A Comparison of Live Counseling With a Web-Based Lifestyle and Medication Intervention to Reduce Coronary Heart Disease Risk: A Randomized Clinical Trial

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Abstract

IMPORTANCE

Most primary care clinicians lack the skills and resources to offer effective lifestyle and medication (L&M) counseling to reduce coronary heart disease (CHD) risk. Thus, effective and feasible CHD prevention programs are needed for typical practice settings.

OBJECTIVE

To assess the effectiveness, acceptability, and cost-effectiveness of a combined L&M intervention to reduce CHD risk offered in counselor-delivered and web-based formats.

DESIGN, SETTING, AND PARTICIPANTS

A comparative effectiveness trial in 5 diverse family medicine practices in North Carolina. Participants were established patients, aged 35 to 79 years, with no known cardiovascular disease, and at moderate to high risk for CHD (10-year Framingham Risk Score [FRS], ≥10%).

INTERVENTIONS

Participants were randomized to counselor-delivered or web-based format, each including 4 intensive and 3 maintenance sessions. After randomization, both formats used a web-based decision aid showing potential CHD risk reduction associated with L&M risk-reducing strategies. Participants chose the risk-reducing strategies they wished to follow.

MAIN OUTCOMES AND MEASURES

The primary outcome was within-group change in FRS at 4-month follow-up. Other measures included standardized assessments of blood pressure, blood lipid levels, lifestyle behaviors, and medication adherence. Acceptability and cost-effectiveness were also assessed. Outcomes were assessed at 4 and 12 months.

RESULTS

Of 2274 screened patients, 385 were randomized (192 counselor; 193 web): mean age, 62 years; 24% African American; and mean FRS, 16.9%. Follow-up at 4 and 12 months included 91% and 87% of the randomized participants, respectively. There was a sustained reduction in FRS at both 4 months (primary outcome) and 12 months for both counselor-based (−2.3% [95% CI, −3.0% to −1.6%] and −1.9% [95% CI, −2.8% to −1.1%], respectively) and web-based groups (−1.5% [95% CI, −2.2% to −0.9%] and −1.7% [95% CI, −2.6% to −0.8%] respectively). At 4 months, the adjusted difference in FRS between groups was −1.0% (95% CI, −1.8% to −0.1%) (P = .03), and at 12 months, it was −0.6% (95% CI, −1.7% to 0.5%) (P = .30). The 12-month costs from the payer perspective were $207 and $110 per person for the counselor- and web-based interventions, respectively.

CONCLUSIONS AND RELEVANCE

Both intervention formats reduced CHD risk through 12-month follow-up. The web format was less expensive.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01245686

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