Hypertension is common and readily treatable, yet only less than 40% of patients are adequately treated. Treatment recommendations come from the 2002 Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), the 2003 7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7), and the 1999 VA/DOD Clinical Practice Guidelines for Hypertension. These reports state that thiazide diuretics should be used as first-line therapy for patients with uncomplicated hypertension The long-term goal of the proposed research is to develop an innovative intervention to implement these recommendations regarding the use of thiazides and improve the blood pressure control of VA primary care patients with hypertension.
An intervention study was implemented. Both the Iowa City VA and associated outpatient clinics as well as the Minneapolis VA and associated clinics were sites chosen for this intervention study. Subjects with a diagnosis of uncontrolled Hypertension or Hypertension controlled by a CCB were recruited. Providers were either placed in the pure control arm of the study, or the intervention arm of the study.
After patients have completed the intervention phase of this study, providers will be interviewed to determine their reaction/feelings regarding this intervention.
The specific aims of the pilot phase were to:
1. Identify modifiable barriers to implementing evidence-based practices for hypertension treatment
2. Develop a multi-component intervention to rapidly change the current practice of anti-hypertensive therapy in VISN 23, based on our conceptual model
3. Identify patient incentive value in implementing treatment discussions initiated by patients
4. Assess adverse events and clinic/hospital visits for those patients starting or switching to a thiazide
5. Assess provider opinions about the patient intervention
This study began with informal focus groups of providers at the Iowa City and Minneapolis VAMCs and affiliated community based outpatient clinics (CBOCs) to discuss the barriers to implementing evidence-based care for hypertension. The literature was reviewed and incorporated. A patient and provider survey instrument were developed with complementary questions in order to gauge both patient and provider attitudes and perceived barriers. Both surveys were pilot tested and revised. Patient surveys were completed by face-to-face interview in the general medicine clinics and providers surveys were sent by email.
The study enrollment has begun at both the Iowa City and MPLS sites. Subjects are then randomly assigned to either pure control or intervention group(s). Within the intervention group are the intervention control, intervention A, intervention B and intervention C groups. Intervention A, B and C receive a one page informational letter (1-3 weeks) prior to their index primary card appointment. Group B receives the informational letter plus a $20 financial incentive for discussing the contents of the letter with their primary care doctor and possible 6 months copay reimbursement if their blood pressure medication is switched or started ($48 possible copay reimbursement). Group C receives the informational letter, $20 incentive & copay reimbursement, plus a phone call reminder 1-3 days prior to their visit. Group A, B and C also receive a postcard stamped and addressed to return to the research team indicating whether the patient had a discussion with their primary care provider about the intervention. The intervention control group does not receive any information or incentive but is utilized to determine if providers clinical decision making is affected by seeing other patients in the intervention groups (A, B or C).
Index visit information is captured by chart review of the primary care provider visit. Blood pressures and medications are collected and analyzed. Additionally, chart review will occur at 6 months and 12 months from baseline. Patients will also be called at 6 and 12 months for interview, completing questionnaires and assessing adverse events and hospitalizations/clinic visits.
220 provider surveys were sent and 143 were returned (65%). Key findings include: 96% of providers had heard of the JNC-7 guidelines and 65% were very familiar with the report. Using a 12-question JNC-7 based knowledge survey, VA providers scored 66% correct, compared with a non-VA cohort that scored 71% (P=.06). 69% recommended thiazide diuretics for first line treatment, compared to only 18% in a previously published non-VA cohort. 65% of providers overestimated the percentage of patients on JNC-7 concordant therapy and 38% overestimated the percent of patients at their goal blood pressure. 190 hypertensive patients were asked to participate and 187 (98%) completed interviews. Key finding include: Only 51% of patients were at their blood pressure goal, 59% were on JNC-7 guideline concordant therapy, and 37% of patients knew their BP goal. Medication cost emerged as an important factor for patients with 65% stating cost was extremely/very important to them and 27% stated the prescription drug benefit at the VA was the only or main reason they came to the VA.
As of 7/2008 study enrollment was complete. Index visits are complete and have been analyzed. Six month visits are complete and have been analyzed. Twelve month follow-up phone call visits were complete by 5/1/09. Provider surveys are now complete and are currently being analyzed.
Conclusions: Providing patient-activation information about thiazides for hypertension resulted in two-thirds of patients having discussions and nearly a third starting or switching to a thiazide; the intervention was more effective if BP was not controlled. Adding a financial incentive and reminder phone call to the letter resulted in incremental increases in both outcomes. This low-cost, low-intensity, patient-activation intervention resulted in high rates of discussions and thiazide treatment and may be a useful intervention to promote evidence-based guidelines and overcome clinical inertia.
The results of the surveys dramatically helped to shape the design of a randomized-controlled clinical intervention that was funded as a VA HSRD Merit Review beginning 1/06. If effective, the methods proposed will serve as a model for expanding the intervention throughout VA and can be applied to other disease states.
The findings, when published, will help to inform policy makers and clinical leadership of barriers and facilitators existing in the management of hypertension.
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