Improving Coronary Prevention in a County Health System

Abbreviations: FBS = fasting blood sugar, SBP = systolic blood pressure, DBP = diastolic
blood pressure, LDL = low-density lipoprotein, HDL = high-density lipoprotein, BMI = body
mass index, TC = total cholesterol, TG = triglycerides, HbA1c = hemoglobin A1c.

Inclusion Criteria

   - The patient has CAD or CAD risk equivalent (abdominal aortic aneurysm, peripheral
   vascular disease, transient ischemic attack, stroke, diabetes, or FBS ≥ 126 mg/dL × 2)
   and has at least one of following: SBP ≥ 130 mmHg, DBP ≥ 80 mmHg, LDL ≥ 100 mg/dL, HDL
   ≤ 40 mg/dL, TG ≥ 150 mg/dL, FBS ≥ 126 mg/dL, BMI ≥ 30, or is a current smoker.

   - The patient does not have CAD or CAD risk equivalent but has at least one of the
   following: SBP ≥ 160 mmHg, DBP ≥ 100 mmHg, LDL ≥ 190 mg/dL, TC ≥ 240 mg/dL, TG ≥ 500
   mg/dL, HbA1c ≥ 8.0%, BMI ≥ 35, or is a current smoker.

   - The patient does not have CAD or CAD risk equivalent but has at least two of the
   following: a) SBP ≥ 140 mmHg or DBP ≤ 90 mmHg, b) HDL ≤ 40 mm/dL or TG ≥ 200 mg/dL, c)
   LDL ≥ 160 mg/dL or TC ≥ 240 mg/dL, d) FBS ≥ 110 mg/dL × 2, or e) male age ≥ 45 or
   female age ≥ 55 or with positive family history of CAD.

Exclusion Criteria:

   - Resident of long-term facility

   - Lack of spoken English or Spanish by patient or household member 18 years or older who
   can serve as an interpreter

   - Moving before end of intervention (30 months)

   - Age between 35 and 85 (inclusive)

   - Significant comorbidities such as: uncontrolled metabolic disorders (renal failure,
   liver failure, etc.), active symptoms suggesting acute myocardial infarction or
   decompensated congestive heart failure, Malignancy or other condition limiting life
   expectancy, psychiatric disorder with active manifestations.

   - Substance abuse.

   - No telephone or means of contacting patient.

   - Family household member already enrolled.

   - Homeless and not living with relatives/friends.

   - Anticipated absence for more than 4 consecutive months.

   - Difficulty coming to appointments approximately every 1-2 months

   - Already participating in the Diabetes program

   - Currently pregnant or intends to get pregnant the next 3 years.