Reducing Total Cardiovascular Risk in an Urban Community

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The proposed study is based on the premise that a community based participatory research partnership model using a team of an advanced practice nurse case manager, community health worker (CHW), and physician can be translated into urban community clinics and improve the quality of care and reduce disparities in cardiovascular health in minority and other underserved populations. Despite well-publicized guidelines on the appropriate management of cardiovascular disease (CVD) and type 2 diabetes, implementation of CVD risk-reducing practices remains poor. In spite of the known benefit of lowering low-density lipoprotein cholesterol levels below 100 mg/dl in persons with existing heart disease, as many as 50-70% of eligible CVD patients are not placed on lipid-lowering therapy by their providers and from 20-80% of patients do not achieve the goals of therapy. The benefits of controlling high blood pressure (HBP) are well established yet national rates of HBP control remain at only 3 1% despite decades of provider and patient education. In addition, it is well established that control of glycemia, hyperlipidemia, and blood pressure reduce the risk of vascular complications in people with diabetes, 75% of whom die from some form of heart or blood vessel disease. This randomized trial will compare the clinical effectiveness and cost-effectiveness of a comprehensive intensive intervention (Cl) with a less intensive intervention (LI) in African American (AA), and White low income patients with known excessive CVD risk. A total of 500 eligible patients with CVD or type 2 diabetes (250 AA and 250 White) will be randomly selected from two urban federally-funded community clinics and randomly assigned to receive either 1) a Cl delivered by a nurse practitioner, a CHW, and the patient's physician, focusing on behavioral interventions to affect therapeutic lifestyle changes and medication adherence as well as the prescription and titration of medications or 2) a LI intervention providing feedback on CVD risk factors and guidelines to patients and their physicians. Outcomes will be measured at baseline, one and two years. It is hypothesized that a higher proportion of patients in the Cl group will achieve the treatment goals for lipid, blood pressure, and diabetes management, lifestyle behaviors and utilization of antiplatelet agent, beta blocker, and ACE inhibitor therapies and that the Cl intervention wilj be cost-effective. Secondary outcomes include assessment of the impact of the Cl model on patients' satisfaction with care and health care utilization. The proposed increase in the percentage of high-risk women and men who receive recommended secondary prevention therapies and achieve goal levels could potentially result in a marked decrement in annual CVD mortality and health disparities if applied within primary care settings to populations with the characteristics of the target groups for this study.