title: Individualized Risk Communication and Outreach for Primary Cardiovascular Disease Prevention in Community Health Centers: Randomized Trial.
abstract: BACKGROUND
  Many eligible primary cardiovascular disease prevention candidates are not treated with statins. Electronic health record data can identify patients with increased cardiovascular disease risk.
  
  
  RESULTS
  We performed a pragmatic randomized controlled trial at community health centers in 2 states. Participants were men aged ≥35 years and women ≥45 years, without cardiovascular disease or diabetes mellitus, and with a 10-year risk of coronary heart disease of at least 10%. The intervention group received telephone and mailed outreach, individualized based on patients' cardiovascular disease risk and uncontrolled risk factors, provided by lay health workers. Main outcomes included: documented discussion of medication treatment for cholesterol with a primary care clinician, receipt of statin prescription within 6 months, and low-density lipoprotein (LDL)-cholesterol repeated and at least 30 mg/dL lower than baseline within 1 year. Six hundred forty-six participants (328 and 318 in the intervention and control groups, respectively) were included. At 6 months, 26.8% of intervention and 11.6% of control patients had discussed cholesterol treatment with a primary care clinician (odds ratio, 2.79; [95% confidence interval, 2.25-3.46]). Statin prescribing occurred for 10.1% in the intervention group and 6.0% in the control group (odds ratio, 1.76; [95% confidence interval, 0.90-3.45]). The cholesterol outcome did not differ, and the majority of patients did not repeat lipid levels during follow-up.
  
  
  CONCLUSIONS
  Risk communication and lay outreach increased cholesterol treatment discussions with primary care clinicians. However, most discussions did not result in statin prescribing. For outreach to be successful, it should be combined with interventions to encourage clinicians to follow contemporary risk-based cholesterol treatment guidelines.
  
  
  BACKGROUND
  URL: http://www.clincialtrials.gov. Unique identifier: NCT01610609.
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.). spersell@nm.org.
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Persell
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Tiffany
authors.initials: T
authors.lastname: Brown
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Ji Young
authors.initials: JY
authors.lastname: Lee
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Shreya
authors.initials: S
authors.lastname: Shah
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Eric
authors.initials: E
authors.lastname: Henley
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Timothy
authors.initials: T
authors.lastname: Long
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Stephanie
authors.initials: S
authors.lastname: Luther
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Donald M
authors.initials: DM
authors.lastname: Lloyd-Jones
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Muriel
authors.initials: M
authors.lastname: Jean-Jacques
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Namratha R
authors.initials: NR
authors.lastname: Kandula
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: Thomas
authors.initials: T
authors.lastname: Sanchez
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, Department of Medicine (S.D.P., T.B., J.Y.L., S.S., M.J.-J., N.R.K., D.W.B.), Center for Primary Care Innovation, Institute for Public Health and Medicine (S.D.P., N.R.K., D.W.B.), Division of Cardiology (D.M.L.-J.), and Department of Preventive Medicine (D.M.L.-J., N.R.K.), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Medicine, Stanford University, Stanford, CA (S.S.); North Country Healthcare, Flagstaff, AZ (E.H.); Near North Health Service Corporation, Chicago, IL (T.L., T.S.); Alliance of Chicago Community Health Services, Chicago, IL (T.L., T.S.); and Heartland Health Outreach, Chicago, IL (S.L.).
authors.forename: David W
authors.initials: DW
authors.lastname: Baker
mesh_terms: D000328:Adult; D000368:Aged; D001130:Arizona; D015415:Biomarkers / Q000097:blood; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D008078:Cholesterol, LDL / Q000097:blood; D003142:Communication; D003151:Community Health Centers / Q000592:standards; D003153:Community Health Services / Q000592:standards; D003159:Community-Institutional Relations / Q000592:standards; D050171:Dyslipidemias / Q000097:blood / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D007087:Illinois; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010353:Patient Education as Topic; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011322:Primary Prevention / Q000379:methods* / Q000592:standards; D018570:Risk Assessment; D012307:Risk Factors; D016037:Single-Blind Method; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D008078:Cholesterol, LDL; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors
keywords: cardiovascular diseases; case management; cholesterol; randomized controlled trial; risk assessment