Cardiovascular disease (CVD) is the leading cause of mortality among Veterans, and sub-optimal risk factor control is an important mechanism for the continued prevalence of CVD. Despite clinic-based programming that includes nurse care management, pharmacy support, telephone care programs, and intensive quality improvement efforts, CVD risk factors remain sub-optimally controlled among Veterans. Given the high prevalence and cost within VHA, cost-effective mechanisms are needed to manage prevalent CVD risk factors. Veteran peer health coaches may be one such mechanism; however, previous work has provided limited data of this model with VHA primary care. Previous studies of peer support in non-VHA populations report significant improvement in hypertension control and CVD risk reduction.
To test the effectiveness of a peer health coaching intervention to reduce CVD risk and promote health behavior change among Veterans with multiple CVD risk factors. To target a high-risk population, Veterans with poorly controlled hypertension and at least one other CVD risk factor are being recruited.
A randomized controlled trial of n=400 Veterans is being conducted to compare a peer health coach intervention consisting of home visits, telephone support, and linkages to community-based and clinic resources as compared to usual VHA care. The primary outcome is reduction in systolic blood pressure from baseline to follow-up at 1-year. Secondary outcomes include a reduction in Framingham Cardiovascular risk score, individual cardiovascular risks, health related quality of life, and health care use. Effects of the intervention on intermediate outcomes will be assessed including social support, patient activation, patient/provider communication and health behaviors. We will identify Veteran and staff satisfaction with the intervention, and barriers and facilitators to adoption by conducting qualitative interviews with a subsection of Veteran participants, peer health coaches, and PACT primary care staff. The intervention cost will be assessed to inform feasibility for future studies.
Trial results are pending; however, preliminary findings indicate data from VA Corporate Data Warehouse (CDW) can be effectively used in conjunction with census tract data to target geographic clustering of high-risk areas. Veterans from these areas can be successfully recruited as peer health coaches. Role play sessions conducted by the health coaches with a standardized patient actor increased observed behavior change in hypertension, smoking cessation and medication adherence counseling by 18 points on the Behavior Change Counseling Index. Results of this trial will inform peer support programs using geographic clustering of health risks to provide community-based delivery of prevention services to high-risk areas.
Integrating peer health coaches into PACT primary care teams may improve VHA's ability to provide community outreach to Veterans. CVD risk reduction provides an ideal target for intervention given the prevalence of modifiable risks among Veterans. The study will increase understanding of the utilization of peer support within PACT teams. If this study proves the main hypothesis, this evidence-based support model could be tested more widely among Veterans with other chronic conditions to improve health outcomes.
- Nelson K, Fennell T, Gray KE, Williams JL, Lutton MC, Silverman J, Jain K, Augustine MR, Kopf W, Taylor L, Sayre G, Vanderwarker C. Veteran peer Coaches Optimizing and Advancing Cardiac Health (Vet-COACH); design and rationale for a randomized controlled trial of peer support among Veterans with poorly controlled hypertension and other CVD risks. Contemporary clinical trials. 2018 Oct 1; 73:61-67.