Elsevier

American Heart Journal

Volume 161, Issue 2, February 2011, Pages 351-359
American Heart Journal

Clinical Investigation
Prevention and Rehabilitation
Reducing cardiovascular disease risk in medically underserved urban and rural communities

https://doi.org/10.1016/j.ahj.2010.11.008Get rights and content

Objectives

The aim of this study is to evaluate methods for lowering cardiovascular disease (CVD) risk in asymptomatic urban and rural underserved subjects.

Background

Medically underserved populations are at increased CVD risk, and systems to lower CVD risk are needed. Nurse management (NM) and telemedicine (T) systems may provide low-cost solutions for this care.

Methods

We randomized 465 subjects without overt CVD, with Framingham CVD risk >10% to NM with 4 visits over 1 year, or NM plus T to facilitate weight, blood pressure (BP), and physical activity reporting. The study goal was to reduce CVD risk by 5%.

Results

Three hundred eighty-eight subjects completed the study. Cardiovascular disease risk fell by ≥5% in 32% of the NM group and 26% of the T group (P, nonsignificant). In hyperlipidemic subjects, total cholesterol decreased (NM −21.9 ± 39.4, T −22.7 ± 41.3 mg/dL) significantly. In subjects with grade II hypertension (systolic BP ≥160 mm Hg, 24% of subjects), both NM and T groups had a similar BP response (average study BP: NM 147.4 ± 17.5, T 145.3. ± 18.4, P is nonsignificant), and for those with grade I hypertension (37% of subjects), T had a lower average study BP compared to NM (NM 140.4 ± 16.9, T 134.6 ± 15.0, P = .058). In subjects at high risk (Framingham score ≥20%), risk fell 6.0% ± 9.9%; in subjects at intermediate risk (Framingham score ≥10, <20), risk fell 1.3% ± 4.5% (P < .001 compared to high-risk subjects). Medication adherence was similar in both high- and intermediate-risk subjects.

Conclusions

In 2 underserved populations, CVD risk was reduced by a nurse intervention; T did not add to the risk improvement. Reductions in BP and blood lipids occurred in both high- and intermediate-risk subjects with greatest reductions noted in the high-risk subjects. Frequent communication using a nurse intervention contributes to improved CVD risk in asymptomatic, underserved subjects with increased CVD risk. Telemedicine did not change the effectiveness of the nurse intervention.

Section snippets

Methods

The study was conducted at Temple University Medical Center, which serves an inner city, predominantly African-American population, and at Geisinger Medical Center, which serves a rural, predominantly white population. Both institutions provide health care in areas designated as medically underserved.11 The study was funded by a Pennsylvania State Department of Health grant number RFA-ME02-380. The study was approved by the Institutional Review Boards at Temple University Medical School, the

Results

Table I shows the baseline characteristics of the 388 subjects (83.4%) who completed the study. Notable differences in the study populations include a dominance of African-American subjects in the urban group, a higher incidence of diabetes, and a higher incidence of smoking in the urban group, whereas hypertension was more prevalent in the rural subjects. One fourth of the rural subjects had a high risk score (≥20%), whereas nearly one third of the urban subjects were at high risk (P = .068).

Discussion

There are ample data that demonstrate significant differences in health status and health care outcome in low-income underserved populations.2, 3, 4, 5, 6 To reduce the incidence of CVD, it is necessary to engage subjects in healthy lifestyle behaviors and to manage treatable CVD risk. Nurse management alone proved to be successful in reducing overall CVD risk. The improved CVD risk occurred primarily by reductions in serum cholesterol and BP. Communication in both groups between subjects, the

Conclusions

In rural and urban medically underserved populations, NM was successful in reducing overall CVD risk. Study subjects who were classified initially as high risk had the greatest response and visited their care provider more often. Medication adherence was similar in subjects who started the study with high risk compared to intermediate risk. Modifying CVD risk in urban communities must focus on diabetes and cigarette smoking in addition to hypertension and hyperlipidemia.

Disclosures

Alfred A. Bove, M.D., Ph.D. is a Consultant for InSight Telehealth Inc. William P. Santamore, Ph.D. owns stocks in InSight Telehealth Inc.

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    Clinical Trial no: NCT00778804.

    This study was supported by Pa State Grant no. RFA-ME02-380, a grant from the Commonwealth of Pennsylvania. The Pennsylvania Department of Health specifically disclaims responsibility for any analyses, interpretations, or conclusions. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.

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