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HTN Treatment by Pharmacists in Black Barbershops
Quick Takes
- Pharmacist-led care of HTN in Black-owned barbershops is a highly cost-effective intervention over a 10-year period that results in an increase in QALYs and a decrease in cardiovascular disease events.
- Building partnerships with trusted community partners like Black-owned barbershops is a unique opportunity to address health disparities in Black men, who suffer from HTN at higher rates than any other racial or ethnic group.
- Interventions such as the LABBPS that can reduce health inequities may be cost-effective, but improving the cardiovascular health of Black men in the United States carries significant non-monetary value for our society as a whole. The LABBPS challenges us to find novel ways to address the legacy of systemic racism in medicine.
Study Questions:
Is hypertension (HTN) care delivered by clinical pharmacists in Black barbershops a cost-effective way to improve blood pressure (BP) control in Black men?
Methods:
The LABBPS (Los Angeles Barbershop Blood Pressure Study) methods, detailed in the original study, compared barber-led HTN education with pharmacist-led HTN management in the setting of Black barbershops and showed an average decrease of over 20 mmHg in systolic BP in the pharmacist-led intervention arm compared with the barber-led arm during the 1-year study period. BP control was achieved in 68% of patients in the intervention arm but only 11% in the control arm. To create a simulated population over a 10-year period, data from the participants in the original 1-year LABBPS were matched 1:1 with patients in the National Heart, Lung and Blood Institute Pooled Cohort Study, which estimates lifetime cardiovascular disease risk. Age, systolic and diastolic BP, use of antihypertensives, and other cardiovascular risk factors were used for matching. In the model, participants in the intervention arm returned to usual care after 1 year. This simulated population was run through the Blood Pressure Control-Cardiovascular Disease Policy Model, which is a hybrid of two models that predict long-term BP outcomes, cardiovascular disease events, survival, quality-adjusted survival, and direct health care costs. Primary outcomes were mean direct medical costs, mean quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios over 10 years. Cost-effectiveness thresholds per QALY were as follows: <$50,000 was highly cost-effective, $50,000 to <$150,000 was intermediately cost-effective, and >$150,000 was not cost-effective. Other outcomes projected over the 10-year period were proportion of participants with controlled BP, cardiovascular disease incidence rate, serious medication-related events, and all-cause and cause-specific mortality. Trial pharmacists participated in semi-structured interviews to assess time and resources used in clinical care. Three scenario analyses were completed and assessed for their impact on cost-effectiveness: exclusive use of generic antihypertensives, an “optimized intervention” that assumed efficiency gains in program delivery, and shortening the original 52-week intervention to 26 weeks.
Results:
Baseline characteristics of the initial LABBPS study participants were a mean age of 55.2 years (95% uncertainty interval [UI], 55-55.4), mean systolic BP of 150.7 (150.5-150.9), and mean diastolic BP of 88.8 (88.6-89). The first-year programmatic costs of the LABBP intervention ($3,713 per participant) included higher medication and adverse event costs, but the largest expenses were pharmacist-related, including clinical care and drive time to the barbershops. After the simulated 1-year intervention, the difference in projected BP control between the intervention and study arms was 22.5 and 22.2, respectively. At 10 years, the projected BP control rate continued to be higher in the intervention arm (60.4% [95% UI, 51.5-69%]). The intervention arm had fewer projected cardiovascular disease events than the control arm, 17.4% [95% UI, 13.9-21.8%] and 24.8% (95% UI, 20.1-31.2%), representing an incidence ratio of 0.67 (95% UI, 0.61-0.73). Over 10 years, the intervention arm was projected to gain a mean of 0.06 QALYs (95% UI, 0.01-0.10) at a projected cost of $2,356 per participant. This resulted in an incremental cost-effectiveness ratio of $42,717 per QALY, representing a 58.2% probability of being highly cost-effective and a 95.6% probability of at least intermediately cost-effective. When evaluated using generic drugs only, the incremental cost-effectiveness ratio decreased to $17,162 per QALY and an 86.4% probability of being highly cost-effective. The simulation with a 26-week initial intervention, with its lower programmatic costs compared to the original study’s 52-week intervention, continued to show high cost-effectiveness at $18,300 per QALY but did result in worse BP control and higher rates of cardiovascular disease at 10 years.
Conclusions:
The original LABBPS showed that the novel approach of pharmacist-led HTN care in Black-owned barbershops was an effective method for lowering BP in Black men. This study showed pharmacist-led care in this setting to be highly cost-effective over a 10-year period, decreasing cardiovascular events in this high-risk population. Additionally, the model showed a profound improvement in cost-effectiveness when only generic medications were used, reducing the incremental cost-effectiveness ratio from $42,717 to $17,162 per QALY. The intervention would reach the level of intermediate cost-effectiveness only if the pharmacists did not intensify treatment for systolic BP ≥150 or if driving time for the pharmacists increases.
Perspective:
HTN in Black men is a devastating example of a health disparity that has a far-reaching impact. The downstream sequelae, including heart failure, stroke, and end-stage renal disease, all are diseases with a high cost in health care dollars, mortality, and quality of life. The relatively low cost of this intervention was further improved in the model by using only generic drugs. Other attempts to lower the intervention cost were successful but did have a negative impact on cardiovascular disease burden, something that would need to be carefully weighed as similar interventions are developed. It is also important to note that in the LABBPS, educating trusted community partners alone was not enough. Embedding trained cardiovascular professionals in non-traditional settings where Black men may be more comfortable receiving care was what had the biggest impact. Interventions such as the LABBPS that can reduce health inequities may be cost-effective, but improving the cardiovascular health of Black men in the United States carries significant non-monetary value for our society as a whole. The LABBPS challenges healthcare providers and systems to find innovative ways to address the legacy of systemic racism in medicine.
Clinical Topics: Cardiovascular Care Team, Prevention, Hypertension
Keywords: Hypertension, Blood Pressure, African Americans, Male, Pharmacists, Antihypertensive Agents, Quality-Adjusted Life Years, Cost-Benefit Analysis, Cardiovascular Diseases, Risk Factors, Delivery of Health Care, Health Care Costs, Drugs, Generic, Quality of Life, Ethnic Groups, Racism
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