronic diseases that have common risk factors.
- Professor Ben Freedman
- Dr Julie Redfern
- Dr Tom Briffa