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 & 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 77 studies of team-based care organized primarily with nurses and pharmacists working in collaboration with primary care providers, patients, and other professionals.

Task Force Finding & Rationale Statement

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 Reviews

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-January 2012).

Previous Review -- Walsh et al. (search period 1980-2003)

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 mm Hg.
• 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 mm Hg (IQI: 4.2 to 14, 17 studies).
• Diastolic blood pressure decreased by 4.2 mm Hg (IQI: 0.2 to 6.8, 21 studies)

Community Guide Review (search period 2003-2012)

Forty-nine studies were included in the review.

• The proportion of patients with controlled blood pressure (less than or equal to 140/90 mm Hg) increased by a median of 12.0 percentage points (IQI: 3.0 to 19.5, 31 studies).
• Systolic blood pressure decreased by a median of 5.6 mm Hg (IQI: 1.95 to 7.3, 43 studies).
• Diastolic blood pressure decreased by 1.8 mm Hg (IQI: 0.7 to 3.2, 38 studies)
• In addition to improvements in blood pressure outcomes, team-based care was effective in improving other CVD 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

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.

Supporting Materials

• Analytic Framework [PDF - 118.6 kb]
• Summary Evidence Table [PDF - 1.82MB]
• Research Gaps
• Included Studies
• Search Strategy

Publications

The findings and results of this systematic review have not been published. You may subscribe to be notified as new materials on this topic become available.

Promotional Materials

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

References

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

---