Community Outreach and Cardiovascular Health (COACH) Trial

Abstract

Background Despite well-publicized guidelines on the appropriate management of cardiovascular disease (CVD) and type 2 diabetes, the implementation of risk-reducing practices remains poor. This paper describes the results of a randomized controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner/community health worker (NP/CHW) teams versus enhanced usual care (EUC) to improve lipids, blood pressure, glycated hemoglobin (HbA1c), and patients’ perceptions of the quality of their chronic illness care in patients in urban community health centers. Methods and Results A total of 525 patients with documented cardiovascular disease, type 2 diabetes, hypercholesterolemia, or hypertension and levels of LDL-cholesterol, blood pressure or HbA1c that exceeded goals established by national guidelines were randomized to NP/CHW (n=261) or EUC (n=264) groups. The NP/CHW intervention included aggressive pharmacologic management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control. As compared to EUC, patients in the NP/CHW group had significantly greater 12 month improvement in total cholesterol (difference, 19.7mg/dL), LDL cholesterol (difference,15.9 mg/dL), triglycerides (difference, 16.3 mg/dL), systolic blood pressure (difference, 6.2 mm Hg), diastolic blood pressure (difference, 3.1 mm Hg), HbA1c (difference, 0.5%), and perceptions of the quality of their chronic illness care (difference, 1.2 points). Conclusions An intervention delivered by a NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illnes care in high risk patients.

Community Health Worker Interventions to Improve Glycemic Control in People with Diabetes: A Systematic Review and Meta-Analysis

“…We identified 13 completed randomized clinical trials. [8][9][10][11][12][13][14][19][20][21][22][23][24] Table 1 describes the basic characteristics of those thirteen trials, including the setting for participant recruitment, duration of the study, and ethnicity of the study populations. Most of them studied minority populations, either AfricanAmerican, 13 Hispanics, 9,10,12,14,19,21,23,24 or both.…”

“…8 Allen et al recruited some White participants (21 % of their study sample), but the majority of their participants were AfricanAmerican. 11 DePue et al recruited American Samoans. 20 The components of the control arm varied substantially across studies.…”

“…19 The study by Babamoto et al had two control arms: in one control arm, the participants were managed by a diabetes nurse, and in the other control arm, participants continued to receive usual care from their primary care providers. 14 In three of the longer studies, the usual care provided by primary care providers was Benhanced^by either feedback to participants and PCP, 11 or regular telephone and mail contact with participants, with 13 or without 21 feedback to the PCP. In the two-year-long MATCH study, participants in the control arm were mailed 36 monthly issues of a diabetes education newsletter.…”

“…24 The components of the CHW intervention also differed substantially from study to study. In eight of the studies, the CHWs worked on their own, whereas in the remaining cases, the CHW worked with either a certified diabetes educator, 19 a nurse and a dietician, 10 a nurse practitioner, 11 or a nurse case manager. 13,20 As described in Table 2, in all the studies, CHWs worked for a local non-profit organization.…”

“…Randomized controlled trials have had conflicting results. Some trials showed a significant reduction in A1c, [8][9][10][11][12] while other trials did not. 13,14 Of note, there was methodological variability across studies, including sample size, target population, intervention protocols, and length of follow-up.…”