Although statins, aspirin, and beta blocker therapy together markedly reduce recurrent coronary artery disease (CAD) events and cardiovascular death and are the mainstay of nationally recommended CAD secondary prevention, these agents remain seriously underutilized in underserved populations. Post-hospitalization CAD case fatality rates are significantly higher in patients from underserved backgrounds, attributed in part to failure to be able to afford, access, and adhere to preventive pharmacotherapy. Complex systems that assure payment for medications are known to be difficult to navigate, particularly for underserved populations. Patient navigators (PN) have been shown to improve access to care and improve outcomes in cancer care in underserved populations. Preliminary data from our randomized Pilot Study of PN in 46 underserved CAD patients show improved medication access and risk factor outcomes in the group randomized to the PN compared with enhanced usual care. We thus propose a larger randomized controlled trial of PN versus EUC in 360 (51% Black American, 26% female) low income or low educational level CAD patients discharged from the hospital without any medication insurance coverage. In the EUC """"""""control"""""""" group, providers are given information about how to access resources whereas in the PN group, the PN interacts with patients regularly using guided interviews.
The specific aims are to compare the impact of the PN vs EUC at 6 and 12 months post CAD discharge on (1) the percent of patients who seek primary care follow-up, (2) adhere to beta-blocker, aspirin, and statin therapy, (3) reduce risk factors (LDL-cholesterol, diastolic and systolic blood pressure, inflammatory cytokines, platelet activation) and (4) demonstrate improved vascular health using brachial artery reactivity flow-mediated dilatation. The analyses will be carried out using GLM and/or GEE techniques. All multivariable analyses will be conducted adjusting for sex, nature of the CAD, age, social support variables, behaviors, education and socioeconomic status, in addition to the intervention contingency. This study offers a significant contribution toward the design of innovative ways to address disparities that persist in CAD outcomes in underserved populations. This application proposes a randomized controlled trial in low income or low educational level coronary disease patients discharged from the hospital without any medication insurance coverage with endpoints focused on (1) improvement in the percent of underserved patients who seek early primary care follow-up, (2) adherence to beta- blocker, aspirin, and statin therapy, (3) reduction in risk factors and (4) improvement in brachial artery reactivity flow-mediated dilatation as a proxy for improved vascular health.
|Nyquist, Paul A; Bilgel, Murat; Gottesman, Rebecca et al. (2015) Age differences in periventricular and deep white matter lesions. Neurobiol Aging 36:1653-1658|