title: Case management to reduce risk of cardiovascular disease in a county health care system.
abstract: BACKGROUND
  Case management (CM) is a systematic approach to supplement physician-centered efforts to prevent cardiovascular disease (CVD). Research is limited on its implementation and efficacy in low-income, ethnic minority populations.
  
  
  METHODS
  We conducted a randomized clinical trial to evaluate a nurse- and dietitian-led CM program for reducing major CVD risk factors in low-income, primarily ethnic minority patients in a county health care system, 63.0% of whom had type 2 diabetes mellitus. The primary outcome was the Framingham risk score (FRS).
  
  
  RESULTS
  A total of 419 patients at elevated risk of CVD events were randomized and followed up for a mean of 16 months (81.4% retention). The mean FRS was significantly lower for the CM vs usual care group at follow-up (7.80 [95% confidence interval, 7.21-8.38] vs 8.93 [8.36-9.49]; P = .001) after adjusting for baseline FRS. This is equivalent to 5 fewer heart disease events per 1000 individuals per year attributable to the intervention or to 200 individuals receiving the intervention to prevent 1 event per year. The pattern of group differences in the FRS was similar in subgroups defined a priori by sex and ethnicity. The main driver of these differences was lowering the mean (SD) systolic (-4.2 [18.5] vs 2.6 [22.7] mm Hg; P = .003) and diastolic (-6.0 [11.6] vs -3.0 [11.7] mm Hg; P = .02) blood pressures for the CM vs usual care group.
  
  
  CONCLUSIONS
  Nurse and dietitian CM targeting multifactor risk reduction can lead to modest improvements in CVD risk factors among high-risk patients in low-income, ethnic minority populations receiving care in county health clinics.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00128687.
authors.affiliation: Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA.
authors.forename: Jun
authors.initials: J
authors.lastname: Ma
authors.forename: Kathy
authors.initials: K
authors.lastname: Berra
authors.forename: William L
authors.initials: WL
authors.lastname: Haskell
authors.forename: Linda
authors.initials: L
authors.lastname: Klieman
authors.forename: Shauna
authors.initials: S
authors.lastname: Hyde
authors.forename: Mark W
authors.initials: MW
authors.lastname: Smith
authors.forename: Lan
authors.initials: L
authors.lastname: Xiao
authors.forename: Randall S
authors.initials: RS
authors.lastname: Stafford
mesh_terms: D000328:Adult; D000368:Aged; D001835:Body Weight; D002140:California; D002318:Cardiovascular Diseases / Q000208:ethnology / Q000209:etiology / Q000517:prevention & control*; D019090:Case Management; D003376:Counseling; D004032:Diet; D005260:Female; D015438:Health Behavior; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D008913:Minority Groups; D024802:Nurse's Role; D011314:Preventive Health Services / Q000379:methods / Q000458:organization & administration*; D018570:Risk Assessment; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012737:Sex Factors