COMMENTARY

Pharmacists and Barbers on the Cutting Edge of Medicine

John M. Mandrola, MD

Disclosures

March 14, 2018

The most important study presented at the American College of Cardiology (ACC) 2018 Annual Scientific Session did not involve a medical device or an expensive new drug. It did not feature doctors. And it did not take place in a hospital or medical office.

These factors alone make "A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops" unique.[1] What makes this study pivotal was its strikingly positive results.

In hypertensive black men, the "intervention" led to an average blood pressure (BP) reduction of 27 mm Hg over 6 months. More than two thirds of men in the intervention group reached a BP of less than 130/80 mm Hg.

The Study

Cedars-Sinai researchers designed a unique approach to treating black men with sustained high BP. This a critical area because black men have the highest rate of hypertension-related death of any racial, ethnic, or sex group.[2]

These authors have previously tested the idea of reaching out to black-owned urban barbershops. An earlier randomized trial found modest improvements in BP control when barbers facilitated BP checks and promoted clinician follow-up.[3]

This latest study went further—the intervention involved prescribing BP-lowering meds at the barbershop, and pharmacists, not doctors, did the prescribing!

To test whether this bold strategy would improve BP control in hypertensive men, the authors cluster-randomized barbershops into two groups. The intervention group of barbershops (n = 28) had barbers who promoted follow-up with specialty-trained pharmacists, and then these pharmacists met patrons monthly at the shop to check BP, prescribe medication, and monitor electrolytes (with point-of-care testing). The pharmacists used a tiered plan for prescribing meds. The control group of shops (n = 24) had barbers who promoted lifestyle modification and follow-up with primary care clinicians.

After screening more than 4500 barbershop patrons, the authors enrolled 139 men to the intervention shops and 180 to the control shops. More than 95% of the cohort remained in the study for the 6 months. The average age of study participants was 54 years, the baseline characteristics matched well, and participants in both groups saw their barber (on average) every 2 weeks throughout the study.

Importantly, both control and intervention groups achieved lower BPs. At the end of 6 months, systolic BP in the control arm went down by 9.3 ± 16 mm Hg, while in the intervention group it fell 27 ± 13.7 mm Hg. The mean systolic BP reduction was 21.6 mm Hg greater with the intervention (95% CI, 14.7 - 28.4; P < .001).

No treatment-related serious adverse events occurred in either treatment arm.

Comments

Increasingly rare is the hype-proof cardiology study.

"Genius" was how my friend Dr Andrew Foy from Penn State University described the idea to use black barbershops for intervention. Foy may be an academic cardiologist, but he also promotes boxing events and works with fighters from urban areas — many of whom are black and Hispanic.

Foy told me barbers lie at the top of the social order in these communities. Why? Perhaps because barbershops themselves offer a trusted environment and a place where black men are treated as equals and with respect. He thought the intervention would have been unlikely to have worked in a pharmacy or grocery store. The barbers and their shops were key.

I reached out to the Association of Black Cardiologists for comment, and President Dr John Fontaine wrote that this study honors the legacy of the late Dr Elijah Saunders,  a pioneering black cardiologist and staunch advocate for hypertension therapy in African Americans. Saunders was known to personally go out to barbershops to measure BP of the patrons. In 1986, he and colleagues at the University of Maryland turned these efforts into a formal outreach program, gaining coverage in the national media.[4]

The latest study had stunning results. The large drops in systolic BP (more than 20 mm Hg on average) with the intervention stand to deliver big benefits. Consider that a 2016 systematic review and meta-analysis of 123 studies with more than 600,000 participants found that for every 10–mm Hg reduction in systolic BP, major cardiovascular events were reduced by 20%, stroke by 27%, heart failure by 28%, and overall mortality by 13%.[5]

If you apply those relative risk reductions to a high-risk group, you get big gains. Don' t miss the fact that the starting systolic BP of participants in this study was 154 mm Hg. In the SPRINT trial,[6]  a study said to have enrolled "high-risk" patients, it was 139 mm Hg.

Primary investigator Dr Ronald Victor said cost-efficacy analyses are planned.

The results of these are easy to predict. If value is defined by outcomes over costs, this intervention stands to deliver great value. Consider how it compares with many recent cardiac interventions. The figure below is modified from a recent review article[7] I coauthored with Foy: reducing hypertension in middle-aged black men represents steep-of-the-curve spending (point A); circulatory support for high risk procedures and PCSK9 inhibitors are examples of flat-of-the curve spending (point C).

Schematic representation of healthcare spending. At point A, additional spending is associated with significant improvement in patient outcomes; at point B, it remains associated with improvement in patient outcomes, but the yield is diminished; and at point C, it is not associated with significant improvement in patient outcomes. Adapted from Prim Care. 2018;45:17-24. 

This trial represents the innovation that the US healthcare system needs. One of the tragic aspects of US healthcare is the inequities. While we spend far more than other countries, much of it on low-value care, we leave large swaths of people, like city-dwelling black men, undertreated for something as simple and deadly as high BP.

The final notable aspect of this study is that specially trained pharmacists, not doctors, did the prescribing. The three-tiered algorithm they used for which BP meds to prescribe worked well, without safety issues. Canadian healthcare embraces the value of pharmacists. This study, and many others, suggests Americans should too.

I'd even argue that the next step for scaling this is to remove the pharmacists. Sure, you can put pharmacists in barbershops if you have grant funding, but that's not feasible in the real world. What if we empower and enable lesser-trained people, perhaps the barbers themselves, with remote backup. It's hardly a stretch to think digital technology and telemedicine could extend this "intervention" with a lot less hands-on help from healthcare professionals.

Conclusion

Clinicians love our work because it is meaningful. Everything about this study radiates meaning.

Dr Victor and his team designed and performed an excellent study, one that delivered stunning results. The intervention will surely be cost-effective, and it addresses a serious inequity in our healthcare system. Nonphysicians featured prominently. Finally, and crucially, it shows a glimpse of the future: that high-value care will increasingly occur not in medical centers but out in the community.

I offer my heartiest congratulations on a study that will be cited for years and decades to come.

Comments

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