HEAR2T Reference Program
SCCIPA Program
The overall objective of the HEAR2T Program at SCCIPA was to reduce the cardiovascular disease risk status of patients selected based on their having coronary heart disease (CHD) or high levels of CHD risk factors. Potentially eligible patients were identified using existing computer databases maintained by the Santa Clara County Independent Practice Association (SCCIPA) and Blue Shield of California (BSC). A primary goal was to implement and evaluate a case-manager model of CHD risk reduction that would provide assistance to primary care physicians who were members of an independent practice association. Evaluation of the program included rates of participation in each phase of the project, change in risk factor status from baseline to a follow-up evaluation at 12-14 months, changes in quality of life (SF-12 questionnaire), dietary changes, participant satisfaction with the program, and physician knowledge of and satisfaction with the program.
A total of 486 patients enrolled in SCCIPA who listed one of 11 pre-determined primary care physicians as their physician were identified as being at high risk for a clinical CVD event using computer databases managed by SCCIPA and BSC. These patients were sent recruitment letters and were contacted by telephone by project staff. As a result of this recruitment, 249 patients completed the baseline evaluation and were entered into the high risk reduction program. Over a period of 12-14 months, patients were seen by the project RN or dietitian an average of 4 times for evaluations and/or counseling. 198 (80%) patients of the 249 originally enrolled in the program completed the follow-up evaluation (6% loss due to moved from area, illness or disability and 13% loss due to lack of interest).
Baseline data indicate that the patient selection method was effective in identifying a group of patients at increased risk of having clinical cardiac events in the future. A total of 25% reported a personal history of heart disease, 48% a personal history of high blood pressure, 81% a history of elevated cholesterol and 16% a history of diabetes. Also, cardiovascular medication use was high with 38% of patients reported taking blood pressure lowering medications, 38% taking cholesterol lowering medications and 15% taking medications for diabetes. This high risk status is also reflected in the clinic measurements and the self reported risk factors. Of particular note is the high prevalence of overweight or obesity (52%), elevated systolic blood pressure (32%), elevated LDL-cholesterol (69%), and elevated TC/HDL-C (54%).
A range of changes between baseline and follow-up were seen in the CHD risk factors with highly significant reductions achieved in systolic blood pressure (131 to 125 mm Hg; p =0.001), total cholesterol (234 to 209 mg/dL; p =0.001), LDL-cholesterol (148 to 123 mg/dL; p =0.001), and TC/HDL-C (5.4 to 4.7; p =0.001). Smaller changes were obtained in diastolic blood pressure, HDL-cholesterol, triglycerides, reported physical activity, stress, and dietary fat intake (all significant at p =0.05 to p =0.001). For many of the risk factors there was a major shift of patients out of the high and very high risk categories to the low and increased risk categories (see Figure 2). There was a significant increase in the use of blood pressure lowering medications (75 to 84 patients; p=0.05) and in the use of medications for hypercholesterolemia (79 to 107 patients; p =0.001). Patients rated their satisfaction with various components of the program as very satisfactory (highest rating) and the ratings by the SCCIPA physicians were generally excellent.
These data indicate that overall the project met major goals to recruit a high risk population, retain a high percentage of them in a nurse case-manager model risk reduction program and have a significant impact on the risk status of a substantial number of patients. The patients were very satisfied with the program and the relationship between the program staff and the participating physicians was excellent.
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