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Modeled Health and Economic Impact of Team-Based Care for Hypertension

      Introduction

      Team-based interventions for hypertension care have been widely studied and shown effective in improving hypertension outcomes. Few studies have evaluated long-term effects of these interventions; none have assessed broad-scale implementation. This study estimates the prospective health, economic, and budgetary impact of universal adoption of a team-based care intervention model that targets people with treated but uncontrolled hypertension in the U.S.

      Methods

      Analysis was conducted in 2014−2015 using a microsimulation model, constructed with various data sources from 1948 to 2014, designed to evaluate prospective cardiovascular disease (CVD)−related interventions in the U.S. population. Ten-year primary outcomes included prevalence of uncontrolled hypertension; incident myocardial infarction, stroke, CVD events, and CVD-related mortality; intervention and net medical costs by payer; productivity; and quality-adjusted life years.

      Results

      About 4.7 million (13%) fewer people with uncontrolled hypertension and 638,000 prevented cardiovascular events would be expected over 10 years. Assuming $525 per enrollee, implementation would cost payers $22.9 billion, but $25.3 billion would be saved in averted medical costs. Estimated net cost savings for Medicare approached $5.8 billion. Net costs were especially sensitive to intervention costs, with break-even thresholds of $300 (private), $450 (Medicaid), and $750 (Medicare).

      Conclusions

      Nationwide adoption of team-based care for uncontrolled hypertension could have sizable effects in reducing CVD burden. Based on the study’s assumptions, the policy would be cost saving from the perspective of Medicare and may prove to be cost effective from other payers’ perspectives. Expected net cost savings for Medicare would more than offset expected net costs for all other insurers.

      Introduction

      Since 1921, cardiovascular disease (CVD) has been the leading cause of mortality in the U.S., and hypertension is a major contributing risk factor for CVD.

      National Center for Health Statistics. Historical leading causes of death: leading causes of death, 1900-1998. NCHS Press Room: A Blog of the National Center for Health Statistics. Hyattsville, MD: U.S. DHHS, CDC, National Center for Health Statistics. 2007. www.cdc.gov/nchs/data/dvs/lead1900_98.pdf. Accessed August 31, 2009.

      CDC. Compressed Mortality File 1999−2010 on CDC WONDER Online Database. http://wonder.cdc.gov/cmf-icd10.html. Published 2013. Accessed June 28, 2014.

      • Chobanian A.V.
      • Bakris G.L.
      • Black H.R.
      • et al.
      Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
      Hypertension affects approximately one in three Americans and contributes to more than $42.9 billion in medical costs annually.
      • Valderrama A.L.
      • Gillespie C.
      • King S.C.
      • George M.G.
      • Hong Y.
      • Gregg E.
      Vital signs: awareness and treatment of uncontrolled hypertension among adults—United States, 2003-2010.
      • Go A.S.
      • Mozaffarian D.
      • Roger V.L.
      • et al.
      Heart disease and stroke statistics—2014 update: a report from the American Heart Association.
      Many effective and well-tolerated drug therapy options exist, with low-cost generics available in most therapeutic classes. Despite this, almost half of the population with hypertension does not meet recommended blood pressure (BP) goals.
      • Valderrama A.L.
      • Gillespie C.
      • King S.C.
      • George M.G.
      • Hong Y.
      • Gregg E.
      Vital signs: awareness and treatment of uncontrolled hypertension among adults—United States, 2003-2010.
      One promising policy to help those with uncontrolled hypertension is managing the disease with a coordinated care team. Team-based hypertension care involves the inclusion of adjunct or allied health professionals—including nurses, pharmacists, dietitians, social workers, and community health workers—in an existing relationship between a patient and primary care provider. Team member responsibilities may include medication management, patient follow-up, self-management support, and attention to adherence. System-level support for team-based care may include integrated use of electronic health records, home BP monitors, and emerging information technologies. An extensive body of research indicates that team-based care improves hypertension control and lowers BP through changes to prescribed medications, improved medication adherence, and improved lifestyle habits, and the care model has been recommended by the U.S. Community Preventive Services Task Force (Community Guide).
      Community Preventive Services Task Force
      Team-based care to improve blood pressure control: recommendation of the Community Preventive Services Task Force.
      Despite compelling evidence for the effectiveness of team-based hypertension care, prior studies have not addressed important dissemination and implementation questions involved with scaling up the intervention model to a broader sample of the U.S. population. This study seeks to bridge the research to practice gap by using a microsimulation model to estimate the potential health, economic, and budgetary impacts over 10 years for a scenario in which team-based hypertension care interventions targeting actively treated but uncontrolled BP patients are hypothetically implemented across the U.S.

      Methods

      Model Design and Analytic Approach

      Analyses were conducted using the HealthPartners Institute ModelHealthTM: Cardiovascular disease (ModelHealth: CVD) microsimulation model. ModelHealth: CVD is an annual-cycle microsimulation model, parameterized to estimate the lifetime incidence of CVD events and associated costs in a cross-section of individuals representative of the U.S. population. Appendix B (available online) provides a detailed description of the model.
      Disease outcomes in ModelHealth: CVD include incidence of myocardial infarction, stroke, congestive heart failure, angina pectoris, intermittent claudication, and CVD-related death. Events are predicted by 1-year risk equations estimated specifically for the model from Framingham Heart Study data.
      Framingham Heart Study−Cohort
      Framingham Heart Study−Offspring
      Event risk is based on a person’s age, sex, BMI, systolic BP (SBP), cholesterol levels, smoking status, and history of CVD.
      Annual progression of BMI is derived from recall data reported in the Behavioral Risk Factor Surveillance System,

      Behavioral Risk Factor Surveillance System Survey Data (2009). Atlanta, GA: U.S. DHHS, CDC; 2010. www.cdc.gov/brfss/annual_data/annual_2009.htm. Accessed May 25, 2011.

      and the natural history of SBP and cholesterol is estimated using Framingham Heart Study data.
      Framingham Heart Study−Cohort
      Framingham Heart Study−Offspring
      Tobacco initiation and cessation probabilities are derived from National Health Interview Survey data
      National Center for Health Statistics
      National Health Interview Survey, 2007.
      and published estimates from longitudinal studies.
      • Hughes J.R.
      • Keely J.P.
      • Niaura R.S.
      • Ossip-Klein D.J.
      • Richmond R.L.
      • Swan G.E.
      Measures of abstinence in clinical trials: issues and recommendations.
      • Wetter D.W.
      • Cofta-Gunn L.
      • Fouladi R.T.
      • Cinciripini P.M.
      • Sui D.
      • Gritz E.R.
      Late relapse/sustained abstinence among former smokers: a longitudinal study.
      Screening and treatment for hypertension and dyslipidemia in the model follow national clinical guidelines,
      • Chobanian A.V.
      • Bakris G.L.
      • Black H.R.
      • et al.
      Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
      Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143−3421.
      and identification and treatment adherence patterns are consistent with rates observed within the National Health and Nutrition Examination Survey.

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

      Use of antihypertensive and lipid-acting medications is modeled as an exogenous treatment effect on SBP and cholesterol, respectively, and alters disease risk accordingly.
      Disease costs in ModelHealth: CVD are estimated from the Medical Expenditure Panel Survey,

      Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. 2001−2010; http://meps.ahrq.gov/mepsweb/. Accessed March 22, 2013.

      with first-year and ongoing disease costs distinguished. Costs are apportioned by payer using an insurance submodel that assigns each simulated individual to a primary payer: private insurance, Medicaid, Medicare (including Medicare/Medicaid dual-eligibles), uninsured, or other/multiple insurance. Initial insurance status is derived from Current Population Survey data,
      • King M.
      • Ruggles S.
      • Alexander J.T.
      • et al.
      Integrated Public Use Microdata Series, Current Population Survey: 2009−2012.
      and year to year transitions are derived from Survey of Income and Program Participation data.

      Survey of Income and Program Participation. 2008. www.census.gov/programs-surveys/sipp/data/2008-panel.html. Accessed September 11, 2013

      Productivity measures in the model capture lost market and household productivity due to premature death, absenteeism, and presenteeism.
      • Grosse S.D.
      • Krueger K.V.
      • Mvundura M.
      Economic productivity by age and sex: 2007 estimates for the United States.
      • Mitchell R.J.
      • Bates P.
      Measuring health-related productivity loss.
      All monetary measures are presented in 2012 U.S. dollars.
      All analyses compare outcomes for a simulated population with nationwide access to a team-based care intervention for uncontrolled hypertension to the same population, all else held equal, without wide-scale access to this intervention. The intervention affects outcomes by lowering SBP in eligible people. Alternative parameter assumptions are assessed with sensitivity analysis. Results are representative of and scaled to the U.S. population aged ≥35 years, based on a simulated sample of 1 million people and with those aged 25−34 years aging into the cross-section over 10 years. Initial demographic characteristics for the modeled population are presented in Table 1.
      Table 1Baseline Characteristics of Intervention and Simulated U.S. Population Cross-Section (Aged 35+ Years)
      CharacteristicBaseline valueSource
      Population characteristics
       Population size (millions)162.8ACS

      Ruggles S, Alexander JT, Genadek K, Goeken R, Schroeder MB, Sobek M. Integrated Public Use Microdata Series: IPUMS-USA, American Community Survey 2011 3-yr Sample. Minneapolis, MN: Minnesota Population Center; 2013.

       Mean SBP, mmHg126.1NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        % Over goal20.6NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        % Treated22.0NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        Treated, mean SBP, mmHg142.0NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        % Treated over goal45.7NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

       Age, %NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        35−44 y25.3ACS

      Ruggles S, Alexander JT, Genadek K, Goeken R, Schroeder MB, Sobek M. Integrated Public Use Microdata Series: IPUMS-USA, American Community Survey 2011 3-yr Sample. Minneapolis, MN: Minnesota Population Center; 2013.

        45−54 y27.5ACS

      Ruggles S, Alexander JT, Genadek K, Goeken R, Schroeder MB, Sobek M. Integrated Public Use Microdata Series: IPUMS-USA, American Community Survey 2011 3-yr Sample. Minneapolis, MN: Minnesota Population Center; 2013.

        55−64 y22.6ACS

      Ruggles S, Alexander JT, Genadek K, Goeken R, Schroeder MB, Sobek M. Integrated Public Use Microdata Series: IPUMS-USA, American Community Survey 2011 3-yr Sample. Minneapolis, MN: Minnesota Population Center; 2013.

        65−74 y13.4ACS

      Ruggles S, Alexander JT, Genadek K, Goeken R, Schroeder MB, Sobek M. Integrated Public Use Microdata Series: IPUMS-USA, American Community Survey 2011 3-yr Sample. Minneapolis, MN: Minnesota Population Center; 2013.

        75 y+11.2ACS

      Ruggles S, Alexander JT, Genadek K, Goeken R, Schroeder MB, Sobek M. Integrated Public Use Microdata Series: IPUMS-USA, American Community Survey 2011 3-yr Sample. Minneapolis, MN: Minnesota Population Center; 2013.

       % Female52.4ACS

      Ruggles S, Alexander JT, Genadek K, Goeken R, Schroeder MB, Sobek M. Integrated Public Use Microdata Series: IPUMS-USA, American Community Survey 2011 3-yr Sample. Minneapolis, MN: Minnesota Population Center; 2013.

       Insurance status, %
        Private53.2CPS
      • King M.
      • Ruggles S.
      • Alexander J.T.
      • et al.
      Integrated Public Use Microdata Series, Current Population Survey: 2009−2012.
        Medicaid3.9CPS
      • King M.
      • Ruggles S.
      • Alexander J.T.
      • et al.
      Integrated Public Use Microdata Series, Current Population Survey: 2009−2012.
        Medicare24.9CPS
      • King M.
      • Ruggles S.
      • Alexander J.T.
      • et al.
      Integrated Public Use Microdata Series, Current Population Survey: 2009−2012.
        Uninsured15.1CPS
      • King M.
      • Ruggles S.
      • Alexander J.T.
      • et al.
      Integrated Public Use Microdata Series, Current Population Survey: 2009−2012.
        Other/multi2.8CPS
      • King M.
      • Ruggles S.
      • Alexander J.T.
      • et al.
      Integrated Public Use Microdata Series, Current Population Survey: 2009−2012.
       Mean BMI29.0NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        % Overweight72.4NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        % Obese40.9NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

       Mean LDL, mg/dL120.3NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        % Over goal28.3NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        % Treated22.5NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

       % Smokers17.4NHIS
      National Center for Health Statistics
      National Health Interview Survey, 2007.
        % With diabetes18.7NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

        % With previous CVD12.8NHANES

      National Health and Nutrition Examination Survey Data (2001−2002). Hyattsville, MD: U.S. DHHS, CDC; 2004. www.cdc.gov/nchs/nhanes/nhanes2001-2002/nhanes01_02.htm. Accessed April 5, 2011.

      National Health and Nutrition Examination Survey Data (2003−2004). Hyattsville, MD: U.S. DHHS, CDC; 2005. www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2005-2006). Hyattsville, MD: U.S. DHHS, CDC; 2007. www.cdc.gov/nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. Accessed April 25, 2011.

      National Health and Nutrition Examination Survey Data (2007−2008). Hyattsville, MD: U.S. DHHS, CDC; 2009. www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm. Accessed March 29, 2011.

      National Health and Nutrition Examination Survey Data (2009-2010). Hyattsville, MD: U.S. DHHS, CDC; 2011. wwwn.cdc.gov/nchs/nhanes/search/nhanes09_10.aspx. Accessed February 29, 2012.

      Intervention characteristics
       Acceptance of TBC intervention, %90Assumption
       Effect of TBC on SBP, mmHg ↓8.1
      • Magid D.J.
      • Olson K.L.
      • Billups S.J.
      • Wagner N.M.
      • Lyons E.E.
      • Kroner B.A.
      A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      • Bogden P.E.
      • Abbott R.D.
      • Williamson P.
      • Onopa J.K.
      • Koontz L.M.
      Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension.
      • Borenstein J.E.
      • Graber G.
      • Saltiel E.
      • et al.
      Physician-pharmacist comanagement of hypertension: a randomized, comparative trial.
      • Bosworth H.B.
      • Powers B.J.
      • Olsen M.K.
      • et al.
      Home blood pressure management and improved blood pressure control: results from a randomized controlled trial.
      • Carter B.L.
      • Bergus G.R.
      • Dawson J.D.
      • et al.
      A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control.
      • Carter B.L.
      • Ardery G.
      • Dawson J.D.
      • et al.
      Physician and pharmacist collaboration to improve blood pressure control.
      • Edelman D.
      • Fredrickson S.K.
      • Melnyk S.D.
      • et al.
      Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial.
      • Green B.B.
      • Cook A.J.
      • Ralston J.D.
      • et al.
      Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial.
      • Hill M.N.
      • Han H.R.
      • Dennison C.R.
      • et al.
      Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months.
      • Hunt J.S.
      • Siemienczuk J.
      • Pape G.
      • et al.
      A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension.
      • Magid D.J.
      • Ho P.M.
      • Olson K.L.
      • et al.
      A multimodal blood pressure control intervention in 3 healthcare systems.
      • Mehos B.M.
      • Saseen J.J.
      • MacLaughlin E.J.
      Effect of pharmacist intervention and initiation of home blood pressure monitoring in patients with uncontrolled hypertension.
      • Vivian E.M.
      Improving blood pressure control in a pharmacist-managed hypertension clinic.
      • Zillich A.J.
      • Sutherland J.M.
      • Kumbera P.A.
      • Carter B.L.
      Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study).
       TBC SBP effect persistence rate, %80Assumption
       TBC re-enroll period, y5Assumption
       TBC program costs, US$525Assumption
       TBC patient costs, US$362Assumption
       With included lipid effects (sensitivity analysis)
        Effect of TBC on LDL, mg/dL ↓11.9
      • Allen J.K.
      • Dennison-Himmelfarb C.R.
      • Szanton S.L.
      • et al.
      Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers.
      • Becker D.M.
      • Yanek L.R.
      • Johnson W.R.J.
      • et al.
      Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease.
      • Fiscella K.
      • Volpe E.
      • Winters P.
      • Brown M.
      • Idris A.
      • Harren T.
      A novel approach to quality improvement in a safety-net practice: concurrent peer review visits.
      • Haskell W.L.
      • Berra K.
      • Arias E.
      • et al.
      Multifactor cardiovascular disease risk reduction in medically underserved, high-risk patients.
      • Katon W.J.
      • Lin E.H.
      • Von Korff M.
      • et al.
      Collaborative care for patients with depression and chronic illnesses.
      • Litaker D.
      • Mion L.
      • Planavsky L.
      • Kippes C.
      • Mehta N.
      • Frolkis J.
      Physician−nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care.
      • Scott D.M.
      • Boyd S.T.
      • Stephan M.
      • Augustine S.C.
      • Reardon T.P.
      Outcomes of pharmacist-managed diabetes care services in a community health center.
        Effect of TBC on HDL, mg/dL ↑1.0
      • Allen J.K.
      • Dennison-Himmelfarb C.R.
      • Szanton S.L.
      • et al.
      Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers.
      • Becker D.M.
      • Yanek L.R.
      • Johnson W.R.J.
      • et al.
      Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease.
      • Fiscella K.
      • Volpe E.
      • Winters P.
      • Brown M.
      • Idris A.
      • Harren T.
      A novel approach to quality improvement in a safety-net practice: concurrent peer review visits.
      • Haskell W.L.
      • Berra K.
      • Arias E.
      • et al.
      Multifactor cardiovascular disease risk reduction in medically underserved, high-risk patients.
      • Katon W.J.
      • Lin E.H.
      • Von Korff M.
      • et al.
      Collaborative care for patients with depression and chronic illnesses.
      • Litaker D.
      • Mion L.
      • Planavsky L.
      • Kippes C.
      • Mehta N.
      • Frolkis J.
      Physician−nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care.
      • Scott D.M.
      • Boyd S.T.
      • Stephan M.
      • Augustine S.C.
      • Reardon T.P.
      Outcomes of pharmacist-managed diabetes care services in a community health center.
        TBC lipid effect persistence rate, %80Assumption
      ACS, American Community Survey; CPS, Current Population Survey; CVD, cardiovascular disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; NHANES, National Health and Nutrition Examination Survey; NHIS, National Health Interview Survey; SBP, systolic blood pressure; TBC, team-based care for hypertension.

      Literature Search and Abstraction

      Along with evidence reviews conducted by the Community Guide,
      • Walsh J.M.
      • McDonald K.M.
      • Shojania K.G.
      • et al.
      Quality improvement strategies for hypertension management: a systematic review.
      • Proia K.K.
      • Thota A.B.
      • Njie G.J.
      • et al.
      Team-based care and improved blood pressure control: a community guide systematic review.
      a number of other systematic reviews and meta-analyses on team-based hypertension care interventions were identified.
      • Carter B.L.
      • Rogers M.
      • Daly J.
      • Zheng S.
      • James P.A.
      The potency of team-based care interventions for hypertension: a meta-analysis.
      • Chisholm-Burns M.A.
      • Kim Lee J.
      • Spivey C.A.
      • et al.
      U.S. pharmacists’ effect as team members on patient care: systematic review and meta-analyses.
      • Clark C.E.
      • Smith L.F.
      • Taylor R.S.
      • Campbell J.L.
      Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis.
      • Glynn L.G.
      • Murphy A.W.
      • Smith S.M.
      • Schroeder K.
      • Fahey T.
      Interventions used to improve control of blood pressure in patients with hypertension.
      • Machado M.
      • Bajcar J.
      • Guzzo G.C.
      • Einarson T.R.
      Sensitivity of patient outcomes to pharmacist interventions. Part II: systematic review and meta-analysis in hypertension management.
      These sources identified 160 study arms related to team-based care for hypertension interventions. To incorporate more recent literature, PubMed was searched from the end of the search period of the most recent review (June 1, 2012) to July 25, 2013 for the terms hypertension AND (trial OR RCT) AND (team OR nurse OR pharmacist). This search yielded 56 articles, from which two studies
      • Magid D.J.
      • Olson K.L.
      • Billups S.J.
      • Wagner N.M.
      • Lyons E.E.
      • Kroner B.A.
      A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      were deemed relevant and included for a total of 162 study arms combined.
      Sixteen study arms met the inclusion and exclusion criteria as described in Appendix A (available online).
      • Magid D.J.
      • Olson K.L.
      • Billups S.J.
      • Wagner N.M.
      • Lyons E.E.
      • Kroner B.A.
      A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      • Bogden P.E.
      • Abbott R.D.
      • Williamson P.
      • Onopa J.K.
      • Koontz L.M.
      Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension.
      • Borenstein J.E.
      • Graber G.
      • Saltiel E.
      • et al.
      Physician-pharmacist comanagement of hypertension: a randomized, comparative trial.
      • Bosworth H.B.
      • Powers B.J.
      • Olsen M.K.
      • et al.
      Home blood pressure management and improved blood pressure control: results from a randomized controlled trial.
      • Carter B.L.
      • Bergus G.R.
      • Dawson J.D.
      • et al.
      A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control.
      • Carter B.L.
      • Ardery G.
      • Dawson J.D.
      • et al.
      Physician and pharmacist collaboration to improve blood pressure control.
      • Edelman D.
      • Fredrickson S.K.
      • Melnyk S.D.
      • et al.
      Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial.
      • Green B.B.
      • Cook A.J.
      • Ralston J.D.
      • et al.
      Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial.
      • Hill M.N.
      • Han H.R.
      • Dennison C.R.
      • et al.
      Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months.
      • Hunt J.S.
      • Siemienczuk J.
      • Pape G.
      • et al.
      A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension.
      • Magid D.J.
      • Ho P.M.
      • Olson K.L.
      • et al.
      A multimodal blood pressure control intervention in 3 healthcare systems.
      • Mehos B.M.
      • Saseen J.J.
      • MacLaughlin E.J.
      Effect of pharmacist intervention and initiation of home blood pressure monitoring in patients with uncontrolled hypertension.
      • Vivian E.M.
      Improving blood pressure control in a pharmacist-managed hypertension clinic.
      • Zillich A.J.
      • Sutherland J.M.
      • Kumbera P.A.
      • Carter B.L.
      Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study).
      Among these studies, an average weighted intervention effect of reducing SBP by 8.1 mmHg was found. Most interventions were implemented in a primary care setting, but two studies were conducted in a Veteran’s Administration medical center
      • Bosworth H.B.
      • Powers B.J.
      • Olsen M.K.
      • et al.
      Home blood pressure management and improved blood pressure control: results from a randomized controlled trial.
      • Edelman D.
      • Fredrickson S.K.
      • Melnyk S.D.
      • et al.
      Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial.
      and one involved community pharmacies.
      • Zillich A.J.
      • Sutherland J.M.
      • Kumbera P.A.
      • Carter B.L.
      Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study).
      Thirteen of the study arms included a pharmacist in the intervention team,
      • Magid D.J.
      • Olson K.L.
      • Billups S.J.
      • Wagner N.M.
      • Lyons E.E.
      • Kroner B.A.
      A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      • Bogden P.E.
      • Abbott R.D.
      • Williamson P.
      • Onopa J.K.
      • Koontz L.M.
      Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension.
      • Borenstein J.E.
      • Graber G.
      • Saltiel E.
      • et al.
      Physician-pharmacist comanagement of hypertension: a randomized, comparative trial.
      • Carter B.L.
      • Bergus G.R.
      • Dawson J.D.
      • et al.
      A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control.
      • Carter B.L.
      • Ardery G.
      • Dawson J.D.
      • et al.
      Physician and pharmacist collaboration to improve blood pressure control.
      • Edelman D.
      • Fredrickson S.K.
      • Melnyk S.D.
      • et al.
      Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial.
      • Green B.B.
      • Cook A.J.
      • Ralston J.D.
      • et al.
      Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial.
      • Hunt J.S.
      • Siemienczuk J.
      • Pape G.
      • et al.
      A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension.
      • Magid D.J.
      • Ho P.M.
      • Olson K.L.
      • et al.
      A multimodal blood pressure control intervention in 3 healthcare systems.
      • Mehos B.M.
      • Saseen J.J.
      • MacLaughlin E.J.
      Effect of pharmacist intervention and initiation of home blood pressure monitoring in patients with uncontrolled hypertension.
      • Vivian E.M.
      Improving blood pressure control in a pharmacist-managed hypertension clinic.
      • Zillich A.J.
      • Sutherland J.M.
      • Kumbera P.A.
      • Carter B.L.
      Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study).
      and others included registered nurses,
      • Bosworth H.B.
      • Powers B.J.
      • Olsen M.K.
      • et al.
      Home blood pressure management and improved blood pressure control: results from a randomized controlled trial.
      • Carter B.L.
      • Ardery G.
      • Dawson J.D.
      • et al.
      Physician and pharmacist collaboration to improve blood pressure control.
      • Edelman D.
      • Fredrickson S.K.
      • Melnyk S.D.
      • et al.
      Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial.
      nurse practitioners,
      • Hill M.N.
      • Han H.R.
      • Dennison C.R.
      • et al.
      Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months.
      health educators,
      • Edelman D.
      • Fredrickson S.K.
      • Melnyk S.D.
      • et al.
      Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial.
      and community health workers.
      • Hill M.N.
      • Han H.R.
      • Dennison C.R.
      • et al.
      Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months.
      All interventions included a medication management component, and for half of the study arms, team care providers were authorized to independently make changes to the patient’s treatment regimen.
      • Magid D.J.
      • Olson K.L.
      • Billups S.J.
      • Wagner N.M.
      • Lyons E.E.
      • Kroner B.A.
      A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      • Edelman D.
      • Fredrickson S.K.
      • Melnyk S.D.
      • et al.
      Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial.
      • Green B.B.
      • Cook A.J.
      • Ralston J.D.
      • et al.
      Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial.
      • Hill M.N.
      • Han H.R.
      • Dennison C.R.
      • et al.
      Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months.
      • Hunt J.S.
      • Siemienczuk J.
      • Pape G.
      • et al.
      A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension.
      • Magid D.J.
      • Ho P.M.
      • Olson K.L.
      • et al.
      A multimodal blood pressure control intervention in 3 healthcare systems.
      • Vivian E.M.
      Improving blood pressure control in a pharmacist-managed hypertension clinic.
      Eleven interventions also included patient education or behavioral counseling components,
      • Magid D.J.
      • Olson K.L.
      • Billups S.J.
      • Wagner N.M.
      • Lyons E.E.
      • Kroner B.A.
      A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      • Bogden P.E.
      • Abbott R.D.
      • Williamson P.
      • Onopa J.K.
      • Koontz L.M.
      Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension.
      • Bosworth H.B.
      • Powers B.J.
      • Olsen M.K.
      • et al.
      Home blood pressure management and improved blood pressure control: results from a randomized controlled trial.
      • Edelman D.
      • Fredrickson S.K.
      • Melnyk S.D.
      • et al.
      Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial.
      • Green B.B.
      • Cook A.J.
      • Ralston J.D.
      • et al.
      Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial.
      • Hill M.N.
      • Han H.R.
      • Dennison C.R.
      • et al.
      Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months.
      • Hunt J.S.
      • Siemienczuk J.
      • Pape G.
      • et al.
      A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension.
      • Magid D.J.
      • Ho P.M.
      • Olson K.L.
      • et al.
      A multimodal blood pressure control intervention in 3 healthcare systems.
      • Mehos B.M.
      • Saseen J.J.
      • MacLaughlin E.J.
      Effect of pharmacist intervention and initiation of home blood pressure monitoring in patients with uncontrolled hypertension.
      • Zillich A.J.
      • Sutherland J.M.
      • Kumbera P.A.
      • Carter B.L.
      Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study).
      and five included home BP monitoring/telemonitoring.
      • Magid D.J.
      • Olson K.L.
      • Billups S.J.
      • Wagner N.M.
      • Lyons E.E.
      • Kroner B.A.
      A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      • Carter B.L.
      • Ardery G.
      • Dawson J.D.
      • et al.
      Physician and pharmacist collaboration to improve blood pressure control.
      • Green B.B.
      • Cook A.J.
      • Ralston J.D.
      • et al.
      Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial.
      • Magid D.J.
      • Ho P.M.
      • Olson K.L.
      • et al.
      A multimodal blood pressure control intervention in 3 healthcare systems.
      Because hypertension management rarely occurs in isolation, evidence was reviewed for secondary benefits to lipid management resulting from team-based hypertension care. Among the seven studies that met the inclusion and exclusion criteria described in Appendix A (available online),
      • Allen J.K.
      • Dennison-Himmelfarb C.R.
      • Szanton S.L.
      • et al.
      Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers.
      • Becker D.M.
      • Yanek L.R.
      • Johnson W.R.J.
      • et al.
      Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease.
      • Fiscella K.
      • Volpe E.
      • Winters P.
      • Brown M.
      • Idris A.
      • Harren T.
      A novel approach to quality improvement in a safety-net practice: concurrent peer review visits.
      • Haskell W.L.
      • Berra K.
      • Arias E.
      • et al.
      Multifactor cardiovascular disease risk reduction in medically underserved, high-risk patients.
      • Katon W.J.
      • Lin E.H.
      • Von Korff M.
      • et al.
      Collaborative care for patients with depression and chronic illnesses.
      • Litaker D.
      • Mion L.
      • Planavsky L.
      • Kippes C.
      • Mehta N.
      • Frolkis J.
      Physician−nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care.
      • Scott D.M.
      • Boyd S.T.
      • Stephan M.
      • Augustine S.C.
      • Reardon T.P.
      Outcomes of pharmacist-managed diabetes care services in a community health center.
      the weighted average intervention effect was an 11.9 mg/dL reduction in low-density lipoprotein and a 1.0 mg/dL increase in high-density lipoprotein. These findings were incorporated into the sensitivity analysis.

      Intervention Design

      For this study, a hypothetical team-based hypertension intervention was designed—evidence-informed and adaptable to a wide variety of care settings—to involve referral by an existing care team to an adjunct hypertension management program involving a pharmacist or nurse with prescribing authority (either autonomously or under arrangement with a physician). All individuals newly diagnosed with hypertension were assumed to pursue usual care for the first year; thereafter, individuals actively taking BP medications but not under control (SBP≥140 mmHg) were eligible for referral to the intensive 1-year team-based intervention. It was assumed that 90% of referred people would accept, and that the persisting treatment effect in each subsequent year would be 80% of the prior year (such that the residual effect drops to about 10% by Year 10). It was also assumed that individuals with uncontrolled BP may re-enroll in the intervention once every 5 years.
      A microcosting approach was used to estimate the resources required to deliver this team-based intervention. Specifically, the composite design assumed four in-person visits and eight phone visits over 1 year. The first in-person visit was assumed to involve new patient intake and require a comprehensive 60-minute visit. Each additional in-person visit and all phone visits were assumed to be 15 minutes. All in-person and over-the-phone clinical costs were based on CPT 99211, an “incident-to-physician” billing procedure code used for charging medication therapy management pharmacy services.

      Stump AL. Creating a fee schedule for the pharmacist CPT codes based on revenue value units (RVUs). www.ashp.org/DocLibrary/MemberCenter/Webinars/Fee_Schedule_Revenue_Value_Units.aspx. Accessed July 25, 2013.

      The estimated typical market provision cost for a 15-minute team care visit was $35, based on analysis of payments for this procedure code by private insurers and patient out-of-pocket costs (assumed to be covered by the payer) reported in the 2012 Truven Health MarketScan® Commercial Claims and Encounters Database. For patient time, it was assumed the intake visit would require 3 hours, subsequent in-person visits would require 2 hours on average, including travel and waiting time, and phone visits would require 20 minutes of total patient time to account for any coordination required. Average hourly earnings plus benefits in 2012 ($31 per hour) were used to estimate the value of patient time.

      Bureau of Labor Statistics. Employer costs for employee compensation. www.bls.gov/news.release/archives/ecec_12112012.pdf. Published September 2012. Accessed March 29, 2013.

      Combined, the total estimated per-person cost of the year-long intervention was $887 ($525 in costs to the health system and $362 in patient time costs). Alternative cost scenarios to the health system were considered in the sensitivity analysis. Intervention characteristics are summarized in Table 1.

      Results

      Ten years after implementation, widespread adoption of the team-based care model would be expected to reduce the number of people with uncontrolled hypertension by 4.7 million—a reduction of about 13% (Table 2). Over 10 years, the team-based approach could be expected to prevent (or postpone) about 48 million person years of uncontrolled hypertension, 130,000 myocardial infarctions, 204,000 strokes, and 638,000 cardiovascular events in those aged ≥35 years. In addition, about 165,000 CVD-related fatalities would be averted over this period. The number of reduced person years with uncontrolled hypertension was similar between those aged 35−64 years and ≥65 years, but most of the prevented disease burden over 10 years was found among people aged ≥65 years.
      Table 2Health and Economic Outcomes from Broad-Scale TBC Adoption Across the U.S. Population
      VariablesStandard careStandard care with TBC10-Year difference95% CI
      All ages (35+ years)
       At 10 years
        Mean SBP, mmHg, treated persons138.7136.4−2.25−2.27, −2.23
        % Treated above goal42.332.0−10.3−10.5, −10.1
        Persons above goal (millions)35.230.5−4.72−4.82, −4.62
       Over 10 years
        Person-years above goal (millions)325.1277.3−47.8−48.4, −47.3
        Incident MI (thousands)7,6027,471−131.2−147.2, −115.2
        Incident stroke (thousands)5,3915,187−203.9−223.0, −184.9
        Incident CVD events (thousands)30,12829,490−638.0−674.4, −601.6
        Incident CVD death (thousands)7,7897,624−164.7−180.7, −148.6
        Total QALYs (thousands)1,664,0561,664,979922.6858.7, 986.5
        Total CVD costs, (billions US$)2,6502,624−25.29−27.08, −23.51
        Private insurance CVD costs (billions US$)800795−4.28−5.21, −3.35
        Medicare CVD costs (billions US$)1,4231,404−19.38−20.79, −17.98
        Medicaid CVD costs (billions US$)263262−0.82−1.10, −0.55
        Uninsured CVD costs (billions US$)9494−0.54−0.68, −0.40
        Other insurer CVD costs (billions US$)7070−0.27−0.41, −0.13
        Total productivity (billions US$)93,23293,24311.059.70, 12.39
      Aged 35−64 years
       At 10 years
        Mean SBP, treated persons, mmHg136.7134.9−1.86−1.89, −1.83
        % Treated above goal35.025.3−9.8−10.1, −9.4
        Persons above goal (millions)14.412.6−1.81−1.87, −1.75
       Over 10 years
        Person-years above goal (millions)150.9129.8−21.2−21.6, −20.8
        Incident MI (thousands)3,1033,069−34.8−44.6, −25.0
        Incident stroke (thousands)1,2611,237−24.4−32.5, −16.4
        Incident CVD events (thousands)10,91910,807−111.3−129.3, −93.3
        Incident CVD death (thousands)2,0161,995−21.0−28.3, −13.7
        Total QALYs (thousands)1,231,6721,231,772100.277.3, 123.0
        Total CVD costs (billions US$)1,2501,245−5.36−6.38, −4.34
        Private insurance CVD costs (billions US$)741737−3.48−4.37, −2.58
        Medicare CVD costs (billions US$)113112−0.64−0.85, −0.43
        Medicaid CVD costs (billions US$)258257−0.78−1.05, −0.51
        Uninsured CVD costs (billions US$)7474−0.25−0.34, −0.15
        Other insurer CVD costs (billions US$)6565−0.21−0.33, −0.09
        Total productivity (billions US$)82,82482,8251.660.96, 42.36
      Aged 65+ years
       At 10 years
        Mean SBP, treated persons, mmHg140.0137.4−2.52−2.54, −2.50
        % Treated above goal47.136.5−10.6−10.9, −10.3
        Persons above goal (millions)20.817.9−2.91−2.99, −2.84
       Over 10 years
        Person-years above goal (millions)174.2147.5−26.7−27.0, −26.3
        Incident MI (thousands)4,4994,403−96.4−109.0, −83.8
        Incident stroke (thousands)4,1303,950−179.5−196.8, −162.3
        Incident CVD events (thousands)19,21018,683−526.7−558.3, −495.1
        Incident CVD death (thousands)5,7735,630−143.7−158.1, −129.3
        Total QALYs (thousands)432,385433,207822.4763.5, 881.3
        Total CVD costs (billions US$)1,4001,380−19.93−21.35, −18.51
        Private insurance CVD costs (billions US$)5958−0.80−1.05, −0.56
        Medicare CVD costs (billions US$)1,3101,291−18.74−20.13, −17.36
        Medicaid CVD costs (billions US$)55−0.04−0.07, −0.01
        Uninsured CVD costs (billions US$)2020−0.29−0.40, −0.19
        Other Insurer CVD costs (billions US$)55−0.05−0.12, 0.01
        Total productivity (billions US$)10,40910,4189.398.26, 10.52
      Note: The incident CVD events rows combine incident MI, incident stroke, incident hospitalization for congestive heart failure, onset of angina pectoris, and onset of intermittent claudication. The 95% CI is based on a simulation of 1 million persons. All costs are presented in undiscounted 2012 U.S. dollars.
      CVD, cardiovascular disease; MI, myocardial infarction; SBP, systolic blood pressure; Stroke, ischemic and hemorrhagic stroke; QALYs, quality-adjusted life years; TBC, team-based care for hypertension.
      Over 10 years, costs to the healthcare system would be expected to total $22.9 billion, but would be offset by almost $25.3 billion in averted disease costs (Table 2, Table 3). Patient time costs would be expected to total approximately $15.8 billion over 10 years; however, these would be expected to be largely offset by productivity gains, which would total just above $11 billion. The policy would be expected to be cost saving for Medicare, with a net savings of $5.8 billion over 10 years.
      Table 3Summary of Intervention Costs Due to Broad-Scale Adoption of Team-Based Care for Hypertension
      VariableIntervention referrals (millions)Direct intervention costs (billions US$)Intervention patient time costs (billions US$)
      Private insurance11.856.234.29
      Medicare25.8913.609.36
      Medicaid2.801.471.01
      Uninsured2.231.170.81
      Other0.860.450.31
      All payers43.6322.9215.78
      Note: All costs are presented in undiscounted 2012 U.S. dollars. Direct intervention costs include all clinical costs borne by the healthcare system in adopting team-based care for hypertension. Intervention patient time costs correspond to the estimated personal time costs required for individual to participate in a team-based care program for hypertension.

      Sensitivity Analysis

      Predicted health outcomes were especially sensitive to three sources of uncertainty: the rate at which patients would accept and participate in the team-based intervention, the expected effect of that intervention on improving BP, and the long-term persisting effect of the intervention. Across each of these parameters, the effect on net outcomes was found to be approximately proportional with the relative change from the base case assumptions. For example, increasing the acceptance rate from 90% to 100% translated to a roughly 10% increase in net benefits (Table 4). Reducing the mean treatment effect from 8.1 to 4.1 mmHg SBP corresponded with an approximate 50% reduction in net benefits. Changing the frequency at which people can re-enroll in a team-based program had only a modest effect on health outcomes. For example, allowing annual re-enrollment added about 8% to the person years of avoided uncontrolled BP; never allowing re-enrollment (i.e., a limit of one lifetime referral) dropped this figure by 15%. The former would increase implementation costs by 130%, and the latter would lead to cost savings of 26%.
      Table 4Sensitivity to Parameter Changes in TBC Adoption Analysis for U.S. Population
      Variable10-Year cumulative difference between groups
      Person-years above goal (millions)Incident MI (thousands)Incident stroke (thousands)Incident CVD death (thousands)QALYs (thousands)Disease costs (billions US$)Intervention costs (billions US$)
      Base case−48−131−204−165923−2523
      Acceptance rate
       50%−27−72−109−93522−1410
       100%−53−146−231−1781,020−2825
      SBP effect
       4.1 mmHg−25−63−109−90503−1323
       12.1 mmHg−67−193−288−2311,356−3722
      SBP effect persistence rate
       50%−32−75−119−94600−1624
       100%−68−217−316−2501,338−4021
      Re-enrollment window
       Never−41−108−162−126826−2217
       1 year−52−158−243−1951,084−3153
      Intervention costs
       $200 per person−48−131−204−165923−259
       $1,200 per person−48−131−204−165923−2552
      Inclusion of lipid effects−48−192−210−2061,116−3123
      LDL effect
       6.9 mmHg−48−171−212−1901,054−3023
       16.9 mmHg−48−216−210−2251,199−3323
      HDL effect
       0.0 mmHg (no effect)−48−182−202−2001,064−3023
       2.0 mmHg−48−201−215−2111,145−3323
      Lipid effect persistence rate
       50%−48−163−209−1891,046−2923
       100%−48−226−213−2331,222−3423
      Note: Table data reflect the difference in outcomes between standard care and standard care with TBC. The SBP and lipid effect persistence rates indicate the percentage of the original treatment effect assumed for each subsequent year after the intensive intervention period. The TBC re-enrollment period refers to the length of time before a person may be eligible to be referred again to a TBC intervention. Intervention costs in this table refer to only the costs borne by the healthcare system in delivering the team-based hypertension care intervention. All costs are presented in undiscounted 2012 U.S. dollars.
      CVD, cardiovascular disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MI, myocardial infarction; QALYs, quality-adjusted life years; SBP, systolic blood pressure; Stroke, ischemic and hemorrhagic stroke; TBC, team-based care for hypertension
      Net costs were particularly sensitive to per-enrollee intervention costs. If the intervention cost the health system $200 per person, total implementation costs over 10 years would drop to $9 billion (−$16 billion net), but would increase to $52 billion ($27 billion net) if those costs were $1,200 per person. Break-even points for 1-year intervention costs relative to averted disease costs over 10 years are about $300 for private insurers, $450 for Medicaid, and $750 for Medicare.
      The effect of including a concomitant intervention benefit of improved lipid management among individuals with uncontrolled hypertension who also are being treated for dyslipidemia was also considered (Table 4). Allowing for a team care member to manage lipids along with BP—either through medications or lifestyle—would be expected to reduce incident myocardial infarctions by almost another 50%. Disease costs across the population would also be expected to drop an additional 25%. The inclusion of a lipid management benefit had little effect on incident stroke, in part because of the limited direct effect of lipids on stroke and the increased competing risk for stroke attributable to reduced coronary heart disease burden.

      Discussion

      This analysis shows that nationwide adoption of a team-based referral program for people with treated but uncontrolled hypertension would have sizeable health impacts and can be expected to reduce the number of individuals with uncontrolled hypertension by 4.7 million and prevent approximately 640,000 cardiovascular events and 165,000 CVD-related deaths in a 10-year period. Improving BP control rates for the reduction of CVD is a goal of the Million Hearts® initiative,
      • Tomaselli G.F.
      • Harty M.B.
      • Horton K.
      • Schoeberl M.
      The American Heart Association and the Million Hearts Initiative: a presidential advisory from the American Heart Association.
      the National Prevention Strategy,
      National Prevention Council
      National Prevention Strategy.
      and national quality improvement measures, such as the Healthcare Effectiveness Data and Information Set.

      National Committee for Quality Assurance. The state of health care quality 2014. http://store.ncqa.org/index.php/2014-state-of-health-care-quality-report.html. Accessed August 25, 2015.

      Opportunities for preventing CVD are greater for populations with higher disease prevalence (i.e., among people aged ≥65 years). Although the intervention would be cost saving for Medicare only, the net social savings to the healthcare system ($2.4 billion) leave room for a possible Kaldor−Hicks welfare-improving arrangement in which payers coordinate to ensure full benefits are realized.
      • Kaldor N.
      Welfare Propositions in economics and interpersonal comparisons of utility.
      • Hicks J.R.
      The foundations of welfare economics.
      Moreover, if intervention costs are a barrier and other approaches are not effective in lowering them, approximately 85% of the benefits can be achieved by offering enrollment in a team-based hypertension program only once for each person, with a corresponding cost savings of about 25%.
      From a policy implementation perspective, team-based care is an integral component of the patient-centered medical home payment and care delivery model that is being widely implemented, tested, and validated by both public and private insurers. With growing evidence from patient-centered medical home demonstration projects, the commitment to advance team-based, coordinated, and accessible care to transform primary care at the practice level has gained momentum and broad support from both the private and public sectors.

      Nielsen M, Langner B, Zema C, Hacker T, Grundy P. Benefits of implementing the primary care patient-centered medical home: a review of cost & quality results, 2012: Patient-Centered Primary Care Collaborative. www.pcpcc.org/sites/default/files/media/benefits_of_implementing_the_primary_care_pcmh.pdf. Published 2012. Accessed August 28, 2015.

      Congressional Budget Office. Lessons from Medicare’s demonstration projects on disease management, care coordination, and value-based payment 2012. www.cbo.gov/sites/default/files/cbofiles/attachments/01-18-12-MedicareDemoBrief.pdf. Accessed August 28, 2015.

      The new evidence provided in this paper may therefore be useful and relevant in informing decision makers in these efforts.

      Limitations

      Model results are always limited by data inputs. Literature reviews reveal a wide variety of intervention and study designs, eligible populations, and healthcare settings.
      • Walsh J.M.
      • McDonald K.M.
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      Quality improvement strategies for hypertension management: a systematic review.
      • Proia K.K.
      • Thota A.B.
      • Njie G.J.
      • et al.
      Team-based care and improved blood pressure control: a community guide systematic review.
      • Carter B.L.
      • Rogers M.
      • Daly J.
      • Zheng S.
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      The potency of team-based care interventions for hypertension: a meta-analysis.
      • Chisholm-Burns M.A.
      • Kim Lee J.
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      • et al.
      U.S. pharmacists’ effect as team members on patient care: systematic review and meta-analyses.
      • Clark C.E.
      • Smith L.F.
      • Taylor R.S.
      • Campbell J.L.
      Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis.
      • Glynn L.G.
      • Murphy A.W.
      • Smith S.M.
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      Interventions used to improve control of blood pressure in patients with hypertension.
      • Machado M.
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      Sensitivity of patient outcomes to pharmacist interventions. Part II: systematic review and meta-analysis in hypertension management.
      This makes the evaluation of an intervention that can be universally adopted difficult, and it is unlikely that a single program design will work effectively and identically across all care settings. As such, important limitations of this analysis include assumptions regarding intervention design, long-term effects, and intervention costs.
      The design of the team-based intervention for this study involved several choices. For example, this study required that a patient be actively using BP medications, but remain uncontrolled in their hypertension, to be eligible for the intervention. The definition of active medication use corresponds with the self-reported “currently taking” hypertension medications question in the National Health and Nutrition Examination Survey, which has been just above 60% among hypertensive patients in the U.S. in recent years.
      • Ho P.M.
      • Bryson C.L.
      • Rumsfeld J.S.
      Medication adherence: its importance in cardiovascular outcomes.
      This adherence stipulation was not required by any of the 16 studies from which treatment effects were derived, but uncontrolled hypertension was requisite and medication adherence at baseline in these studies was generally high (ranging from 60% to 90%, varyingly defined). These study populations demonstrated a high degree of engagement by self-selecting enrollment in a clinical trial, and the adherence requirement identifies a translational equivalent population within the general hypertensive populace. Finally, although team-based approaches to hypertension care may also be effective for people with controlled hypertension, this analysis focuses on a large, uncontrolled population for which the marginal value and organizational willingness to adopt a new approach to hypertension care is likely highest.
      Long-term follow-up data on team-based care interventions are lacking. Among the few studies with outcomes reported at multiple time points, no clear trend is revealed. For example, Hill et al.
      • Hill M.N.
      • Han H.R.
      • Dennison C.R.
      • et al.
      Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months.
      found continued BP improvement over time, Carter and colleagues
      • Carter B.L.
      • Coffey C.S.
      • Ardery G.
      • et al.
      Cluster-randomized trial of a physician/pharmacist collaborative model to improve blood pressure control.
      recently found BP improvements holding well 15 months after a 9-month intervention, and Margolis et al.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      found long-term incremental impact on BP diminishing over time. The latter finding was deemed most plausible; therefore, the base case results assume that BP improvements attenuate by 80% each year after the initial intervention. Because hypertension management can evolve over one’s lifespan, the analysis also incorporated repeated opportunities for intervention enrollment, as may be warranted and practical within the clinical setting. Table 4 shows that findings are relatively insensitive to re-enrollment opportunities but better data on long-term durability of team-based care interventions would improve precision of model results.
      Predicted intervention effects depend on baseline event rates in the model. Disease risk is not adjusted by race/ethnicity in ModelHealth: CVD, but model validation to National Health and Nutrition Examination Survey data suggests that differences in observable risk factors are generally sufficient to explain differences in observed disease rates, and this conclusion is supported by other recent evidence.
      • Berry J.D.
      • Dyer A.
      • Cai X.
      • et al.
      Lifetime risks of cardiovascular disease.
      Appendix B, Table B18 (available online) shows that ModelHealth: CVD event rates compare well with national prevalence data.
      An economic analysis by the Community Preventive Services Task Force
      • Jacob V.
      • Chattopadhyay S.K.
      • Thota A.B.
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      Economics of team-based care in controlling blood pressure: a community guide systematic review.
      found a mean team-based intervention cost of $284 per enrollee with an interquartile range ($153−$670) that encompasses this study’s estimated annual intervention cost of $525 per enrollee. Among the 16 study arms used to derive the base case effect, eight reported annualized intervention costs ranging from $35 to $1,350, with a mean of $618 and a median of $428.
      • Margolis K.L.
      • Asche S.E.
      • Bergdall A.R.
      • et al.
      Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.
      • Bosworth H.B.
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      Home blood pressure management and improved blood pressure control: results from a randomized controlled trial.
      • Edelman D.
      • Fredrickson S.K.
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      • Zillich A.J.
      • Sutherland J.M.
      • Kumbera P.A.
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      Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study).
      • Bosworth H.B.
      • Olsen M.K.
      • Dudley T.
      • et al.
      Patient education and provider decision support to control blood pressure in primary care: a cluster randomized trial.
      • Bosworth H.B.
      • Olsen M.K.
      • Grubber J.M.
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      Two self-management interventions to improve hypertension control: a randomized trial.
      If design efficiencies or patient cost sharing could lower the health system intervention cost to $200 per enrollee, net savings are predicted for all payers ($16 billion over 10 years, combined).
      Only one study that assessed direct cost savings from averted cardiovascular events for a team-based hypertension intervention was identified.
      • Bunting B.A.
      • Smith B.H.
      • Sutherland S.E.
      The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia.
      In this quasi-experimental pre−post study, they found approximately $730 per person per year in event cost savings. Five studies that assessed broader healthcare utilization were also found (e.g., outpatient visits, hospitalizations, or emergency encounters
      • Bosworth H.B.
      • Powers B.J.
      • Olsen M.K.
      • et al.
      Home blood pressure management and improved blood pressure control: results from a randomized controlled trial.
      • Bosworth H.B.
      • Olsen M.K.
      • Grubber J.M.
      • et al.
      Two self-management interventions to improve hypertension control: a randomized trial.
      • Datta S.K.
      • Oddone E.Z.
      • Olsen M.K.
      • et al.
      Economic analysis of a tailored behavioral intervention to improve blood pressure control for primary care patients.
      • Okamoto M.P.
      • Nakahiro R.K.
      Pharmacoeconomic evaluation of a pharmacist-managed hypertension clinic.
      • Reed S.D.
      • Li Y.
      • Oddone E.Z.
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      ) but none found statistically significant differences in these costs between intervention and control groups.

      Conclusions

      Despite numerous challenges and limitations, this analysis shows that wide-scale adoption of team-based programs to lower BP among people with uncontrolled hypertension shows good potential in improving hypertension control rates, reducing CVD, and stemming disease costs. No other study has considered the health and economic impacts of a nationwide adoption of team-based programs for hypertension care. These findings indicate that such programs could potentially accomplish at least two objectives of the Triple Aim
      • Berwick D.M.
      • Nolan T.W.
      • Whittington J.
      The triple aim: care, health, and cost.
      —improved outcomes and lower costs—and support their broader dissemination and implementation.

      Acknowledgments

      Publication of this article has been sponsored by the Centers for Disease Control and Prevention (CDC), Office of the Associate Director for Policy. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of CDC.
      The authors wish to acknowledge Zhuo Yang, in the Office of the Associate Director for Policy at CDC, for his data assistance and Anil Thota, formerly in the Community Guide Branch at CDC, for his subject matter expertise. Support for this study was provided under contract 200-2012-53738 with CDC.
      No financial disclosures were reported by the authors of this paper.

      Appendix. Supplementary data

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