Becker Diane M, Yanek Lisa R, Johnson Wallace R, Garrett Diane, Moy Taryn F, Reynolds Stasia Stott, Blumenthal Roger S, Vaidya Dhananjay, Becker Lewis C
Division of General Internal Medicine, Johns Hopkins Medical Institutions, 1830 E Monument St, Room 8028, Baltimore, MD 21287, USA.
Circulation. 2005 Mar 15;111(10):1298-304. doi: 10.1161/01.CIR.0000157734.97351.B2.
Black subjects with a family history of premature coronary heart disease (CHD) have a marked excess risk, yet barriers prevent effective risk reduction. We tested a community-based multiple risk factor intervention (community-based care [CBC]) and compared it with "enhanced" primary care (EPC) to reduce CHD risk in high-risk black families.
Black 30- to 59-year-old siblings of a proband with CHD aged <60 years were randomized for care of BP > or =140/90 mm Hg, LDL cholesterol > or =3.37 mmol/L, or current smoking to EPC (n=168) or CBC (n=196) and monitored for 1 year. EPC and CBC were designed to eliminate barriers to care. The CBC group received care by a nurse practitioner and a community health worker in a community setting. The CBC group was 2 times more likely to achieve goal levels of LDL cholesterol and blood pressure compared with the EPC group (95% CI, 1.11 to 4.20 and 1.39 to 3.88, respectively) with adjustment for baseline levels of age, sex, education, and baseline use of medications. The CBC group demonstrated a significant reduction in global CHD risk, whereas no reduction was seen in the EPC group (P<0.0001).
Eliminating known barriers may not be sufficient to reduce CHD risk in primary care settings. An alternative community care model that addresses barriers may be a more effective way to ameliorate CHD risk in high-risk black families.
有早发性冠心病（CHD）家族史的黑人受试者存在显著的额外风险，但存在障碍阻碍有效降低风险。我们测试了一种基于社区的多危险因素干预措施（社区护理 [CBC]），并将其与“强化”初级护理（EPC）进行比较，以降低高危黑人家庭的冠心病风险。
将年龄在30至59岁之间、先证者患有年龄小于60岁的冠心病的黑人兄弟姐妹随机分为EPC组（n = 168）或CBC组（n = 196），对血压≥140/90 mmHg、低密度脂蛋白胆固醇≥3.37 mmol/L或当前吸烟的情况进行护理，并监测1年。EPC和CBC旨在消除护理障碍。CBC组由一名执业护士和一名社区卫生工作者在社区环境中提供护理。在对年龄、性别、教育程度和药物基线使用情况进行基线水平调整后，CBC组实现低密度脂蛋白胆固醇和血压目标水平的可能性是EPC组的2倍（95% CI分别为1.11至4.20和1.39至3.88）。CBC组的总体冠心病风险显著降低，而EPC组未见降低（P<0.0001）。
消除已知障碍可能不足以降低初级护理环境中的冠心病风险。一种解决障碍的替代性社区护理模式可能是降低高危黑人家庭冠心病风险的更有效方法。
