Kaboli PJ (Iowa City VAMC (CRIISP)), Ishani A
(Minneapolis VAMC), Holman J
(Iowa City VAMC (CRIISP)), VanderWeg M
(Iowa City VAMC (CRIISP)), Carter BL
(Iowa City VAMC (CRIISP)), Christensen A
(Iowa City VAMC (CRIISP))
In spite of years of evidence-based guidelines and performance measures, hypertension remains sub-optimally treated, with little focus on activating patients to engage providers. This randomized, controlled trial tests the efficacy of a patient-activation intervention to initiate thiazide diuretics.
From 12 VA clinics, we recruited 573 hypertensive patients not taking a thiazide and not at goal blood pressure (BP) on two prior visits. Patients were randomized to control or three intervention groups: Group A-activation letter, Group B-letter with financial incentive, Group C-letter, financial incentive, and health educator call. Outcomes were: 1) patient-initiated hypertension discussion, 2) thiazide prescribing, 3) therapy intensification, 4) BP goal at 6 months.
Overall the intervention resulted in Group A, B, and C discussion rates of 46%, 49%, and 69%, and thiazide prescribing rates of 24%, 26%, and 33%, respectively; control group thiazide prescription rate was 9.6% (all P < 0.01). Intensification of therapy occurred in 35%, 31%, and 38%, with control rate of 14% (P < .0001). Six-months BP goal attainment was 28%, 31%, and 32%, with control rate of 26% (P = .30). Although all subjects had uncontrolled hypertension at enrollment, 33% achieved goal BP after randomization, yet before provider interaction. When analysis was limited to the 66% (N = 379) uncontrolled after randomization, thiazide prescribing was higher for Groups A, B, and C (33%, 32%, and 39%) with control rate 13%; intensification of therapy was 46%, 37%, and 47% with a control rate of 20% (P < .0001 for both). Six-month BP goal rates (26%, 27%, and 29%) were no different than control rate of 24% (P = .90).
Activating patients to engage providers about hypertension treatment resulted in half of patients initiating a discussion and one-fourth prescribed a thiazide, but no improvement in BP control at 6 months; financial incentives and health educator phone calls added little benefit. Simply enrolling in the trial resulted in one-third achieving BP goal.
This low-cost, low-intensity, patient-activation intervention resulted in high rates of discussion and thiazide prescribing and may help overcome clinical inertia. Financial incentives and health educator calls had little impact in the context of chronic disease management. Future studies should investigate patient-activation in other areas of evidence-based care.