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Team-Based Care for Hypertension Management
Although blood pressure (BP) control has improved substantially in the last five decades, only half of the United States population with hypertension have adequate BP control. In contrast, BP control in some high-performing health systems is much better and can be as high as 80% to 90%. The strategies used by these high-performing systems may help other providers to improve BP control within their offices or health care settings.
There are many causes for poor BP control besides lifestyle choices, including suboptimal patient medication adherence and failure to intensify therapy (clinical inertia) by clinicians. Clinical inertia occurs when physicians do not intensify antihypertensives, perhaps because of concern about the predictive value or accuracy of clinic BP measurements, BP that was close to, but not at or below, goal, patient resistance to adding medications, lower home BP measurements, suspected white-coat hypertension, more urgent competing medical problems, or the patient stating they are experiencing more stress on the day of the clinic visit. However, many of these barriers could be overcome if the organizational structure of health care delivery adequately supported physicians and patients ( Fig. 48.1 ).
Hypertension health care delivery.
Many quality improvement strategies have been tried to improve BP including patient education, reminders, physician alerts, and others. Most of these had modest effects, with the exception of team-based care, which was the most effective strategy to improve BP.
The Patient-Centered Medical Home
The patient-centered medical home (PCMH) has been promoted to minimize episodic care, improve continuity, and provide more comprehensive management of chronic illness and preventive care. The PCMH was developed and endorsed by the American Academy of Family Physicians, American Academy Pediatrics, American College of Physicians, and is now a major component of Accountable Care Organizations within health care reform as a strategy to improve care quality at lower costs. The National Committee on Quality Assurance (NCQA) has developed standards and provided formal recognition of health plans and individual providers for many years. NCQA revised the standards to score health systems in 2014 ( Table 48.1 ). Although previous standards supported team-based care, the 2014 standards made team care an essential component of the PCMH by including it as one of the six key standards. Health systems that want to achieve the highest level (level 3, Table 48.1 ) of PCMH recognition must have well-functioning health care teams because this component is responsible for 20% of the total score. In addition, care management, medication management, care coordination, and coordination of care transitions are all functions typically performed by nonphysicians and make up another 14% of the score ( Table 48.1 ).
TABLE 48.1
National Center on Quality Assurance Patient-Centered Medical Home 2014 Content and Scoring of Practices on Progress Towards the Patient-Centered Medical Home
(Patient Centered Medical Home (PCMH 2014) Standards Training material is reproduced with permission from the National Committee for Quality Assurance (NCQA) website. Source: http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/RecognitionTraining/PCMH2014Standards.aspx . Last accessed: September 2016.)
| Standard 1: Enhance Access and Continuity | Points | Standard 4: Plan and Manage Care | |
Total points: |
Points 4.5 3.5 2 10 |
Total points: |
4 4 4 3 5 20 |
| Standard 2: Team-Based Care | Standard 5: Track and Coordinate Care | ||
Total points: |
3 2.5 2.5 4 12 |
Total points: |
6 6 6 18 |
| Standard 3: Population Health Management | Standard 6: Measure and Improve Performance | ||
Total points: |
3 4 4 5 4 20 |
Total points: |
3 3 4 4 3 3 0 20 |
| Scoring Levels | |||
|
|||
The standards also require medication reconciliation across health systems (e.g., between inpatient and primary care) for more than 80% of patients, families, and caregivers, providing information about new prescriptions to more than 80% of patients, assessing medications and barriers to adherence for more than 50% of patients, and documenting over-the-counter medications, herbal therapies, and supplements for more than 50% of patients.
The PCMH emphasizes that care should be organized around the needs of the patient, their relationship with their personal physician, and that physician-led teams assist with care according to the needs of the patient. The standards do not dictate who is on the team or how the team functions and communicates. However, the highest performing health systems have nurses, pharmacists, and behavioral health professions (e.g., counselors), and other critical members on this team. The physician delegates responsibility to other members of the team to perform a medication history, identify problems and barriers to achieving disease control, perform counseling on lifestyle modification, and adjust medications following hypertension guidelines. Frequent communication by team members concerning goal-directed therapy allows the physician to address more acute problems and complications. There is early evidence that the PCMH can be used to improve health care outcomes, increase physician satisfaction, and decrease the costs of health care. The personal relationship between the patient, physician, and the team has also been used to overcome barriers to care often seen in minorities or other vulnerable populations (see later).
Providers might assume that the PCMH standards apply only to those in typical primary care settings. However, the Referral Tracking and Follow-up standard 5B requires that providers have established agreements and criteria for specialists and the specialist be given the clinical question and type of referral. NCQA maintains a directory of specialists who have been recognized by NCQA as meeting the standards. Therefore, hypertension specialists and primary care providers who wish to become members of health systems and accountable care organizations will increasingly need to meet these standards.
The challenges of managing chronic conditions have led to strategies to provide care management, previously termed disease-state management. These programs usually focused on a given condition, such as hypertension. The PCMH demands more comprehensive programs that manage multiple conditions such as diabetes, dyslipidemia, hypertension, smoking cessation, and weight management, in an attempt to provide cardiac risk reduction. Large health systems may provide population-based strategies to target these patients, identify gaps in care, and guide these patients to programs that improve care. Smaller offices or clinics frequently do not have the resources to provide these comprehensive services because physicians are overworked and the offices do not have resources to hire key team members. Our research team is studying the effect of a centralized cardiovascular risk service in two clinical trials that can provide remote clinical pharmacy services to private physician offices and even patients in rural areas (see later).
Team-Based Care of Hypertension
Systematic Reviews
Care management within the PCMH emphasizes changes in health care delivery, self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources. One of the most studied areas of system redesign, or organizational change, is the inclusion of pharmacists or nurses as members of the health care team.
Walsh and colleagues evaluated 63 controlled studies using various quality improvement strategies to improve BP control such as patient education, physician reminders, or other approaches. These investigators found that the only statistically significant improvement in BP occurred with organizational change, which included team-based care (37 comparisons), and resulted in a median reduction in systolic BP (SBP) of 9.7 mm Hg and a 21.8% net increase in SBP control. Another meta-analysis of pharmacy based-interventions evaluated 13 studies that included 2200 individuals and found that pharmacists’ interventions significantly reduced SBP (10.7 ± 11.6 mm Hg; p = 0.002), whereas controls remained unchanged. A meta-analysis evaluated 39 randomized controlled trials in 14,224 patients and found pharmacist interventions reduced SBP by 7.6 mm Hg (95% confidence interval [CI]: −9.0 to −6.3 mm Hg) compared with usual care.
A meta-analysis evaluated 37 controlled clinical trials that involved either pharmacist or nurse case management of hypertension. The type of practitioner and training varied considerably. Although the Pharm.D degree is the only professional degree now awarded in pharmacy, at the time many of these studies were conducted, some pharmacists had a Bachelor of Science degree. Most studies that specified qualifications for nurses involved registered nurses (RN) or nurse practitioners. Nearly all studies involving nurses or pharmacists embedded within clinics provided for dedicated case management activities. Community pharmacists, however, usually had to incorporate the intervention within traditional medication dispensing functions. One goal of this meta-analysis was to evaluate the potency of individual components of team-based care interventions ( Table 48.2 ). The most effective strategies to reduce SBP were when the pharmacist made treatment recommendations to the physician (−9.3 mm Hg), the nurse or pharmacist educated the patient about their medications (−8.75 mm Hg), the pharmacists made the medication intervention changes (−8.44 mm Hg), medication adherence was assessed and addressed by the pharmacist or nurse (−7.9 mm Hg), counseling about lifestyle modification was performed (−7.59 mm Hg), or the nurse made the medication intervention changes (−4.8 mm Hg). When we examined the odds ratios for controlled BP with either nurses, pharmacists in clinics, or community pharmacists, all three types of interventions were significant ( Table 48.3 ), although the pharmacy interventions appeared to be more potent.
TABLE 48.2
Components of Team-Based Care Shown to Improve Blood Pressure
(Data adapted from Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med . 2009;169:1748-1755.)
| Type of Individual Intervention | Median Reduction in Systolic Blood Pressure (Mm Hg) | Median Reduction in Diastolic Blood Pressure (Mm Hg) |
|---|---|---|
| Pharmacist made treatment recommendation to physician | −9.30 a | −3.60 |
| Patient education provided | −8.75 b | −3.60 b |
| Pharmacist conducted the medication intervention | −8.44 | −3.30 |
| Medication adherence assessed and addressed | −7.90 | −3.25 |
| Provided lifestyle modification counseling | −7.59 | −3.30 |
| Nurse conducted the medication intervention | −4.80 a | −3.10 |
b p < 0.05 for Mann-Whitney analysis of reduction in systolic blood pressure and diastolic blood pressure comparing studies with the specific intervention strategy with those without it.
TABLE 48.3
Odds Ratios for Controlled Blood Pressure With Team-Based Interventions
Adapted from Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med . 2009;169:1748-1755.
| Type of Care Management | Odds Ratio | 95% Confidence Interval |
|---|---|---|
| Interventions by nurses | 1.69 | 1.48-1.93 |
| Interventions by pharmacists within clinics a | 2.48 | 2.05-2.99 |
| Interventions by pharmacists within community pharmacies | 2.89 a | 1.83-4.55 a |
a Includes an additional study in 410 patients published after the meta-analysis was published from Carter BL, Ardery G, Dawson JD, et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med . 2009;169:1996-2002.
A meta-analysis of nurse-led interventions with treatment algorithms showed greater reductions in SBP (−8.2 mm Hg, 95% CI −11.5 to −4.9) compared with usual care but no difference in BP control. When results were pooled, nurse interventions significantly lowered SBP compared with usual care in African Americans but there was little difference for other ethnic minority groups.
The Community Prevention Services Task Force conducted a systematic review of team-based care in 2014. The study evaluated 52 international studies involving pharmacists and nurses and 41% of the trials involved a majority of African Americans. BP control was improved by a median of 12 percentage points (interquartile interval [IQI] 3.2, 20.8), SBP 5.4 mm Hg (2.0, 7.2) and diastolic blood pressure (DBP) 1.8 mm Hg (0.7, 3.2). The percent improvement in BP control was “considerably higher” when pharmacists were added (22.0%), compared with nurses (8.5%) or nurses plus pharmacists (16.2%). The improvement was much greater when the team member could make independent changes (17.4%) compared with those that required PCP approval (15.0) or support only (7.9%).
Cost-Effectiveness Analyses
Until recently, few cost-effectiveness studies had been conducted but several studies have now assessed the cost-to-benefit ratio of team-based care. Total costs for the pharmacist-managed group were similar to those in the physician-managed clinic group ($242.46 versus $233.20, p = 0.71), but cost effectiveness ratios were lower in the pharmacist-managed group ($27 versus $193/mm Hg for SBP readings, and $48 versus $151/mm Hg for DBP readings). The authors concluded that pharmacist management was cost effective.
We evaluated the cost of a 6-month intervention by pharmacists embedded within primary care clinics from two clinical trials involving 496 subjects. Total adjusted costs were $775 in the intervention group and $446 in the control group (difference $329.16, p < 0.001). Total costs between the two groups ranged from $224 to $516 with a sensitivity analysis. The cost to lower SBP 1 mm Hg was $36.
We conducted the Collaboration Among Pharmacist and Physicians to Improve Blood Pressure Now (CAPTION) trial that randomized 625 patients from 32 medical offices in 15 states. Each office had an existing clinical pharmacist on staff. Cost-effectiveness ratios were calculated based on changes in BP measurements and hypertension control rates. Thirty-eight percent of patients were African American, 14% were Hispanic, and 49% had annual income less than $25 000. At 9 months, average SBP was 6.1 mm Hg lower (±3.5), DBP was 2.9 mm Hg lower (±1.9) in the intervention group compared with the control group. Total costs for the intervention group were $1462.87 (±132.51) and $1259.94 (±183.30) for the control group, a difference of $202.93. The cost to lower BP by 1 mm Hg was $33.27 for SBP. The cost to increase the rate of hypertension control by 1 percentage point in the study population was $23.
The Community Prevention Services Task Force evaluated costs of team-based care. They determined that the cost to provide either a nurse or pharmacist intervention was $198 per year. The cost to reduce SBP 1 mm Hg was $87 which is much higher than our cost analyses in the two studies above. However, when these authors examined the 20-year cost per quality-adjusted life years (QALY) gained, the cost for the nurse intervention was $16,696 to $24,042 whereas it was $7,114 to $10,244 for pharmacists and “other.”
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