REVIEW ARTICLE

The Potency of Team-Based Care Interventions

for Hypertension
A Meta-analysis
Barry L. Carter, PharmD; Meaghan Rogers, PharmD; Jeanette Daly, RN, PhD;
Shimin Zheng, PhD; Paul A. James, MD

Background: Team-based care is the strategy that has
had the greatest effect on improving blood pressure (BP).
The purpose of this systematic review was to determine
the potency of interventions for BP involving nurses or
pharmacists.
Methods: A MEDLINE search for controlled clinical trials
that involved a nurse or pharmacist intervention was con-
ducted. Mean reductions in systolic (S) and diastolic (D)
BP were determined by 2 reviewers who independently
abstracted data and classified the different intervention
components.
Results: Thirty-seven articles met the inclusion criteria.
Education about BP medications was significantly asso-
ciated with a reduction in mean BP (−8.75/−3.60 mm Hg).
Other strategies that had large effect sizes on SBP include
pharmacist treatment recommendations (−9.30 mm Hg),
intervention by nurses (−4.80 mm Hg), and use of a treat-
ment algorithm (−4.00 mm Hg). The odds ratios (95% con-
fidence intervals) for controlled BP were: nurses, 1.69 (1.48-
1.93); pharmacists within primary care clinics, 2.17 (1.75-
2.68); and community pharmacists, 2.89 (1.83-4.55). Mean
(SD) reductions in SBP were: nursing studies,5.84(8.05)
mm Hg; pharmacists in clinics,7.76(7.81) mm Hg; and
community pharmacists, 9.31(5.00) mm Hg. There were
no significant differences between the nursing and phar-
macy studies (Pⱖ.19).
Conclusions: Team-based care was associated with im-
proved BP control, and individual components of the in-
tervention appeared to predict potency. Implementation
of new hypertension guidelines should consider changes
in health care organizational structure to include impor-
tant components of team-based care.
Arch Intern Med. 2009;169(19):1748-1755

Author Affiliations:
Department of Pharmacy
Practice and Science, College of
Pharmacy (Drs Carter and
Rogers), and Department of
Family Medicine, Roy J. and
Lucille A. Carver College of
Medicine (Drs Carter, Daly,
Zheng, and James), The
University of Iowa, Iowa City.
B
L O O D P R E S S U R E (BP) I S
poorly controlled in the
United States. 1-5 The 8th
Joint National Committee
on Prevention, Detection,
Evaluation and Treatment of High Blood
Pressure ( JNC-8) is currently consider-
ing strategies to improve the implemen-
tation of the guidelines and achieve higher
BP control rates. Investigators from the
Stanford University/University of Califor-
nia, San Francisco, Evidence-Based Prac-
tice Center conducted an analysis of con-
trolled clinical trials examining quality
improvement strategies and found that the
only strategy that significantly improved
BP involved interdisciplinary, team-
based care.6 Most of the quality improve-
ment interventions included multiple com-
ponents. These different strategies or the
potency of the intervention may explain
the apparent differences in effect sizes.7
One strategy to improve guideline ad-
herence is to use team-based care involv-
ing pharmacists or nurses.8-13 The pur-
pose of the present study was to conduct a
systematic review of the research litera-
ture and to evaluate the potency of team-
based care involving pharmacists or nurses.
We theorized that the effect size would be
greater for nurses or pharmacists working
in a physician’s office or more indepen-
dently by protocol than with more distant
interventions, such as recommendations
from a community pharmacist.
METHODS
We followed the same process as Walsh et al6
by including quasi-randomized trials, con-
trolled before-after studies, interrupted time-
series studies, patient-randomized trials, and
cluster-randomized trials. Quasi-randomized
trials were defined as those that included at least
2 patient cohorts identified prospectively using
an arbitrary but nonrandom allocation proce-
dure.6 Controlled before-after studies were de-
fined as those with contemporaneous observa-
tion of cohorts that differed primarily with
respect to exposure to the intervention.6 Inter-
rupted time series required that the study re-

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 port outcomes from at least 3 time points
in the preintervention and postinterven-
tion periods.6
SEARCH STRATEGY
Walsh et al6 performed their search of
the MEDLINE database from January 1,
1980, through July 31, 2003, and we ex-
tended the search to include articles pub-
lished from January 1, 1970, through
February 5, 2009. The search was con-
ducted by a research librarian. Titles and
abstracts were then screened to deter-
mine whether the article included team-
based care of hypertension involving
pharmacists or nurses. Next, we searched
the reference list of included papers and
the reviews by Walsh et al6 to identify
additional citations. Once the full-text
articles were selected, 2 reviewers (1
clinical pharmacist with a PharmD [doc-
tor of pharmacy] degree [M.R.] and 1
nurse with a PhD [doctor of philoso-
phy] degree [ J.D.]) independently de-
termined whether each paper met the
study criteria. If so, the reviewers inde-
pendently abstracted critical informa-
tion including study design, setting, type
of intervention, components of the in-
tervention, and degree of SBP and DBP
change. The intervention components
included supplying free medications,
education about BP medications, coun-
seling about lifestyle modifications,
assessing medication compliance, algo-
rithms for treatment, home visits, pre-
scribing medications by intervention
health care providers (nurses or phar-
macists), laboratory tests ordered by in-
tervention health care providers, length
of the study, completion of a drug pro-
file and/or medication history, physical
examination, nurse-provided interven-
tion, pharmacist-provided interven-
tion, and/or whether medication recom-
mendations were made to a physician vs
independent changes. Because every
study included different combinations
of these components, the reviewers in-
dependently assigned a potency score
representing the predicted potency of the
combination of interventions for affect-
ing outcomes; scores ranged from 0
(brings about no result) to 10 (brings
about the best result). Disagreements be-
tween the reviewers were resolved by an
open dialogue to develop consensus.
Confirmation of the reviewers’ find-
ings was adjudicated by a biostatisti-
cian (S.Z.).
INTERVENTION
EFFECT SIZE
We calculated effect size by determin-
ing the change in SBP or DBP attribut-
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able to the intervention for each study
defined as6:
Net ⌬ in BP=(Postintervention BP – Pre-
intervention BP)study group – (Postinter-
vention BP – Preintervention BP)control group
Blood pressure control was defined
as a BP lower than 140/90 mm Hg for
patients with uncomplicated BP and
lower than 130/80 mm Hg for those with
diabetes mellitus or chronic kidney dis-
ease.14 The net change in BP control rates
attributable to the intervention for each
study was defined as:
Net ⌬ in BP Control=(Postintervention
BP Control − Preintervention BP Control)
study group − (Postintervention BP Control
− Preintervention BP Control)control group
The odds ratio (OR) and 95% confi-
dence interval (CI) for controlled BP
was calculated (22 studies) and weighted
by the sample size of the study.8,15-35 For
15 studies, ORs could not be calcu-
lated.36-50 We divided the studies into 3
groups to evaluate intervention po-
tency: nursing interventions, pharma-
cist interventions delivered in commu-
nity pharmacies, and interventions by
clinical pharmacists working within a pri-
mary care office. We performed sensitiv-
ity analyses to determine the effect of as-
signing studies to different categories
when they had multiple strategies (eg, in-
volved both community pharmacists and
nurses).
STATISTICAL ANALYSIS
Stepwise regression analyses and non-
parametric analyses were performed
using the Mann-Whitney test to evalu-
ate the postintervention difference be-
tween the intervention and control
groups for mean SBP and DBP while con-
trolling for study sample size. Analyses
were performed using SPSS statistical
software, version 17.0.0 (SPSS Inc, Chi-
cago, Illinois).
One study had a large number of in-
formed dropouts and found no signifi-
cant difference between nurse vs phy-
sician management. 1 5 A stepwise
regression analysis was conducted with-
out this study (n = 36) to predict the
effect of individual intervention com-
ponents on BP.
Unadjusted ORs for controlled BP
were calculated so studies could be com-
pared. The ORs were compared using a
simple logistics regression model with
1 variable, unadjusted for any other item.
We created a funnel plot of the log of the
OR plotted against the standard error for
each study to assess the possibility that
publication bias might exist.
WWW.ARCHINTERNMED.COM
1749
583 Original article citations
from search
452 Articles excluded based on title
264 Were drug/diet trials only
148 Included nonteam care
by nurses or pharmacists
or were behavioral studies,
descriptive only, or design
only
40 Did not involve hypertension
131 Full abstracts reviewed
92 Abstracts excluded
49 Did not describe nurse or
pharmacist team care
33 Were descriptive or behavioral
only or had insufficient BP
outcome data
9 Were not hypertension studies
1 Was a secondary analysis of
other abstracted article
39 Full articles reviewed
7 Articles excluded
2 Did not describe team care
1 Was a descriptive study only
4 Did not include enough BP data
to meet criteria
5 Articles added from journal citations
and from Walsh et al6
37 Full articles extracted
Figure 1. Flow diagram depicting reasons trials
were excluded.
RESULTS
The literature review identified 583
citations and 37 articles that met the
inclusion criteria (Figure 1). In-
terrater reliability for the 2 review-
ers was good (Pearson product mo-
ment correlation r=0.74; P⬍.001).
Each study specified unique health
care provider qualifications and train-
ing. For instance, studies involving
community pharmacists may have in-
cluded pharmacists with BS (bachelor
of science) degrees8,22,51 or those with
PharmD degrees.20,21 Nearly all stud-
ies that involved pharmacists in clin-
ics included clinical pharmacists with
PharmD or MS (master of science) de-
greeswhohadcompletedpostdoctoral
residency training in primary care and
whose duties involved direct patient
management,24,26,28,30,34,36,48 although
several studies did not provide these
details.25,27,35,46 Most of the studies in-
volving nurses did not specify their
qualifications,17,19,33,38-41,44,45,47 butsome
noted that health care providers were
registered nurses (RNs)42,49 or nurse
practitioners.16,18 Training of the in-
tervention nurses or pharmacists typi-

Table 1. Stepwise Regression Analysis of the Intervention Effect on BP a
Regression Predicted
Outcome Variable Coefficient Change, mm Hg
Systolic BP
Pharmacist recommended medication −9.68 −27.21
to physician
Counseling about lifestyle modification 5.20 −12.63
Pharmacist performed the intervention 6.13 −11.70
Treatment algorithm used 9.37 −8.46
Drug profile and/or medication history 9.55 −8.28
completed
Overall intervention potency score b −2.76 NA
Diastolic BP
Referral made to specialist −7.71 −19.61
Physical examination conducted −6.65 −18.55
Education about BP medications −5.70 −17.60
Length of intervention 0.04 −10.13
Treatment algorithm used 3.12 −8.78
Drug profile and/or medication history 4.63 −7.27
completed
Pharmacist performed the intervention 7.87 −4.03
Nurse performed the intervention 7.96 −3.94
Abbreviations: BP, blood pressure; NA, not applicable.
a Analysis includes 36 studies; McClellan and Craxton15 was excluded.
b This variable was controlled for in the analyses and was only significant for systolic BP.
cally involved sessions on hyperten- gorithm (−8.46 mm Hg; P⬍.001),
sion guidelines given by an expert,* completion of a drug profile and/or
but again, many did not specify the medication history (−8.28 mm Hg;
training program.† Only a few stud- P=.001), and the overall intervention
ies described patient empowerment potency score assigned by the study
or strategies such as home BP moni- reviewers (P⬍.001) (Table 1). For
toring to assist with the interven- example, the regression coefficient for
tion.23,34,35,40 Innearlyallstudiesinvolv- use of an algorithm was significant
ing nurses or pharmacists in clinics, (9.37; P⬍.001), which indicated that,
consistentanddedicatedcasemanage- given all other factors in the model,
ment activities were provided that the mean reduction in SBP for the 9
were distinct from traditional nursing studies using a treatment algorithm
or pharmacist duties. However, phar- was 9.37 less than the change in SBP
macists in community pharmacies
for the 27 studies not using an algo-
usually had to incorporate the inter-
rithm. Assuming that a study used an
vention with traditional medication
algorithm and no other intervention,
dispensing functions.
the predicted reduction in SBP was
Stepwise regression was used to
8.46 mm Hg (Table 1).
compare studies that included a given
The factors associated with a re-
intervention strategy with studies that
duction in DBP were: referral was
didnot.Severalindividualcomponents
made to a specialist (−19.61 mm Hg;
of the interventions were associated
with significant reductions in mean P = .04), providing patient educa-
SBP including pharmacist recom- tion about BP medications (−17.60
mended medication to physician mm Hg; P = .003), completion of a
(−27.21 mm Hg; P=.002), counseling drug profile and/or medication his-
about lifestyle modification (−12.63 tory (−7.27 mm Hg; P=.006), phar-
mm Hg; P=.03), pharmacist per- macist performed the intervention
formed the intervention (−11.70 (−4.03 mm Hg; P=.04), or nurse per-
formed the intervention (−3.94
mm Hg; P=.03), use of a treatment al-
mm Hg; P=.04).
*References 8, 17, 19-25, 30, 32, 33, 35, Next, a nonparametric analysis
41, 42, 47, 49. was performed because the data were
†References 16, 18, 26-29, 34, 36-40, not normally distributed. The only
44-46, 48, 50. individual component associated
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with a significant reduction in BP
was education about BP medica-
tions (−8.75/−3.60 mm Hg). How-
ever, several other intervention com-
P Value
ponents had a large effect size for
SBP (−11.0 to −4.8 mm Hg) includ-
.002
ing: free medications (−10.80
.03 mm Hg), pharmacist made treat-
.03 ment recommendations to the phy-
⬍.001 sician (−9.30 mm Hg), pharmacist
.001 performed the intervention (−8.44
mm Hg), a drug profile and/or medi-
⬍.001
cation history was completed (−8.19
mm Hg), medication compliance
.04 was assessed (−7.90 mm Hg), coun-
.08
seling about lifestyle modification
.003
.06 was performed (−7.59 mm Hg), in-
.05 tervention provider could order
.006 laboratory tests (−7.00), and a nurse
performed the intervention (−4.80
.04 mm Hg) (Table 2).
.04
The estimated ORs (95% CIs) for
controlled BP were 1.69 (1.48-1.93)
for nursing studies (Figure 2A), 2.89
(1.83-4.55) for community pharma-
cists (Figure 2B), and 2.17 (1.75-
2.68) for pharmacists within pri-
mary care clinics (Figure 2C).
In the nonparametric analyses of
the 36 studies, the mean (SD) re-
duction in SBP was 5.84 (8.05)
mm Hg for nursing studies (n=16)
compared with 7.76(7.81) mm Hg
in the studies involving pharma-
cists in clinics (n = 7) and 9.31
(5.00) mm Hg for studies involv-
ing community pharmacists (n=13).
Reductions in DBP were 3.46
(4.15) mm Hg for nursing studies,
4.18(4.25) mm Hg for pharmacists
in clinics, and 4.59(4.64) mm Hg for
community pharmacists (SBP and
DBP were not significantly differ-
ent among any groups).
We constructed a funnel plot to
evaluate whether there may have
been publication bias (Figure 3).
Three of 4 studies with the largest
log ORs had moderate to low stan-
dard errors, suggesting the absence
of publication bias. However, pub-
lication bias cannot be ruled out be-
cause few studies had high log ORs
and low standard errors.
COMMENT
This study found that interventions
involving pharmacists or nurses were
associated with significantly im-
proved BP control. These results ex-
WWW.ARCHINTERNMED.COM
 Table 2. Effect of Quality Improvement Strategies on BP Outcomes

Median Reduction Median Reduction

Type of Quality
Improvement
Free medications
Pharmacist recommended
medication to physician
Education about BP
medications
Pharmacist performed the
intervention
Drug profile and/or medication
history completed
Medication compliance
assessed
Counseling about lifestyle
modification
Intervention provider could
order laboratory tests
Nurse performed intervention
Treatment algorithm used
Made a home visit
Intervention provider could
prescribe medication
Physical examination
conducted
in Systolic BP in Diastolic BP
Source (IQR), a mm Hg Source (IQR), a mm Hg
18, 39, 50 −10.80 (−14.9 to −9.10) 18, 39, 50 −6.4 (−8.70 to −3.90)
8, 20-24, 26, 27, 29, 30, 35, 37, 43, −9.30 (−13.00 to −5.00) b 8, 20-24, 26, 27, 29, 30, 35, 37, 43, −3.60 (−7.03 to −1.00)
46, 48 46, 48
8, 17-23, 26-30, 32, 34, 35, 37, −8.75 (−11.90 to −4.25) c 8, 17, 18, 20-23, 26-30, 32, 34, 35, −3.60 (−7.03 to −1.00) c
39-44, 46-50 37, 39-44, 46-50
8, 19-22, 24-30, 34-37, 41, 43, 46, −8.44 (−12.25 to −4.00) 8, 19-22, 24-30, 34-37, 41, 43, 46, −3.30 (−6.87 to −0.90)
48, 50, 51 48, 50, 51
8, 17, 20, 21, 23, 25-27, 29, 30, 32, −8.19 (−11.45 to −2.93) 8, 17, 20, 21, 23, 25-27, 29, 30, 32, −3.25 (−4.67 to −1.00)
35, 40, 42-44, 46, 48 35, 40, 42-44, 46, 48
8,17, 20, 21, 23, 25-30, 34-37, −7.90 (−11.90 to −3.48) 8, 17, 20, 21, 23, 25-30, 34-37, −3.25 (−8.65 to −0.85)
39-44, 46, 47, 50 39-44, 46, 47, 50
8, 16, 17, 19-23, 26-32, 34, 35, 37, −7.59 (−11.45 to −2.40) 8, 16, 17, 20-23, 26-32, 34, 35, 37, −3.30 (−6.70 to −1.00)
38, 40-42, 45-50 38, 40-42, 45-50
16, 22, 25, 31, 33, 44, 48-50 −7.00 (−8.94 to −1.30) 16, 22, 25, 31, 33, 44, 48-50 −3.68 (−5.40 to −0.15)
16-19, 31-33, 38-42, 44, 45, 47, 49 −4.80 (−9.63 to −0.43) b 16-18, 31-33, 38-42, 44, 45, 47, 49 −3.10 (−6.00 to −0.10)
16, 23, 25, 32, 33, 35, 37, 44, 49 −4.00 (−8.15 to −0.90) b 16, 23, 25, 32, 33, 35, 37, 44, 49 −1.00 (−4.20 to −0.15) b
17, 18, 38, 41, 44 −4.00 (−9.95 to 0.15) 17, 18, 38, 41, 44 −1.00 (−4.95 to 0.60)
16, 25, 28, 32 −2.40 (−11.28 to 4.75) 16, 25, 28, 32 −0.65 (−11.35 to −0.08)
16, 25 2.10 (−2.80 to 7.00) a,b 16, 25 −0.15 (−0.30 to 0.00) a,b

Abbreviations: BP, blood pressure; IQR, interquartile range.

a When the sample size is 2 studies, the numbers in parentheses show the actual results of each study rather than the interpolated interquartile range.
b P⬍.10 for Mann-Whitney analysis of reduction in systolic and diastolic BP comparing studies with the quality improvement strategy with those without.
c P⬍.05 for Mann-Whitney analysis of reduction in systolic and diastolic BP comparing studies with the quality improvement strategy with those without.

tended those of the previous report6
that found involving pharmacists or
nurses was the most potent quality
improvement strategy to improve BP
control. We also wanted to deter-
mine whether specific aspects of team
care were more potent. Our analysis
found that studies involving phar-
macists resulted in not only lower BP
but also a greater OR of achieving BP
control compared with studies in-
volving nurses. However, the reduc-
tions in SBP and CIs for controlled
BP overlap for the different health
care providers (Figure 2).
We had hypothesized that stud-
ies involving community pharma-
cists would be less potent than those
involving nurses or pharmacists
within primary care clinics. Of in-
terest, studies involving commu-
nity pharmacists had the highest OR
(2.89). These findings may be based
on how the reviewers categorized the
studies. First, one study conducted
in community pharmacies in Por-
tugal had an extremely high OR
(29.71).22 Another study in a com-
munity pharmacy had an OR of 4.29,
but this pharmacist worked closely
with 2 physicians and reviewed
medical records of study partici-
pants in the physicians’ office.20 We
could also have classified this study
as “pharmacist in the clinic,” which
would have reduced the OR for com-
munity pharmacy studies and in-
creased the OR for studies involv-
ing pharmacists in clinics. Second,
we classified one study as a nursing
intervention for the OR calcula-
tions, but the intervention in-
volved both a nurse and a commu-
nity pharmacist (OR, 1.79). 1 9
Excluding the first 2 studies and add-
ing the third study to the analysis of
community pharmacy studies would
have resulted in an OR closer to 1.8
for the community pharmacy group.
Finally, one large study was con-
ducted within a managed care orga-
nization that involved education by
a pharmacist via the Internet.35 We
classified this study as one within
primary care, but the effect was not
as great (OR,1.88) compared with
studies in which the pharmacist
adjusted therapy either alone or in
collaboration with physicians
(ORs, 7.38-9.98). Without that
study, the OR would have been 3.27
for pharmacists in clinics.
It may be possible to explain our
findings based on the dose, dura-
tion, and potency of the interven-
tion. For instance, Carter et al8,21,23
conducted 3 studies in community
pharmacies, where the pharmacists
had no prior established relation-
ship with the physicians and the in-
terventions were only 4 and 5
months in length. These studies had
modest ORs for controlled BP (1.56,
1.74, and 2.46). Carter et al52 re-
cently completed a randomized,
controlled effectiveness (ie, prag-
matic) study of a 6-month pharma-
cist intervention among 402 pa-
tients from 6 family medicine clinics
that was not included in this sys-
tematic review because it had not
been published at the time of our
evaluation. In that study, SBP was re-
duced by 12.0 mm Hg more in the
intervention group than the con-
trol group, and the OR for con-
trolled BP was 3.2 (95% CI, 2.0-
5.1). Finally, these investigators
conducted an efficacy study in which
BP was controlled in 54% of pa-
tients in the control group and 89%
in the intervention group (OR, 7.38;
95% CI, 3.43-15.91).30 The main rea-
son for high BP control in this lat-
ter study was attributed to asser-
tive and frequent medication

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 A
McCellan and Craxton,15 1985
Curzio et al,16 1990
Garcia-Peña et al,17 2001
Hill et al,18 2003
Woollard et al,31 2003
New et al,32 2003
Bebb et al,33 2007
McLean et al,19 2008
All Studies
B
Mckenny et al,20 1973
Park et al,21 1996
Carter et al,8 1997
Garcao et al,22 2002
Zillich et al,23 2005
All Studies
C
Schneider et al,24 1982
McGhan et al,25 1983
Erickson et al,26 1997
Bogden et al,27 1998
Mehos et al,34 2000
Vivian et al,28 2002
Borenstein et al,29 2003
Green et al,35 2008
Carter et al,30 2008
All Studies
Figure 2. The odds ratio (OR) (confidence interval [CI]) that systolic blood pressure is controlled in the intervention group compared with the control group. A
higher OR indicates a more effective intervention. A, Eight studies involving nurses. B, Five studies conducted in community pharmacies. C, Nine studies involving
pharmacists in primary care clinics.
intensification recommended by the
pharmacist. Therefore, the ORs for
the 5 studies by these investigators
were: community pharmacy stud-
ies (BS-trained pharmacists), be-
tween 1.56 and 2.46; the pragmatic
trial of clinical pharmacists (PharmD
with residency or fellowship), 3.20;
and the efficacy trial (ideal interven-
tion delivery) with clinical pharma-
cists (PharmD with residency), 7.38.
Therefore, when the literature in-
volving team care is evaluated, it is
critical to assess the duration of the
intervention, the type of organiza-
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2.0 (0.35-11.58)
2.86 (1.45-5.63)
8.16 (5.03-13.25)
1.41 (0.89-2.23)
1.81 (1.01-3.24)
1.15 (0.87-1.53)
1.11 (0.89-1.38)
1.79 (1.05-3.07)
1.69 (1.48-1.93)
0.00 1.00 3.00 6.00 9.00 12.00
OR (95% CI)
4.29 (0.99-18.59)
2.46 (0.76-7.89)
1.56 (0.50-4.90)
29.71 (6.89-128.19)
1.74 (0.83-3.66)
2.89 (1.83-4.55)
0.00 1.00 3.00 6.00 9.00 12.00 15.00
OR (95% CI)
3.54 (0.78-16.03)
8.4 (0.97-72.95)
1.91 (0.76-4.79)
5.05 (2.01-12.67)
2.80 (0.66-11.92)
9.98 (2.78-35.81)
1.97 (1.12-3.47)
1.88 (1.36-2.60)
7.38 (3.43-15.91)
2.17 (1.75-2.68)
0.00 1.00 3.00 6.00 9.00 12.00
OR (95% CI)
tion in which the intervention is per- laboratively with physician col-
formed (home, work site, commu- leagues and/or provided more
nity pharmacy, or primary care autonomous care. Pharmacists
clinic), and whether the study is an within primary care clinics work
efficacy or effectiveness trial. These closely with physicians, and the ex-
factors, as well as the intervention pected levels of trust and coopera-
procedures, predict the potency of tion might be higher than with com-
the intervention. munity pharmacists, for whom
Studies involving community interaction is usually not in person
pharmacists largely involved mak- and occurs from distant loca-
ing recommendations to physi- tions.23,51,53 In fact, recommenda-
cians by telephone or facsimile. Stud- tions to change BP medications were
ies involving pharmacists in clinics accepted 95% of the time from phar-
typically involved pharmacists em- macists within the same clinic30 but
ployed in the clinic who worked col- only 45% to 50% when recommen-
WWW.ARCHINTERNMED.COM
1752
 dations were made by community
pharmacists.8,21,23 Therefore, lower
acceptance for community pharma-
cists’ recommendations could be ow-
ing to lower levels of trust and co-
operation by physicians.51,53
Many of the nursing studies did
not describe the types of nurses, their
educational background, or train-
ing, but 4 studies used either RNs or
nurse practitioners.16,18,42,49 Nursing
interventions seemed more likely to
involve home visits, use of a treat-
ment algorithm, and patient engage-
ment than pharmacy studies. It is
likely that many of the interventions
involving nurses or pharmacists in-
creased patient empowerment, but
few studies specifically provided such
descriptions. Only 5 nursing studies
described a patient-led process17,47,49
or home BP monitoring,41,42 and 3
pharmacy studies used home BP
monitoring.23,34,35 We suspect that
nurse practitioners would have more
autonomy than RNs, and, in some
cases, nurse practitioners can pre-
scribe medications. We could not de-
tect whether nursing degree or train-
ing influenced the results. However,
using a treatment algorithm or mak-
ing a home visit both had a pre-
dicted reduction in SBP of 4 mm Hg.
Each intervention or combina-
tion of intervention components is
unique. It is not possible to state that
either nurses or pharmacists can im-
prove BP control without first deter-
mining the patient population, the or-
ganizational structure involved, and
the amount of autonomy the inter-
ventionist has to alter therapy. Strat-
egies that provided medication edu-
cation were the most effective, but this
strategy is impossible to evaluate alone
because it was usually provided with
additional strategies by the nurse or
pharmacist who may have recom-
mended therapy changes or person-
ally changed therapy within a pri-
mary care office. Any incremental
addition of components from Table 2
that a physician office or health sys-
tem can implement should improve
BP control rates, but this requires ad-
ditional research. We believe that
nurses possess unique skills in pa-
tient management and nonmedica-
tion counseling techniques that phar-
macists usually do not. Likewise,
pharmacists receive 4 years of con-
centrated education in medication
(REPRINTED) ARCH INTERN MED/ VOL 169 (NO. 19), OCT 26, 2009
©2009 American Medical Association. All rights reserved.
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0.80
0.70
0.60
0.50
SE
0.40
0.30
0.20
0.10
0.00
–.50 0 .50
Log OR
Figure 3. Funnel plot for all studies included in Figure 2. OR indicates odds ratio.
pharmacology, pharmacokinetics,
pharmacodynamics, therapeutics, and
chronic disease drug-therapy guide-
lines. Including both nurses and phar-
macists in an integrated hyperten-
sion management program should be
even more effective, and more cost-
effective, than including either group
alone. Consistent with our findings,
the pharmacists could adjust medi-
cations until BP is controlled, while
the nurse provides continuity and
counseling about lifestyle and social
support.9,10 The nurse would con-
tinue to serve as a case manager be-
tween physician visits when BP is con-
trolled. The pharmacist would then
only be involved if BP is no longer
controlled. Such an approach can-
not only improve BP control rates but
markedly improve the efficiency and
productivity of the physician.54,55 In-
cluding many of the components of
these interventions in hypertension
management programs could im-
prove the implementation of the
JNC-8 or other chronic disease guide-
lines.
The vast majority of the studies
(32 of 37 [86%]) were randomized,
controlled trials (eTable; http://www
.archinternmed.com). The quality of
the studies supports the findings that
these interventions are likely to be ef-
fective. There were, however, large
differences in the duration of the in-
tervention (4-24 months), sample
size (26-1534), and participant drop-
out rate (2%-62%). Nearly all of the
studies adequately described the most
important characteristics of the pa-
WWW.ARCHINTERNMED.COM
1753
1.00 1.50 2.00 2.50
tients, but many did not adequately
describe the number, educational
background, and training of the in-
tervention pharmacists or nurses. Our
analysis could not determine if there
is a preferred level of qualifications,
such as a PharmD degree with resi-
dency or an MS nurse practitioner de-
gree. Likewise, many studies did not
describe the intervention training, but
those that did typically noted one-
half– to 2-day training programs on
the hypertension guidelines and BP
measurement. It is possible that RNs
or pharmacists with BS degrees may
have required more intense or longer
training than nurse practitioners or
pharmacists with PharmD degrees
with residencies, but this could not
be determined from these studies. Fu-
ture interventional studies of this type
should specify the educational back-
ground, postgraduate training, and
specific training programs used to
implement the intervention.
Only 1 study performed a cost-
effectiveness analysis.48 Clinic visit
costs were significantly higher in the
pharmacist-managed clinic ($131
per patient) than the physician clinic
($74) (P ⬍ .001), but the costs for
emergency department visits were
significantly lower in the pharmacist-
managed clinic than in the physi-
cian clinic ($0 vs $10.84 per pa-
tient; P⬍.04). The cost of decreasing
SBP was $27 per millimeter of mer-
cury for the pharmacist-managed
clinic and $193 for the physician
clinic. The cost of decreasing DBP
 was $48 per millimeter of mercury
in the pharmacist-managed clinic
and $151 in the physician clinic.
Twelve studies (9 nursing, 2 in
community pharmacies, and 1
pharmacist in clinics) were con-
ducted in countries other than the
United States.‡ It is not known
what effects the unique character-
istics of the health care system in
these countries might have had on
the interventions. Likewise, some
studies were conducted in inte-
grated managed care settings29,35 or
the Department of Defense or Vet-
erans Administration.28,50 Future
research should clarify the func-
tional components of a team and
how best to utilize the strengths of
team members as they fit into the
chronic care model.56,57 Also, the
larger impact of the health care de-
livery system on the potency of these
interventions should be assessed,
specifically whether incentives might
be aligned to optimize perfor-
mance. Finally, we cannot rule out
publication bias in our analyses be-
cause only 3 studies had high ORs
and low standard error.
CONCLUSION
This evaluation of team-based care
for hypertension found that inter-
ventions involving nurses or phar-
macists are effective strategies to im-
prove BP control. Several individual
components were associated with
improvements in BP. Research in-
volving team-based care must be
carefully designed, reported, and
interpreted to include the organiza-
tional structure in which the inter-
vention is performed, the educa-
tional level and training of the
intervention providers, and the in-
dividual components of the inter-
vention so that similar interven-
tions can be implemented within a
given health system.
Accepted for Publication: June 26,
2009.
Correspondence: Barry L. Carter,
PharmD, Department of Pharmacy
Practice and Science, Room 527,
College of Pharmacy, The Univer-
‡References 16, 17, 19, 22, 31-33, 39,
43-45, 47.
(REPRINTED) ARCH INTERN MED/ VOL 169 (NO. 19), OCT 26, 2009
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sity of Iowa, Iowa City, IA 52242
(barry-carter@uiowa.edu).
Author Contributions: All authors
had full access to all the data and take
responsibility for the integrity of the
data and the accuracy of the data
analysis. Study concept and design:
Carter and James. Acquisition of data:
Carter, Rogers, and Daly. Analysis and
interpretation of data: Carter, Rogers,
and Zheng. Drafting of the manu-
script: Carter. Critical revision of the
manuscript for important intellectual
content: Carter, Rogers, Daly, Zheng,
and James. Statistical analysis: Zheng.
Obtained funding: Carter. Adminis-
trative, technical, and material sup-
port: Rogers, Daly, Zheng, and
James. Study supervision: Carter.
Financial Disclosure: None re-
ported.
Funding/Support: This study was
supported in part by grant
HL070740 from the National Heart,
Lung, and Blood Institute; coopera-
tive agreement 5U18HSO16094
from the Agency for Healthcare Re-
search and Quality Centers for Edu-
cation and Research on Therapeu-
tics; and grant HFP 04-149 from the
Center for Research in Implemen-
tation in Innovative Strategies in
Practice, Veterans Health Adminis-
tration Health Services Research and
Development Service, US Depart-
ment of Veterans Affairs (Dr Carter).
Disclaimer: The views expressed in
this article are those of the authors
and do not necessarily reflect the po-
sition or policy of the Department of
Veterans Affairs.
Additional Information: The
eTable is available at http://www
.archinternmed.com.
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