Introduction

Arterial hypertension, or elevated blood pressure, is highly prevalent worldwide and remains the leading cause of cardiovascular diseases and mortality despite the fact that it is relatively easy to detect and can often be controlled with effective low-cost medications [1]. In this respect, a recent survey has shown that both the detection and the control of hypertension are low in most regions of the world, particularly in low-income countries, although some improvements have been noticed mainly in high-income countries [1]. Several reasons have been evoked to explain these rather poor results including weaknesses in healthcare systems and problems of access to care in some countries. In developed countries, other issues have been identified as major factors resulting in poor blood pressure control, the most prevalent being poor adherence and persistence to prescribed medications and therapeutic inertia. In a meta-analysis involving 27 million patients with elevated blood pressure, non-adherence to medications was found to be the leading cause of uncontrolled hypertension and once again, the problem was more prevalent in low-income countries [2]. Yet, even in high-income areas of the world, the prevalence of non-adherence to antihypertensive drugs ranged between 25% and 40% depending on the methodology used to measure adherence. A lower prevalence of non-adherence (8–9%) has been reported in some groups of patients with apparent resistant hypertension using determinations of plasma or urine drug levels [3, 4]. In fact, these lower percentages reveal the major challenge of medication adherence research, i.e. the reliability of methods used to assess non-adherence. Indeed, as reported previously, simple and cheap methods e.g., patient interviews or questionnaires are unreliable and overestimate medication adherence [5, 6]. More expensive methods such as dosing of drugs in plasma or urine can ascertain drug intake but they do not provide any information on the dosing history. The same is true for the percentage of days covered by the prescriptions, a method generally used in epidemiological studies. Thus, in one of the studies reported above, patients were informed that drug adherence would be measured during each term [4]. In the other study, the low percentage is probably explained by the “white coat” adherence phenomenon according to which patients tend to improve their adherence before clinical terms [5]. Hence, drug adherence may look perfect even though it is low between consultations. Therefore, the true prevalence of non-adherence remains unprecise. Of note, figures reported with non-objective methods are generally underestimated because non-adherence is under-reported by patients [7]. Regarding the prevalence of therapeutic inertia, defined as the failure to intensify treatment when the targets are not achieved, several national surveys reported prevalence of therapeutic inertia ranging between 50% and 60% in patients with uncontrolled hypertension [8–10].

Considering the high prevalence of both non-adherence and therapeutic inertia, it is important to develop clinical strategies to fight against these two major limiting factors in the management of hypertensive patients. In the last decade, international hypertension guidelines have strongly emphasized the need to consider non-adherence and inertia as important topics to improve blood pressure control in the population and have proposed clear suggestions on how physicians, health care systems, and patients themselves could contribute to reducing nonadherence and therapeutic inertia [11–14]. Table 1 illustrates the recommendations from the European Society of Hypertension and European Society of Cardiology in 2018. These recommendations include easy to implement and effective strategies such as simplifying treatments using single-pill combinations or promoting the share-decision processes [15–17]. Published in 2018, they were maintained by both Societies in their most recent guidelines [13, 18].

Among the various approaches proposed by these guidelines, one of them implies the collaboration between healthcare providers in the concept of team-based care [19]. The purpose of this small review is to discuss the evidence, and the potential benefits of the team-based care approach based on recent publications.

What is team-based care?

Team-based care is usually defined as the provision of health services to individuals or families by at least two healthcare professionals who work collaboratively with patients and their caregivers to accomplish shared goals within and across settings to achieve coordinated, high-quality care. The concept is designed to unload physicians delegating several of their tasks to other healthcare providers and should enhance efficiency and access to care, improve quality, and increase the satisfaction of all stakeholders involved in medical care (physicians, employees, and patients). Figure 1 illustrates one of the possible structures of a team. In this example, the patient-physician partnership is the basis of the team-based care structure. Once the therapeutic goals are defined by the physician in agreement with the patient, tasks can be delegated to various healthcare providers. These latter should coordinate their efforts sharing their results in regular encounters. The composition of the team may vary depending on the clinical setting (hospital, ambulatory care), the type of hypertensive patients (with or without hypertensive complications such as heart failure, stroke, or chronic kidney disease), and the structure of the local healthcare system. In most cases, the team is coordinated by a physician and involves registered nurses or nurse practitioners and pharmacists who can handle medications. In some cases, the team is led by a nurse or a pharmacist. The group may also include other healthcare professionals such as dieticians, psychologists, physiotherapists, and social workers. In 2018, the World Health Organization published recommendations for the implementation of team-based care in the management of cardiovascular diseases in primary health care [20].

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Figure 1. 

Example of a team-based care structure based on the physician-patient partnership

For the detection of hypertension and sometimes for the follow-up of patients with low resources, other settings have been developed with some success such as barbershops [21, 22], hairdressers [23], faith-based organizations [24], and pharmacies [25]. Interestingly, these latter opportunities to get access to patients not consulting regularly, such as Black patients or patients of Hispanic origin, have been shown to provide sustained and cost-effective improvements in blood pressure control when compared to a standard management of hypertension [24, 26–29].

There are several important rules and conditions for a team to work effectively. The first is undoubtedly effective communication between partners. Today, patients are often sent to the different members of the team without sufficient communication between the disciplines. As suggested recently, the scheme of interdisciplinary teams working around the patient should evolve [30]. Another important condition is the trust and the respect between the disciplines. The role of each participant should be well defined, and a goal of care should be agreed upon and accepted unanimously to improve the patient’s health. Further, all partners of the team follow evidence-based protocols. The team may also reinforce the engagement of patients in their own care and provide health behavior counseling, coaching, and education to empower patients and support blood pressure management. In this respect, both nurses and pharmacists have areas of expertise that might help support and improve medication adherence, for example [31]. In the future, the team-based work may also include statistical assessments and cost-effectiveness evaluations as well as interactive artificial intelligence means to support patients and promote recommendations. One important aspect of the team-based care approach is the improved follow-up and monitoring of clinical results. Indeed, today, because of the heavy load of physicians, the number of terms with general practitioners tends to decrease. The opportunity to meet on a more regular basis with either a practicing nurse or a pharmacist increases the number of encounters, in which issues linked to drug therapy (unwanted side effects, missed doses, drug interactions, etc.) can be discussed. Moreover, clinical parameters can be monitored more regularly providing useful information to treating physicians on how to adapt or eventually modify the drug prescription to ensure long-term persistence with good clinical control. In this respect, the use of electronic health records accessible to all team members is important. These records should contain information on demographics, medical history, and clinical data such as blood pressure, heart rate, body weight, medications and allergies, immunization status, and laboratory test results.

Finally, the collaboration with social workers, home visiting nurses and psychologists provides a unique opportunity to gather useful information on the social determinants of health, which are known to play an important role in the successful management of hypertensive patients [32]. This includes the quality of the neighborhood, economic security, food security, the social and community context, and the level of education. More recently, other factors such as noise or air pollution and the access to green spaces have also been shown to affect blood pressure control and to increase the cardiovascular risk in exposed populations [33].

Taken together, all these aspects tend to demonstrate that team-based care is advantageous and may improve both patient and physician satisfaction [34]. Yet, team-based care can also confront barriers. Patients may develop a negative attitude with the feeling of being treated only by non-physicians. In addition, physicians’ attitudes and reactions may not be supportive. Finally, depending on country legislations, regulatory aspects may limit the management opportunities by nurses due to their impossibility to prescribe.

Does team-based care improve adherence and blood pressure control in hypertension?

In the last two decades, several systematic reviews and meta-analyses have assessed the capacity of the team-based care approach to improve blood pressure control and medication adherence [9, 29, 35–44]. From these reviews, it appears that among all clinical strategies developed to improve medication adherence and hence blood pressure control, team-based care has the largest effect size resulting in significant reductions in blood pressure when compared to usual care. In an early meta-analysis of controlled clinical trials involving a nurse or a pharmacist by Carter et al. [35], team-based care was the most effective way to lower systolic blood pressure with a mean effect of –8.7 to –3.6 mmHg. Interestingly, however, the individual components of the team had also a large effect size on systolic blood pressure including pharmacist treatment recommendations (–9.30 mmHg), intervention by nurses (–4.80 mmHg), and use of a treatment algorithm (–4.00 mmHg). The odds ratios (95% confidence intervals) for controlled blood pressure 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). In a more recent meta-analysis of 19 studies comprising 5,993 adult patients with uncontrolled hypertension, the team-based care-induced 12-month systolic blood pressure change versus usual care was –5.0 mmHg (–7.9 to –2.2 mmHg) for team-based care with physician titration [29]. Interestingly, when treatments were titrated by a non-physician the reduction in systolic blood pressure with team-based care was even greater at –10.5 mmHg (–16.2 to –4.8 mmHg) [29]. These findings confirm earlier observations on the benefits of the teamwork even when drug titration is not performed by a physician. However, a strict drug management protocol must be followed by non-physicians.

In general, the improvement of blood pressure when patients are managed by a team of healthcare professionals is attributed to better medication adherence and persistence and to a reduction of therapeutic inertia. In a randomized controlled study among older patients with high cardiovascular risk and taking at least 4 drugs, a comprehensive pharmacy care system has reported a significant improvement in drug adherence and persistence along with improvements in clinical parameters including blood pressure and the lipid profile [45]. Sometimes, ameliorations of drug adherence are modest, but this may be due to the lack of sensitivity of the method used to monitor drug adherence [46].

Team-based care also prevents therapeutic inertia. In the analyses performed by Bryant et al. [29], the time for blood pressure control was significantly shorter when patients were handled by team with a nurse or a pharmacist leading the team and adapting medications. A reduction of therapeutic inertia when implementing the team-based care strategy has been demonstrated in a study of uninsured patients [47]. This study included 377 patients. The median time to BP goal was 36 days in the physician-pharmacist collaboration group and 259 days in the usual care cohort (p < 0.001). At 12 months, blood pressure control was 81% in the team-based care group and 44% in the usual care cohort, respectively (p < 0.001) and therapeutic inertia was lower in the collaborative cohort (27.6%) than in the usual care group (43.7%) (p < 0.0001).

As mentioned above, the problem of poor adherence to medications and uncontrolled blood pressure is particularly prominent in middle- and low-income countries and in low-resource patients [41, 48]. Ogungbe et al. [40] have performed another systematic review and meta-analysis testing team-based care efficacy at different levels of hypertension team-based care complexity in low- and middle-income countries. In their analysis, the mean effect of team-based care versus usual care on blood pressure was –4.6 mmHg (–5.8 to –3.4 mmHg). The greatest reduction in systolic blood pressure was observed in team-based care involving pharmacists (–7.3 mmHg; –9.2 to –5.4 mmHg) followed by nurses (–5.1 mmHg; –8.0 to –2.2 mmHg). Significant decreases in blood pressure were also observed with the interventions of dieticians (–4.7 mmHg) or community health workers (–3.3 mmHg). The results clearly show that a team-based care approach can be implemented successfully in low- and middle-income countries.

Besides interventions involving pharmacists, several studies have demonstrated the impact of nurse interventions [36]. In a systematic review of randomized controlled trials of nursing interventions for hypertension compared with usual care in adults, Clark et al. [36] showed that nurse interventions that included the use of a stepped treatment algorithm showed greater reductions in systolic blood pressure than usual care (weighted mean difference –8.2 mmHg, –11.5 to –4.9 mmHg). Nurse prescribing showed also greater reductions in blood pressure (systolic –8.9 mmHg, –12.5 to –5.3 mmHg and diastolic –4.0 mmHg, –5.3 to –2.7 mmHg) than usual care [36]. In addition, recent evidence has demonstrated that medication management by nurses or registered dietitian nutritionists leads to clinically significant improvements in the management of patients with diabetes, dyslipidemia, or hypertension when using physician-approved protocols or treatment algorithms [49]. These findings further support the collaboration with nurses and other healthcare professionals in the management of hypertension.

Conclusions

There is now increasing evidence supporting the management of hypertensive patients using a team-based care approach, particularly in those patients with uncontrolled hypertension. The main mechanisms resulting in faster and better control of blood pressure with team-based care are an improvement in medication adherence and persistence and a reduction of therapeutic inertia. This latter is probably due to a stricter application of therapeutic protocols by non-physicians [50].

In addition, increased implementation of home blood pressure monitoring and a greater use of single-pill combinations may contribute to the success of the team-based care strategy [5, 17, 51]. It is therefore not surprising that medical associations and international guidelines now strongly recommend approaches involving several healthcare professionals [12–14, 19, 52, 53].

With the actual development of new tools (electronic monitoring, eHealth, telehealth, artificial intelligence, etc.), opportunities to involve more healthcare partners, without increasing the workload and the costs, are becoming possible [54, 55]. In addition, recent analyses of hypertension have demonstrated that team-based care is cost-effective [28, 29, 56]. Therefore, hypertension centers should engage in the development of this strategy. In this context, the hypertension community could learn from other fields of medicine such as HIV or oncology, in which team-based care programs have been implemented successfully within outpatient departments resulting in an improved medication adherence and clinical outcomes [31, 57–59].