Improved Cardiovascular Risk Reduction to Enhance Rural Primary Care:I-CARE

心血管疾病（CVD）每天在美国造成2，200人死亡，每39秒就有一人死亡。有证据表明，这些死亡是可以通过更好的风险因素管理来预防的，但是，许多风险因素仍然不受控制。CVD患者具有高度的复杂性，并且往往具有许多慢性疾病。以患者为中心的医疗之家包括自我管理、个性化健康记录和基于团队的护理，是改善对患有多种慢性病的患者的护理的一种策略。管理式医疗组织发现，集中管理的心血管风险服务可以降低死亡率。目前尚不清楚，包括癌症筛查在内的预防健康和心血管风险服务（PHCVRS）是否会在缺乏临床药剂师或专业护士的私人诊所实施。我们的长期目标是通过基于团队的护理改善对具有复杂病史的患者的管理。我们开创了使用随机分组试验评估团队护理实施和指南依从性的策略。本申请的目的是进行一项多中心、随机分组研究，利用集中式PHCVRS支持缺乏大型综合健康计划的更多农村地区的私人医疗机构。这项研究的标题是“改善心血管风险降低，以加强农村初级保健：ICARE。“我们将在爱荷华州研究网络（IRENE）中对12个初级保健办公室进行分层和随机分配，以进行PHCVRS或常规护理，并招募300名受试者。我们还将在每个办公室随机选择25名患者（n=300，总计n=600）进入被动观察组，这将使我们能够确定干预在未暴露患者中更广泛扩散的程度。我们的中心假设是，PHCVRS将显着提高遵守由五个国家组织支持的指南优势指标。这项拟议研究的理由是，实施一种新的方法，以改善心血管疾病和癌症筛查的管理，将导致创新的战略，更广泛地采用整个美国的卫生系统，我们将实现我们的目标，并测试我们的中心假设与以下具体目标：目的1：以确定是否基于网络的PHCVRS将在私人初级保健办公室内实施。目标2：确定PHCVRS干预措施是否在整个干预办公室扩散。我们的方法是创新的，因为它会问这样的问题：“PHCVRS模型会成功实施吗？以及“护理管理是否有效？“这些问题还没有得到解决的病人有多种慢性疾病的私人执业。这项研究设计是新颖的，因为它将：1）是在小型私人诊所中使用群集随机设计测试该模型的最稳健的研究，2）评估效果是否可以长期持续，3）评估“被动观察组”以确定干预是否在整个实践中扩散。

DESCRIPTION (provided by applicant): Cardiovascular disease (CVD) causes 2,200 deaths in Americans every day, with one death every 39 seconds. There is evidence that these deaths can be prevented with better risk factor management, however, many risk factors remain uncontrolled. Patients with CVD have high levels of complexity and tend to have numerous chronic conditions. The Patient-Centered Medical Home including self- management, personalized health records and team-based care is a strategy to improve care for patients with multiple chronic conditions. Managed care organizations have found that a centralized cardiovascular risk service managed can reduce mortality. It is not known if a Prevention Health & Cardiovascular Risk Service (PHCVRS) including cancer screening would be implemented in private office practices that lack clinical pharmacists or specialized nurses. Our long-range goal is to improve the management of patients with complex medical histories with team-based care. We have pioneered strategies to evaluate team care implementation and guideline adherence using cluster-randomized trials. The objective of this application is to conduct a multi-center, cluster-randomized study utilizing a centralized PHCVRS to support private medical offices in more rural areas that lack large integrated health plans. This study is titled "Improved Cardiovascular Risk Reduction to Enhance Rural Primary Care: ICARE." We will stratify and randomize 12 primary care offices in the Iowa Research Network (IRENE) to PHCVRS or usual care and enroll 300 subjects. We will also randomly select 25 patients per office (n=300, total n=600) into a passive observation group that will allow us to determine the extent to which the intervention diffuses more broadly for unexposed patients. Our central hypothesis is that the PHCVRS will significantly improve adherence to The Guideline Advantage metrics that are supported by five national organizations. The rationale for this proposed study is that implementation of a novel approach to improve management of CVD and cancer screening will lead to innovative strategies for broader adoption by health systems throughout the U.S. We will accomplish our objectives and test our central hypothesis with the following specific aims: Aim 1: To determine if a web-based PHCVRS will be implemented within private primary care offices. Aim 2: To determine if the PHCVRS intervention diffuses throughout the intervention offices. Our approach is innovative because it will ask the questions: "Will the PHCVRS model be successfully implemented?" as well as "Is care management effective?" These questions have not been addressed for patients with multiple chronic conditions in private practice. This study design is novel because it will: 1) be the most robust study to test this model using a cluster randomized design in small private practice clinics, 2) evaluate whether the effect can be sustained long-term, and 3) evaluate a "passive observation group" to determine if the intervention diffuses throughout the practice.