Part II, provider perspectives: should patients be activated to request evidence-based medicine? A qualitative study of the VA project to implement diuretics (VAPID).
ABSTRACT: BACKGROUND:Hypertension guidelines recommend the use of thiazide diuretics as first-line therapy for uncomplicated hypertension, yet diuretics are under-prescribed, and hypertension is frequently inadequately treated. This qualitative evaluation of provider attitudes follows a randomized controlled trial of a patient activation strategy in which hypertensive patients received letters and incentives to discuss thiazides with their provider. The strategy prompted high discussion rates and enhanced thiazide-prescribing rates. Our objective was to interview providers to understand the effectiveness and acceptability of the intervention from their perspective, as well as the suitability of patient activation for more widespread guideline implementation. METHODS:Semi-structured phone interviews were conducted with 21 primary care providers. Interviews were transcribed verbatim and reviewed by the interviewer before being analyzed for content. Interviews were coded, and relevant themes and specific responses were identified, grouped, and compared. RESULTS:Of the 21 providers interviewed, 20 (95%) had a positive opinion of the intervention, and 18 of 20 (90%) thought the strategy was suitable for wider use. In explaining their opinions of the intervention, many providers discussed a positive effect on treatment, but they more often focused on the process of patient activation itself, describing how the intervention facilitated discussions by informing patients and making them more pro-active. Regarding effectiveness, providers suggested the intervention worked like a reminder, highlighted oversights, or changed their approach to hypertension management. Many providers also explained that the intervention 'aligned' patients' objectives with theirs, or made patients more likely to accept a change in medications. Negative aspects were mentioned infrequently, but concerns about the use of financial incentives were most common. Relevant barriers to initiating thiazide treatment included a hesitancy to switch medications if the patient was at or near goal blood pressure on a different anti-hypertensive. CONCLUSIONS:Patient activation was acceptable to providers as a guideline implementation strategy, with considerable value placed on the activation process itself. By 'aligning' patients' objectives with those of their providers, this process also facilitated part of the effectiveness of the intervention. Patient activation shows promise for wider use as an implementation strategy, and should be tested in other areas of evidence-based medicine. TRIAL REGISTRATION:National Clinical Trial Registry number NCT00265538.
Project description:This qualitative evaluation follows a randomized-control trial of a patient activation intervention in which hypertensive patients received a letter in the mail asking them to discuss thiazide diuretics with their provider. Results of the parent study indicated that the intervention was effective at facilitating discussions between patients and providers and enhancing thiazide prescribing rates. In the research presented here, our objective was to interview patients to determine their receptivity to patient activation, a potential leverage point for implementing interventions.Semi-structured phone interviews were conducted with 54 patients, purposefully sampled from a randomized controlled trial of a patient activation intervention. All subjects had a history of hypertension and received primary care from one of twelve Veterans Affairs primary care clinics. All interviews were transcribed verbatim and reviewed by the interviewer. Interviews were independently coded by three qualitative researchers until consensus was attained, and relevant themes and responses were identified, grouped, and compared. NVivo 8.0 was used for data management and analysis.Data from this qualitative study revealed that most participants held favorable opinions toward the patient activation intervention used in the clinical trial. Most (82%) stated they had a positive reaction. Patients emphasized they liked the intervention because it was straightforward and encouraged them to initiate discussions with their provider. Also, by being active participants in their healthcare, patients felt more invested. Of the few patients offering negative feedback (11%), their main concern was discomfort with possibly challenging their providers' healthcare practices. Another outcome of interest was the patients' perceptions of why they were or were not prescribed a thiazide diuretic, for which several clinically relevant reasons were provided.Patients' perceptions of the intervention indicated it was effective via the encouragement of dialogue between themselves and their provider regarding evidence-based treatment options for hypertension. Additionally, patients' experiences with thiazide prescribing discussions shed light on the facilitators and barriers to implementing clinical practice guidelines regarding thiazides as first-line therapy for hypertension.National Clinical Trial Registry number NCT00265538.
Project description:Importance:Evidence-based guidelines recommend thiazide diuretics as a first-line therapy for uncomplicated hypertension; however, thiazides are underused, and hypertension remains inadequately managed. Objective:To test the efficacy of a patient activation intervention with financial incentives to promote thiazide prescribing. Design, Setting, and Participants:The Veterans Affairs Project to Implement Diuretics, a randomized clinical trial, was conducted at 13 Veterans Affairs primary care clinics from August 1, 2006, to July 31, 2008, with 12 months of follow-up. A total of 61?019 patients were screened to identify 2853 eligible patients who were not taking a thiazide and not at their blood pressure (BP) goal; 598 consented to participate. Statistical analysis was conducted from December 1, 2017, to September 12, 2018. Interventions:Patients were randomized to a control group (n?=?196) or 1 of 3 intervention groups designed to activate patients to talk with their primary care clinicians about thiazides and hypertension: group A (n?=?143) received an activation letter, group B (n?=?128) received a letter plus a financial incentive, and group C (n?=?131) received a letter, financial incentive, and a telephone call encouraging patients to speak with their primary care clinicians. Main Outcomes and Measures:Primary outcomes were thiazide prescribing and BP control. A secondary process measure was discussion between patient and primary care clinician about thiazides. Results:Among 598 participants (588 men and 10 women), the mean (SD) age for the combined intervention groups (n?=?402) was 62.9 (8.8) years, and the mean baseline BP was 148.1/83.8 mm Hg; the mean (SD) age for the control group (n?=?196) was 64.1 (9.2) years, and the mean baseline BP was 151.0/83.4 mm Hg. At index visits, the unadjusted rate of thiazide prescribing was 9.7% for the control group (19 of 196) and 24.5% (35 of 143) for group A, 25.8% (33 of 128) for group B, and 32.8% (43 of 131) for group C (P?<?.001). Adjusted analyses demonstrated an intervention effect on thiazide prescribing at the index visit and 6-month visit, which diminished at the 12-month visit. For BP control, there was a significant intervention effect at the 12-month follow-up for group C (adjusted odds ratio, 1.73; 95% CI, 1.06-2.83; P?=?.04). Intervention groups exhibited improved thiazide discussion rates in a dose-response fashion: group A, 44.1% (63 of 143); group B, 56.3% (72 of 128); and group C, 68.7% (90 of 131) (P?=?.004). Conclusions and Relevance:This patient activation intervention about thiazides for hypertension resulted in two-thirds of patients having discussions and nearly one-third initiating a prescription of thiazide. Adding a financial incentive and telephone call to the letter resulted in incremental improvements in both outcomes. By 12 months, improved BP control was also evident. This low-cost, low-intensity intervention resulted in high rates of discussions between patients and clinicians and subsequent thiazide treatment and may be used to promote evidence-based guidelines and overcome clinical inertia. Trial Registration:ClinicalTrials.gov Identifier: NCT00265538.
Project description:To analyze patient perspectives of the use of financial incentives in a hypertension intervention. Study Setting. Twelve Veterans Affairs primary care clinics over a 9-month period.Qualitative semistructured interviews conducted with 54 hypertensive veterans participating in an intervention to promote guideline-consistent therapy. Intervention components included an intervention letter requesting patients talk with their providers, an offer of U.S.$20 to bring in the letter to their provider, and a health educator phone call.Semistructured interviews were conducted. Transcripts were coded for thematic content. The financial incentive theme was then subcoded for more detailed analysis.Most participants (n=48; 88.9 percent) stated the incentive had (or would have) no effect on their decision to initiate a discussion with their provider. Some participants articulated reservations about the effectiveness and/or appropriateness of financial incentives in health care decisions; however, a few expressed the opinion that there may be some potential benefits to the use of financial incentives if they encourage patients to be active in their health care.The findings of this study raise questions about the appropriateness and unintended consequences of employing patient-directed financial incentives in health care settings.
Project description:OBJECTIVES:Thiazide diuretics are one of the first choice antihypertensives but not optimally utilised because of concerns regarding their adverse effects on glucose metabolism. The Diuretics In the Management of Essential hypertension (DIME) study was designed, for the first time, to assess the risk for type 2 diabetes mellitus in patients with essential hypertension during antihypertensive treatment with low-dose thiazide diuretics compared to those not treated with diuretics. DESIGN:Multicentre, unblinded, pragmatic, randomised, controlled trial with blinded assessment of end points and intention-to-treat analysis that was started in 2004 and finished in 2012. SETTING:Hypertension clinics at 106 sites in Japan, including general practitioners' offices and teaching hospitals. PARTICIPANTS:Non-diabetic patients with essential hypertension. INTERVENTIONS:Antihypertensive treatment with low-dose thiazide diuretics at 12.5?mg/day of hydrochlorothiazide or equivalent (Diuretics group) or that without thiazide diuretics (No-diuretics group). MAIN OUTCOME:The primary outcome was new onset of type 2 diabetes diagnosed according to WHO criteria and the criteria of Japanese Society of Diabetes. RESULTS:1130 patients were allocated to Diuretics (n=544) or No-diuretics group (n=586). Complete end point information was collected for 1049 participants after a median follow-up of 4.4?years. Diabetes developed in 25 (4.6%) participants in the Diuretics group, as compared with 29 (4.9%) in the No-diuretics group (HR 0.93; 95% CI 0.55 to 1.58; p=0.800). CONCLUSIONS:Antihypertensive treatment with thiazide diuretics at low doses may not be associated with an increased risk for new onset of type 2 diabetes. This result might suggest safety of use of low doses of thiazide diuretics. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov NCT00131846.
Project description:Thiazides and thiazide-type diuretics are recommended as first-line agents for the treatment of hypertension, but contemporary information on their use in clinical practice is lacking. We examined patterns and correlates of thiazide prescription in a cross-sectional analysis of baseline data from participants enrolled in the Systolic Blood Pressure Intervention Trial (SPRINT). We examined baseline prescription of thiazides in 7582 participants receiving at least 1 antihypertensive medication by subgroup, and used log-binomial regression to calculate adjusted prevalence ratios for thiazide prescription (versus no thiazide). Forty-three percent of all participants were prescribed a thiazide at baseline, but among participants prescribed a single agent, the proportion was only 16%. The prevalence of thiazide prescription differed significantly by demographic factors, with younger participants, women, and blacks all having higher adjusted prevalence of thiazide prescription than other corresponding subgroups. Participants in the lowest category of kidney function (estimated glomerular filtration rate <30 mL/min per 1.73 m2) were half as likely to be prescribed a thiazide as participants with preserved kidney function. In conclusion, among persons with hypertension and heightened cardiovascular risk, we found that thiazide prescription varied significantly by demographics and kidney disease status, despite limited evidence about relative differences in effectiveness.
Project description:The burden of chronic diseases is increasing in both low- and middle-income countries. However, healthcare systems in low-income countries are inadequately equipped to deal with the growing disease burden, which requires chronic care for patients. The aim of this study was to assess the capacity of health facilities to manage hypertension in two districts in Uganda.In a cross-sectional study conducted between June and October 2012, we surveyed 126 health facilities (6 hospitals, 4 Health Center IV (HCIV), 23 Health Center III (HCIII), 41 Health Center II (HCII) and 52 private clinics/dispensaries) in Mukono and Buikwe districts in Uganda. We assessed records, conducted structured interviews with heads of facilities, and administered questionnaires to 271 health workers. The study assessed service provision for hypertension, availability of supplies such as medicines, guidelines and equipment, in-service training for hypertension, knowledge of hypertension management, challenges and recommendations.Of the 126 health facilities, 92.9% reported managing (diagnosing/treating) patients with hypertension, and most (80.2%) were run by non-medical doctors or non-physician health workers (NPHW). Less than half (46%) of the facilities had guidelines for managing hypertension. A 10th of the facilities lacked functioning blood pressure devices and 28% did not have stethoscopes. No facilities ever calibrated their BP devices except one. About a half of the facilities had anti-hypertensive medicines in stock; mainly thiazide diuretics (46%), beta blockers (56%) and calcium channel blockers (48.4%). Alpha blockers, mixed alpha & beta blockers and angiotensin II receptor antagonists were only stocked by private clinics/dispensaries. Most HCIIs lacked anti-hypertensive medicines, including the first line thiazide diuretics. Significant knowledge gaps in classification of patients as hypertensive were noted among respondents. All health workers (except 5, 1.9%) indicated that they needed additional training in hypertension management. Several provider and patient related challenges were also observed in this study.Health facilities in this setting are inadequately equipped to provide services for management of hypertension. Diagnostic equipment, anti-hypertensive drugs and personnel present great challenges. To address the increasing burden of hypertension and other chronic diseases, measures are needed to substantially strengthen the healthcare facilities, including training of personnel in management of hypertension and other chronic diseases, and improving diagnostic and treatment supplies.
Project description:Background:Hypertension is the most common modifiable risk factor for cardiovascular disease, with an increasing prevalence with age, but with easily available medications to control it. Adverse effects of these medications do limit their use, in particular hyponatremia due to thiazide and thiazide-like diuretics. This is more common in the elderly patients due to a combination of inadequate protein intake and impaired urinary dilution capability, made worse by additional thiazide use. Limiting free water intake and increasing protein intake are often not successful resulting in thiazide avoidance. Daily protein supplement is a potential option in this clinical scenario. We describe the protocol for a feasibility study to explore this option. Methods:This is a single-arm, prospective, open-label proof-of-concept trial, including elderly patients with thiazide diuretic-induced hyponatremia. Forty patients will be enrolled and receive a bottle of a protein supplement daily, providing 120 mmol of solutes and permitting an extra 163 mL free water loss, for 4 weeks. The main outcome measures will be (1) feasibility for enrollment, (2) safety of the intervention, and (3) potential efficacy of the intervention in improving hyponatremia. Secondary outcome measures will include changes in urine osmolality, body weight, and urea measurements. Discussion:Thiazide diuretic-induced hyponatremia is an important adverse effect, with significant clinical impact, such as delirium and falls, and limits the use of these potent antihypertensive agents. There are little data on the effect or safety of protein supplementation and also on whether a trial of this is feasible. The results of this proof-of-concept feasibility trial will help plan and execute a larger definitive trial to test protein supplementation as an effective strategy in this condition. Trial registration:The trial is registered with Clinical trials, registration identifier: NCT02614807.
Project description:Adherence to hypertension guidelines in the outpatient setting is low.To evaluate adherence to JNC VII guidelines in nursing home patients.Data were obtained from the 2004 National Nursing Home Survey (NNHS), a nationally representative sample of US nursing homes. Patients with hypertension were identified using ICD-9 codes. Adherence to JNC VII guidelines was defined as the use of a thiazide diuretic in patients without a compelling indication for a different class of antihypertensive medication, such as diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke.There were 13,507 patients in the 2004 NNHS survey, of whom 7,129 had hypertension.Of these 7,129 hypertensive patients, only 12.6% were on a thiazide. Out of the 7,129 hypertensive patients, 3,113 did not have diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke. Of these 3,113 patients, only 13.9% were on a thiazide. After excluding patients with a potential contraindication to a diuretic, such as hospice care or incontinence, only 18% were prescribed a thiazide. Of the 3,113 patients, 1,148 were on a single class of antihypertensive and more were prescribed a beta blocker, ACE inhibitor, calcium channel blocker, loop diuretic, and ARB than a thiazide diuretic.Adherence to hypertension guidelines among nursing home patients is low. The appropriate use of thiazide diuretics could reduce costs and improve blood pressure control and patient outcomes.
Project description:BACKGROUND:Thiazide diuretics reduce the risk of recurrent kidney calculi in patients with kidney calculi or hypercalciuria. However, whether thiazide diuretics can definitely prevent recurrent kidney calculi remains unclear. We aimed to evaluate the effect and safety of thiazide diuretics on recurrent kidney calculi. METHODS:The PubMed, Cochrane Library, and EMBASE databases were systematically searched using the keywords thiazide diuretics and kidney calculi to identify randomized controlled trials (RCTs). The primary outcome was the incidence of recurrent kidney calculi, and the secondary outcome was the 24-h urinary calcium level. The pooled risk ratio (RR), risk difference (RD), standardized mean difference (SMD), and 95% confidence interval (CI) were calculated. The evidence quality was graded using the GRADE criteria, and recommendations for recurrent kidney calculus prevention using thiazide diuretics were reassessed. RESULTS:Eight RCTs involving 571 patients were included. The pooled RR for the incidence of kidney calculi in the thiazide diuretic groups was 0.44 (95% CI 0.33-0.58, P?<?0.0001) compared to that in the placebo and untreated groups; the pooled RD was -?0.23 (95% CI -?0.30 to -?0.16, P?<?0.0001). The pooled SMD for the 24-h urinary calcium level was -?18.59 (95% CI -?25.11 to -?12.08, P?<?0.0001). The thiazide diuretic groups had a high incidence of adverse reactions and low tolerance. The evidence quality for decrease in kidney calculus incidence using thiazide diuretics was low, while that for the 24-h urinary calcium level decrease among those with recurrent kidney calculi was moderate, and that for the decrease in kidney calculus incidence using short-acting and long-acting thiazide diuretics was low. The overall strength of recommendation for prevention of recurrent renal calculi using thiazide diuretics was not recommended. The subgroup and sensitivity analysis findings were robust. CONCLUSIONS:Long-term use of thiazide diuretics reduces the incidence of recurrent renal calculi and 24-h urinary calcium level. However, the benefits are insufficient, and the evidence quality is low. Considering the adverse effects, poor patient compliance, and economic burden of long-term medication, their use in preventing recurrent kidney calculi is not recommended.
Project description:Background: The monitoring of hypertension treatment can provide insight into the rational drug use pattern. The objective of this study was to examine the antihypertensive medication use among South Indian adults with hypertension in compliance with the hypertension treatment guidelines (Seventh Joint National Committee [JNC 7] and JNC 8). Methods and Results: A total of 550 hypertensive people aged >25 years were included in this retrospective cross-sectional study. The order of drugs prescribed in the year 2012 was beta blockers (BB) > calcium channel blockers (CCB) > CCB + BB > angiotensin receptor blockers (ARB) > angiotensin-converting enzyme inhibitors (ACEI) > thiazide diuretics, whereas in the year 2014, the order has changed drastically, namely, ACEI > CCB > ARB > BB > thiazide diuretics (P < .001). Most notably, there was a large increase in the use of monotherapy (from 56.9% to 82.5%, P < .001). The usage of BB has simply moved from the first position to the last position in concordance with JNC 8 guidelines, whereas use of thiazide diuretics was found to be the least preferred drug in the 2012 prescriptions, thus deviating from JNC 7 guidelines. The use of generic names (28.3% vs 11.3%) and National List of Essential Medicines (NLEM) compliance (79.3% vs 60.9%) were significantly more in the calendar year 2012 than in the calendar year 2014 (P < .001). Conclusions: Antihypertensive medication use has gone through wide variations among south Indian adults with hypertension. Combination therapy regimens must be adopted as per the guidelines for achievement of blood pressure goals.