Key result
Case management cuts 10-year CHD risk by ~2% absolute vs. usual primary care alone.
Why the study?
Implementation of case management for cardiac risk factors is difficult, especially in low-income, ethnically diverse populations within county health systems.
Does case management plus usual primary care reduce 10-year CHD risk in a low-income, multiethnic population at elevated risk of CHD?
RCT (n=419)
randomized
Does case management plus usual primary care reduce 10-year CHD risk in a low-income, multiethnic population at elevated risk of CHD?
Mean Difference: 1.56
Absolute Risk Reduction: 1.56%
p-value: p=0.007
Intensive case management significantly reduces calculated 10-year CHD risk in low-income, multiethnic populations, though implementation faces systemic barriers.
METHODS: Case-management (CM) can positively influence chronic disease care by facilitating guideline-concordant interventions that improve outcomes through intensive, individualized, longitudinal care. Implementation of CM, however, is difficult. We have identified lessons learned from a cardiovascular risk reduction CM program that may aid future CM implementation. INTRODUCTION: Heart to Heart is both a clinical trial and program dissemination project implementing CM for persons at elevated risk of coronary heart disease (CHD) events in a multiethnic, low-income population in a county health system. Patients were randomized to CM plus usual primary care (N = 212) or primary care alone (N = 207). CM patients received face-to-face nurse and dietitian visits (mean of 14 hours) over 17 months. Visits emphasized behavior change, risk-factor monitoring, and guideline-based pharmacotherapy. A total of 341 patients (81%) were available for follow-up. This CM model is currently transitioning to a County-run program. RESULTS: Findings demonstrated statistically significant reductions in mean Framingham Risk for CM versus usual primary care (1.56% absolute decrease in 10-year CHD risk, P = 0.007). Favorable changes were noted across most major CHD risk factors. Lessons learned are the need for the following: (1) Strategies for implementing CM in low-income, ethnically-diverse populations, (2) Methods for developing clinically more effective CM, and (3) Approaches to increase the efficiency of cardiovascular CM. CONCLUSIONS: CM for cardiac risk factors faces notable implementation barriers, particularly in County health systems. Specific implementation solutions recommended may help confront these barriers and improve diffusion of this evidence-based and patient centered model of care.
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Berra et al. (2007) conducted an RCT in Elevated risk of coronary heart disease (n=419). Case-management plus usual primary care vs. Primary care alone was evaluated on Mean Framingham Risk (10-year CHD risk) (1.56% absolute decrease, p=0.007). Case-management plus usual primary care significantly reduced mean 10-year Framingham coronary heart disease risk compared to usual care alone (1.56% absolute decrease, P=0.007).
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