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

作者：Keyserling Thomas C^*; Sheridan Stacey L; Draeger Lindy B; Finkelstein Eric A; Gizlice Ziya; Kruger Eliza; Johnston Larry F; Sloane Philip D; Samuel Hodge Carmen; Evenson Kelly R; Gross Myron D; Donahue Katrina E; Pignone Michael P; Vu Maihan B; Steinbacher Erika A; Weiner Bryan J; Bangdiwala Shrikant I; Ammerman Alice S

来源：JAMA Internal Medicine, 2014, 174(7): 1144-1157.

DOI：10.1001/jamainternmed.2014.1984

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.

• 出版日期2014-7