标题：Case Management to Reduce Cardiovascular Disease Risk in American Indians and Alaska Natives With Diabetes: Results From the Special Diabetes Program for Indians Healthy Heart Demonstration Project
摘要：Objectives. We evaluated cardiovascular disease (CVD) risk factors in American Indians/Alaska Natives (AI/ANs) with diabetes in the Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project. Methods. Multidisciplinary teams implemented an intensive case management intervention among 30 health care programs serving 138 tribes. The project recruited 3373 participants, with and without current CVD, between 2006 and 2009. We examined data collected at baseline and 1 year later to determine whether improvements occurred in CVD risk factors and in Framingham coronary heart disease (CHD) risk scores, aspirin use, and smoking status. Results. A1c levels decreased an average of 0.2% ( P < .001). Systolic and diastolic blood pressure, low-density lipoprotein (LDL) cholesterol, and triglyceride levels decreased, with the largest significant reduction in LDL cholesterol (∆ = −5.29 mg/dL; P < .001). Average Framingham CHD risk scores also decreased significantly. Aspirin therapy increased significantly, and smoking decreased. Participants with more case management visits had significantly greater reductions in LDL cholesterol and A1c values. Conclusions. SDPI-HH successfully translated an intensive case management intervention. Creative retention strategies and an improved understanding of organizational challenges are needed for future Indian health translational efforts. Cardiovascular disease (CVD), a leading cause of death among American Indian and Alaska Native (AI/AN) adults, 1,2 is more common among this population than in the United States generally. 1–6 This excessive burden of CVD appears to be attributable to a high prevalence of diabetes, reportedly twice as high as among non-Hispanic Whites and significantly higher than among Asian Americans, Hispanics, and non-Hispanic Blacks. 7–9 People with diabetes have 2 to 4 times the risk of heart disease as people without diabetes. 1,3 CVD risk reduction, therefore, is critical to reducing morbidity and mortality and improving health and quality of life in AI/ANs, especially among those with diabetes. In 1986, the Indian Health Service (IHS) Division of Diabetes developed its first IHS Standards of Care for Diabetes. For more than 20 years, these guidelines have helped health care professionals provide excellent diabetes care to AI/ANs. Indeed, rates of adherence to nationally recommended guidelines for AI/AN health programs frequently equal or surpass rates described for the general population. 10,11 Yet the continued growth of the diabetes and CVD epidemic among AI/ANs and the rise of other complex chronic conditions in this population render sustained improvements in diabetes management an unrelenting challenge. Case management is an important approach to enhancing traditional health care delivery for people at elevated risk of adverse outcomes and high utilization of health care resources, such as individuals with diabetes. 12,13 The efficacy of case management has been demonstrated, particularly in improving glycemic control among individuals with diabetes 14,15 and in preventing subsequent cardiac events among those with existing CVD. 16,17 A case manager—typically a nurse, dietitian, or pharmacist—is assigned responsibility for oversight and coordination of care across a spectrum of clinic and community services. Required features of case management are identification of a target population, comprehensive assessment of individual patient needs, development of an individual participant care plan, implementation of the care plan, and monitoring of outcomes. 12 Case management has been shown to improve CVD risk factor control, although most studies have concentrated on the control of a single risk factor, such as blood glucose or blood pressure, 18,19 and many have been conducted in academic health centers rather than community settings. 20 However, the risk of CVD events in individuals with diabetes can be reduced by as much as 50% through intensive control of multiple risk factors, for example, by reducing blood pressure and cholesterol levels and using aspirin. 21–26 Glycemic control, smoking cessation, physical activity, and weight management also have been shown to reduce CVD risk. 27 We evaluated the effect on multiple CVD disease risk factors among AI/ANs with diabetes who participated in a large-scale, multidisciplinary, intensive case management intervention, the Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project.
