Reducing Total Cardiovascular Risk in an Urban Community

降低城市社区的总体心血管风险

• 批准号: 7435329
• 负责人: JERILYN K ALLEN
• 金额: $ 76.19万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2005
• 资助国家: 美国
• 起止时间: 2005-09-01 至 2010-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7435329
• 关键词: Achievement; Adoption; Adrenergic beta-Antagonists; Advanced Practice Nurse; Affect; African American; American; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Antiplatelet Drugs; Behavior; Behavior Therapy; Blood Pressure; Blood Vessels; Cardiovascular Diseases; Cardiovascular system; Case Manager; Characteristics; Client satisfaction; Clinic; Clinical; Clinical Research; Clinical effectiveness; Communities; Community Health; Community Workers; Coronary Arteriosclerosis; Coronary heart disease; Cost Effectiveness Analysis; Diabetes Mellitus; Disease; Disease Management; Documentation; Effectiveness; Experimental Designs; Feedback; Funding; Glycosylated hemoglobin A; Goals; Guidelines; Health; Healthcare; Heart; Heart Diseases; High Blood Pressure; High Risk Woman; Hyperlipidemia; Hypertension; Individual; Inequality; Institute of Medicine (U.S.); Intervention; Intervention Studies; Kidney Failure; LDL Cholesterol Lipoproteins; Life Style; Link; Lipids; Low income; Measures; Methodology; Modeling; Morbidity - disease rate; Myocardial Infarction; Non-Insulin-Dependent Diabetes Mellitus; Nurse Practitioners; Other Minority; Outcome; Patient Education; Patients; Personal Satisfaction; Persons; Pharmaceutical Preparations; Phase; Physical activity; Physicians; Population; Prevention therapy; Primary Health Care; Provider; Quality of Care; Randomized; Randomized Controlled Clinical Trials; Rate; Recommendation; Relative (related person); Reporting; Research; Research Design; Research Methodology; Research Personnel; Risk; Risk Factors; Risk Management; Risk Reduction; Secondary Prevention; Smoker; Testing; Therapeutic; Titrations; Tobacco; Translating; Underserved Population; United States National Institutes of Health; Week; base; blood pressure regulation; cardiovascular disorder risk; cardiovascular risk factor; caucasian American; community based participatory research; compare effectiveness; cost; cost effectiveness; day; diabetes management; diabetic; experience; health care service utilization; health disparity; heart disease risk; improved; medication compliance; men; mortality; multidisciplinary; prescription document; prescription procedure; programs; racial and ethnic disparities; research to practice; smoking cessation

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.

拟议的研究是基于这样一个前提，即基于社区的参与式研究伙伴关系模式，使用一个团队的高级实践护士病例经理，社区卫生工作者（CHW），和医生可以转化为城市社区诊所，提高护理质量和减少差异心血管健康在少数民族和其他服务不足的人群。尽管关于心血管疾病（CVD）和2型糖尿病的适当管理的指南广为宣传，但CVD风险降低实践的实施仍然很差。尽管已知在患有现有心脏病的人中将低密度脂蛋白胆固醇水平降低到100 mg/dl以下的益处，但多达50-70%的合格CVD患者没有被其提供者置于降脂治疗，并且20-80%的患者没有实现治疗目标。控制高血压（HBP）的好处是公认的，但尽管几十年的供应商和患者的教育，全国HBP控制率仍然只有31%。此外，众所周知，控制糖尿病、高脂血症和血压可降低糖尿病患者血管并发症的风险，其中75%的糖尿病患者死于某种形式的心脏或血管疾病。本随机试验将在非洲裔美国人（AA）和已知心血管疾病风险过高的低收入白色患者中比较综合强化干预（Cl）与较低强化干预（LI）的临床有效性和成本效益。共500例符合条件的CVD或2型糖尿病患者（250名AA和250名白色）将从两个城市联邦资助的社区诊所中随机选择，并随机分配接受1）由执业护士、CHW和患者医生提供的CI，关注行为干预，以影响治疗性生活方式改变和药物依从性以及药物处方和滴定，或2）LI干预，为患者及其医生提供关于CVD风险因素的反馈和指南。将在基线、一年和两年时衡量结果。假设CI组中有更高比例的患者将实现血脂、血压和糖尿病管理、生活方式行为和抗血小板药物、β受体阻滞剂和ACE抑制剂治疗的使用的治疗目标，并且CI干预将具有成本效益。次要结果包括评估Cl模型对患者对护理和医疗保健利用的满意度的影响。如果在初级保健环境中应用于具有本研究目标群体特征的人群，则建议增加接受推荐的二级预防治疗并达到目标水平的高风险女性和男性的百分比可能会导致年度心血管疾病死亡率和健康差异显著降低。