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Cardiovascular Disease: Interventions Engaging Community Health Workers

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What the Task Force Found

About The Systematic Review

The Task Force finding is based on evidence from a systematic review of 31 studies with 35 study arms (search period: beginning of database – July 2013). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention.

Context

There is no information for this section.

Summary of Results

  • Included studies were stratified based on suitability of study designs, as defined by the Task Force (Briss et al., 2000).
    • 18 studies used designs considered to be of greatest/moderate suitability: individual randomized controlled trial (7 studies), group randomized controlled trial (4 studies), non-randomized trial (3 studies), prospective cohort (1 study), case-control (1 study), and other designs that have a concurrent comparison group (2 studies).
    • 13 studies used a design considered to be least suitable: before-after without a comparison group.
  • Included studies evaluated interventions that engaged CHWs as screening and health education providers (31 study arms), outreach, enrollment, and information agents (20 study arms), members of care delivery teams (17 study arms), patient navigators (8 study arms), and community organizers (4 study arms).
  • Among populations at increased risk for CVD, interventions that engaged CHWs in a team-based care model led to large improvements in blood pressure and cholesterol outcomes while interventions that engaged CHWs as health educators or as outreach, enrollment, and information agents led to modest improvements in health behavior outcomes.
  • There was not enough evidence to draw conclusions on interventions engaging CHWs as patient navigators or as community organizers.
  • Most included studies engaged CHWs to work with underserved groups suggesting these interventions can be effective in improving minority health and reducing health disparities related to cardiovascular disease (22 studies).

Interventions that Engaged CHWs in a Team-Based Care Model

  • Blood Pressure Outcomes
    • Proportion of clients with blood pressure at goal
      • Greatest/moderate suitability studies: median increase of 17.6 percentage points (range: 3.8 to 22.5; 4 studies)
      • Least suitable studies: increase of 10.8 percentage points (95% confidence interval [CI]: 3.2, 18.3; 1 study) and increase of 14.5 percentage points (95% CI: 11.1, 18.0; 1 study)
    • Change in systolic blood pressure
      • Greatest/moderate suitability studies: median reduction of 6.0 mmHg (interquartile interval [IQI]: ‑6.4 to 2.4; 6 studies with 7 study arms)
      • Least suitable studies: median reduction of 11.2 mmHg (range: ‑17.9 to ‑2.0; 4 studies)
    • Change in diastolic blood pressure
      • Greatest/moderate suitability studies: median reduction of 1.1 mmHg (IQI: ‑4.0 to 0.21; 6 studies with 7 study arms)
      • Least suitable studies: median reduction of 4.2 mmHg (range: ‑11.4 to 5.0; 3 studies)
  • Cholesterol Outcomes
    • Proportion of clients with total cholesterol at goal
      • Greatest/moderate suitability studies: increase of 7.0 percentage points (95% CI: ‑5.5, 19.5; 1 study)
    • Change in total cholesterol
      • Greatest/moderate suitability studies: decreases of 19.7 mg/dL (p>0.05; 1 study) and 0.4 mg/dL (not significant; 1 study)
      • Least suitable studies: increase of 1.5 mg/dL (not significant; 1 study)
    • Proportion of clients with LDL cholesterol at goal
      • Greatest/moderate suitability studies: increase of 28.9 percentage points (1 study) and increase of 3.2 percentage points (95% CI: ‑6.1, 12.5; 1 study)
      • Least suitable studies: increase of 10.0 percentage points (95% CI: ‑1.0, 2.1; 1 study)
    • Change in LDL cholesterol
      • Greatest/moderate suitability studies: median decrease of 15.5 mg/dL (range: ‑15.9 to ‑2.7; 3 studies)
      • Least suitable studies: median decrease of 15.0 mg/dL (range: ‑22.0 to 3.2; 3 studies)
    • Change in HDL cholesterol
      • Greatest/moderate suitability studies: median of 0 mg/dL (range: ‑0.4 to 0.8; 3 studies)
      • Least suitable studies: increase of 1.0 mg/dL (not significant; 1 study) and decrease of 2.1 mg/dL (not significant; 1 study)
    • Change in triglycerides
      • Greatest/moderate suitability studies: median decrease of 8.0 mg/dL (range: ‑16.3 to 2.7; 3 studies)
      • Least suitable studies: decrease of 23.0 mg/dL (p<0.05; 1 study) and increase of 1.7 mg/dL (not significant; 1 study)
  • When team-based care was not implemented with interventions that engaged CHWs as health educators; as outreach, enrollment, and information agents; or as patient navigators; improvements in blood pressure and cholesterol outcomes were smaller.

Interventions that Engaged CHWs as Health Educators

  • Physical activity outcomes
    • Greatest/moderate suitability studies: one study reported a statistically significant improvement in physical activity and one study reported non-significant improvements
    • Least suitable studies: five studies with 6 study arms reported statistically significant improvements
  • Nutrition outcomes
    • Greatest/moderate suitability studies: two studies reported statistically significant improvements
    • Least suitable studies: five studies with 6 study arms reported statistically significant improvements
  • Smoking outcomes
    • Greatest/moderate suitability studies: median decrease of 0.5 percentage points in the proportion of current smokers (range: ‑1.9 to 1.0; 3 studies)
    • Least suitable studies: decrease in the proportion of current smokers of 3.7 percentage points (95% CI: ‑10.7, 3.3; 1 study) and 0.6 percentage points (95% CI: ‑4.4, 3.3; 1 study)

Interventions that Engaged CHWs as Outreach, Enrollment, and Information Agents

  • Physical activity outcomes
    • Greatest/moderate suitability studies: one study reported statistically significant improvements in physical activity and one study reported non-significant improvements
    • Least suitable studies: three studies with 4 study arms reported statistically significant improvements
  • Nutrition outcomes
    • Greatest/moderate suitability studies: two studies reported statistically significant improvements
    • Least suitable studies: three studies with 4 study arms reported statistically significant improvements
  • Smoking outcomes
    • Greatest/moderate suitability studies: decreases in the proportion of current smokers of 1.9 percentage points (95% CI: ‑5.1, 1.3; 1 study) and 0.5 percentage points (95% CI: ‑2.5, 1.5; 1 study)

Additional Findings Across all Models of Care

  • Improvements also were found for appropriate use of health care services (2 studies); screening for CVD risk factors (1 study); and CVD-related morbidity and mortality (2 studies).

Summary of Economic Evidence

Four studies were included in the review, all of which evaluated community health workers in team-based care arrangements. Monetary values are presented in 2013 U.S dollars.

  • Estimated intervention costs were $17 and $271 per person per year (2 studies).
  • Estimated healthcare cost decreased by a mean of $1377 per person per year (range $19 to $3616; 3 studies).
    • The incremental cost of adding a CHW to the care team could not be calculated from information reported.
    • The large healthcare cost savings reported in one study was from averted emergency room visits and in-patient stays for recently discharged Medicaid patients with diabetes.
    • The study that reported both the smallest intervention cost ($17 per person per year) and smallest healthcare cost saving ($19 per person per year), was a community-wide trial conducted among the elderly in multiple locations. Analysis was based on the entire eligible population and cost averted included all healthcare costs and not just those specific to cardiovascular disease.
  • None of the included studies provided cost-effectiveness information and there was not enough evidence to determine cost-benefit ratios.

Applicability

Based on results for interventions in different settings and populations, findings are applicable to the following:

  • Adults and older adults who have high blood pressure or high cholesterol
  • Women and men
  • African-American, Hispanic, and low-income populations
  • Urban environments
  • Healthcare systems and community settings

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

  • Most studies evaluated outcomes at 12 months, a relatively short follow-up time for some CVD risk factors. More evidence is needed on longer duration interventions to assess sustained, ongoing program effects across different CVD risk factor outcomes (e.g., blood pressure, cholesterol, morbidity and mortality).
  • Continued evaluation of intervention effectiveness among diverse population subgroups based on characteristics such as comorbidity, sexual orientation, disability, race and ethnicity (e.g., American Indian, Alaskan native, Asian) and SES (e.g., educational attainment and insurance status) is needed.
  • More evidence is needed on interaction frequency and visit length between community health workers (CHWs) and clients. Similarly, further evaluation on the effectiveness of the different modes in which CHWs deliver their services (e.g., face-to-face, telephone, groups) on individual client outcomes would be useful.
  • Further assessment of CHW financing, communication, and organization are needed to help facilitate better integration of CHWs into health promotion and health care efforts in order to bridge clients, community resources, and healthcare systems.
  • More evidence is needed on effectiveness of CHWs who work interchangeably in both community and healthcare settings to determine whether they can help build and enhance community-clinical linkages and provide effective patient navigation.
  • More evidence is needed on CVD screening outcomes to better identify clients with CVD risk factors especially among those who do not have a usual source of healthcare. Similarly, assessments evaluating the effectiveness of CHWs in helping these clients access the appropriate care and services would be beneficial.
  • Identification of mechanisms for sustaining CHW programs and funding/reimbursement arrangements including payment for CHW services is needed.
  • Further examination of CHW recruitment, including optimal selection criteria and matching characteristics (e.g., SES and personal experience) would be useful along with effective methods for training, supervising, and evaluating CHW performance.
  • Regarding interventions where CHWs are part of a care delivery team (i.e., team-based care), more evidence is needed on the incremental value of adding a CHW to the team. Future studies that engage CHWs to provide culturally appropriate health education and engage CHWs as outreach, enrollment, and information agents (without team-based care) should assess intervention effects on CVD risk factor outcomes. Lastly, evaluating the effectiveness of engaging CHWs as community organizers and patient navigators would be useful.
  • In most studies, interventions engaging CHWs usually delivered services in either community or healthcare settings and on a smaller-scale (i.e., ≤ 500 clients). Further assessment of CHW engagements in rural and worksite settings along with more evidence evaluating the impact of larger-scale interventions (i.e., >500 clients) on program effectiveness would be useful.
  • Most studies were funded by public grants, it would be useful to understand whether CHW interventions funded by other mechanisms are equally effective, and how well interventions that use a community-based participatory approach work to prevent CVD.
  • More complete assessments of both costs and benefits of CHW interventions are needed to determine their economic value.
  • Studies that engage CHWs in a team-based care arrangement should provide combined and separate intervention cost estimates for each part so the incremental cost can be determined.

Study Characteristics

  • Studies were conducted in the United States (28 studies), Canada (2 studies), and Western Europe (1 study).
  • Included studies evaluated interventions within the healthcare system (13 studies), community (11 studies), or both (7 studies).
  • Studies were set primarily in urban areas (22 studies).
  • Study populations mainly included adults ages 18-64 years old (23 studies) and older adults 65 years and older (5 studies) who had one or more of the following risk factors: high blood pressure, high cholesterol, obesity, diabetes, or tobacco use.
  • Included studies mainly covered underserved populations, that is, 75% or more of clients enrolled were African-American (9 studies), Hispanic (8 studies), or low-income (12 studies).
  • Community health workers were frequently matched to the population they served by location (16 study arms), race/ethnicity (17 study arms), or language (15 study arms).
  • Community health workers provided clients with culturally appropriate information and education on cardiovascular disease risk factors (21 study arms), lifestyle counseling (20 study arms), informal counseling and social support (22 study arms), and information on community resources (16 study arms).

Publications

There are no publications for this systematic review.