Improving Coronary Prevention in a County Health System

描述(由申请人提供)：来自广泛的人口研究和临床试验的证据表明，风险因素管理在降低冠状动脉疾病(CAD)的发病率和死亡率方面是有效的。这些研究产生了重要的国家临床实践指南。然而，目前的预防做法未能实现这些国家指南中建议的目标。这些不足导致了不必要的冠心病负担，以及社会经济差异的永久化。事实证明，病例管理增强了当前的CAD预防活动，并提高了对国家指南的遵从性。斯坦福大学健康教育和降低风险培训(HEAR2T)计划是一种创新的、经过充分测试的病例管理工具。通过严格评估HEAR2T在由加利福尼亚州圣马特奥县(SMC)县医疗保健系统服务的低社会经济地位(SES)高危人群中的作用，本研究将：1)加强HEAR2T计划在低社会经济地位人群中的应用；2)将该计划作为临床护理的组成部分加以实施；3)实施一项随机对照试验，以评估HEAR2T在降低总的CAD风险方面的有效性；4)确定HEAR2T是否可以缩小社会经济差异；5)评估HEAR2T的成本效益；以及6)将干预从一项研究性研究转变为持续的县CAD病例管理计划。我们的主要结果衡量标准将是总的CAD风险分数的变化，这是根据基于单个CAD风险因素的Framingham模型计算的。我们的主要假设是，与常规护理中的对照患者相比，通过HEAR2T模型进行患者病例管理将在总体CAD风险评分方面产生有利的变化。我们将在SMC系统中招募来自四个卫生中心的200名干预和200名常规护理患者。15个月后，常规护理患者将交叉接受干预，以便对干预的影响进行额外评估。参与者的持续后续行动将评估在最初的密集病例管理期间实现的风险变化的持久性。这项研究将对确定低SES人群的最佳疾病管理做出关键和创新的贡献。在这样做的过程中，我们将帮助更广泛的国家努力，寻求从循证预防中获得社会“投资回报”。

DESCRIPTION (provided by applicant): Evidence from extensive population studies and clinical trials shows the effectiveness of risk factor management in reducing morbidity and mortality from coronary artery disease (CAD). These studies have generated important national clinical practice guidelines. Current prevention practices, however, fall short of attaining the goals recommended in these national guidelines. These shortfalls lead to unnecessary CAD disease burden, as well as perpetuation of socioeconomic disparities. Case management proves to augment current CAD prevention activities and improve adherence with national guidelines. The Stanford Health Education and Risk Reduction Training (HEAR2T) program is an innovative, yet well-tested, case management tool. By rigorously evaluating HEAR2T in a high-risk population of low socioeconomic status (SES) served by the county health care system of San Mateo County (SMC), CA, this study will: 1) enhance the HEAR2T program for use in Iow-SES populations; 2) implement this program as an integral part of clinical care; 3) implement a randomized controlled trial to evaluate the effectiveness of HEAR2T in lowering aggregate CAD risk; 4) determine if HEAR2T diminishes socioeconomic disparities; 5) estimate HEAR2T's cost effectiveness; and 6) transition the intervention from a research study to an ongoing County CAD case management program. Our primary outcome measure will be change in aggregate CAD risk score, calculated from a Framingham model based on individual CAD risk factors. Our primary hypothesis is that patients case-management via the HEAR2T model will produce favorable changes in aggregate CAD risk score compared to control patients in usual care. We will enroll 200 intervention and 200 usual care patients from four health centers in the SMC system. Usual care patients will crossover to the intervention after 15 months, allowing for additional assessment of the intervention's impact. Continued follow-up of the participants will assess the durability of risk changes achieved during initial intensive case-management. This study will make a critical and innovative contribution to defining optimal disease management in a Iow-SES population. In so doing, we will aid broader national efforts seeking to reap the societal "return on investment" available from evidence-based prevention.