eCare for Heart Wellness A Trial to Test the Feasibility of Web Based Dietician Care to Reduce Cardiovascular Disease Risk GREEN


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Behavior Change Interventions

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eCare for Heart Wellness A Trial to Test the Feasibility of Web Based Dietician Care to Reduce Cardiovascular Disease Risk GREEN

  1. 1. e-Care for Heart Wellness • Funded by the National Heart, Lung, and Blood Institute: American Recovery and Reinvestment Act • RC1 HL100590-01
  2. 2. Special Thanks Investigators Team Andrea Cook, PhD Aaron Scrol, MA Paul Fishman, PhD Ron Johnson Sheryl Catz, PhD Julie Reardon Jennifer McClure PhD Melissa Anderson MS Dietitians Rob Reid MD, PhD Terri Fox LD Consultants: Eileen Paul LD • Ann Vernez-Moudon Dawn Wilson LD • Kevin Patrick  Deborah Tate
  3. 3. The Electronic Communications and Home Blood Pressure Trial (e-BP)• The e-BP study was a 3 arm-randomized controlled trial that randomized patients with hypertension and uncontrolled BP and Web access to receive either.• All patients were signed up to use the myGroupHealth patient Web portal  Usual Care –were told their BP was not under control and to work with their physician  Web only – were given a home BP monitor and portal training and encourage to use these tools to work with their physician to improve their BP control  Web-pharmacist care – received this plus Web-based pharmacist collaborative care  Action plan – with 5 activities: BP monitoring plan, medication list, lifestyle activity to decrease BP or CVD risk, recommendations from the pharmacist, and the follow-up plan Pharmacist had prescriptive authority to adjust and add anti-hypertensive medications Communications occurred every 2 weeks for the first 2 months or until BP was controlled, then less frequently for 1 year.
  4. 4. Smart Phrase: eBP1stActPlanWeb communications – Action PlanHI .NAMEHere is your current action plan:1. BP monitoring:Measure your BP at least 2 times each week (with two BP measurements each time). Choose two days of the week that are easy to remember, like Saturday and Thursday or Monday and Friday and a time that is convenient, by making a regular time it will be easier to remember. Remember to: (refer to your e-BP notebook for more detailed instruction Avoid exercise, caffeine, and tobacco for at least 30 minutes before you take your measurement. Remove tight fitting clothing from your upper arm. Sit in a comfortable position with your legs and back supported. Rest quietly for at least two minutes. Wait at least two minutes between BP measurements. Place your arm on a table or desk so that your arm is at the level of your heart. I will be sending you a secure message asking you for your BP measurements.2. Medications:Your current medications are on ***If these are not correct please let me know.3. Lifestyle Changes:You decided to work on ***You might want to check out some Group Health Resources such ***4. Assessment Your average BP was 148/84. The next step would be to increase your dose of xxLet me know if you have any concern about this plan5. Follow-up Plan:Please go to a Group Health Lab to have: ***I will send you a reminder to send me more BP readings in 2 weeks..Me
  5. 5. e-BP Blood pressure control at 12 months Usual Care Home BP-Web Home BP-Web- Pharmacist All 31% 36% 56%** Systolic BP at 20% 26% 54%** baseline >160 **P < 0.001 compared to Usual Care and Home-BP Web JAMA 2008
  6. 6. e-BP - Questions remained:  Only 7% of e-BP participants had a normal BMI at baseline and over 2/3 had a BMI >30  The pharmacist action plan included a lifestyle behavior goal. Many patients chose weight loss.  The pharmacist intervention however, did not lead to significant weight change  However BP control was related to weight change for the entire study population. Patients who lost >2 kg were more likely to have controlled BP (p=.008) Could a Web-based dietitian intervention lead to improved BP control?
  7. 7. The e-Care for Heart Wellness Study We proposed to conduct a pilot to test whether aWeb-based dietitian- delivered behavioral intervention could be integrated into routine health care and would result in improved control BP, weight loss, and reduction in CVD risk.• Primary Outcomes  Change in mean systolic and diastolic BP, weight, and CVD risk• Secondary Outcomes  Patient satisfaction with the intervention, its effects on health related quality of life, and the cost of delivering the intervention
  8. 8. e-Care Patient Eligibility Patients age 30 – 70 were eligible if  They had a Framingham 10-year risk for cardiovascular disease of 10 -25% (moderate to high-moderate)  No existing cardiovascular disease or diabetes  Were secure users of MyGroupHealth  Had a BMI >26  Their last BP at an outpatient visit was > 140 mm Hg systolic or > 90 mm Hg diastolic  At the research visit they also had to have a BP of > 140 mm Hg systolic or > 90 mm Hg diastolic
  9. 9. e-Care Interventions Patients randomized to Web-dietitian collaborative care received  A home BP monitor, scale, and a pedometer  One in-person 40 minute visit with a dietitian – they reviewed Home Monitoring Schedule - BP, weight, fruit and vegetables 3 days a week– pedometer reporting was optional Heart age– their age and CVD risk (which was elevated) compared to the age this would be not elevated Dash Diet, low salt, weight loss optional Action Plan for decreasing BP and CVD risk  Web communications Schedule (weekly for 2 months, then every 2 weeks for 2 months, then monthly)
  10. 10. Monitoring Schedule Weekly Record For the week starting: Monday, _____________, 2010 Check your blood pressure and weight Eat more fruits & vegetables Choose three days in a row to check your blood pressure and weight. Try to eat 8-10 servings per day. The best time to check your blood pressure is one hour after you wake up. Please take two Even if you don’t meet this goal, every serving readings in the morning and two in the evening on each of the three days. of fruit or veggies helps.Day (circle): M T W Th F S S Day (circle): M T W Th F S S Day (circle): M T W Th F S SWeight: _____________________________lbs Weight: _____________________________lbs Weight: _____________________________lbsBlood Pressure (am): ____/_____, _____/_____ Blood Pressure (am): ____/_____, _____/_____ Blood Pressure (am): ____/_____, _____/_____Blood Pressure (pm): ____/_____, _____/_____ Blood Pressure (pm): ____/_____, _____/_____ Blood Pressure (pm): ____/_____, _____/_____Servings of Fruits and Vegetables: ___________ Servings of Fruits and Vegetables: ___________ Servings of Fruits and Vegetables: ___________(List all the fruits and vegetables you ate today) (List all the fruits and vegetables you ate today) (List all the fruits and vegetables you ate today)Breakfast:______________________________ Breakfast:______________________________ Breakfast:______________________________Lunch: _________________________________ Lunch: _________________________________ Lunch: _________________________________Dinner:_________________________________ Dinner:_________________________________ Dinner:_________________________________Snacks:_________________________________ Snacks:_________________________________ Snacks:_________________________________Note: A vegetable serving = ½ cup cooked vegetables, 1 cup leafy greens, 6oz juice A fruit serving = 1 small fruit, ¼ cup dried fruit, 1 cup diced fruit, 4oz juice
  11. 11. You are in the e-Care study because you are at moderate risk for heart disease. This means you have one or more risk factors that increase your chances of having a heart attack or stroke. Common risk factors areWeb- based Dietitian Care high blood pressure, high LDL cholesterol, and being overweight. One way to think about your risk for heart disease is to look at your heart age.* Ideally, you want your heart age to be the same or less than your real age. Your age is: What does this mean? Based on your risk factors, you have the same risk for heart attack or stroke as 62 someone who is 73 years old. Your heart age is: You can lower your heart age. When you decrease your risk factors, you lower your heart age and 76 reduce your chances of having a heart attack or stroke. To lower your heart age: ? Bring your blood pressure down to below 140 over 90 below 135 over 85 at home ? ? Bring your LDL cholesterol down to below 130 ? ? Stay at your current weight—or try to lose 10 pounds ? The e-Care study was designed to help you meet these goals. The e-Care study is asking you to do these steps each week Check your blood pressure and weight Eat more fruits & vegetables Choose three days in a row to check your Try to eat 8-10 servings per day. One blood pressure and weight. serving = ½ cup. The best time to check your blood pressure Even if you don’t meet this goal, every is one hour after you wake up. Please take serving of fruit or veggies helps. two readings in the morning and two in the Tips for increasing your servings: evening on each of the three days.  Eat at least 1 serving of fruit at every Weigh yourself once each of the three days. meal—and 2 at breakfast.  Eat 2 to 3 servings of veggies at lunch Write down your weight and blood pressure and dinner. readings on your form. (You can print extra Eat less salt copies at Try to stay away from salty foods—such Send the results to us in a weekly email. We will as packaged snacks, canned foods, and email you each Monday to remind you to send us frozen prepared foods. the results, so the best days to check are Friday, Use salt substitutes to season your food Saturday, and Sunday and at the dinner table.
  12. 12. e-CareAction Plan Used for Web CommunicationsSmart Phrase: eCareAVS1stactionplanBelow is the Action Plan we worked on together to decrease your heart disease and stroke risk.PLEASE LET ME KNOW – if anything is incorrectThere are 4 parts –1. Your monitoring plan (things you check at home)2. Your medications for blood pressure (BP) and cholesterol3. Your LONG-term targets and SHORT-term plans to achieve these.4. Follow-up plans
  13. 13. e-Care Action Plan Used for Web Communications1. MONITORING – (1) Blood Pressure - Measure your blood pressure 3 days a week (with 2 blood pressure measurements each day). Measuring your blood pressure more often is fine. Experts say to check your blood pressure within 1 hour of waking up, but it is OK if you check at other times of the day. (2) Weight – you agreed to measure your weight *** (3) Fruits and Vegetables**** (4) Other***2. MEDICATIONS – this is your list of blood pressure and cholesterol medications.{CHRONIC DISEASE BP MEDS: 20657}...actmed or .actmedn if in clinic3. (1) LONG-TERM TARGETS Blood pressure <135/85 home (<140/90 office) LDL <130 Increasing fruit and veggies 8-10 servings a day ***Losing 10 pounds (2) SHORT-TERM PLANS:4. FOLLOW-UP PLAN- I will send you an e-mail reminder in 1 week. Please go to your MyGroupHealth Inbox when youget this
  14. 14. e-Care Recruitment Flow Eligible based on automated records, sent invitation letters, and called (age 30-70, CVD risk 10 – 25%, BMI > 26, no diabetes, no cardiovascular disease) N = 965 Unable to contact = 108 (11%) Refused = 345 (36%) Ineligible = 126 (13%) Remained eligible and invited to attend a screening visit N = 386 (40%) No show = 39 (10%) Refused = 39 (10%) BP controlled = 206 (54%) Ineligible = 1 (BP monitor errors) Enrolled N = 101 (26%)
  15. 15. Baseline Characteristics Characteristics Controls Web-dietitian n = 50 n = 51 Age (mean) 57 58 Female (%) 30% 53% Race, nonwhite (%) 16% 14% Education, > college degree 66% 58% Systolic BP mm Hg (SD) 151 (11.9) 150 (11.6) Diastolic BP mm Hg (SD) 91 (9.5) 93 (8.8) BMI (SD) 33.3 (5.6) 34.5 (5.8) CVD risk, Framingham CVD 10 yr 17 (6.6) 15.6 (6.7)
  16. 16. Primary Outcomes Control Web-dietitian P-value n = 46 n=51Change from baseline: Systolic BP (mm Hg) - 11.4 (-7.2, -15.5) - 13.9 (-9.7, -18.1) 0.40 Weight loss ( kg) -0.4 (-0.7, -1.2) -3.7 (-2.5, -4.9) <0.001 CVD Risk Score -2.5 (-1.4,-3.5) -3.0 (-2.0,-4.0) 0.5Binary outcomes at follow-up BP control 39% (25% ,54%) 55% (39% ,70%) 0.32 Wt Loss > 4 11% (2%, 20%) 32% (18%, 46%) 0.02
  17. 17. Secondary Outcomes Change from baseline Control Web-Dietitian P-value HbA1c 0.07 (-.01,.14) -0.02 (-0.11,0.06) 0.11 Fasting BS -1.0 (-3.9,1.8) -0.7 (-3.3,1.9) 0.86 Fruits and vegetables 0.1 (-0.5,0.6) 2.3 (1.4,3.2) 0.003 (number of servings) Regular physical activity at 71% (57%,84%) 95% (89%, 100%) 0.002 follow up Satisfaction with -0.5(-1.1,0.2) 1.3 (0.4,2.1) 0.01 BP/cholesterol care
  18. 18. Patient Perceptions • Heart age  “shocking” - “I wanted to take the corrective stuff”  “shocking” - “Your heart is already aged to 80 years, how are you going to correct that?” • Collaborative dietitian care  “If I had some input to her, she could help me with a suggestion, she was right on target (snaps finger), getting it back ASAP – “a little dietitian in your pocket”  “I receive an e-mail from the doctor’s office who said we saw these BP’s, we would like you to come in – saying I was in the e-Care study and he said okay, never mind”
  19. 19. Dietitian Exit Comments • Patients want to work on lifestyle not medications  Patients wanted to try diet and lifestyle changes for 3 months or more before considering medication. One patient wanted to wait until study completion even when warned of risks of high blood pressure.  Some patients stopped responding to my emails when medication was encouraged.  Many patients were opposed to cholesterol lowering medication because of strong negative perceptions (media related).  There were challenges in providing collaborative care with the physician  Doctors were not well integrated into the study care team. One doctor said “if the patient is not interested in taking meds, then I am not interested in meds for this patient.”
  20. 20. Conclusions • E-care Dietitian led to weight loss but did not significantly decrease systolic BP • Patients found e-Care convenient and self-monitoring was not burdensome • We need to understand more about how patients make decisions about lifestyle versus medication changes • Next steps  Training physicians to pay attention to dietitian based team care?  Linking care to pharmacist who could adjust meds?