The American Heart Hospital Journal
continues to be a significant cause of morbidity and mortality in the US, recent data have demonstrated a significant reduction in CVD mortality, in part related to more aggressive management of modifiable CVD risk factors.12
Original Contribution
Figure 2: Hospital Admissions Comparing a Usual Care Heart Failure Group with a Group Using Telemedicine
While mortality from CVD is diminishing, several populations have not shared in this reduction. In particular, ethnic minorities and medically under-served populations are at increased CVD risk due to a high prevalence of obesity with accompanying glucose intolerance, hyperlipidemia, and hypertension;13
also, in
under-served populations, lack of risk assessment and subsequent intervention allows these conditions to persist until an actual cardiovascular event occurs (heart attack, new angina, sudden death, or stroke).
Management of the pre-symptomatic phase of these disorders is best achieved using a patient-centered approach that incorporates patient participation, improved health literacy, and monitoring of patient status through frequent communication between patient and healthcare provider.
In a study of asymptomatic subjects with high CVD risk, we compared a nurse-managed CVD risk reduction program with a nurse management system augmented with Telemedicine communication. The Telemedicine system allowed subjects living in urban and rural medically under- served communities to report their weight, blood pressure, and physical activity and to receive frequent feedback regarding CVD risk management. We focused on blood lipid and blood pressure management as these involve both practice and patient participation to achieve treatment goals.
We studied 465 patients with a 10% or greater 10-year Framingham risk for CVD14
who were randomized to nurse
management or nurse management plus Telemedicine communication. The patients were provided with resources for measuring blood pressure, weight, and daily activity at home and were followed for one year, with the primary end-point being a 5% reduction in their 10-year CVD risk.
Nurse Management. Nurse management involved office encounters with our research nurses at four-month intervals for one year. All subjects were provided with a digital sphygmomanometer, a scale if needed, and a pedometer to count their steps per day. Subjects were instructed to record their data (weight, blood pressure, steps/day, and cigarettes/day) at least weekly and enter the data in a logbook, which was reviewed quarterly during a clinic visit with a research nurse. Subjects received education and counseling regarding healthy lifestyle behaviors (blood pressure goals, weight loss, diet, smoking cessation, physical activity) at baseline and at each clinical encounter.
Summer 2010
10 20 30 40 50
0 Usual care Telemedicine
p=0.045
Table 1: Framingham Risk Score in Patients with Increased Cardiovascular Disease Risk Who Achieved the Goal of ≥5% Reduction in Score Compared with Those Who Did Not at One Year
NURSE-MANAGED Baseline
Goal reached TELEMEDICINE Final Baseline Final 23.5±10.7 13.2±8.1 23.8±13.3 13.9±9.5 Goal not reached 15.2±7.7 16.0±9.7 15.3±8.1 15.4±9.3
Both nurse management and Telemedicine resulted in significant reductions in risk.
Telemedicine. Subjects in the Telemedicine group were provided with the nurse management program described above. In addition, each subject was provided with a login name and password to gain access to the secure Internet- based Telemedicine system and received instructions on how to access and use the Telemedicine system. Laboratory data and medications were entered into the Telemedicine system by a research nurse, and were accessible to the subject via the Internet. To increase computer access for subjects in the Telemedicine group, we identified community centers and libraries where Internet access was available.
Both nurse management and Telemedicine communication proved to be successful in reducing overall CVD risk. Communication between subjects and the research nurses in both groups provided the needed support to improve CVD risk. The subjects were provided with their individual lipid and blood pressure data and encouraged to discuss their CVD status with their physicians.
Because we expected a proportion of the subjects to reach goal in the two groups, we separated the total cohort into those who reached the goal of ≥5% reduction in Framingham score and those who did not. One hundred and twelve subjects (28.6%) achieved an improvement of
Using Modern Communications to Manage Chronic Heart Disease 27
Hospital admissions
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