CREATE Wellness: A multi-component behavioral intervention for patients not responding to traditional Cardiovascular disease management

Chris Miller-Rosales, Stacy A Sterling, Sabrina B Wood, Thekla Ross, Mojdeh Makki, Cindy Zamudio, Irene M Kane, Megan C Richardson, Claudia Samayoa, Nancy Charvat-Aguilar, Wendy Y Lu, Michelle Vo, Kimberly Whelan, Connie S Uratsu, Richard W Grant, Chris Miller-Rosales, Stacy A Sterling, Sabrina B Wood, Thekla Ross, Mojdeh Makki, Cindy Zamudio, Irene M Kane, Megan C Richardson, Claudia Samayoa, Nancy Charvat-Aguilar, Wendy Y Lu, Michelle Vo, Kimberly Whelan, Connie S Uratsu, Richard W Grant

Abstract

Background/aims: Cardiovascular disease (CVD) is the leading cause of death in the US. Many patients do not benefit from traditional disease management approaches to CVD risk reduction. Here we describe the rationale, development, and implementation of a multi-component behavioral intervention targeting patients who have persistently not met goals of CVD risk factor control.

Methods: Informed by published evidence, relevant theoretical frameworks, stakeholder advice, and patient input, we developed a group-based intervention (Changing Results: Engage and Activate to Enhance Wellness; "CREATE Wellness") to address the complex needs of patients with elevated or unmeasured CVD-related risk factors. We are testing this intervention in a randomized trial among patients with persistent (i.e > 2 years) sub-optimal risk factor control despite being enrolled in an advanced and highly successful CVD disease management program.

Results: The CREATE Wellness intervention is designed as a 3 session, group-based intervention combining proven elements of patient activation, health system engagement skills training, shared decision making, care planning, and identification of lifestyle change barriers. Our key learnings in designing the intervention included the value of multi-level stakeholder input and the importance of pragmatic skills training to address barriers to care.

Conclusions: The CREATE Wellness intervention represents an evidence-based, patient-centered approach for patients not responding to traditional disease management. The trial is currently underway at three medical facilities within Kaiser Permanente Northern California and next steps include an evaluation of efficacy, adaptation for non-English speaking patient populations, and modification of the curriculum for web- or phone-based versions.

Clinicaltrialsgov identifier: NCT02302612.

Keywords: Intervention research; Patient-centered; Stakeholder engagement research.

Figures

Fig. 1
Fig. 1
Conceptual model for how the CREATE Wellness intervention supports the Medical Care Plan developed by the patient's physician and the existing Disease Management process to help achieve improved clinical care outcomes. Patients randomized to usual care continue with physician-defined Medical Care Plan and Disease Management, whereas patients randomized to the CREATE Wellness intervention participate in three group-based sessions over six weeks designed to support traditional disease management by increasing patient activation, engagement, and pragmatic self-care skills.
Fig. 2
Fig. 2
Conceptual Framework showing the flow from enrolling eligible patients, components of the CREATE Wellness intervention, patient-oriented intermediate measures, and downstream clinical outcomes. PAM = Patient Activation Measure, PHQ-9 = Patient Health Questionnaire, PASE = Physical Activity Scale for the Elderly, PEPPI = Perceived Efficacy in Patient-Physician Interactions Questionnaire, SBP = Systolic Blood Pressure, LDL = Low Density Lipoprotein Cholesterol; CVD = Cardiovascular Disease.
Fig. 3
Fig. 3
Illustration of how initial intervention plans (based on review of literature and investigator ideas) were modified by input from multiple stakeholders to design to final CREATE Wellness intervention.

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Source: PubMed

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