Article

Case management to reduce risk of cardiovascular disease in a county health care system.

Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA.
Archives of internal medicine (Impact Factor: 11.46). 11/2009; 169(21):1988-95. DOI:10.1001/archinternmed.2009.381
Source: PubMed

ABSTRACT Case management (CM) is a systematic approach to supplement physician-centered efforts to prevent cardiovascular disease (CVD). Research is limited on its implementation and efficacy in low-income, ethnic minority populations.
We conducted a randomized clinical trial to evaluate a nurse- and dietitian-led CM program for reducing major CVD risk factors in low-income, primarily ethnic minority patients in a county health care system, 63.0% of whom had type 2 diabetes mellitus. The primary outcome was the Framingham risk score (FRS).
A total of 419 patients at elevated risk of CVD events were randomized and followed up for a mean of 16 months (81.4% retention). The mean FRS was significantly lower for the CM vs usual care group at follow-up (7.80 [95% confidence interval, 7.21-8.38] vs 8.93 [8.36-9.49]; P = .001) after adjusting for baseline FRS. This is equivalent to 5 fewer heart disease events per 1000 individuals per year attributable to the intervention or to 200 individuals receiving the intervention to prevent 1 event per year. The pattern of group differences in the FRS was similar in subgroups defined a priori by sex and ethnicity. The main driver of these differences was lowering the mean (SD) systolic (-4.2 [18.5] vs 2.6 [22.7] mm Hg; P = .003) and diastolic (-6.0 [11.6] vs -3.0 [11.7] mm Hg; P = .02) blood pressures for the CM vs usual care group.
Nurse and dietitian CM targeting multifactor risk reduction can lead to modest improvements in CVD risk factors among high-risk patients in low-income, ethnic minority populations receiving care in county health clinics.
clinicaltrials.gov Identifier: NCT00128687.

0 0
 · 
0 Bookmarks
 · 
80 Views
  • Source
    Circulation 01/2012; 125(1):171-84. · 15.20 Impact Factor
  • Source
    [show abstract] [hide abstract]
    ABSTRACT: Adult and childhood obesity and related adverse outcomes are most common among racial/ethnic minorities and socio-economically disadvantaged populations in the United States . Research approaches to obesity developed in mainstream populations and deploying new information technologies may exacerbate existing disparities in obesity. Current obesity management and prevention research priorities will not maximally impact this critical problem unless investigators explicitly focus on discovering innovative strategies for preventing and managing obesity in the disadvantaged populations that are most affected. On the basis of our research experience, four key research approaches are needed: (1) elucidating the underlying social forces that lead to disparities; (2) directly involving community members in the development of research questions and research methods; (3) developing flexible strategies that allow tailoring to multiple disadvantaged populations; and (4) building culturally and socio-economically tailored strategies specifically for populations most affected by obesity. Our experience with a community-based longitudinal cohort study and two health center-based clinical trials illustrate these principles as a contrast to traditional research priorities that can inadvertently worsen existing social inequities. If obesity research does not directly address healthcare and health-outcome disparities, it will contribute to their perpetuation.
    International journal of obesity (2005) 07/2012; 2012(2):s16-s22. · 5.22 Impact Factor
  • [show abstract] [hide abstract]
    ABSTRACT: This 24 month study evaluated the effect of dietitian coaching combined with minimal endocrinologist follow up on the glycemic control and cardiovascular risks of diabetic participants, compared with conventional endocrinologist follow up. Participants with type 1 or type 2 diabetes were assigned to either the control group with conventional endocrinologist follow up (C; n = 50) or the dietitian-coached group (DC; n = 51) with on-site diabetes self-management education every 3 months combined with annual endocrinologist followup. Over the 24 month intervention, weight (-0.7 vs. +2.1 kg; p = 0.04), BMI (+0.3 vs. +0.7 kg/m(2); p = 0.009), and waist circumference (-1.3 vs. +2.4 cm; p = 0.01) significantly differed between the DC and control groups. HbA(1C) dropped significantly in participants of the DC versus the control group (-0.6% vs.-0.3%; p = 0.04). This was accompanied by improved overall energy intake (-548 vs. -74 kcal/day; p = 0.04). However, no link associated glycemic control to nutrient intake or intensiveness of pharmacotherapy. Coaching by a dietitian improves glycemic control and reduces certain cardiovascular risk factors in diabetic subjects, demonstrating that a joint dietitian-endocrinologist model of care provides a convenient strategy for cardiovascular risk management in the diabetic population.
    Applied Physiology Nutrition and Metabolism 04/2012; 37(4):610-20. · 2.01 Impact Factor

Full-text (4 Sources)

View
15 Downloads
Available from
Aug 30, 2013