From Western University of Health Sciences College of Pharmacy, Department of Pharmacy Practice and Administration, Pomona, CA.
- Objective: To review the current literature regarding the clinical effectiveness and cost-effectiveness of implementing hypertension team-based care (TBC) interventions in the outpatient setting, and discuss challenges to implementation.
- Methods: A literature review was conducted of meta-analyses, systematic reviews, and randomized controlled trials comparing TBC models to usual care for hypertension management.
- Results: Compared to usual care, TBC models have demonstrated greater blood pressure reductions and improved blood pressure control rates. Evidence was strongest for models involving nurses and pharmacists whose roles included medication management, patient education and counseling, coordination of care and follow-up, population health management, and performance measurement with quality improvement. Although TBC results in an increase in health care costs, the overall long-term benefits support the cost-effectiveness of these models over usual care. The most common barriers to TBC implementation include underutilization of technology, stakeholder engagement, and reimbursement issues.
- Conclusion: Hypertension TBC models have been shown to be clinically effective and cost-effective, but continued research comparing different models is warranted to determine which combination of health professionals and interventions is most impactful and cost-effective in practice. An implementation science approach, in which TBC models unique to each organization’s situation are created, will be useful to identify and overcome challenges and provide a solid foundation for sustainment.
Keywords: blood pressure; pharmacist; nurse; nurse practitioner; cost-effectiveness; team-based care.
Approximately 1 in 3 US adults—or about 100 million people—have high blood pressure, and only about half (48%) have their blood pressure under control.1 Effective blood pressure management has been shown to decrease the incidence of stroke, heart attack, and heart failure.2-4 The American College of Cardiology/American Heart Association (ACC/AHA) 2017 blood pressure guidelines recommended lower thresholds for diagnosing hypertension and initiating antihypertensive medication, and intensified the blood pressure goal to less than 130/80 mm Hg.5 Changing practice standards to more intensive blood pressure goals requires significant adjustments by clinicians and health care systems. In fact, new guideline uptake is often delayed, ignored, or sparsely applied.6 Due to this dramatic change in hypertension practice standards, the ACC/AHA guidelines support interdisciplinary team-based care (TBC) for hypertension management.5,7 Additionally, the Centers for Disease Control and Prevention (CDC) and the Community Preventive Services Task Force (CPSTF) promote TBC to improve blood pressure control in their initiatives to prevent heart disease and stroke.8,9
The National Academy of Medicine defines TBC as “the provision of health services to individuals, families, and/or their communities by at least 2 healthcare providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care.”10 Specific goals for TBC in hypertension treatment are listed in Table 1, and a checklist of key elements of TBC to consider before implementation are presented in Table 2.
TBC has been shown to have many advantages, including increased access to care due to expanded hours of operation and shorter wait times.11 Team-based models also provide effective and efficient delivery of patient education, behavioral health care, and care coordination.12-14 Patients are more likely to receive high-quality care when multiple providers, each with varied expertise, are on the health care team.11,15 Furthermore, clinicians report improved professional job satisfaction related to their ability to practice in environments where they are encouraged to work at the top of their licenses.16 Consequently, TBC has been accepted as a vital part of the patient-centered medical home (PCMH) model.17-19 Standards set by the National Committee for Quality Assurance (NCQA) include TBC as a requirement health systems must meet in order to achieve the highest level of PCMH recognition. While a team-based approach offers substantial benefits and is recognized as a marker of quality, implementation has presented various challenges, and the sustainability of these models in care settings has been questioned.20
In this article, we review the current literature regarding the clinical effectiveness and cost-effectiveness of implementing hypertension TBC interventions in the outpatient setting. We also discuss the challenges and opportunities of implementing this strategy in health systems and community settings in the United States.