Cost-effectiveness and challenges of implementing intensive blood pressure goals and team-based care

Abstract

Purpose:

Review the effectiveness, cost-effectiveness, and implementation challenges of intensive blood pressure (BP) control and team-based care initiatives.

Recent Findings:

Intensive BP control is an effective and cost-effective intervention, yet implementation in routine clinical practice is challenging. Several models of team-based care for hypertension management have been shown to be more effective than usual care to control BP. Additional research is needed to determine the cost-effectiveness of team-based care models relative to one another and as they relate to implementing intensive BP goals.

Summary:

As a focus of healthcare shifts to value (i.e., cost, effectiveness, and patient preferences), formal cost-effectiveness analyses will inform which team-based initiatives hold the highest value in different healthcare settings with different populations and needs. Several challenges, including clinical inertia, financial investment, and billing restrictions for pharmacist-delivered services, will need to be addressed in order to improve public health through intensive BP control and team-based care.

Introduction

Globally, high blood pressure (BP) is the leading modifiable risk factor for cardiovascular morbidity and mortality [1–3]. Of the 116 million American adults with hypertension, 53.4% are treated, and 24.7% are both treated and have controlled BP [4]. Given the widespread availability of low-cost, effective antihypertensive medications, uncontrolled BP represents a missed public health opportunity for the prevention of cardiovascular, neurologic, and renal diseases.

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) BP guidelines lowered the threshold for defining hypertension and recommended a more intensive BP threshold for initiation and intensification of antihypertensive medication. Implementing and maintaining these more intensive BP goals requires significant culture shifts and investments by health systems. To achieve and maintain lower BP treatment goals, the ACC/AHA guidelines endorse comprehensive, team-based care (TBC) for hypertension management [5–7]. Furthermore, the Centers for Disease Control and Prevention recently incorporated TBC into its strategic initiatives to improve BP control [8].

Health systems are tasked with maximizing the value of healthcare services by improving quality and patient satisfaction while controlling costs [9]. In the context of hypertension management, clinicians and health systems must carefully consider the logistics of targeting intensive BP goals and, where needed, how to implement TBC programs to reach intensive BP goals. These health services must be effective and cost-effective while considering patient preferences and quality of life [10–13].

The objective of this review is to appraise the current literature regarding the effectiveness and cost-effectiveness of intensive systolic BP (SBP) goals and implementation of TBC interventions. We also discuss challenges of implementing these strategies within health systems in the US.

Cost-effectiveness analysis translates evidence from diverse sources to quantify the value of healthcare interventions

Cost-effectiveness analysis (CEA) provides a framework for payers, population health managers, governments, and clinicians to quantify the incremental health benefits, costs, and downstream consequences of an intervention relative to other options. While CEA incurs criticisms regarding uncertainty about how both cost and health outcome inputs are estimated, these analyses reveal the underlying assumptions clinicians make when considering a new therapy compared to a previous standard (e.g., how much weight to place on risk vs. benefit when initiating a medication therapy for a particular patient demographic). As such, decision-makers in the US have historically been reluctant to use CEA formally to prioritize health services [14]. However, the ACC and AHA recommend that CEAs be used in creating treatment guidelines and recently used them to make recommendations for lipid lowering treatments [15,16]. The 2018 ACC/AHA Cholesterol Management Guidelines acknowledged that proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, a novel antihyperlipidemic class, are low value for most patients at conventional cost-effectiveness thresholds and recommended maximally tolerated statins and ezetimibe be used first in high-risk patients [16–18].

High-quality evidence supports the cost and population health impacts of widespread achievement of standard BP goals (i.e., SBP/diastolic [DBP] <140/90 mm Hg). One analysis found that if 100% of guideline-recommended services were successfully implemented, the incremental cost per person newly-attaining BP treatment goals over two years would be $1,696 (2009 US Dollars [USD]) overall, $801 for moderate hypertension, and $850 for severe hypertension [19]. Additionally, treating to a standard SBP/DBP goal of <140/90 mm Hg is cost-saving or cost-effective in most age and sex groups [20,21].

Targeting intensive BP goals reduces CVD risk compared to standard goals

Meta-analyses of randomized trials of BP-lowering show that targeting an intensive SBP goal (i.e., lower by at least 10 mm Hg or to less than 130 mm Hg) results in a larger relative risk reduction in all-cause mortality and cardiovascular disease (CVD) events, compared to targeting standard BP goals (e.g., <140 mm Hg) [22–24]. In 2015, SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated that treating to an intensive SBP target of <120 mm Hg compared to a standard target of <140 mm Hg significantly reduced all-cause mortality and CVD events among high CVD risk adults without a history of diabetes, stroke, or heart failure [25]. With and without the SPRINT results, a meta-analysis of 42 BP-lowering trials with 144,220 participants concluded that achieving an SBP of 120–124 mm Hg was associated with a significantly lower risk of CVD events compared to groups with higher achieved SBP [22]. These data prompted the 2017 ACC/AHA BP guidelines to recommend a SBP/DBP goal of <130/80 mm Hg in treated adults less than 65 years old with prior CVD or a 10-year CVD risk greater than 10%, and an SBP goal of <130 mm Hg for adults aged 65 years or older [5]. Over ten years, achieving and maintaining the 2017 ACC/AHA BP goals compared with achieving 2003 Seventh Joint National Committee Report goals or achieving 2014 Eighth Joint National Committee goals is projected to prevent 0.5 million (95% confidence interval [CI], 0.2–0.7 million) or 1.4 million (95% CI, 0.6–2.0 million) CVD events, respectively [26].

Concerns remain that the benefits of targeting intensive SBP goals as described in SPRINT and meta-analyses do not apply to all patient populations, particularly those with diabetes. The ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure) trial used a double 2×2 factorial design to simultaneously investigate BP, lipid, and glycemic control interventions. Participants were randomized to BP goals identical to SPRINT: <120 mm Hg or <140 mm Hg. After one year, there were no differences between the BP treatment groups for the primary composite outcome of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes (hazard ratio [HR] 0.88, 95% CI 0.73 to 1.06) [27]. However, among ACCORD-BP participants in the standard glycemia treatment arm, targeting an intensive SBP did significantly reduce CVD events similar to the risk reduction observed in SPRINT (HR 0.74; 95% CI 0.55 to 1.00) [28]. In a post-hoc analysis of SPRINT, the benefits of targeting intensive SBP goals were similar among those with and without prediabetes and were not attenuated by higher serum glucose levels at baseline [29].

Cost-effectiveness of intensive vs. standard BP control

The benefits of targeting intensive SBP goals (e.g., decreased CVD events and improved survival) must be weighed against the potential harms (e.g., serious adverse events [SAE]) and implementation and maintenance costs (e.g., additional office visits, laboratory tests, personnel, and medications). Early CEAs of SPRINT data found intensive SBP goals were cost-effective (Table 1) [30,31], but these analyses assumed lifetime persistence of the benefits of intensive control or did not account for costs of treating non-cardiovascular diseases.

Table 1:

Studies assessing the cost-effectiveness of intensive systolic blood pressure control

Author (Year) [Reference]	Country	Comparators	Clinical inputs	Model Description	Costs considered	Time Horizon	Perspective	Base Case ICER
Moise (2016) [30]	United States	JNC8 Guideline strategies alone* vs. Guideline-directed strategies* + “Intensive” strategy to SBP <120 mm Hg in select groups	CVD Policy Model + SPRINT	Markov model	Background health care, acute and chronic CVD, medications, monitoring, side effects	Lifetime	Payer	Men Cost-saving for both guidelines+intensive Women Cost-saving for JNC8+intensive $21,000 2016 USD per QALY gained for JNC7+intensive strategy
Richman (2016) [31]	United States	SBP <140 mm Hg vs. SBP <120 mm Hg	SPRINT	Markov model	Background medical costs, acute and chronic CVD events, medications, physician visits, adverse events	Lifetime	Not reported	$23,777 2016 USD per QALY gained
Lee (2016) [98]	Korea	SBP <140 mm Hg vs. SBP <120 mm Hg	SPRINT	“Decision model”	Medications, CVD events	Not reported	Not reported	2,513,799 Korean won (~$2,302 2014 USD†) per QALY gained
Bress and Bellows (2017) [32]	United States	SBP <140 mm Hg vs. BP <120 mm Hg	SPRINT	Microsimulation	Medications, office visits, laboratory monitoring, acute and chronic CVD, adverse events, background non-CVD health care	Lifetime	Payer	$46,546 2017 USD per QALY gained

Abbreviations: CVD: Cardiovascular Disease; ICER: Incremental Cost-Effectiveness Ratio; JNC7: Seventh Joint National Committee; JNC8: Eighth Joint National Committee; QALY: Quality-Adjusted Life Year; SBP: Systolic Blood Pressure; SPRINT: Systolic Blood Pressure Intervention Trial; USD: United States Dollars

^*Analyses were completed for JNC-7 goals and JNC-8 goals. Goals varied based on age and presence of diabetes or CKD

^†In 2014, 1 US Dollar = 1,091.85 Korean won.

A model developed by the SPRINT Research Group estimated healthcare costs and quality-adjusted life years (QALY) gained from targeting intensive versus standard SBP goals in SPRINT-eligible US adults over a lifetime time horizon [32]. The model incorporated decays in medication adherence and treatment effects, a range of treatment costs and office visit frequencies, and varying baseline SAE and CVD event rates. The analysis showed targeting an intensive SBP goal was cost-effective according to accepted cost-effectiveness thresholds regardless of whether treatment benefits decayed or persisted beyond the end of SPRINT follow-up (median follow up 3.26 years) [15,33]. The incremental cost-effective ratio (ICER) was ~$47,000/QALY gained (2015 USD) for intensive goals relative to standard goals if effects decayed over time, and ~$28,000/QALY gained if treatment effects persisted over a lifetime. A scenario analysis found that the baseline risk of SAEs observed in SPRINT would need to be inflated by a factor of 2.8, or the SAE risk with the intensive treatment alone would need to be increased by a factor of 1.6, in order for the ICER to be greater than $50,000/QALY gained. Varying the number of office visits per year and medication prices did not significantly impact the results.

Opportunities and challenges

Targeting more-intensive SBP goals is effective and cost-effective in high CVD risk populations, yet applying and implementing intensive goals to the guideline-directed patient population with hypertension represents a deviation from the status quo. Nearly 1 in 3 US adults with treated hypertension have BP greater than previous guideline-recommended targets of <140/90 mm Hg [34]. As such, more-intensive SBP goals have not been widely adopted by clinicians, health systems, or professional societies.

Several challenges limit widespread implementation of intensive BP targets. First, in order to attain the lower SBP thresholds as demonstrated in SPRINT, clinical practice would need to mirror both the high-quality measurement of BP and treatment with medications (combinations and doses) used in SPRINT [35]. In SPRINT, BP was measured three times using an automated device (Omron HEM 907XL) at each clinic visit after a five-minute rest period [36], which typically takes 8–10 minutes [37]. For many clinics and health systems, the real and perceived constraints on space, staffing, and time limit the ability to measure and treat BP as performed under research conditions [38].

Additionally, targeting more-intensive BP goals has significant implications for medication management. Achieving lower BP may require more medications, improved adherence, higher doses, or all of these. Patients with hypertension at high risk of CVD events are likely to have multiple comorbidities and high existing medication burden, including non-antihypertensive medications [39]. Thus, medication adherence, drug interactions, and patient satisfaction and acceptance become important concerns when considering whether to add more antihypertensive medications or increase antihypertensive medication doses. When all else is equal, medication regimens that are less complex (e.g., single-pill combinations, less-frequent daily dosing) should be favored for the benefit of improved medication adherence [40–42]. The optimal doses and combinations of evidence-based antihypertensive medication classes to achieve intensive goals are unknown. It is even less clear how intensive SBP goals should be broadly applied to treatment decisions in populations that were excluded from SPRINT (e.g., age <50 years, prior diagnosis of diabetes, stroke, or heart failure).

Beyond logistics, integrating more-intensive BP goals into clinical practice will be challenging at the prescriber level. Clinical inertia, the phenomenon of not initiating or intensifying therapy at the point of care despite a BP reading that is above goal, is highly prevalent in hypertension management [43,44] and may be a key factor preventing BP control [45]. Several factors associated with the patient, provider, and system elicit clinical inertia [46], such as low health literacy, insufficient provider-patient time, or lack of protocols. Clinical inertia must be distinguished from clinical uncertainty, which may result from variability in BP measurement, poor quality data on medication adherence, or other modifiable factors. Indeed, both clinical inertia and clinical uncertainty may affect the implementation of an appropriate therapeutic regimen, reducing the likelihood of attaining intensive SBP goals.

Nonetheless, improved hypertension treatment and control rates can be achieved. Health systems like Kaiser Permanente and the Department of Veterans Affairs have successfully achieved BP control rates of 80% to standard goals among those with treated hypertension using standardized protocols and TBC [47,48]. Systematic, durable, multi-faceted interventions are needed to improve hypertension control. Using TBC has great potential to expand capacity and mitigate challenges that directly affect BP control rates.

Team-based care is more effective than usual care

TBC can be delivered with a wide variety models and more effectively lowers BP than usual care [12]. The types of TBC models studied are diverse and include non-physician provider clinic visits, utilizing non-physician providers (i.e., nurses, nurse practitioners [NP], physician assistants [PA], or pharmacists) to manage hypertension, and optimizing patient education and support personnel [12,49,50]. One recent meta-analysis of over 100 trials and 55,920 patients concluded that the most effective BP-lowering strategies use multilevel, multicomponent approaches to address barriers to hypertension control and often involve non-physician providers assessing the patients, measuring BP and laboratory values, then titrating medications [51]. Compared with usual care, TBC with non-physician medication titration resulted in a 7.1 mm Hg mean SBP reduction, and TBC with physician medication titration resulted in a 6.2 mm Hg mean SBP reduction. Similar trends were observed with DBP reductions.

Pharmacists are widely employed in TBC for hypertension management [12,49–52]. In one randomized trial of 625 patients, 43% of patients achieved BP control at nine months under pharmacist-physician collaboration, compared to 34% of those participating in usual care [53]. In another study of 450 patients, combining pharmacists with telehealth management yielded BP control rates greater than 70%, significantly more than the 45% of participants who achieved BP control via usual care [54]. Additionally, a pharmacist-led intervention in a community setting for non-Hispanic Black male patrons of barbershops with uncontrolled BP resulted in a mean SBP reduction of 21.6 mm Hg greater than usual care at six months [55]. The effects of pharmacist-provided hypertension care often persist beyond the initial intervention period [56,57]. Strong patient-pharmacist and community relationships in addition to individualized treatment plans have been considered as drivers for these successful interventions [57–59].

Nurses are also widely used for effective hypertension management in TBC models [60–62]. One meta-analysis of national and international studies that stratified results by specific nurse-led interventions found a mean decrease in SBP from baseline of 8.2 mm Hg with nurse management using treatment algorithms, and 8.9 mm Hg with nurse prescribing [62]. Another meta-analysis of 11 national and international nurse-led interventions to improve BP control in patients with diabetes demonstrated an overall 5.8 mm Hg mean decrease in SBP compared to physician-led care [63]. Nursing personnel also serve in administrative or leadership positions, liaise between the medical team and the patient, and act as crucial care coordinators in the patient care process.

Beyond pharmacist and nurse management, there are several ongoing studies to improve hypertension care using innovative TBC approaches. Notably, the RICH-LIFE (Reducing Inequities in Care of Hypertension, Lifestyle Improvement for Everyone) study will evaluate BP outcomes among underserved patients randomized to usual care compared to a comprehensive team of physicians, care managers, community health workers, pharmacists, and dietitians (). Results from this study may inform future CEA to guide value-based implementation decisions in underserved populations.

Team-based care is cost-effective relative to usual care

TBC to manage hypertension has been shown to be cost-effective in several analyses (Table 2). These studies can be broadly categorized into formal CEAs (e.g., simulation, Markov modeling) and cost analyses of observational or interventional studies. Key findings are highlighted here, as exhaustive reviews and discussions about TBC for hypertension including international studies are provided elsewhere [49,50,64].

Table 2:

Studies assessing cost outcomes of team-based care models for hypertension management in the US (selected recent studies)

Author (Year) [Reference]	Comparators	Clinical inputs [Reference]	Model Description	Costs considered	Time Horizon or Follow-up Period	Perspective	Base Case ICER or Main Results	Notes
Pharmacist Interventions
Polgreen (2015) [68]	Clinical pharmacist providing real-time recommendations to provider vs. usual care	CAPTION [53]	N/A	Physician time, pharmacist time, medications	9 months	“Society in general”	Intervention cost $33 (2013 USD) per 1-mm Hg reduction in SBP and $70 per 1-mm Hg reduction in DBP relative to usual care.	Did not incorporate patient preferences or utility values
Dehmer (2018) [70]	Clinical pharmacist telehealth management vs. usual care	Hyperlink [54]	N/A	Outpatient chronic management*, acute care management*, medications	12 months	Health care sector	Intervention cost $139 (2012 USD) per 1-mm Hg reduction in SBP and $265 per 1-mm Hg reduction in DBP relative to usual care	Did not incorporate patient preferences or utility values
Kulchaitanaroaj (2012) [69]	Clinical pharmacist-physician collaboration vs. usual care	Pooled two cluster randomized trials [66,99]	N/A	Provider time, pharmacist time, specialist time, laboratory tests, medications, overhead costs	6 months	Not reported	Intervention cost $36 (2008 USD) per 1-mm Hg reduction in SBP and $94 per 1-mm Hg reduction in DBP relative to usual care	Did not incorporate patient preferences or utility values
Kulchaitanaroaj (2017) [72]	Clinical pharmacist-physician collaboration vs. usual care	Pooled two cluster randomized trials [66,99]	Markov model	Provider time, pharmacist time, specialist time, acute and chronic CVD, laboratory tests, medications	Lifetime 5 years 10 years	Payer	Lifetime: $26,807.83 (2015 USD) per QALY gained 5 years: $78,547.07 per QALY gained 10 years: $39,084.65 per QALY gained	Base case assumed one-time, 6-month intervention with sustained effects for up to 2 years, then deterioration of effects thereafter
Nurse Interventions
Datta (2010) [79]	Nurse-led behavioral intervention vs. usual care	V-STITCH [78]	Monte Carlo Simulation	Intervention costs (nurse time, supplies), variable indirect costs, resource utilization costs,	2 years	Payer	Men Normal weight: $87,300 per LY gained Overweight: $43,567 per LY gained Women Normal weight: $42,457 per LY gained Overweight: $58,560 per LY gained	Did not incorporate patient preference or utility values
Allen (2014) [80]	NP/CHW management vs. usual care	COACH [100]	N/A	NP and CHW time, laboratory tests, medications	12 months	“Health services”	Intervention cost $101 (2010 USD) per 1-mm Hg reduction in SBP and $209 per 1-mm Hg reduction in DBP relative to usual care	Did not incorporate patient preference or utility values
Wang (2012) [101]	Nurse-led behavioral intervention vs. nurse-led medication management vs. combined vs. usual care	HINTS [102]	N/A	Intervention costs (supplies, nurse time, physician time, home monitors), inpatient and outpatient care, medications	18 months	Payer	Mean total costs per patient: $14,441 behavioral management $14,453 medication management $13,009 combined $12,328 for usual care	Did not incorporate patient preference or utility values
Other
Hollenbeak (2014) [103]	Telephone patient peer counseling sessions and in-office medical assistant visits vs. usual care	Randomized controlled trial	Markov model	Provider time, participant and peer compensation, acute and chronic CVD, medications	10 years	Provider	$10,866 per QALY gained (2010 USD)	Assumed yearly reinforcements of the 6-month intervention across the time horizon

Abbreviations: CAPTION: Collaboration Among Pharmacists and physicians To Improve Outcomes trial; CHW: Community Health Worker; COACH: Community Outreach and Cardiovascular Health; DBP: diastolic blood pressure HINTS: Hypertension Intervention Nurse Telemedicine Study; ICER: Incremental Cost-Effectiveness Ratio; LY: Life Year; NP: Nurse Practitioner; QALY: Quality-Adjusted Life Year; SBP: Systolic Blood Pressure; USD: United States Dollars; V-STITCH: Veterans–Study to Improve the Control of Hypertension

^*Queried from insurance claims data

One recent systematic review assessed 34 national and international cost-effectiveness studies of community interventions to manage patients with hypertension, most of which incorporated non-physician providers alone or in conjunction with physician-provided care [64]. Among 25 studies that implemented educational interventions for lifestyle and/or medication adherence, the median cost (2014 USD) to lower SBP by 1 mm Hg was $62 (range: $40-$114) with a median ICER of $13,986/QALY gained (range $6,683-$58,610). Importantly, the authors noted that community-based interventions for hypertension care are significantly heterogeneous in setting and outcomes studied. Most studies assessed outcomes at less than one year, and longer follow-up is needed to confidently estimate long-term ICERs. Many of the studies were not randomized or controlled, or the economic analyses did not implement uncertainty or sensitivity analyses. Regardless, the findings from this review confirm estimates from a previous systematic review of 31 TBC studies from the US and internationally, which reported a median ICER of $10,511-$15,137/QALY gained (2010 USD) and a median total implementation cost of $355 per patient [65].

Several cost analyses of pharmacist-provided care models for hypertension management have been published based on results from interventional studies [53,54,66,67]. Clinic-embedded clinical pharmacists cost $33 (2013 USD) per 1-mm Hg reduction in SBP and $70 per 1-mm Hg reduction in DBP relative to usual care [68], similar to 2008 estimates [69]. Combining pharmacist-managed hypertension care with telehealth is slightly more expensive at $139 per 1-mm Hg reduction in SBP and $265 per 1-mm Hg reduction in DBP (2012 USD) [70]. One economic evaluation found that, assuming an intervention cost of $525 per patient, a pharmacist-delivered hypertension management program could generate 5-year cost-savings in Medicare patients with treated, persistently uncontrolled BP [71]. In one formal CEA, compared to usual care, the ICER for pharmacists to manage hypertension was $26,800 (2015 USD) per QALY gained, and the intervention was broadly cost-effective for the highest risk patients (i.e., comorbid diabetes, smoking, hypercholesterolemia, or obesity) [72]. At the community pharmacist level, interventions largely focus on improving antihypertensive medication adherence, although results show both cost-savings of more than $6,000 per patient [73,74] or minimal effectiveness and cost-effectiveness compared to usual care [75,76].

For a broad range of chronic disease management, the inclusion of nurses and NPs on teams is widely considered cost-effective, especially when added to a team of other qualified healthcare professionals [77]. The most robust analyses of a nurse-administered telephone education program [78] demonstrated a lifetime ICER of $87,300 per life-year (LY) gained for normal-weight males and $43,600/LY gained for overweight males compared to usual care [79]. Including direct and indirect costs, the mean cost to deliver the intervention was $112 per patient, with a range of $61 to $259 depending on salary, number of patients managed, and types of indirect costs. In another analysis, combining an NP and community health worker to manage CVD risk factors demonstrated that for every one-mm Hg reduction in SBP and DBP, the intervention cost $101 and $209 (2010 USD), respectively, compared to usual care [80]. More economic and CEA data specific to NP-delivered hypertension care are needed to guide implementation decisions by health systems.

The variation in models for pharmacist- and nurse-delivered interventions for hypertension care hampers definitive conclusions on the cost-effectiveness of TBC. Given that TBC is effective and recommended by current clinical practice guidelines, formal CEAs that compare TBC strategies to one another rather than usual care are needed. Additionally, no CEA has assessed the cost-effectiveness of TBC strategies specifically to achieve the more-intensive SBP goals recommended by the 2017 ACC/AHA guidelines.

Opportunities and challenges preventing widespread adoption of TBC to manage hypertension

There are numerous opportunities to increase adoption of TBC in hypertension, but not without challenges. First, scopes of practice for non-physician providers (e.g., nurses and pharmacists) are managed by country or state laws, thereby dictating the degree to which non-physician providers can be integrated into clinical practice [7]. Laws differ in required physician oversight, allowable activities (e.g., medication prescribing, laboratory ordering), and protocol requirements [81]. Billing and reimbursement practices also vary, which are key institutional considerations in assessing the financial feasibility to hire a new employee. For example, pharmacists are not currently recognized as healthcare providers by Medicare in the United States, which is frequently cited by state-based programs and insurance carriers as a justification for limiting reimbursement for pharmacist-provided services [82,83]. The utilization and optimization of non-physician providers is crucial to public health. Current U.S.-based estimates project a shortage of over 40,000 primary care practitioners by 2030 [84]. There are also opportunities for including supportive healthcare personnel, such as certified nursing assistants, medical assistants, or pharmacy technicians and interns, but specific roles have yet to be delineated or evaluated formally.

In low- and middle-income countries (LMIC), integration of TBC for hypertension management is met with additional high-level systems barriers. Several competing acute healthcare, political, and social concerns may impede funding and focus for improving chronic disease management [85]. Examples include infectious diseases (e.g., malaria), armed conflict, or access to family planning services. From a funding perspective, the status quo of funding “vertical” interventions which target specific populations or diseases challenges the shift to fund “horizontal” interventions which focus on comprehensive, system-based solutions such as primary health care [86]. A three-round panel consultation with 141 experts from 50 LMIC identified the horizontal integration of multidisciplinary teams as a priority area to improve health care [87]. Depending on country-specific laws and regulations for healthcare professionals, utilization of diverse members of the healthcare team with strong community linkages will likely be required to develop effective and sustainable care delivery models for hypertension management in LMIC [88].

Health systems bear the cost burdens of implementing and maintaining TBC. Cost decisions are influenced by available funds, perceived or actual relative value, alignment with the organization’s mission and vision, feasibility of implementation, capacity for risk management and administrative support, and estimates for return on investment. The most effective, efficient, and feasible method for implementing TBC has yet to be determined and likely varies by practice setting, patient population, and geographic region. Given the minimal up-front costs, serious sequalae associated with uncontrolled hypertension, and effectiveness of TBC, health systems should invest in TBC with the long-term goals of improving patient outcomes and satisfaction with hypertension care.

New technology, such as smart phone apps, wearables, and Bluetooth-enabled home BP monitors may augment TBC for the management of hypertension. Technology allows for quick transmission of information, such as home BP readings, to the hypertension management team. Hypertension care can be integrated with electronic patient portals, telehealth programs, or wearable products (e.g., Fitbit™). In fact, titrating medications according to BP measurements assessed via telemonitoring has shown to be effective and cost-effective compared to usual care, particularly when combining self-monitoring with TBC interventions [89–91]. Future research could incorporate patient-reported outcomes and measure the impact of technology on patient engagement, acceptance, and satisfaction. From the patient perspective, some technology may be cost-prohibitive, which must be considered when deciding whether and how to implement certain telehealth services. Technology will undoubtedly play a crucial role to manage hypertension in patients who may not be as accessible to healthcare providers, such as those who are bedridden, live in rural areas, work during clinic hours, or struggle with access to reliable transportation.

Patient acceptance and engagement are critical to effectively manage hypertension. Patients ultimately share responsibility for their daily hypertension management including home BP monitoring, lifestyle modifications, and antihypertensive medication adherence. Unfortunately, antihypertensive medication non-adherence remains common, found in approximately 45% of treated patients, and increases with the prevalence of uncontrolled BP [92,93]. Adherence to various non-pharmacologic lifestyle modifications to reduce BP is even lower [94]. High-quality data on the effectiveness of interventions to support shared decision-making for hypertension management are lacking [95,96]. Successful strategies for sustaining patient engagement in various TBC interventions are needed.

Conclusion

Intensive therapy for SBP is an effective and cost-effective intervention to prevent complications from hypertension. Team-based care that includes non-physician providers to manage hypertension is more effective than usual care and will become increasingly important to achieve and maintain intensive SBP goals at scale. TBC strategies have been shown to be cost-effective compared to usual care. Research is needed to evaluate the efficacy and cost-effectiveness of several team-based care interventions relative to one another to achieve widespread intensive BP control targets.