Scaling Up Pharmacist-Led Blood Pressure Control Programs in Black Barbershops: Projected Population Health Impact and Value
2021; Lippincott Williams & Wilkins; Volume: 143; Issue: 24 Linguagem: Inglês
10.1161/circulationaha.120.051782
ISSN1524-4539
AutoresDhruv S. Kazi, Pengxiao C. Wei, Joanne Penko, Brandon K. Bellows, Pamela G. Coxson, Kelsey B. Bryant, Valy Fontil, Ciantel A. Blyler, Courtney R. Lyles, Kathleen Lynch, Joseph E. Ebinger, Yiyi Zhang, Gabriel S. Tajeu, Ross Boylan, Mark J. Pletcher, Florian Rader, Andrew E. Moran, Kirsten Bibbins‐Domingo,
Tópico(s)Cardiac Health and Mental Health
ResumoHomeCirculationVol. 143, No. 24Scaling Up Pharmacist-Led Blood Pressure Control Programs in Black Barbershops: Projected Population Health Impact and Value Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessLetterPDF/EPUBScaling Up Pharmacist-Led Blood Pressure Control Programs in Black Barbershops: Projected Population Health Impact and Value Dhruv S. Kazi, MD, MSc, MS, Pengxiao C. Wei, BS, MPH, Joanne Penko, MS, MPH, Brandon K. Bellows, PharmD, MS, Pamela Coxson, PhD, Kelsey B. Bryant, MD, MPH, MS, Valy Fontil, MD, MPH, Ciantel A. Blyler, PharmD, Courtney Lyles, PhD, Kathleen Lynch, PharmD, Joseph Ebinger, MD, MS, Yiyi Zhang, PhD, Gabriel S. Tajeu, DrPH, MPH, Ross Boylan, PhD, Mark J. Pletcher, MD, MPH, Florian Rader, MD, MSc, Andrew E. Moran, MD, MPH and Kirsten Bibbins-Domingo, PhD, MD Dhruv S. KaziDhruv S. Kazi Correspondence to: Dhruv S. Kazi, MD, MSc, MS, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, 375 Longwood Avenue, 4th Floor, Boston MA 02215. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9510-2979 Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (D.S.K.). Harvard Medical School, Boston, MA (D.S.K.). , Pengxiao C. WeiPengxiao C. Wei University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.). , Joanne PenkoJoanne Penko University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.). , Brandon K. BellowsBrandon K. Bellows https://orcid.org/0000-0003-1395-6047 Vagelos College of Physicians and Surgeons, Columbia University, NY (B.K.B., K.B.B., Y.Z., A.E.M.). , Pamela CoxsonPamela Coxson University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.). , Kelsey B. BryantKelsey B. Bryant https://orcid.org/0000-0001-7180-8064 Vagelos College of Physicians and Surgeons, Columbia University, NY (B.K.B., K.B.B., Y.Z., A.E.M.). , Valy FontilValy Fontil University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.). , Ciantel A. BlylerCiantel A. Blyler Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.A.B., J.E., F.R.). , Courtney LylesCourtney Lyles University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.). , Kathleen LynchKathleen Lynch Harvard Medical School, Boston, MA (D.S.K.). Providence Saint John's Health Center, John Wayne Cancer Institute, Santa Monica, CA (K.L.). , Joseph EbingerJoseph Ebinger https://orcid.org/0000-0002-0587-1572 Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.A.B., J.E., F.R.). , Yiyi ZhangYiyi Zhang https://orcid.org/0000-0002-8663-5001 Vagelos College of Physicians and Surgeons, Columbia University, NY (B.K.B., K.B.B., Y.Z., A.E.M.). , Gabriel S. TajeuGabriel S. Tajeu College of Public Health, Temple University, Philadelphia, PA (G.S.T.). , Ross BoylanRoss Boylan University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.). , Mark J. PletcherMark J. Pletcher https://orcid.org/0000-0002-6966-1312 University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.). , Florian RaderFlorian Rader https://orcid.org/0000-0003-1637-5096 Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.A.B., J.E., F.R.). , Andrew E. MoranAndrew E. Moran Vagelos College of Physicians and Surgeons, Columbia University, NY (B.K.B., K.B.B., Y.Z., A.E.M.). and Kirsten Bibbins-DomingoKirsten Bibbins-Domingo University of California, San Francisco (P.C.W., J.P., P.C., V.F., C.L., R.B., M.J.P., K.B.-D.). Originally published14 Jun 2021https://doi.org/10.1161/CIRCULATIONAHA.120.051782Circulation. 2021;143:2406–2408A barbershop-based, pharmacist-led blood pressure (BP) control program significantly improved hypertension control among Black men in the Los Angeles Barbershop BP study (LABBPS).1 This result generated intense interest in community-based BP control, but critical knowledge gaps regarding implementation and costs remain. We sought to evaluate the potential population health impact and economic value of scaling up barbershop-based, pharmacist-led BP control programs targeted to eligible non-Hispanic Black men in the United States.We used the Cardiovascular Disease Policy Model, an established Markov state-transition model of cardiovascular risk, clinical outcomes, and health care costs in the United States, to project clinical outcomes and direct health care costs of nationwide scale-up of barbershop-based, pharmacist-led BP control programs relative to usual care over 10 years.2,3 We evaluated a hypothetical cohort of Black men 35 to 79 years of age living in US metropolitan areas with a systolic BP of ≥140 mm Hg. The effect of reducing systolic BP on coronary heart disease and stroke was based on a meta-analysis of trials4; the effect on noncardiovascular death was estimated from data collected from Black adults in 6 observational cohort studies from the National Heart, Lung, and Blood Institute Pooled Cohorts Study.5 We included costs related to pharmacist clinical encounters, generic antihypertensive medications, medication-related adverse events, cardiovascular hospitalizations, and chronic health care. Quality-of-life inputs reflected cardiovascular health and short-term tolls for acute events (eg, medication-related adverse events). We assumed that 34% of Black men with hypertension could be reached by the programs (85% of Black men live in metropolitan areas, half of these men patronize Black barbershops and, among those eligible, we assumed 80% would participate). Key end points were annual number of major adverse cardiovascular events (a composite of myocardial infarctions, strokes, and deaths from cardiovascular causes) averted, and the annual costs of implementing the program at which it would be cost-effective given a range of effectiveness (systolic BP reduction of 10–25 mm Hg; bracketing the 20.8-mm Hg reduction observed in LABBPS) and cost-effectiveness thresholds ($50 000 to $150 000 per quality-adjusted life-year gained). Additional information regarding modeling methods and key data sources have been made available online. The institutional review board at the University of California, San Francisco, approved the research undertaken with the Cardiovascular Disease Policy Model.Scaled-up barbershop-based BP control programs are projected to reach approximately 941 000 Black men each year. If the programs reduced mean systolic BP by 20 mm Hg (comparable to that achieved in the LABBPS), they would avert 8600 major adverse cardiovascular events (95% uncertainty interval, 7200–9700) annually relative to usual care, including 1800 myocardial infarctions (95% uncertainty interval, 1200–2400) and 5500 strokes (95% uncertainty interval, 4400–6600; Table). The programs would be cost-effective at $100 000 per quality-adjusted life-year gained if implementation costs were ≤$1440 per patient-year enrolled (95% uncertainty interval, 1065–1839; Figure I in the Data Supplement). Lower effectiveness and lower cost-effectiveness thresholds would reduce the amount that payors would be willing to pay for patient enrollment in the program.3Table. Results: Projected Annual Population Health Impact of a National Scale-Up of Pharmacist-Led Blood Pressure Control Programs in Black Barbershops Under Varying Assumptions of Program EffectivenessAnnual outcomesEffect size, mm Hg (mean reduction in systolic blood pressure)10152025Projected clinical outcomes (95% UI) CVD deaths prevented*1200 (900–1500)1700 (1300–2100)2100 (1700–2500)2500 (2000–2900) Myocardial infarction prevented*1000 (700–1300)1400 (1000–1900)1800 (1200–2400)2200 (1500–2800) Stroke prevented*3100 (2400–3800)4400 (3500–5300)5500 (4400–6600)6400 (5200–7600) Major adverse cardiovascular events (fatal and nonfatal myocardial infarction and stroke, and deaths from coronary heart disease) prevented*4800 (4100–5600)6800 (5900–7800)8600 (7200–9700)10 100 (8600–11 400) Quality-adjusted life-year gained6300 (4800–7800)9000 (6900–11 200)11 500 (8800–14 300)13 800 (10 500–17 100) Life-years gained5200 (3800–6600)7500 (5600–9600)9600 (7100–12 200)11 600 (8600–14 700)Projected cost outcomes, 2019 US dollars, millions (95% UI) Incremental cost of CVD care–$376 (–$499 to –$295)–$535 (–$707 to –$421)–$675 (–$892 to –$535)–$800 (–1050 to –$637) Incremental cost of pharmacist clinical time, antihypertensive drugs, and related adverse events$360 ($303 to $422)$369 ($312 to $431)$382 ($325 to $444)$394 ($336 to $456) Incremental cost of non-CVD care$46 ($35 to $513)$66 ($50 to $736)$85 ($64 to $944)$102 ($77 to $1134) Incremental aggregate costs$30 (–$100 to $138)–$100 (–$270 to $37)–$208 (–$420 to –$50)–$304 (–$548 to –$125)The simulation included approximately 941 000 Black men 35–79 years of age living in US metropolitan areas with a systolic blood pressure of ≥140 mm Hg. The exact number varied from year to year of the 10-year model (with the entry of new individuals who turned 35 years of age or who developed hypertension during follow-up and therefore became eligible for enrollment). The 95% UIs were derived from a probabilistic sensitivity analysis in which each of 1000 simulations sampled (with replacement) key input parameters from prespecified statistical distributions. CVD indicates cardiovascular disease; and UI, uncertainty interval.* For comparison, the annual number of events in the control arm are as follows: 6000 CVD deaths, 5800 myocardial infarctions, 11 800 strokes, and 21 900 major adverse cardiovascular events.A barbershop-based, pharmacist-led BP control program represents a novel and effective way to deliver hypertension care to Black men, an underserved and systemically disenfranchised population with substantial morbidity and mortality from uncontrolled hypertension. Scaling up such programs could reach a third of all Black men with hypertension and generate substantial population health benefits at a reasonable cost per participant. If BP reductions similar to those achieved in the LABBPS were reproduced in community settings, nearly 40% of expected major adverse cardiovascular events in participants could be averted. Assuming a cost-effectiveness threshold of $100 000 per quality-adjusted life-year, payors should be willing to pay $1440 per patient-year enrolled in the program.Prevention programs are often held to the high bar of cost neutrality or cost savings, suggesting that programs must pay for themselves in the long run, although we tolerate higher cost-effectiveness thresholds for therapeutic interventions. A better way to evaluate the value of a barbershop-based hypertension program is to estimate how much we would be willing to pay for a pill or device with an equivalent reduction in disease burden. In addition, conventional cost-effectiveness analyses do not capture the societal value of reductions in between-group health disparities—we should be willing to pay more for interventions that improve health outcomes in traditionally underserved communities (such as BP control in Black men). As these programs are scaled up, care delivery models will likely be adapted to match local resources and capacity. This may alter their effectiveness, which must be monitored. Our findings provide a range that payors should be willing to pay (beyond medical costs and pharmacist encounter time) to cost-effectively implement such programs on the basis of the observed effectiveness.Our analysis is limited by drawing on a single randomized controlled trial, although we examine a range of possible effectiveness estimates. It does not examine heterogeneity of benefit or risk among individual patients. The health care sector perspective accounts only for health care–related costs. Because we do not consider productivity losses, we likely underestimate the societal value of averting cardiovascular events that occur at younger ages.Barbershop-based, pharmacist-led BP control programs that target Black men are projected to generate substantial population health benefits. Innovative health care models should examine how community-based hypertension care can be sustainably delivered at scale within the cost constraints identified in this study.Nonstandard Abbreviations and AcronymsBPblood pressureLABBPSLos Angeles Barbershop BP StudyAcknowledgmentsD.S. Kazi, P.C. Wei, J. Penko, P. Coxson, and K. Bibbins-Domingo had full access to the data in the study and take responsibility for the integrity of the data and the accuracy for the data analysis. Detailed roles are as follows: concept and design, D.S. Kazi and K. Bibbins-Domingo; acquisition, analysis, or interpretation of data, D.S. Kazi, P.C. Wei, J. Penko, B.K. Bellows, P. Coxson, K.B. Bryant, C.A. Blyler, K. Lynch, Y. Zhang, G.S. Tajeu, R. Boylan, A.E. Moran, and K. Bibbins-Domingo; drafting of the article, D.S. Kazi, P.C. Wei, J. Penko, K. Bibbins-Domingo; critical revision of the article for important intellectual content, D.S. Kazi, P.C. Wei, J. Penko, B.K. Bellows, P. Coxson, K.B. Bryant, V. Fontil, C.A. Blyler, C. Lyles, K. Lynch, J. Ebinger, Y. Zhang, R. Boylan, M.J. Pletcher, F. Rader, A.E. Moran, and K. Bibbins-Domingo; statistical analysis, P.C. Wei, J. Penko, B.K. Bellows, P. Coxson, Y. Zhang, G.S. Tajeu, and R. Boylan; obtaining funding, K. Bibbins-Domingo; administrative, technical, or material support, P.C. Wei and J. Penko; and study supervision, D.S. Kazi and K. Bibbins-Domingo. The authors acknowledge Linda Valsdottir for her editorial assistance. The authors dedicate this article to Ronald G. Victor, MD, the architect of the Los Angeles Barbershop Blood Pressure Control Study and a beloved colleague and mentor. This economic evaluation was inspired by Dr Victor's belief that this new model of care could succeed in reaching high-risk hypertensive populations, but that "scalability [would] depend on our ability to adapt the model to create operational efficiencies while maintaining intervention potency."1Sources of FundingThis work was supported by the National Institutes of Health (R01HL117983, R01HL130500, 3R01HL117983-01A1S1), the University of California Los Angeles Clinical and Translational Science Institute (UL1TR001881, K01-HL140170 [to B.K. Bellows], K23-HL153888 [to J. Ebinger], 1K01HL151974-01 [to G.S. Tajeu], 3R01DK108628-05S1 [to G.S. Tajeu], K24DK103992 [to K. Bibbins-Domingo]), the California Endowment (20131872 and 20162257), and the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology at the Beth Israel Deaconess Medical Center (to D.S. Kazi). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; or decision to submit the article for publication.Supplemental MaterialData Supplement Figure IDisclosures Dr Lyles has received institutional contract funding from InquisitHealth, AppliedVR, and SomnologyMD. Dr Rader reports receiving consultation fees from Medtronic Inc, Recor Medical, and MyoKardia for work unrelated to this article. The other authors have no disclosures.Footnoteswww.ahajournals.org/journal/circThe Data Supplement, podcast, and transcript are available with this article at https://www.ahajournals.org/doi/suppl/10.1161/CIRCULATIONAHA.120.051782.For Sources of Funding and Disclosures, see page 2408.Correspondence to: Dhruv S. Kazi, MD, MSc, MS, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, 375 Longwood Avenue, 4th Floor, Boston MA 02215. 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Associations of blood pressure and cholesterol levels during young adulthood with later cardiovascular events.J Am Coll Cardiol. 2019; 74:330–341. doi: 10.1016/j.jacc.2019.03.529CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByAlbert M, Carnethon M and Watson K (2021) Disparities in Cardiovascular Medicine, Circulation, 143:24, (2319-2320), Online publication date: 15-Jun-2021.Bryant K, Moran A, Kazi D, Zhang Y, Penko J, Ruiz-Negrón N, Coxson P, Blyler C, Lynch K, Cohen L, Tajeu G, Fontil V, Moy N, Ebinger J, Rader F, Bibbins-Domingo K and Bellows B (2021) Cost-Effectiveness of Hypertension Treatment by Pharmacists in Black Barbershops, Circulation, 143:24, (2384-2394), Online publication date: 15-Jun-2021.Aggarwal R, Chiu N, Wadhera R, Moran A, Raber I, Shen C, Yeh R and Kazi D (2021) Racial/Ethnic Disparities in Hypertension Prevalence, Awareness, Treatment, and Control in the United States, 2013 to 2018, Hypertension, 78:6, (1719-1726), Online publication date: 1-Dec-2021. June 15, 2021Vol 143, Issue 24Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.051782PMID: 34125566 Originally publishedJune 14, 2021 Keywordscost-effectivenessAfrican Americansblood pressurecommunity health carepopulation healthpharmacistsPDF download Advertisement SubjectsCardiovascular DiseaseCost-EffectivenessDisparitiesHealth EquityHypertension
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