Reducing Total Cardiovascular Risk in an Urban Community

这项拟议的研究基于这样一个前提，即由高级执业护士病例经理、社区卫生工作者(CHW)和医生组成的团队基于社区的参与式研究伙伴关系模式可以转化为城市社区诊所，提高护理质量，减少少数族裔和其他服务不足人群在心血管健康方面的差距。尽管关于心血管疾病(CVD)和2型糖尿病的适当管理的指导方针得到了广泛宣传，但降低心血管疾病风险的做法执行情况仍然很差。尽管已知将现有心脏病患者的低密度脂蛋白胆固醇水平降低到100毫克/分升以下的好处，但多达50%-70%的符合条件的心血管疾病患者没有接受提供者的降脂治疗，20%-80%的患者没有达到治疗目标。控制高血压(HBP)的好处是众所周知的，尽管经过几十年的提供者和患者的教育，全国的HBP控制率仍然只有31%。此外，控制血糖、高脂血症和血压可以降低糖尿病患者血管并发症的风险，糖尿病患者中75%的人死于某种形式的心脏或血管疾病。这项随机试验将对已知心血管疾病风险过高的非裔美国人(AA)和白人低收入患者进行综合强化干预(CL)和较低强度干预(LI)的临床效果和成本效益进行比较。总共500名符合条件的心血管疾病或2型糖尿病患者(250名AA和250名怀特)将从两家由联邦政府资助的城市社区诊所随机选择，并随机分配接受1)由护师、CHW和患者的医生提供的CL，重点是影响治疗方式改变、药物依从性以及药物处方和滴定的行为干预措施，或2)LI干预措施，向患者及其医生提供关于心血管疾病危险因素和指南的反馈。结果将在基线、一年和两年内进行衡量。据推测，氯化组中更高比例的患者将在血脂、血压和糖尿病管理、生活方式行为以及抗血小板药物、β受体阻滞剂和血管紧张素转换酶抑制剂的使用方面达到治疗目标，并且氯化干预将具有成本效益。次要结果包括评估CI模型对患者对护理和卫生保健利用的满意度的影响。建议增加接受推荐二级预防治疗并达到目标水平的高危女性和男性的百分比，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，可能会显著减少年度心血管疾病死亡率和健康差距。

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.