Individual-Level and Neighborhood-Level Factors Associated with Longitudinal Changes in Cardiometabolic Measures in Participants of a Care Coordination Program

Abstract

Background: Identifying clinical, sociodemographic, and neighborhood-level risk factors associated with less improvement or worsening cardiometabolic measures despite access to a clinic-based care coordination program may help identify candidates that need additional disease management support outside clinic walls. Methods: Secondary data analysis of data from care coordination program cohort, Leveraging Information Technology to Guide High Tech, High Touch Care (LIGHT2). Setting/Participants: Medicare, Medicaid, dual-eligible adults from ten Midwestern primary care clinics in the US. Intervention: Two-year nurse-led care coordination program. Outcome Measures: Hemoglobin A1C, low-density-lipoprotein (LDL) cholesterol, and blood pressure. Multivariable generalized linear regression models assessed each patient's clinical, sociodemographic, and neighborhood-level factors associated with change in outcome measures from before to after completion of LIGHT2 program. Results: 6378 participants had pre-and post-intervention levels reported for at least one outcome measure (61.6% women, 86.3% White, non-Hispanic ethnicity, mean age 62.7 [SD, 18.5] years). In adjusted models, higher pre-intervention measures were associated with worsening of all cardiometabolic measures (LDL-cholesterol β 0.56, 95% CI 0.52 to 0.60, p < 0.001; HbA1C β 0.51, 95% CI 0.43 to 0.59, p < 0.001; Systolic blood pressure β 0.95, 95% CI 0.83 to 1.08, p < 0.001). Women had worsening LDL- cholesterol compared to men (β 7.76, 95% CI 5.21 to 10.32, p <0.001). Women with pre-intervention HbA1C > 6.8% and systolic blood pressure >131 mm of Hg had worse post-intervention HbA1C (main effect β -1.29, 95% CI -1.95 to -0.62, p < 0.001; interaction effect β 0.19, 95% CI 0.09 to 0.28, p < 0.001), and systolic blood pressure (main effect β -7.86, 95% CI -15.55 to -0.17 p = 0.04; interaction effect β 0.06, 95% CI 0.002 to 0.12, p = 0.043) compared to men. Adding individual’s neighborhood-level risks or sensitivity analysis for clustering by clinics and census tracts did not change effect sizes significantly.Conclusions: Higher baseline cardiometabolic measures and women with high baseline cardiometabolic measures (compared to men) were associated with worsening of cardiometabolic outcomes in participants of a solely clinic-based care coordination program. Understanding the contextual causes for these associations may aid in tailoring disease management support outside clinic walls.