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Does Patient Role-orientation Predict Patient-initiated Discussions with Providers? Insights from the VA Project to Implement Diuretics (VAPID)

Egts S, Baldwin A, Ishani A, Wilson HS, Vander Weg MW, Christensen AJ, Kaboli PJ. Does Patient Role-orientation Predict Patient-initiated Discussions with Providers? Insights from the VA Project to Implement Diuretics (VAPID). Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 11; Pittsburgh, PA.


BACKGROUND: Evidence-based guidelines for uncomplicated hypertension state thiazide-type diuretics (thiazides) should be first-line therapy; however, many patients are not prescribed this cost-effective treatment. One area not sufficiently studied to improve guideline adherence is the patient's role in promoting evidence-based care. Our work investigates the relationship between patients' attitudes toward care (preferred role orientation) and discussion rates about thiazides between patients and their primary care provider. METHODS: Patients with a diagnosis of hypertension and not currently taking a thiazide were selected from 13 VA outpatient clinics in the Midwest. Patients either were not at their blood pressure goal or were at goal and taking a calcium channel blocker (CCB), not considered first line therapy for uncomplicated hypertension. Subjects were randomized into one of five groups. Three groups received tiered interventions encouraging patients to talk to their providers about adding or switching to a thiazide: Group A received an educational letter, Group B received the letter with a monetary incentive, and Group C received the letter, monetary incentive, and a reminder phone call. Two control groups included an "intervention" control group of patients whose providers saw intervention patients and a "pure" control group of patients whose providers saw no intervention patients. The primary outcome of interest was whether a discussion occurred about starting a thiazide. Determination of a discussion was based on chart review and/ or return of a postcard signed by the provider. The Patient Provider Orientation Scale (PPOS) was used to measure patients' attitudinal preferences for taking an active, involved role in their own care ("patient centered") versus a more passive role. Association between PPOS scores and discussion rates was measured using logistic regression. RESULTS: To date, 479 patients have completed the intervention. All intervention groups had significantly higher discussion rates than the control groups (P < 0.05) and increasing the intensity of the intervention was associated with increasing discussion rates (P < 0.05). Further, having a discussion was predictive of initiation of a thiazide (P < 0.05). However, degree of patient-centeredness, as measured by the PPOS scale, did not predict whether a thiazide discussion with their provider occurred (OR = 1.02; 95% CI 0.99, 1.04). CONCLUSIONS: Providing VA patients with information about adding or changing to a thiazide for hypertension can lead to high rates of discussion with providers about hypertension therapy. Interestingly, the degree of patient-centeredness did not affect whether a discussion occurred. This somewhat unexpected observation suggests either that the intervention does not challenge patient role orientation or that it may appeal to both patient-centered and physician-centered patients. Additional analyses will evaluate whether patient-provider congruency in orientation is a more significant factor than patient attitudes alone. Future studies should investigate the efficacy of using patients to promote other areas of evidence-based medicine to overcome clinical inertia

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