Individualized Risk Communication and Outreach for Primary Cardiovascular Disease Prevention in Community Health Centers

Abstract

T he risk of developing cardiovascular disease (CVD) can be greatly reduced through lifestyle and medical therapies that address diet, overweight and obesity, smoking, dysplipidemia, hypertension, and diabetes mellitus. Irrespective of which factors are contributing on an individual's risk for the development of CVD, treatment with statins safely and effectively reduces morbidity and mortality from CVD. 1,2The recent American College of Cardiology/American Heart Association cholesterol treatment guideline emphasizes identifying and treating individuals at risk for developing CVD. 3 However, fewer than half of high-risk individuals are treated with statins. 4,5 Statin use is lower among blacks, 4,6 Hispanics, 5,6 the uninsured, 7 and poorer individuals. 8,9 Reducing the population burden of CVD and decreasing disparities will require maximizing the use of preventive strategies among all individuals likely to benefit from them.Statins may be underused for primary prevention for several reasons. Clinicians and patients may not readily appreciate increased CVD risk, particularly when risk comes from factors other than elevated cholesterol. 10,11 Patients may also Background-Many eligible primary cardiovascular disease prevention candidates are not treated with statins. Electronic health record data can identify patients with increased cardiovascular disease risk. Methods and Results-We performed a pragmatic randomized controlled trial at community health centers in 2 states.Participants were men aged ≥35 years and women ≥45 years, without cardiovascular disease or diabetes mellitus, and with a 10-year risk of coronary heart disease of at least 10%. The intervention group received telephone and mailed outreach, individualized based on patients' cardiovascular disease risk and uncontrolled risk factors, provided by lay health workers. Main outcomes included: documented discussion of medication treatment for cholesterol with a primary care clinician, receipt of statin prescription within 6 months, and low-density lipoprotein (LDL)-cholesterol repeated and at least 30 mg/dL lower than baseline within 1 year. Six hundred forty-six participants (328 and 318 in the intervention and control groups, respectively) were included. At 6 months, 26.8% of intervention and 11.6% of control patients had discussed cholesterol treatment with a primary care clinician (odds ratio, 2.79; [95% confidence interval, 2.25-3.46]). Statin prescribing occurred for 10.1% in the intervention group and 6.0% in the control group (odds ratio, [12][13][14] Outreach interventions focused on addressing this risk could increase the number of high-risk patients who seek out treatment. 15Implementing population health management strategies in settings that serve large numbers of patients from low income and minority populations may be an effective way to reduce disparities. 16,17 In addition, testing strategies in safety net settings will help ensure that the study findings are applicable to low income and minority populations.We hypothesized that m...

Development of a Risk Equation for the Incidence of Coronary Artery Disease and Ischemic Stroke for Middle-Aged Japanese – Japan Public Health Center-Based Prospective Study –

“…Whether the prediction equation would be helpful for risk stratification to guide clinical decision-making to prevent CAD and ischemic stroke would need to be tested in a future clinical trial. 41 In addition, population-wide effort to control levels of each risk factor should complement an approach to identify high-risk individuals by the risk estimator incidence in the present study independent of other risk factors (data not shown 33 The proportion of subjects whose 10-year CAD risk was 5.0-7.4% or 7.5%+ in the present sample was small (5.1% in total), reflecting the low incidence rate of CAD in the cohort (crude rate: 0.91 per 1,000 person-years). The incidence rate was low partly because we included only hard CAD outcomes.…”

Predictors of cholesterol treatment discussions and statin prescribing for primary cardiovascular disease prevention in community health centers

“…(12) Briefly, the trial recruited participants from 11 federally qualified community health centers in Illinois and Arizona from August 2012 to March 2013. Participants were eligible for the study if they: were men ≥35 years old and women ≥45 years old, visited a study site for ≥1 face to face visit in the 6 months prior to randomization, had an LDL-C checked within the preceding 5 years, did not have a lipid lowering medication on their active medication list, had a calculated 10-year CHD risk ≥10% based on the ATP-III risk calculator, had an LDL-C of ≥100 mg/dL and did not have diabetes.…”

“…(12) We demonstrated that individualized CVD risk communication with patients increased discussions about cholesterol treatment with primary care clinicians but these discussions infrequently led to a statin prescription. In this post-hoc secondary analysis, we aimed to identify factors associated with cholesterol treatment discussion and statin prescription.…”

Community health center patients' response to and beliefs about outreach promoting clinical preventive services

“…Eligibility criteria for the randomized trial have been reported previously (Persell et al, 2015). Briefly, criteria included men ≥ 35 and women ≥ 45 years old with a 10-year risk of coronary death or myocardial infarction (based on Framingham risk score) of at least 10%, English or Spanish listed as preferred language, and a visit to the participating CHC within 6 months prior to randomization.…”

“…One potential strategy to reduce national CVD disparities is to deliver outreach promoting the primary prevention of cardiovascular disease to CHC patients. We recently reported the results of a randomized controlled trial within three CHC networks evaluating the effect of an individualized outreach intervention aimed at improving the appropriate use of statins for primary prevention of CVD among high risk patients (Persell et al, 2015). The intervention consisted of mailed and telephone outreach by a care manager that informed the patient that (1) they were at higher than average risk of CVD and estimated the patient's global CVD risk and (2) recommended actions to discuss with their clinician which included the use of medication to lower cholesterol.…”