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Original Investigation
Health Care Reform
November 23, 2009

Case Management to Reduce Risk of Cardiovascular Disease in a County Health Care System

Author Affiliations

Authors Affiliations: Palo Alto Medical Foundation Research Institute (Drs Ma and Xiao) and Palo Alto Medical Foundation (Mss Klieman and Hyde), Palo Alto, California; Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine (Ms Berra and Drs Haskell and Stafford), and Center for Primary Care and Outcomes Research, Stanford University (Dr Smith), Stanford, California; and Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California (Dr Smith).

Arch Intern Med. 2009;169(21):1988-1995. doi:10.1001/archinternmed.2009.381

Background  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.

Methods  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).

Results  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.

Conclusion  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.

Trial Registration  clinicaltrials.gov Identifier: NCT00128687