Reducing Total Cardiovascular Risk in an Urban Community

提出的研究是基于一个前提，即基于社区的参与式研究伙伴关系模式，由高级实践护士、病例管理人员、社区卫生工作者（CHW）和医生组成的团队可以转化为城市社区诊所，提高护理质量，减少少数民族和其他服务不足人群心血管健康的差异。尽管心血管疾病（CVD）和2型糖尿病的适当管理指南广为宣传，但降低心血管疾病风险的实践实施仍然很差。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 mg/dl以下有益，但多达50-70%的符合条件的CVD患者没有接受其提供者的降脂治疗，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，但尽管几十年来提供者和患者的教育，全国的HBP控制率仍然只有3.1%。此外，已经确定的是，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，75%的糖尿病患者死于某种形式的心脏或血管疾病。这项随机试验将比较非裔美国人（AA）和白人低收入已知心血管疾病风险过高患者的综合强化干预（Cl）与低强化干预（LI）的临床效果和成本效益。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White）将从两个城市联邦政府资助的社区诊所随机选择，并随机分配接受1)由执业护士、CHW和患者医生提供的Cl；侧重于行为干预，以影响治疗性生活方式的改变和药物依从性，以及药物的处方和滴定，或2)LI干预，为患者及其医生提供心血管疾病危险因素和指南的反馈。结果将在基线、1年和2年进行测量。假设Cl组中较高比例的患者在血脂、血压和糖尿病管理、生活方式行为和使用抗血小板药物、受体阻滞剂和ACE抑制剂治疗方面达到治疗目标，并且Cl干预将具有成本效益。次要结局包括评估Cl模型对患者护理满意度和医疗保健利用的影响。建议增加接受推荐的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，如果在初级保健机构中应用于具有本研究目标群体特征的人群，可能会导致年心血管疾病死亡率和健康差异的显着下降。

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.