Cardiovascular Disease Prevention and Control: Team-Based Care to Improve Blood Pressure Control
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)
Summary of Task Force Recommendations and Findings
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 80 studies of team-based care organized primarily with nurses and pharmacists working in collaboration with primary care providers, patients, and other professionals. The economic evidence indicates that team-based care is cost-effective.
About the Intervention
- Team members who most often worked with patients and primary care providers were pharmacists and nurses.
- Medication management roles for team members were implemented in three different ways. Team members could:
- Change medications independent of the primary care provider
- Change medications with primary care provider approval or consultation
- Provide only adherence support and hypertension-related information, with no direct influence on prescribed medications
Results from the Systematic Review
The Task Force finding is based on evidence from a systematic review published in 2006 (Walsh et al., search period January 1980-July 2003) and a more recent Community Guide review (search period July 2003-May 2012). Economic evidence comes from a Community Guide economic review (search period January 1980 – May 2012).
Previous Review – Walsh et al. (search period January 1980- July 2003)
Twenty-eight studies were included in the review.
- Overall, there was an increase in the proportion of patients with controlled blood pressure, defined as being less than or equal to 140/90 mmHg.
- Controlled systolic blood pressure: median increase of 21.8 percentage points (Interquartile interval [IQI]: 9.0 to 33.8, 9 studies)
- Controlled diastolic blood pressure: median increase of 17.0 percentage points (IQI: 5.7 to 24.5, 6 studies)
- Systolic blood pressure decreased by a median of 9.7 mmHg (IQI: 4.2 to 14, 17 studies).
- Diastolic blood pressure decreased by 4.2 mmHg (IQI: 0.2 to 6.8, 21 studies).
Community Guide Review (search period July 2003- May 2012)
Fifty-two studies were included in the review.
- The proportion of patients with controlled blood pressure (less than or equal to 140/90 mmHg) increased by a median of 12.0 percentage points (IQI: 3.2 to 20.8, 33 studies).
- Systolic blood pressure decreased by a median of 5.4 mmHg (IQI: 2.0 to 7.2, 44 studies).
- Diastolic blood pressure decreased by 1.8 mmHg (IQI: 0.7 to 3.2, 38 studies).
- In addition to improvements in blood pressure outcomes, team-based care was effective in improving other cardiovascular disease risk factors, including:
- Diabetes (HbA1c and Blood Glucose levels)
- Cholesterol (Total and LDL cholesterol)
- For teams that included pharmacists, the median improvement in the proportion of patients with controlled blood pressure was considerably higher than the overall median increase.
- The effectiveness of team-based care was greater when team members could change hypertensive medications independent of the primary care provider, or with primary care provider approval or consultation.
- Results from included studies are applicable to various groups and settings, including:
- Adults and older adults
- Women and men
- White and African-American populations
- Health care and community-based settings
Economic Evidence (search period January 1980-May 2012)
Thirty-one studies were included in the review. Eleven studies provided cost-effectiveness estimates while the other studies provided estimates for the cost of intervention and the change in health care cost. All monetary values reported are in 2010 U.S. dollars.
- Intervention cost of team-based care is the cost of labor and resources that complement the activities of the primary care provider by providing process support and sharing the responsibility of hypertension care.
- Median intervention cost per patient per year was $284 (IQI: $153 to $670; 29 estimates from 20 studies).
- Change in health care cost includes outpatient visits, emergency department visits, hospital stays, and medications.
- Compared to usual care, the median health care cost per patient per year was $65 higher for team-based care (IQI: -$235 to $318; 23 estimates from 20 studies).
- Cost effectiveness is intervention cost per quality adjusted life year (QALY) saved.
- One study directly estimated intervention cost per QALY saved to be $4763.
- Ten additional studies provided 14 estimates of the cost associated with reductions in SBP due to team-based care, and these estimates were translated to cost per QALY saved using two separate formulas.
- Median intervention cost per QALY saved was $13,992 (IQI: $8339 to $32,292) based on one formula (Mason et al. 2005).
- Median intervention cost per QALY saved was $9716 (IQI: $5791 to $22,425) based on the other formula (McEwan et al. 2006).
Twenty seven of 29 cost-effectiveness estimates (from 11 studies) were below the conservative threshold of $50,000 per QALY saved, which indicates that team-based care for blood pressure control is cost-effective.
These results were based on a systematic review of all available studies, 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 and control.
Mason JM, Freemantle N, Gibson JM, New JP. Specialist nurse-led clinics to improve control of hypertension and hyperlipidemia in diabetes: economic analysis of the SPLINT trial. Diabetes Care 2005;28(1):40-6.
McEwan P, Peters JR, Bergenheim K, Currie CJ. Evaluation of the costs and outcomes from changes in risk factors in type 2 diabetes using the Cardiff stochastic simulation cost-utility model (DiabForecaster). Curr Med Res Opin 2006;22(1):121-9.
Walsh J, McDonald K, Shojania K, et al. Quality improvement strategies for hypertension management: a systematic review. Medical Care 2006;44:646-57.
- Analytic Framework [PDF - 118.6 kB]
- Evidence Gaps
- Summary Evidence Table [PDF - 1.82 MB]
- Summary Evidence Table – Economic Review [PDF - 315 kB]
- Included Studies
- Search Strategy
Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe to be notified when we post these publications or other materials. See our library for Community Guide publications on other topics.
- CDC Media Release: Task Force Recommends Team-Based Care for Improving Blood Pressure Control
Developed by CDC's Division for Heart Disease and Stroke in collaboration with Prevention The Community Guide
Community Guide News
- Community Preventive Services Task Force Recommends Team-Based Care to Improve Blood Pressure Control
Developed by The Community Guide in collaboration with CDC's Division for Heart Disease and Stroke Prevention
More promotional materials for Community Guide reviews about Cardiovascular Disease Prevention and Control.
The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC.
The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Cardiovascular disease prevention and control: team-based care to improve blood pressure control. www.thecommunityguide.org/cvd/teambasedcare.html. Last updated: MM/DD/YYYY.
Review Completed: April 2012
- Page last reviewed: December 11, 2013
- Page last updated: December 11, 2013
- Content source: The Guide to Community Preventive Services