Implementing cardiac risk-factor case management: lessons learned in a county health system.
Implementing cardiac risk-factor case management: lessons learned in a county health system.
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DOI：
10.1097/hpc.0b013e31815b5609
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发表时间：
2007-12-01
影响因子：
--
通讯作者：
Stafford, Randall S
中科院分区：
文献类型：
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作者：
Berra, Kathy;Ma, Jun;Stafford, Randall S
方法：病例管理（CM）可以通过促进指南一致的干预措施，改善结果，通过密集的，个性化的，纵向护理，积极影响慢性病护理。然而，CM的实施是困难的。我们已经确定了从心血管风险降低CM程序，可能有助于未来CM implementation.INTRODUCTION：心到心是一个临床试验和程序传播项目，实施CM的人在冠心病（CHD）事件的高风险在一个多民族，低收入人口在县卫生系统。患者被随机分配至CM+常规初级护理组（N = 212）或仅接受初级护理组（N = 207）。CM患者在17个月内接受了面对面的护士和营养师访问（平均14小时）。访问强调行为改变、风险因素监测和基于指南的药物治疗。共有341例患者（81%）可接受随访。这CM模型目前正在过渡到县运行program.RESULTS：调查结果显示，与普通的初级保健（10年CHD风险绝对下降1.56%，P = 0.007）的平均Fragrance风险CM统计学显着降低。在大多数主要CHD风险因素中观察到有利的变化。吸取的经验教训是需要以下方面：（1）在低收入、种族多元化人群中实施CM的策略，（2）开发临床上更有效的CM的方法，以及（3）提高心血管CM效率的方法。结论：针对心脏风险因素的CM面临显着的实施障碍，特别是在县卫生系统中。建议的具体实施解决方案可能有助于应对这些障碍，并改善这种以证据为基础和以患者为中心的护理模式的传播。
METHODS: Case-management (CM) can positively influence chronic disease care by facilitating guideline-concordant interventions that improve outcomes through intensive, individualized, longitudinal care. Implementation of CM, however, is difficult. We have identified lessons learned from a cardiovascular risk reduction CM program that may aid future CM implementation.INTRODUCTION: Heart to Heart is both a clinical trial and program dissemination project implementing CM for persons at elevated risk of coronary heart disease (CHD) events in a multiethnic, low-income population in a county health system. Patients were randomized to CM plus usual primary care (N = 212) or primary care alone (N = 207). CM patients received face-to-face nurse and dietitian visits (mean of 14 hours) over 17 months. Visits emphasized behavior change, risk-factor monitoring, and guideline-based pharmacotherapy. A total of 341 patients (81%) were available for follow-up. This CM model is currently transitioning to a County-run program.RESULTS: Findings demonstrated statistically significant reductions in mean Framingham Risk for CM versus usual primary care (1.56% absolute decrease in 10-year CHD risk, P = 0.007). Favorable changes were noted across most major CHD risk factors. Lessons learned are the need for the following: (1) Strategies for implementing CM in low-income, ethnically-diverse populations, (2) Methods for developing clinically more effective CM, and (3) Approaches to increase the efficiency of cardiovascular CM.CONCLUSIONS: CM for cardiac risk factors faces notable implementation barriers, particularly in County health systems. Specific implementation solutions recommended may help confront these barriers and improve diffusion of this evidence-based and patient centered model of care.