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

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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.

Context

  • 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

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 220 kB].

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

The systematic review included 28 studies.

  • Overall, there was an increase in the proportion of patients with controlled blood pressure (less than or equal to 140/90 mmHg).
    • Controlled systolic blood pressure: median increase of 21.8 percentage points (9 studies)
    • Controlled diastolic blood pressure: median increase of 17.0 percentage points (6 studies)
  • Systolic blood pressure decreased by a median of 9.7 mmHg (17 studies).
  • Diastolic blood pressure decreased by 4.2 mmHg (21 studies).

Community Guide Review (search period July 2003- May 2012)

The systematic review included 52 studies.

  • 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 (33 studies).
  • Systolic blood pressure decreased by a median of 5.4 mmHg (44 studies).
  • Diastolic blood pressure decreased by 1.8 mmHg (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)
  • When teams included pharmacists, the median improvement in the proportion of patients with controlled blood pressure was considerably higher than the median increase reported overall.
  • 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

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 220 kB].

The economic review included 31 studies (search period January 1980 – May 2012). Studies provided cost-effectiveness estimates (11 studies) or estimates for the cost of intervention and change in health care cost (20 studies). All monetary values reported are in 2010 U.S. dollars.

  • The median intervention cost per patient per year was $284 (29 estimates from 20 studies).
    • Intervention cost was the cost of labor and resources needed to complement the activities of primary care providers. This typically included process support and shared responsibility for hypertension care.
  • Compared to usual care, the median health care cost per patient per year was $65 higher for team-based care (23 estimates from 20 studies).
    • Health care costs included outpatient visits, emergency department visits, hospital stays, and medications.
  • Cost effectiveness is intervention cost per quality adjusted life year (QALY) saved.
    • One study directly estimated intervention cost per QALY saved to be $4763.
    • The economic review team translated estimates from 10 additional studies to cost per QALY saved.
      • Median intervention cost per QALY saved was $13,992 based on a formula from Mason et al. (2005).
      • Median intervention cost per QALY saved was $9716 based on a formula from McEwan et al. (2006).

Of the 29 cost-effectiveness estimates (from 11 studies), 27 were below the conservative threshold of $50,000 per QALY saved, which indicates that team-based care for blood pressure control is cost-effective.

Applicability

Based on the settings and populations from studies included in the Community Guide review, the CPSTF finding should be applicable to the following:

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

Evidence Gaps

Additional research and evaluation are needed to answer the following questions and fill existing gaps in the evidence base. (What are evidence gaps?)

  • Only a few of the included studies used large sample sizes. What is the effectiveness of team-based care when used for large populations?
  • How effective are team-based care interventions among patients from low socioeconomic status (SES) groups and racial and ethnic groups other than Whites and African-Americans?
  • How does effectiveness vary by patients’ race, ethnicity, income, education level, or insurance status?
  • Most of the included studies evaluated teams with primary care providers, nurses and pharmacists; very few included other providers, such as community health workers or dietitians. How does intervention effectiveness vary by the type of professional included on a team?
  • How do communication channels used within teams (e.g., face-to-face, telephone, e-mail, text message) and communication frequency between patients and providers (e.g., weekly, monthly) effect outcomes?
  • What is the role of technology in facilitating team-based care?
  • What are patient-centered outcomes associated with team-based care, such as satisfaction with care and adherence to healthy behaviors (e.g. increased physical activity)?
  • How sustainable are the benefits from team-based care over time?
  • How are reimbursement mechanisms, including incentives, used to support team-based care? How do these mechanisms effect outcomes?
  • What are the primary components and drivers of intervention cost and economic benefits of team-based care?
  • What are the economic benefits and costs of intervention?
  • What are intervention effects on worker productivity?
  • There is no standard translation of QALY saved from reduction in blood pressure at the population level. How can a translation be developed as an approximation to long term benefits that are impractical and expensive to measure in research studies?

Study Characteristics

  • Thirty-eight studies were conducted in the United States; remaining studies were from 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. 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.
  • 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.

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