Kaboli PJ (Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VAMC), Ishani A
(Minneapolis VAMC), Wilson H
(CRIISP, Iowa City VAMC), VanderWeg M
(CRIISP, Iowa City VAMC), Carter BL
(CRIISP, Iowa City VAMC), Christensen A
(CRIISP, Iowa City VAMC)
Evidence-based guidelines recommend thiazide diuretics as first-line therapy for uncomplicated hypertension; however, thiazides remain under-utilized. The objective of our study was to test the efficacy of a patient-oriented intervention to initiate thiazides.
383 eligible hypertensive patients from 12 VA clinics not taking a thiazide and either previously not at blood pressure (BP) goal (uncontrolled HTN) or at goal and taking a calcium channel blocker (controlled CCB), which is not first-line therapy, were enrolled. Patients were randomized to a control group or three intervention groups designed to activate patients to talk to their providers about thiazides: Group A received an activation letter, Group B the letter with financial incentives, and Group C the letter, financial incentives, and reminder phone call. Outcomes were: 1) patient-initiated hypertension discussion and 2) thiazide prescribing.
Overall, the intervention resulted in Group A, B, and C discussion rates of 51%, 54%, and 71% (P < .001) with thiazide prescribing rates of 23%, 25%, and 32% (P < .001). In the uncontrolled HTN sub-group (N=184), Group A, B, and C discussion rates were 47%, 48%, and 75% (P < .001) with thiazide prescribing rates of 31%, 25%, and 32% (P < .01). In the controlled CCB sub-group (N=69), Group A, B, and C discussion rates were 57%, 74%, and 59% (P < .01) with thiazide prescribing rates of 7%, 26%, and 32% (P < .01). The control group (N=130) thiazide prescription rate was 2.6%; all groups were significantly different from controls (P < 0.01). Patients not at BP goal were more likely to initiate thiazides than those at goal (OR 5.2, 95%CI 3.0-9.0). Of note, 51% of uncontrolled HTN patients had controlled BP at their clinic visit without change in their hypertension treatment.
Providing patient-oriented information about thiazides for hypertension resulted in half of patients initiating discussions and one-fourth starting or switching to a thiazide, with a greater effect in uncontrolled patients than controlled patients. Adding a financial incentive and reminder phone call to the letter resulted in modest, but inconsistent, increases in both outcomes.
This low-cost, low-intensity, patient-activation intervention resulted in high rates of patient-initiated discussions and thiazide treatment. Future studies should investigate patient-activation to promote other areas of evidence-based medicine.