Reducing Cardiovascular Risk With NP Care

Community Outreach and Cardiovascular Health (COACH) Trial: A Randomized, Controlled Trial of Nurse Practitioner/Community Health Worker Cardiovascular Disease Risk Reduction in Urban Community Health Centers: Rationale and Design

Allen JK, Dennison-Himmelfarb CR, Szanton SL, Bone L, Hill MN, Levine DM
Contemp Clin Trials. 2011;32:403-411

Study Summary

Background. Cardiovascular disease is a major cause of morbidity and mortality in the United States, with a disproportionate impact in low-income and minority populations. Despite widely disseminated, evidence-based guidelines describing management of both cardiovascular disease and type 2 diabetes (disease states that frequently coexist), application of the risk-reduction strategies emphasized in these documents is poor. The purpose of this study was to examine the effectiveness of a comprehensive cardiovascular disease risk-reduction program implemented by a nurse practitioner (NP)-led team that included a partnership with a community health worker (CHW).

Methodology. The COACH study was a randomized controlled trial of high-risk patients with known cardiovascular disease seen at a federally qualified health center located in an urban area. More than 500 patients were randomly assigned to 1 of 2 treatment strategies:

An NP/CHW team that implemented treat-to-target, guideline-based management algorithms combined with a strong focus on therapeutic lifestyle changes; or
Enhanced usual care , defined as usual care by the patient's primary care provider along with provision of patient educational materials and professional literature (including copies of applicable guidelines) to the providers.

Baseline data were collected from both groups and patients were then followed for a year. Primary outcomes were blood pressure, lipid levels, and hemoglobin A1c levels. Patients' perception of the quality of their care was measured by a standardized tool that included subscales to assess perception of the delivery system, patient ability to set goals and solve problems, and a measure of follow-up care and coordination. Secondary outcomes were dietary intake and physical activity.

The care provided by the NP/CHW teams was extensive and individualized, with a focus on problem-solving for anticipated barriers to treatment adherence, assisting patients in developing strategies to enhance adherence, increased attention to patients not meeting treatment goals, emphasis on smoking cessation, use of a low-literacy wellness guide, dietary counseling, and instruction in a home-based exercise program. Participating NPs and CHWs received additional training in motivational interviewing and behavior change techniques.

Results. Participants were predominantly women (71%) and black (79%). More than half had incomes of less than $20,000 per year, and less than half had private health insurance. Most of the intervention group (70%) completed at least 4 in-person visits during the 12-month study period. At 1 year, patients in the intervention group had achieved statistically significant reductions in total cholesterol, low-density lipoprotein, triglycerides, systolic and diastolic blood pressure, and A1c. These changes occurred despite the fact that there were no significant differences between the 2 groups in level of physical activity, changes in body mass index, or dietary intake of fat, sodium, or total calories. However, patients in the intervention group perceived their chronic-illness care to be significantly improved compared with the group receiving enhanced usual care. This positive perception of their care was true across all subscales.

Viewpoint

A growing body of research demonstrates that NPs can effectively manage the large population of patients with chronic disease; however, this was the first study to assess the effectiveness of an NP/CHW team. The fact that this impressive improvement in a variety of outcomes occurred in a highly vulnerable patient population with previously uncontrolled cardiovascular disease risk factors makes the outcome that much more impressive. However, before this model can be widely embraced, a number of barriers must be overcome, most notably in the area of reimbursement. Currently, no mechanisms exist for reimbursement of care provided by CHWs. The extensive training provided to both the NPs and CHWs also presents a financial barrier. Finally, the time required to implement these strategies, although not explicitly discussed in this paper, was likely greater than the amount of time that patients with enhanced usual care spent with providers. The researchers promise further analyses examining the long-term cost effectiveness of this approach. Those data will be essential in truly evaluating the viability of this model.

Abstract

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