Cardiovascular Disease Prevention and Control: Team-Based Care to Improve Blood Pressure Control

Task Force Finding & Rationale Statement

Definition

Team-based care to improve blood pressure control is a health systems-level, organizational intervention that incorporates a multidisciplinary team to improve the quality of hypertension care for patients. Team-based care is established by adding new staff or changing the roles of existing staff to work with a primary care provider.

Each team includes the patient, the patient's primary care provider, and other professionals such as nurses, pharmacists, dietitians, social workers, and community health workers. Team members provide process support and share responsibilities of hypertension care to complement the activities of the primary care provider. These responsibilities include medication management; patient follow-up; and adherence and self-management support.

Team-based care interventions typically include activities to:

• Facilitate communication and coordination of care support among various team members
• Enhance use of evidence-based guidelines by team members
• Establish regular, structured follow-up mechanisms to monitor patients' progress and schedule additional visits as needed
• Actively engage patients in their own care by providing them with education about hypertension medication, adherence support (for medication and other treatments), and tools and resources for self-management (including health behavior change)

Task Force Finding

The Community Preventive Services Task Force recommends team-based care to improve blood pressure control on the basis of strong evidence of effectiveness in improving the proportion of patients with controlled blood pressure and in reducing systolic (SBP) and diastolic (DBP) blood pressure. Evidence was considered strong based on findings from 77 studies of team-based care organized primarily with nurses and pharmacists working in collaboration with primary care providers, patients, and other professionals.

Rationale

Basis of Finding
The Task Force finding is based on evidence from a systematic review published in 2006 (Walsh et al., 28 studies, search period January 1980-July 2003) and a more recent Community Guide review (49 studies, search period July 2003-January 2012). Results from both reviews demonstrate the effectiveness of team-based care in improving blood pressure outcomes. Magnitude of effect estimates, number of studies, and consistency of effects provide the basis for the strong evidence finding (Table).

Team-Based Care for Improved Blood Pressure (BP) Control: Results

Outcome	Walsh 2006 (1980 - 2003)		Community Guide (2003 - 2012)
	Number of Studies	Median Effect Estimate	Number of Studies	Median Effect Estimate
Improvement in proportion of patients with BP controlled*	9 (SBP)   6 (DBP)	21.8 pct pts (IQI: 9.0, 33.8) 17.0 pct pts (IQI: 5.7, 24.5)	31 (SBP+DBP)	12.0 pct pts (IQI: 3.0, 19.5)
Reduction in Systolic BP (SBP)	17	9.7 mm Hg (IQI: 4.2, 14)	43	5.6 mm Hg (IQI: 1.95, 7.3)
Reduction in Diastolic BP (DBP)	21	4.2 mm Hg (IQI: 0.2, 6.8)	38	1.8 mm Hg (IQI: 0.7, 3.2)

*Absolute percentage point increase in proportion of patients achieving BP control
IQI = Interquartile Interval; pct pts = percentage points

 

The benefits of team-based care in organizing around a system of care may apply to comprehensive cardiovascular disease risk reduction. The current review found that in addition to improvements in blood pressure outcomes, team-based care (TBC) was effective in improving diabetes-related outcomes and lipid outcomes, especially total cholesterol and LDL-cholesterol.

In the current review, the predominant team members who worked with patients and primary care providers were nurses (25 studies), pharmacists (13 studies), or both (4 studies). When pharmacists were added to teams, the median improvement in the proportion of patients with controlled blood pressure was considerably higher than the overall median increase for this outcome. Median reductions in SBP and DBP were similar to overall estimates. When nurses or both nurses and pharmacists were added to teams, median estimates for all three outcomes were comparable to overall effect estimates. Only four studies examined the effectiveness of adding other team members, such as community health workers, social workers, or dietitians without nurses or pharmacists. In these few instances, median effect estimates were smaller in magnitude compared to overall effect estimates. Most studies added one team member; results were similar when compared to studies that added two or more team members, for all three outcomes.

Studies in the current review also examined effectiveness of TBC when team members could make changes to hypertensive medications independent of the primary care provider (14 studies); with primary care provider approval or consultation (14 studies); or not at all (21 studies). The first two levels of medication management achieved larger improvements in blood pressure outcomes when compared to the third level, where team members provided adherence support and hypertension-related information but did not make medication changes or recommendations. Other important team member roles include support for health behavior change (e.g., counseling sessions) and systems support mainly via telephone follow-up.

Patients, an integral part of the team, work with primary care providers and other team members to improve involvement in self-management activities. Compared with patients treated by primary care providers only, a higher proportion of patients in TBC adhered to prescribed medication (>80%; 9 studies) and had greater satisfaction (3 studies). These improvements are likely attributable to greater emphasis in TBC on improving patient engagement and the quality of self-management support through health behavior change activities (34 studies) and pro-active follow-up, mainly via telephone (22 studies).

Applicability and Generalizability Issues
A majority of included studies in the current update were from the U.S. (35 studies), with other studies from Canada, Japan, and Western Europe. Although most studies were implemented in healthcare settings (40 studies), TBC was also evaluated in community settings (8 studies), indicating applicability of findings to both.

Evidence from the current review suggests TBC is effective in populations where a majority has uncontrolled blood pressure (≥140/90 mm Hg), with larger improvements observed in these populations. However, median effect estimates from studies where mean baseline SBP was 130-140 mm Hg and from studies where mean DBP was 80-90 mm Hg were similar to the overall effect estimates, suggesting that the benefit of TBC interventions extends even to populations whose hypertension is managed at enrolment.

Adults, older adults, and male and female patients were balanced across study populations. White and African-American populations were well-represented across studies, indicating applicability of findings to these populations. Three studies that targeted low-income populations showed mixed results. Four studies with greater than 50% of target populations considered low-income had improvements in all three recommendation outcomes. Six studies with greater than 50% of target populations receiving public health insurance (Medicare or Medicaid) or being uninsured, and one study with 100% of the target population receiving public health insurance, had improved blood pressure outcomes.

Information about patients' education levels was limited, and results from a small number of studies where a higher proportion of patients had less than a high school education were mixed. Information on SES and analysis by these variables was generally sparse across the body of evidence.

Data Quality Issues
Forty-five studies from the current review were randomized controlled trials; remaining studies were quasi-RCTs or used other study designs with concurrent comparison groups. The most common limitations affecting this body of evidence were significant differences between intervention and comparison groups at baseline and potential for contamination.

Other Benefits and Harms
Median effect estimates for lipid outcomes (reported in 15 studies) and diabetes outcomes (17 studies) indicated improvement associated with TBC. Researchers assessing these outcomes usually organized teams to address multiple cardiovascular risk factors, such as hypertension, hyperlipidemia, and diabetes. Two studies also reported a reduction in depressive symptoms from TBC interventions that incorporated services to address depression. Eight studies from the current review targeted blood pressure control in persons with diabetes and three other studies in populations in which the majority had diabetes. Improvements were found for all three blood pressure outcomes, suggesting applicability of findings to efforts targeting blood pressure control in populations with diabetes. No harms to patients were identified from TBC interventions in included studies or the broader literature. Potential adverse effects from medication for hypertension (and related risk factors) could be mitigated through TBC by facilitating efficient communication between patients and providers on the team.

Implementation Issues
At the health system level, important considerations include resource allocation; effective reimbursement mechanisms for all team members; and return on investment. Additional strategies to maintain provider engagement such as feedback mechanisms and incentives are valuable. Health systems would need an effective method for identifying and prioritizing patients into these TBC arrangements and a clear understanding of the scope of the team's activities, mainly in targeting multiple cardiovascular disease risk factors in addition to hypertension (e.g., hyperlipidemia, diabetes, smoking, poor nutrition).

At the intervention level, decisions about team constitution and the establishment of sufficient support to offer provider training, foster team-building, and ensure effective communication are crucial. Various modalities for care delivery and communication need to be considered, including telephones and mobile phones, the Internet, and newer technologies.

Team member roles regarding medication management is another important factor in implementation. Medication management roles where team members can make changes to medications independently or make recommendations to primary care providers may be more pertinent in achieving blood pressure control and lipid control, whereas team member roles to provide support for adherence and information on hypertension and other cardiovascular risk factors might be more relevant in maintaining control in blood pressure and related cardiovascular disease risk factors. It is essential that self-management support for patients be integrated into TBC. Systems supports such as electronic medical records (EMRs) and home BP monitors are also important in these efforts.

Research and Evidence Gaps
More research is needed on larger-scale studies (n>500). Only four studies from the current review were considered large in scale and their effect estimates were smaller in magnitude compared with overall effect estimates. TBC interventions also should be implemented to serve minority and low-SES populations to gain a better understanding of effectiveness in various contexts. Though included studies had information on race, ethnicity, income, education level, and insurance status, results were seldom analyzed by these variables.

More research is needed also on the effectiveness of TBC with team members such as community health workers or dietitians. Few studies evaluated the type and frequency of interaction between primary care providers and other team members. More research is needed to evaluate the role communication plays in TBC. Future studies should provide information on patient and provider preferences for communication within teams. New technology has the potential to improve the sharing of evidence-based recommendations between team members and the subsequent uptake of these suggested changes. Use of new and emerging technologies is especially important in developing better channels of communication among providers and between providers and patients.

Patient-centered outcomes of satisfaction with care and adherence to behavioral change activities were rarely reported. More research is needed on patient perspectives, including TBC's effects on uptake of self-management activities.

Additional research is needed on the long-term sustainability of TBC interventions. Most studies in the current review conducted TBC interventions that lasted between 6 and 12 months. More information is needed about costs and effective reimbursement mechanisms that might impact the intensity of TBC.

References

Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic review. Medical Care 2006;44:646-57.