HEAR2T Reference Program
San Mateo County Program
The overall objective of the HEAR2T Program at San Mateo County 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. The project design was similar to General Electric, San Jose. 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 the three insurance plans providing insurance to San Mateo County (Blue Shield of California, Kaiser Permenente, and Aetna US Healthcare). A unique feature of this model was that the three insurance plans and the County provided financial support as well as written support for the project within their physician membership. Another unique aspect of this program was the equal ratio of men to women employees and the heterogeneous nature of the age, ethnicity and jobs of the employees.
The target population for this project was the San Mateo County government with program participants being employees and their spouses or domestic partners and retirees and their spouses or partners and consists of approximately 8,000 persons. Following program promotion in the County, a cardiovascular risk questionnaire (CRA) was sent by mail to all eligible participants. People completing the questionnaire were provided a written computer-generated evaluation of their risk status and a suggested plan of action. Participants considered to be at high risk were invited into a clinic screening visit where basic risk factors were measured and a brief counseling session was held. Those persons at highest risk were invited to participate in the counseling program for 12-15 months. A specially trained nurse and dietitian following project protocols provide this counseling. The staff coordinates medical management of the patient with their primary physician or clinic. Project evaluation includes measures of participant enrollment, program adherence, risk factor change, clinical cardiac events, quality of life, program satisfaction and health care utilization and physician knowledge about and satisfaction with the program.
A total of 2,693 (34%) of the CRAs were returned. We used a predefined set of criteria to assign people to low (10%), increased (43%), high (24%) and very high risk (24%) categories based on their self-reported values. Using these criteria, a total of 715 persons (27%) out of the 2,693 completing the CRA were considered to be at very high risk or had reported CVD or diabetes and received an invitation to the risk factor screen as a part of their action plan (included in the computer generated CRA report). Of 715 invited to the risk factor screen, 319 (48%) completed the risk screening examination, with 266 considered to be at high risk and invited into the counseling program, 83 (24%) considered to be moderate risk and 13 (4%) considered to be a low risk. Eleven of the participants invited into the counseling program decided not to participate.
A total of 255 participants were enrolled in the high risk counseling program between September 1997 and February 1998. After 12-15 months of the counseling program 209 (79%) of the high risk patients completed a follow-up evaluation. As with the General Electric and SCCIPA projects, these high risk patients demonstrated significant reductions in major CVD risk factors, including LDL-cholesterol, HDDL-cholesterol, triglycerides, systolic and diastolic blood pressure, physical activity and nutrition. For example, at baseline 47% of participants in the counseling program had systolic blood pressures above 140 mm. Hg while at the follow-up examination this was decreased to just 19% and the percentage of patients with LDL-C greater than 160 mg. dL. decreased from 33% to 22%. A summary of the changes in risk factor status is provided in Figure 3. Ninety eight percent of the participants rated their experience with the counseling program as satisfied or very satisfied.
All participants who completed a CRA at baseline were sent a follow-up CRA in November 1999. Of those participants not in the high risk counseling program but completed a CRA at baseline (N = 2429), 1142 (47%) completed a follow-up CRA. Those CRAs have been edited and scanned into the computer database. Analysis of these data is currently being performed.
There was good but slow acceptance of the program by the program participant's physicians, with many of them at the end of one year still very passive in managing these high risk persons. Some participants, after a year or more in the program, were just beginning to make progress, especially in getting support or action from their physicians. Thus, this program is being support by San Mateo County government and the three insurance plans for a second year (April 1999 to March 2000). The objectives of this continuation is to evaluate the effects of new attempts to get more active participation by the primary care physicians in the medical management of the high risk patients, determine the maintenance of risk reduction in patients who achieved significant risk reduction during the first year and to establish a health care utilization database in collaboration with the three health plans. The objective of this database is to determine if data routinely collected by health plans can be used to evaluate the effects of case management programs on health care use and costs.
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