Team-Based Care and Improved Blood Pressure Control: A Community Guide Systematic Review

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Context

Uncontrolled hypertension remains a widely prevalent cardiovascular risk factor in the U.S. team-based care, established by adding new staff or changing the roles of existing staff such as nurses and pharmacists to work with a primary care provider and the patient. Team-based care has the potential to improve the quality of hypertension management. The goal of this Community Guide systematic review was to examine the effectiveness of team-based care in improving blood pressure (BP) outcomes.

Evidence acquisition

An existing systematic review (search period, January 1980–July 2003) assessing team-based care for BP control was supplemented with a Community Guide update (January 2003–May 2012). For the Community Guide update, two reviewers independently abstracted data and assessed quality of eligible studies.

Evidence synthesis

Twenty-eight studies in the prior review (1980–2003) and an additional 52 studies from the Community Guide update (2003–2012) qualified for inclusion. Results from both bodies of evidence suggest that team-based care is effective in improving BP outcomes. From the update, the proportion of patients with controlled BP improved (median increase=12 percentage points); systolic BP decreased (median reduction=5.4 mmHg); and diastolic BP also decreased (median reduction=1.8 mmHg).

Conclusions

Team-based care increased the proportion of people with controlled BP and reduced both systolic and diastolic BP, especially when pharmacists and nurses were part of the team. Findings are applicable to a range of U.S. settings and population groups. Implementation of this multidisciplinary approach will require health system–level organizational changes and could be an important element of the medical home.

Section snippets

Context

Hypertension, defined as having systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg at two or more office visits or current use of BP-lowering medications,1, 2 remains the predominant risk factor for cardiovascular mortality in the U.S.3, 4 The prevalence of hypertension among U.S. adults (aged ≥18 years) from 2003 to 2010 was 30.4%—approximately 66.9 million adults.5 Estimated annual costs of hypertension are $93.5 billion per year1 and are projected to increase

Evidence Acquisition

Systematic review methods used by The Community Guide can be found at www.thecommunityguide.org/about/methods.html.18, 19 For this review, a coordination team was constituted, including subject matter experts on CVD from various agencies, organizations, and institutions together with qualified systematic reviewers from The Community Guide. The team worked under the oversight of the Community Preventive Services Task Force.

Evidence Synthesis

The existing systematic review by Walsh et al.17 included 28 studies published between January 1980 and July 2003. For the current Community Guide review (July 2003–May 2012), 1,628 potentially relevant titles and abstracts were found, of which 77 articles21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81,

Summary of Findings

There is strong evidence that team-based care is effective in improving BP outcomes, especially when pharmacists and nurses are part of the team. These findings are broadly applicable to various U.S. settings and population groups. Further, an independent Community Guide review99 of economic evidence indicates that team-based care for BP control is cost-effective. Implementation of this multidisciplinary team-based approach requires organizational change within the healthcare system.

Evidence Gaps

Although

Acknowledgments

The authors acknowledge Michael Schooley, David Callahan, Diane Dunet, and the Division for Heart Disease and Stroke Prevention (CDC) for their support at every step of the review. Barry Carter; Jeanette Daly (both at the University of Iowa); Kathryn MacDonald (Stanford University); and Paula Yoon (Division of Epidemiology, Analysis, and Library Services, CDC) provided guidance during the initial conceptualization. Kimberly Lane and Heba Athar (both CDC) contributed to review processes. Randy

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    Names and affiliations of the Community Preventive Services Task Force members can be found at www.thecommmunityguide.org/about/task-force-members.html

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