Barbershop Blood Pressure Model Too Costly for Wide-Scale Use?

December 28, 2018

A Los Angeles study in which pharmacists treated black male patients in their local barbershop yielded impressive reductions in blood pressure. Nevertheless, a leading expert in the field says he does not believe this is the best way forward to treat hypertension in this difficult-to-reach population on a national level.

Keith C. Ferdinand, MD, Gerald S. Berenson Endowed Chair in Preventive Cardiology, Tulane University, New Orleans, has been heavily involved in many organizations promoting public health in minorities, including the Association of Black Cardiologists and the Healthy Heart Community Prevention Program, a cardiovascular risk program targeting African American and other high-risk populations. Ferdinand believes the barbershop model, as practiced in the Los Angeles study, will cost too much to implement across the nation.

"The model they used, with a PharmD in the barbershops, is very expensive, and the funds needed to roll such a service out nationally would be better spent on improving the services offered to black patients by primary care doctors," he commented to Medscape Medical News.

The study involved 313 black men with uncontrolled hypertension (systolic blood pressure >140 mmHg) who were randomly assigned to a group that received a pharmacist-led intervention or to an active control group.

In the intervention group, pharmacists in the barbershop regularly checked blood pressure, prescribed medications, and monitored electrolyte and creatinine levels. In the control group, barbers promoted follow-up with primary care providers and lifestyle modification.

Results showed that at 6 months, 63.6% of the men in the intervention group had achieved the new blood pressure target of 130/80 mmHg, vs just 11.6% in the control group. Systolic pressure was reduced by a mean of 27 mmHg in the intervention group vs 9.3 mmHg in the control group.

Recently reported results at 12 months showed that these impressive reductions in blood pressure and the achievement of targets were maintained at 1 year in the intervention group.

However, Ferdinand, who was chair of the data safety monitoring board of the Los Angeles study and who coauthored an accompanying editorial regarding the 12-month results in Circulation, is still not convinced of the viability of the approach.

Ferdinand told Medscape Medical News that he applauds all attempts at improving care for minority groups, "but the Los Angeles study had several unique qualities that led to its success."

These included the fact that there was a trained PharmD with prescribing ability in the barbershops, that automated digital blood pressure testing and onsite electrolyte testing was provided, and that a specified combination-drug first-line treatment known to be very effective in reducing blood pressure was employed. "These factors are why the study was successful. There is nothing magic about the barbershop," he notes. "It was more about the good quality care delivered."

He also pointed out that the participants were incentivized to participate by being offered finances to cover their travel expenses and free haircuts.

Ferdinand agrees that the barbershop model was successful in building trust in healthcare services within the male African American community.

"Yes, of course we need to do that," he said. "The reason for studying the barbershop model in the first place is that this segment of the community has lost trust in the medical profession, but we should be rebuilding that trust in traditional healthcare settings, such as doctors' offices.

"We should be doing more to reach these patients, making them feel comfortable when they come in, use culturally sensitive language, make it free to access care, then measuring and treating blood pressure appropriately and making the medications affordable to the poorest in our community and providing follow-up," he added. "The usual care we see in doctors' offices at present does not do these things."

What About the Uninsured?

Ferdinand also made the point that all of the participants in the LA study were insured.

"They were offered incentives to come in, were given first-class care and education, and were able to access the medications prescribed," he said. "If we offered a similar service in the general healthcare settings, then we would see similarly good results, but we don't, and a great many African American people in the poorest areas of the US — the ones we really need to reach — do not have insurance and cannot pay for doctors' visits and for the medication they need. This is where we need to spend healthcare dollars.

"I don't want to discourage barbershop and other sorts of outreach, but I don't think we should be developing an entirely separate healthcare system for one part of the population. Instead, we should be ensuring that everyone can access best care in traditional healthcare settings," Ferdinand added. "We don't need to spend millions turning all barber shops into healthcare clinics. We need to revise and improve care for this community and others where we already are, and then we can use the barbershops and other outreach programs for education.

"They could be health ambassadors to help people access the healthcare system. That would be a more cost-effective option," he said.

Study Authors: "Approach Should Be Cost-effective"

A coauthor of the Los Angeles study, Florian Rader, MD, Cedars-Sinai Medical Center, Los Angeles, responded to these comments.

"We realize that this is an expensive model, but we believe it will be cost-effective because of the large reduction in blood pressure achieved, which will translate into a substantial reduction in strokes, heart attacks, and heart failure hospitalizations," he told Medscape Medical News.

Rader noted that they are currently assessing the feasibility of rolling out their approach in other areas, initially in Nashville, Tennessee, in conjunction with Vanderbilt University, which is in the middle of the so-called stroke belt.

"We are also working with insurance companies. It is in their interest for their clients to be involved in this scheme, as it will lead to a large fall in event rates," he added.

The researchers are also investigating ways to reduce the cost of the program.

"The most expensive part of this approach is the travel time of the clinical pharmacist," Rader noted. "We're looking at whether we can continue using telemedicine with the pharmacist available by Skype. The barbers can be trained to instruct patients how to use the automatic blood pressure reader, and medication prescriptions can be sent directly to the patient's pharmacy."

He stressed that the main reason for the success of this program is that it overcame the distrust of the male African American population in the healthcare system.

"We provided great care in an environment they were comfortable in. Yes, you can get community healthcare advocates to advise these individuals to go to their local primary care provider, but they often don't get treated well there.

"We might indeed get similarly good results if good care was delivered to this population in the primary care setting, and that of course would be the best option, but so far, this approach has failed, and African American men don't go to the doctor's office, whereas they go regularly to their barbershop."

Rader admits the scheme may not work well for uninsured patients. "Our patients were insured. If we were working with an uninsured population, we would have to find a way to offer free medications, and that is another barrier."

The study was funded by the the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH); the NIH National Center for Advancing Translational Sciences; the UCLA Clinical and Translational Science Institute; the California Endowment; the Lincy Foundation; the Harriet and Steven Nichols Foundation; the Burns and Allen Chair in Cardiology Research at the Smidt Heart Institute; and Cedars-Sinai Medical Center. Dr Rader has consulted for Recor Medical. The other authors have disclosed no relevant financial relationships. Dr Ferdinand has served on the LA Barbershop Data and Monitoring Board. Dr Graham has disclosed no relevant financial relationships.

Circulation. Published online December 17, 2018. Abstract, Editorial


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