Hypertension
Blood Pressure Control—Implementing a Team Approach Barry L Carter, PharmD, FCCP, FAHA, FASH
Patrick E Keefe Professor of Pharmacy, Department of Pharmacy Practice and Science, College of Pharmacy and Professor and Associate Head for Research, Department of Family Medicine, Roy J and Lucille A Carver College of Medicine, University of Iowa
Abstract
There are many types of quality improvement strategies that can be used to improve blood pressure (BP) control. Team-based care models have achieved much higher rates of BP control than other strategies. Team-based care interventions have been shown to lead to improved 24-hour BP control and control is sustained when specific interventions are discontinued. In some cases, collaborative care is effective because there is greater opportunity to focus on behavioral approaches to improve patient self-efficacy and resulting medication adherence. In many cases, however, high BP control rates are achieved because of reduced clinical inertia and much more attention to frequent medication titration. In order to deliver team-based care for hypertension, the entire healthcare delivery system may need to be restructured to focus on chronic care rather than on acute, episodic care. The team can implement strategies to ensure adherence to office visits through reminders and telephone calls for missed appointments. Because healthcare teams can substantially improve outcomes, pay for performance and other approaches will make such approaches much more attractive to providers and health systems. Physicians and health system administrators should determine how they can incorporate team-based care for patients with hypertension.
Keywords Hypertension, blood pressure, team-care, collaborative management, home blood pressure monitoring, medication adherence, clinical inertia
Disclosure: Barry L Carter, PharmD, FCCP, FAHA, FASH, is supported in part from National Heart, Lung, and Blood Institute grants 1RO1 HL082711 and RO1 HL091841, the Agency for Healthcare Research and Quality (AHRQ) Centers for Education and Research on Therapeutics Cooperative Agreement #5U18HSO16094 and the Center for Research in Implementation in Innovative Strategies in Practice (CRIISP), Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (HFP 04-149). The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Received: June 9, 2011 Accepted: June 26, 2011 Citation: US Cardiology, 2011;8(2):108–13 Correspondence: Barry L Carter, PharmD, FCCP, FAHA, FASH, Department of Pharmacy Practice and Science, Room 527, College of Pharmacy, University of Iowa, Iowa City, IA 52242. E:
barry.carter@
uiowa.edu
A 2011 report from the American Heart Association states that “On the basis of 2007 mortality rate data, more than 2,200 Americans die of CVD every day, an average of 1 death every 39 seconds.”1
The economic cost
of cardiovascular disease (CVD) in the US was nearly $286 billion in 2007, which is 15 % of total healthcare expenditure.
There are 13 million people living with a diagnosis of CVD.2 Stroke is the
third leading cause of death and someone died every four minutes from stroke in 2007.1
to 2020 will be well over a trillion dollars.3
One estimate is that the projected cost of stroke from 2005 There were 1.1 million
hospitalizations for heart failure in 2007 at a projected cost of $10.5 billion.
There are many causes of poor BP control but poor patient adherence and failure to intensify therapy (clinical inertia) are two of the major reasons. This article will review team-based care strategies to improve BP control and will focus on more recent controlled trials and systematic reviews.
Uncontrolled hypertension is one of the major causes of all of these CVD events. The Centers for Disease Control and Prevention estimated that blood pressure (BP) was controlled in 46 % of the US population with hypertension.4
108
Meta-analyses and Systematic Reviews The Patient-centered Medical Home (PCMH) is a system of care that has received a great deal of attention lately even though the concept is not new.5–11
Some of the key components of the PCMH include system changes in healthcare delivery, self-management support, clinical information systems, delivery system redesign, decision support, healthcare organization, and community resources.12–15
A major change
in healthcare organization or delivery includes involving pharmacists or nurses as members of the healthcare team.16–18
A meta-analysis
identified 298 clinical trials in the US that evaluated pharmacist-provided direct patient care for various chronic conditions, and found significant improvements in glycated hemoglobin (HgA1c), low density lipoprotein cholesterol, BP, adverse drug events, medication adherence, quality of life, and patient knowledge (p<0.05).16
Another meta-analysis evaluated
37 controlled clinical trials that involved either pharmacist or nurse case management in hypertension and found such strategies were the most effective quality improvement approaches to achieve BP control.19
A meta-analysis of team-based care evaluated the potency of either nurse- or pharmacist-assisted management of hypertension.20
This © TOUCH BRIEFINGS 2011
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