Abstract 2097: Case-Management for Multiple CHD Risk Factors is Effective in a Low-Income, Ethnically Diverse Population
Background: Case management (CM) can improve outcomes and quality of care in chronic diseases such as coronary heart disease (CHD). Data are lacking, however, on its efficacy in ethnic and low-income populations. We implemented the Stanford and San Mateo Heart to Heart program to assess CM in low-income, mostly ethnic minority patients receiving ongoing primary care in a county health system.
Methods: We randomized 419 participants with elevated CHD risk to longitudinal nurse-dietitian CM or to usual physician-only care (UC). Our primary outcome measure was a Framingham risk probability (FRP) representing the estimated 10-year risk of a CHD event based on aggregated CHD risk factors. We report interim intention to treat outcomes based on 297 patients with a mean follow-up time of 17.4 months (78% retention to date). Follow-up will be complete in 8/06. We compared outcome changes over time between the CM and UC groups using SAS PROC MIXED to account for multi-level patient clustering by physician and health care clinic.
Results: Baseline clinical and behavioral characteristics did not differ by group. Mean age was 56 years, 63% were Latino, 65% female, and 61% had ≤ 11 yrs education. Obesity (69%), diabetes (63%), and metabolic syndrome (22%) were common. Under CM, FRP declined from a 13.3% mean probability of a CHD event over 10 yrs to 11.9% (Δ −1.4%, 95%CL −2.3%, −0.4%). For UC, FRP increased from 12.6% to 13.0% (Δ + 0.4%, CL −0.8%, 1.5%, p < .03 for CM vs. UC). This amounts to a differential relative reduction in CHD risk of 14% (1.8%/13%). The main driver of this change was lowering mean systolic BP (CM 132 to 127, Δ −4.2, CL −7.2, 1.2 vs. UC 136 to 139, Δ + 3.3, CL −0.3, 6.8, p < .001). A decrease also was noted for diastolic BP (CM 79 to 73, UC 79 to 77, CM vs. UC p = .009). For CM vs. UC, LDL, HDL, BMI, HbA1c, and physical activity changes were favorable but not statistically significant.
Conclusions: Significant CHD risk reduction occurred under CM while risk was noted to increase for those patients in the UC group. While risk factor changes were modest, CM improved a broad range of CHD risk factors through clinical and lifestyle interventions. Given the difficulties providing prevention to low-income, minority populations, CM may be an important means of augmenting physician services.