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Heart Disease and Stroke Prevention: Reducing Out-of-Pocket Costs for Cardiovascular Disease Preventive Services for Patients with High Blood Pressure and High Cholesterol


What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 18 studies (search period: January 1980 to July 2015).

The systematic 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.

Summary of Results

More details about study results are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 248 KB].

  • Reducing out-of-pocket costs for patients was associated with improvements in medication adherence, and blood pressure and cholesterol outcomes.
  • Included studies were stratified based on suitability of study designs, as defined by the CPSTF (Briss et al., 2000).
    • Twelve studies used designs considered to be of greatest/moderate suitability: individual randomized controlled trial (3 studies), other designs that have a concurrent comparison group (6 studies), retrospective cohort (2 studies), post only with concurrent comparison (1).
    • Six studies used a design considered to be least suitable: before-after without a comparison group.

Medication Adherence

  • Patients' adherence to blood pressure and cholesterol-lowering medications
  • Proportion of patients achieving 80% adherence
    • Greatest/moderate suitability studies: increase of 5.1 percentage points (1 study)

Blood Pressure

  • Patients' systolic blood pressure
    • Greatest/moderate suitability studies: median decrease of 5.9 mmHg (4 studies)
    • Least suitability studies: median decrease of 8.7 mmHg (6 studies)
  • Patients' diastolic blood pressure
    • Greatest/moderate suitability studies: median decrease of 3.8 mmHg (4 studies)
    • Least suitability studies: median decrease of 4.5 mmHg (6 studies)
  • Proportion of patients achieving blood pressure goal (<140 mmHg/90 mmHg; ≤130/80 mmHg for people with diabetes)
    • Greatest/moderate: median increase of 6.0 percentage points (3 studies)
    • Least suitability studies: median increase of 30.1 percentage points (4 studies)


  • Patients' total cholesterol
    • Greatest/moderate suitability design: decrease of 15.0 mg/dL (1 study)
    • Least suitability design: decrease of 25.0 mg/dL (1 study)
  • Patients' low-density lipoprotein (LDL)
    • Greatest suitability design: median decrease of 14 mg/dL (3 studies)
    • Least suitability of design: median decrease of 14 mg.dL (3 studies, 6 study arms)
  • Patients LDL level at goal (<100mg/dL for most patients)
    • Greatest suitability studies: increases of 13.0 and 24.0 percentage points (2 studies)
    • Least suitability studies: increase of 10 percentage points (1 study)
  • Patients' triglycerides
    • Greatest suitability studies: decreases of 13.0 and 9.8 mg/dL (2 studies)
    • Lest suitability studies: decreases of 38.4 and 25.0 mg/dL (2 studies)

Summary of Economic Evidence

More details about study results are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 248 KB].

The economic review included nine studies. Monetary values are reported in 2014 U.S. dollars.

  • No studies reported cost-effectiveness results.
  • The median intervention cost per person per year was $172 (9 studies).
    • Higher estimates included blood pressure-lowering and diabetes medications.
  • Healthcare cost decreased by a median of $127 (7 studies)
    • Estimates from all but two studies were the result of ROPC combined with other interventions.

An overall economic conclusion cannot be reached because the net benefit evidence is small and inconsistent and no studies reported cost-effectiveness.


The CPSTF finding should be applicable to various groups with access to health care, including:

  • Adults (18-64 years old)
  • Women and men
  • Hispanic, white, and African-American patients
  • Low-income patients

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • Does ROPC for behavioral counseling or behavioral support interventions independent of ROPC for medications improve health outcomes?
  • How does the dollar amount saved by patients affect intervention effectiveness? What is the effectiveness of ROPC by total medication cost, proportional cost-reduction, patient income, or drug patent type?
  • When the cost for generic medications is eliminated and the cost for brand name medications is reduced, are patients more or less likely to choose generic options?
  • What clinical outcomes are associated with policies that reduce out-of-pocket costs for an entire patient population? How is medication adherence affected by multicomponent programs that include ROPC?
  • What are the most effective strategies to promote covered benefits to patients and providers?
  • What costs are associated with each component of a combined ROPC intervention?

Study Characteristics

  • Included studies came from the United States (15 studies), Israel (1 study), Italy (1 study), and Australia (1 study).
  • Seven of the studies used Value-based Insurance Design plans, and three used pharmaceutical medication assistance programs (PMAP) programs to procure medications for low-income patients.
  • Most studies reported implementing ROPC for medications with one or more health care intervention components, such as medication counseling; seven studies used a team-based care approach combined with medication counseling.
  • Study populations primarily included working-age adults (median age of 55 years).
  • Populations included diverse racial and ethnic groups, which were predominantly white in three studies; African American in 2 studies, and Hispanic in one study.
  • Patients in 12 studies were fully insured. Patients in the remaining six studies were mostly uninsured or underinsured.