Heart Disease and Stroke Prevention: Team-based Care to Improve Blood Pressure Control

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends team-based care to improve patients’ blood pressure. Evidence shows team-based care increases the proportion of patients with controlled blood pressure and reduces systolic (SBP) and diastolic (DBP) blood pressure. Economic evidence indicates team-based care is cost-effective.

The full CPSTF Finding and Rationale Statement and supporting documents for Heart Disease and Stroke Prevention: Team-based Care to Improve Blood Pressure Control are available in The Community Guide Collection on CDC Stacks.

Intervention

Team-based care to improve blood pressure control is a health systems-level, organizational intervention that uses a multidisciplinary team to improve the quality of care. Team-based care is established by adding new staff or changing the roles of existing staff who 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 blood pressure control to complement the activities of the primary care provider. Responsibilities include medication management, patient follow-up, and adherence and self-management support.

Team-based care interventions typically include activities to do the following:

Facilitate communication and coordination of care support among various team members
Enhance the 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 blood pressure (i.e., hypertension) medication, adherence support (for medication and other treatments), and tools and resources for self-management (including self-measured blood pressure monitoring and health behavior change)

About The Systematic Review

The CPSTF recommendation is based on evidence from a review of 54 studies (search period January 2012 — June 2020). This recommendation updates and replaces the 2012 finding of strong evidence of effectiveness for team-based care to improve blood pressure control. This update focuses on evidence from studies published since 2012.

Study Characteristics

Study designs included randomized controlled trials (27 studies), non-randomized trials (2 studies), other designs with a concurrent comparison group (1 study), retrospective and other cohorts (9 studies), time series (4 studies), and before-after without control (11 studies).
Studies were conducted in the United States (38 studies), Australia (3 studies), Germany (2 studies), Hong Kong, China (2 studies), and the United Kingdom (2 studies); one each was done in Canada, Denmark, Italy, Netherlands, South Korea, Sweden, and Switzerland.
Team-based care members who worked with patients and primary care providers were predominately nurses (22 studies), pharmacists (13 studies), or both (7 studies).
Team members commonly provided health behavior counseling, coaching, or education to support blood pressure management (18 studies), medication adherence (19 studies), or lifestyle activities (31 studies).
Primary care providers most often communicated with one or more team members through electronic medical records (27 studies) or direct team communication (22 studies).

Summary of Results

The systematic review included 54 studies.

The proportion of patients with controlled blood pressure increased by a median of 8.5 percentage points (39 studies).
Systolic blood pressure measurements were reduced by a median of 3.5 mmHg (44 studies).
Diastolic blood pressure measurements were reduced by a median of 2.1 mmHg (35 studies).

Summary of Economic Evidence

A systematic review of economic evidence shows team-based care interventions to improve blood pressure control are cost-effective, based on a median cost per quality adjusted life year (QALY) gained of $15,202, which is below a conservative threshold of $50,000.

The systematic economic review included 35 studies (search period January 2011 through January 2021). Monetary values are reported in 2020 U.S. dollars.

The median intervention cost per patient per year was $299 (29 studies).
The median change in healthcare cost per patient per year was a decrease of $140 (16 studies).
The median net cost (intervention cost plus change in healthcare cost) per patient per year was $133 (17 studies with 19 estimates). A positive value indicates the averted healthcare cost is less than the intervention cost.
- 14 estimates were positive and 5 were negative.
The median return on investment (ROI) was –80% (14 studies with 14 estimates). ROI, from the health system perspective, is the ratio of the difference in averted health care cost and intervention cost to intervention cost. ROI is not favorable if the estimate is less than zero.
- 10 estimates were negative and 4 were positive.
The median cost per quality-adjusted life year (QALY) gained was $15,202 (14 studies with 15 estimates).
- Fourteen of 15 estimates were below a conservative $50,000 threshold, indicating cost-effectiveness.

Applicability

Based on the results from the review, findings should be applicable to patients with high blood pressure in the United States. Studies conducted in health care settings serving racial and ethnic minority populations found meaningful improvements in blood pressure control for Black or African American and Hispanic or Latino patients.

Evidence Gaps

Which factors affect sustainability and intensity of team-based care interventions?
How should these interventions be used by systems of care?
Are there differences in the effectiveness and economic efficiency of these interventions when they include all patients with hypertension rather than limiting participation to those with uncontrolled blood pressure?
How does intervention effectiveness vary based on patients’ baseline rates of blood pressure control? At what baseline rate does team-based care become an inefficient intervention for improving blood pressure control in a patient population?
What are the effects of adding digital interventions and innovative use of technology-enabled resources to team-based care? Specifically, what are the benefits associated with patients’ use of web portals and mobile technology?
How do costs and reimbursement mechanisms impact the effectiveness of team-based care?
What are the long-term effects of team-based care on morbidity and mortality outcomes? More studies of longer duration are needed to capture effects.
Is the intervention cost-effective over 5- to 10-year time horizons?
What are the economic outcomes for interventions implemented in rural areas?
How do interventions affect productivity of patients at their worksites?
What are the development, implementation, and training costs associated with the intervention?

Implementation Considerations and Resources

Several resources offer guidance on the use and translation of team-based care interventions to control blood pressure.

The Surgeon General’s Call to Action to Control Hypertension (2020) provides team-based care strategies to promote and optimize care for blood pressure control.
The Hypertension Control Change Package from Million Hearts presents a list of process improvements that outpatient clinical settings can implement to promote blood pressure control. It is composed of change concepts, change ideas, and evidence- or practice-based tools and resources.

The CPSTF recommends the following intervention approaches that complement this one.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.