1. Community Outreach to Reduce Disparities in Cardiovascular & Diabetes Morbidity & Mortality in the South Bronx Michael Alderman, MD Michelle Johnson, MD, MPH A.H. Strelnick, MD Montefiore Medical Center Albert Einstein College of Medicine

2. Overall Goal To reduce the excess burden of heart disease, stroke, and diabetes in minority populations

3. Overall Aim To demonstrate that medical care and clinical outcomes can be improved at a reasonable cost for Black and Latino patients with the highest risk for cardiovascular disease

4. Specific Aim To determine whether community outreach through community health workers (CHWs) supporting peer educators will improve medical care and reduce cardiovascular risk and adverse outcomes among inner-city minority patients

5. Hypotheses Adherence, follow-up, and risk reduction will be higher and clinical indicators and adverse outcomes lower among Black and Latino adults at very high risk for cardiovascular disease when community outreach supplements primary care

6. Hypotheses Peer educators will be a cost-effective, culturally-appropriate model of community outreach Peer educators will demonstrate a dose- response effect in the extent of their contacts with individual patients

7. Research Strategy Pilot the measurement of the efficacy and cost-effectiveness of peer educators supported by CHWs in reducing excess morbidity and mortality suffered by people of color in the South Bronx from diabetes and cardiovascular diseases Develop efficient strategies for identifying the highest risk quartile of patients as a research cohort

8. Research Strategy Conduct statistical meta-analysis on the quantitative impact of peer education achievable through multiple risk factor reduction intervention in very high risk groups Conduct a 5 year, randomized clinical trial in the South Bronx

9. Background & Significance South Bronx suffers from poverty & racism –16th Congressional district is nation’s poorest –3 of 4 of NYC’s poorest neighborhoods –3 of 4 of NYC’s most segregated neighborhoods 3 highest neighborhood rates of hospital admissions for heart disease

10. Causes of Excess Mortality CVD is greatest single cause of excess deaths for females & major factor for males in South Bronx Stroke & hypertensive heart disease rather than coronary artery disease accounts for excess deaths

11. Excess Mortality Mortality rates from diabetes for Black males and females is three times that of whites Diabetes accounts for 1.5% of all excess mortality among Black males Diabetes accounts for 5.1% of all excess mortality among Black females Bronx mortality rate from diabetes doubled from 1990 to 1995, highest in NYS

12. Excess Hospitalizations South Bronx hospitalization rates are average for : –arrhythmias (palpitations) –myocardial infarctions (heart attacks) South Bronx hospitalization rates are twice that of NYC and NYS for: –congestive heart failure & shock –hypertension –angina pectoris (chest pain) –atherosclerosis

13. Improvement from Treatment Treatment effect in hypertensive patients –94% less likely to progress from mild to moderate to severe hypertension –52% less likely to develop CHF –38% less likely to suffer a stroke (CVA) –35% less likely to develop LVH –21% less likely to die from heart disease –16% less likely to have a heart attack

14. Improvement from Treatment in Elderly Reduction in disease progress among elderly treated for systolic hypertension –54% less likely to develop CHF –37% less likely to suffer stroke (CVA) –37% less likely to have coronary bypass surgery –30% less likely to have heart attack (MI) –25% less likely to have TIA –14% less likely to coronary angioplasty

15. Treatment of High Cholesterol For each 1% of reduction in serum cholesterol yields approximately a 2% reduction in cardiovascular disease rates (for patients who have cholesterol = 250- 300 mg/dl)

16. Research Design & Methods Identify patients with the 20-25% highest risk for cardiovascular disease over age 45 Patients must have two or more of the following: –hypertension –hyperlipidemia –smoking –diabetes –chronic cardiac arrhythmias –history of heart disease or diabetes

17. Power Analysis Assumptions –Treatment effect of 30% reduction of CVD events –5% annual CVD event rate –95% confidence intervals –80% power Sample size needed (N=647) in each arm Recruit 1620 subjects (810 in each arm) –assumes 5% annual attrition rate

18. Clinical Endpoints to be Measured All deaths (by cause) All hospitalizations (by cause) All cardiac procedures –catheterizations –angioplasties –coronary artery by-pass graft surgery (CABG)

19. Measurement Instruments Annual patient questionnaires –health care utilization –adherence –patient education –peer educator contacts Annual physician questionnaires Medical & hospital chart reviews Peer educator diaries & contact data Costs