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


What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review published in 2006 (Walsh et al., 28 studies, search period January 1980-July 2003) combined with more recent evidence (52 studies, search period July 2003-May 2012). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cardiovascular disease prevention and control.


  • 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

Summary of Results

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.

Summary of Economic Evidence

Economic evidence comes from a Community Guide economic review (31 studies, search period January 1980 – May 2012). 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.


Based on the settings and populations from studies included in the Community Guide review, results are applicable to the following:

  • Adults and older adults
  • Women and men
  • White and African-American populations
  • Health care and community-based settings

Evidence Gaps

Each Community Preventive Services Task Force (CPSTF) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the CPSTF finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the CPSTF recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the CPSTF recommendation is based.

Identified Evidence Gaps

  • Only a few of the included studies used large sample sizes. More studies are needed to assess the effectiveness of team-based care when it is used for large populations.
  • More information is needed about the effectiveness of team-based care for patients from low socioeconomic status (SES) groups and racial and ethnic groups other than Whites and African-Americans.
  • There were few analyses to determine the influence of factors such as race, ethnicity, income, education level and insurance status on the effectiveness of team-based care. More evidence on these factors in team-based care studies is needed.
  • Only a few studies evaluated teams including members besides primary care providers, nurses and pharmacists, such as community health workers and dietitians. More evidence is needed on differences in effectiveness when different types of professionals are on the team.
  • More information is needed about communication within teams, including how (e.g., face-to-face, telephone, e-mail, text message) and how often (e.g., weekly, monthly) patients and providers should communicate with each other.
  • The role of technology in facilitating team-based care needs to be examined extensively.
  • More information is needed about patient-centered outcomes such as satisfaction with care and adherence to healthy behaviors (e.g. increased physical activity).
  • Long-term studies are needed to understand the sustainability of benefits from team-based care.
  • Very limited information is available about reimbursement mechanisms for providers, including the role of incentives. Evidence is needed to assess the types and effectiveness of different mechanisms in use.
  • More information is needed to identify the primary components and drivers of intervention cost and economic benefits of team-based care. Only a few studies provided complete reporting of these components.
  • Several studies that reported effects on health care cost did not report the cost of the intervention. Information about both the economic benefits and the cost of intervention is necessary to determine whether the intervention provides positive net benefit.
  • More evidence is needed for any favorable effects on worker productivity due to team-based care. Worksite productivity effects were not considered in any study, including those implemented at worksites.
  • There is no standard translation of QALY saved from reduction in BP at the population level. Such a translation would be a useful approximation to long term benefits that are impractical and expensive to measure in research studies.

Study Characteristics

  • Limitations identified in the included studies showed significant differences in patient demographics between intervention and comparison groups at baseline, possible contamination within intervention and comparison groups, and issues related to inadequate description of populations and implemented interventions.
  • Thirty-eight studies were conducted in the U.S.; remaining studies were done in Europe, Canada, and Japan.
  • Studies were implemented solely within healthcare settings (41 studies), in community settings (9 studies), or in both a healthcare system and community setting (1 study).
  • Team members who collaborated with patients and primary care providers were predominantly pharmacists (15 interventions), nurses (28 interventions), or both (5 interventions).
  • The median duration of team-based care interventions was 12 months (IQI=6 to 12 months). Only six studies addressed team-based care interventions delivered to more than 500 patients.
  • Study populations included adults and older adults and were balanced across gender. For most studies, the majority of patients were either white or African American.
  • Eight studies focused predominantly on populations where more than 50% of participants identified as low-income. In studies providing information on education level, the majority of participants identified as having a high school education or less.