Background-Black subjects with a family history of premature coronary heart disease (CHD) have a marked excess risk, yet barriers prevent effective risk reduction. We tested a community-based multiple risk factor intervention (community-based care [CBC]) and compared it with "enhanced" primary care (EPC) to reduce CHD risk in high-risk black families. Methods and Results-Black 30-to 59-year-old siblings of a proband with CHD aged Ͻ60 years were randomized for care of BP Ն140/90 mm Hg, LDL cholesterol Ն3.37 mmol/L, or current smoking to EPC (nϭ168) or CBC (nϭ196) and monitored for 1 year. EPC and CBC were designed to eliminate barriers to care. The CBC group received care by a nurse practitioner and a community health worker in a community setting. The CBC group was 2 times more likely to achieve goal levels of LDL cholesterol and blood pressure compared with the EPC group (95% CI, 1.11 to 4.20 and 1.39 to 3.88, respectively) with adjustment for baseline levels of age, sex, education, and baseline use of medications. The CBC group demonstrated a significant reduction in global CHD risk, whereas no reduction was seen in the EPC group (PϽ0.0001). Conclusions-Eliminating

Structured episodes of direct observation and coaching in the outpatient setting, with a behavior checklist, appear acceptable and useful for internal medicine residents' learning and development.

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