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

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What the CPSTF Found

About The Systematic Review

The CPSTF recommendation is based on evidence from a review of 54 studies (search period January 2012 - June 2020). 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.

This recommendation updates and replaces the 2012 finding of strong evidence of effectiveness for team-based care to improve blood pressure control pdf icon [PDF – 460 KB]. This update focuses on evidence from studies published since 2012.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

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

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

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 $24,472, which is below a conservative threshold of $50,000.

The systematic economic review included 27 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 $311 (22 studies).
  • The median change in healthcare cost per patient per year was -$167 (13 studies).
  • The median total cost (intervention cost plus change in healthcare cost) per patient per year was $72 (15 studies with 17 estimates). A negative value indicates the averted healthcare cost is greater than the intervention cost.
    • 11 estimates were positive and 6 were negative.
  • The median ROI was -0.7 (12 studies). 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 favorable if the estimate is greater than zero.
    • 7 estimates were negative and 5 were positive.
  • The median cost per quality-adjusted life year (QALY) gained was $24,472 (11 studies).
    • Eleven of 12 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

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?)

  • 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?

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).