Barbershop Intervention for High BP Has Lasting Effects

The blood pressure-lowering benefits of taking an intervention that partnered trusted barbers with pharmacists specially trained to treat hypertension to where black men get their hair cut can be sustained out to 1 year, an extension study shows.

As reported in March at the American College of Cardiology 2018 Scientific Session and in the New England Journal of Medicine, the innovative barbershop-based effort resulted in an average reduction in systolic BP of 27 mm Hg through 6 months, compared with just 9 mm Hg in a control group. Nearly two-thirds of the men in the intervention group attained a BP goal of less than 130/80 mm Hg.

Now, results from a 6-month extension study published online December 17, 2018, ahead of print in Circulation show that those effects were maintained, with little change in either the intervention or control group, through 1 year.

Study author Ciantel Blyler, PharmD (Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA), was one of two pharmacists who received clinical training and certification as a hypertension clinician from the American Society of Hypertension (ASH) and met with men in the barbershops. She said the rapport built through that personal interaction outside of a formal healthcare setting was key to the intervention’s success.

“We were able to be effective because we met people where they were comfortable, and when they were comfortable they were more receptive to the messages we were trying to share, they were more receptive to treatment,” Blyler told TCTMD. “Many of the men had physicians, had good insurance coverage, but they weren’t seeking it out, and I think because we were willing to get out of our comfort zone and meet people on their own turf that’s why we were ultimately so successful.”

We were able to be effective because we met people where they were comfortable, and when they were comfortable they were more receptive to the messages we were trying to share. Ciantel Blyler

The idea of bringing hypertension treatment into barbershops was the brainchild of Ronald Victor, MD (Smidt Heart Institute at Cedars-Sinai Medical Center), who died earlier this year and is listed as the lead author on the new paper.

Building on previous work in Dallas, TX, Victor’s team undertook a cluster-randomized trial in 52 barbershops in Los Angeles County, CA. The trial included 319 non-Hispanic black men with uncontrolled systolic BP (≥ 140 mm Hg) who received regular haircuts at one of those shops. During the initial 6-month trial, participants randomized to the intervention received health promotion from their barbers coupled with on-site antihypertensive medication management from the specially trained pharmacists, who prescribed medications under collaborative practice agreements with the men’s primary care providers (PCPs). In the control barbershops, barbers promoted follow-up with PCPs and lifestyle modification.

The same protocol was followed for the 6-month extension study, although pharmacist visits were less frequent. Men in both study groups received follow-up calls on health changes 9 months from baseline, culturally tailored health lessons, and monthly haircut vouchers. In the intervention arm only, participants received $25 per pharmacist visit to offset costs of generic drugs and to compensate for the time at the visits.

Blood pressure differences seen at 6 months were maintained with little change at 1 year, at which point the mean reduction in systolic BP was 20.8 mm Hg greater in the intervention arm (P < 0.0001). In addition, the proportion of men meeting the BP goal of less than 130/80 mm Hg was higher with the pharmacist-led intervention (68.0% vs 11.0%; P < 0.0001).

Importantly, Blyler noted, “not only were we able to sustain the large drop in blood pressure, but we were able to sustain it with fewer pharmacist visits.” The average number of pharmacist visits was seven in the first 6 months and four in the latter half of the year.

Looking at Wider Adoption

Blyler said the team is now performing additional research to address the feasibility of wider adoption of the approach. A cost-effectiveness analysis is ongoing to assess whether it would make financial sense for public and private payers, and a pilot study is ongoing in Nashville, TN, to see whether the success of the Los Angeles-based trial can be replicated with a different care team in another part of the country.

One big logistical issue that needs to be worked out is the time commitment of the pharmacists. Blyler and the other pharmacist spent hours a day driving to barbershops throughout Los Angeles County, which would be inefficient if scaled nationally. A new study that is currently enrolling, conducted among men in the control arm of the initial trial, will explore whether using telemedicine after an initial period of in-person visits can reduce the need for pharmacists to travel to barbershops without dampening the effectiveness of the approach.

Widespread dissemination of such an intervention in the United States will also require “the expansion of collaborative practice between pharmacists and physicians, or the elimination of the requirement altogether (as in Canada and the UK),” the authors say.

“While team-based care models that include pharmacists have proven an effective way to manage chronic disease, many states have been slow to adopt broad collaborative practice authorities for pharmacists,” they explain. “Board certification and other credentialing opportunities (ie, ASH certification) prepare pharmacists for advanced patient care and may help allay concerns about pharmacist readiness for an expanded scope of practice.”