Intervention trial summary
The results from the intervention trial showed that, on average, 61% of intervention patients discussed thiazides with their providers [
27]. In the three intervention arms, 26% of patients were prescribed a thiazide compared to only 6.7% of control patients. The addition of financial incentives and a phone call from a health educator each showed modest, incremental effects on discussion rates and subsequent thiazide prescribing.
Below, we focus on the results from the semi-structured provider interviews, which revealed a number of opinions and common themes that help to explain this demonstrated effectiveness and further speak to both the acceptability and wider applicability of the intervention.
Influence on prescribing behavior
Most providers (19/21) prescribed thiazides to at least one patient as a result of the intervention. Their descriptions of the influence of the intervention can be broadly categorized into three themes: reinforced their existing knowledge or prescribing behavior, changed their approach to hypertension management, and patient activation itself lowered barriers to thiazide prescribing.
The intervention reinforced existing knowledge or prescribing behavior
More than half of interviewed providers suggested the effect of the intervention was not to change their clinical approach to hypertension management, but rather to reinforce their training and current prescribing practice in a number of ways. Some cited their clinical experience and understanding of the role of thiazides in suggesting the intervention simply 'acted like a reminder' to consider a thiazide. Others said the intervention brought their attention to specific patients for whom they would typically prescribe a thiazide, but were not on one:
'There were some that were oversight...they were supposed to be on hydrochlorothiazide. They have no reason not to be on it, and yet they...were not on it, and your letter brought my attention to it.'
A few providers explained they manage over 1,000 patients, so 'oversights' can happen, particularly with new patients or those co-managed with non-VA providers. Several providers elaborated on how the intervention brought the patients' treatment regimens under new scrutiny:
'With our co-managed patients...I just...tended to assume, you know, that a thiazide had been tried at some point, if they're already on something that I would've picked second, third, or fourth, you know, as an agent. And, and I've, I mean that was, uh, a big message to me that I can't assume that.'
Two providers also suggested the intervention provided previously unknown information that moved patients into a category for which the provider would usually prescribe a thiazide:
'Something that came up a couple times...the letter, it said 'on a certain date the blood pressure had been high,' and that date had been like on a specialty care visit, so it was a number that I probably...wasn't aware of...because maybe they were fine the day I saw them...and it did change my plan, you know, after...seeing that.'
The intervention changed the provider's approach to hypertension management
Several providers suggested the intervention didn't just reinforce existing knowledge or prescribing behavior, but actually changed their clinical approach to hypertension management. Some stated the intervention provided new information about thiazides, or otherwise changed their view of thiazides as a first-line management option:
'It helped certainly, you know, if you come up to me with a letter and said, 'hey, this evidence and all that, you can do this with less cost and equal efficacy,' then certainly, you know...that would change my...practice, behavior, certainly, yeah.'
Others emphasized the intervention brought their attention to patients who were not simply oversights, but for whom they may not have considered a thiazide:
'It was almost as if, uh, someone were looking over my shoulder and saying 'here, try this.' I think in most cases I agreed and incorporated that as one of the medications.'
Patient activation itself lowered barriers to thiazide prescribing
Many providers also described the process of patient activation as lowering barriers that might otherwise prevent prescribing a thiazide. Some suggested the intervention made patients more receptive to adding or switching to a thiazide. Particularly with co-managed patients, several providers said that patients 'that have been on...whatever [other] medication for years and years' would typically be hesitant to change, especially if their blood pressure was near or at goal. These providers suggested the intervention lowered a barrier to thiazide prescribing by providing patients with information and facilitating a discussion:
'Through...the discussion of them even receiving this invitation in, in the first place, uh, prompted them to be more willing to start the medicine.'
'Some of them didn't want to change, but...a couple of them said, 'well, let's, you know, with that information, let's change over'.'
Other providers described the intervention as 'aligning' patient and provider 'priorities':
'One of the most difficult...problems for a practicing, full-time clinician is trying to stay on schedule, and if we can help patients to have the same objectives, align our...priorities, then I think we'll reach them. Um, the problem often times is that there's another issue, a distracter issue that the patients want to talk about. They don't frequently want to talk about or mention a chronic asymptomatic disease. They have a rash on their elbow and a little ringing in their ear...and they'll often consume time just unloading their frustrations. If, on the other hand, there was an incentive for them to, uh, focus their energies on the same objectives WE have, then I think we could meet those objectives, but we have to stay on time.'
Influence on prescribing behavior beyond the intervention
Over the course of the intervention, providers who had patients in the intervention were somewhat more likely to prescribe a thiazide to their patients in the control group (i.e., 'contaminated' controls) than the providers who had no intervention patients, but had control patients (i.e., 'pure' controls) (13.2% versus 5.7%; P = .09). Correspondingly, 11 of 17 providers stated they felt the intervention changed the way they prescribed to patients not involved in the study. Most providers said they were more likely to think of thiazides first when managing hypertensive patients, and some suggested it changed the question in their minds from 'what anti-hypertensive should be used?' or 'is the patient's hypertension controlled?' to 'why is this patient not on a thiazide?' Below is a sampling of responses to the question 'do you think it [the intervention] changed the way you prescribed thiazides with other patients?'
'I think it really re-emphasized to me, you know, going with thiazide diuretics as the first choice.'
'Yeah, it did...believe me. Uh, after I started getting that letter I started looking more closely at, uh, if I have a patient with hypertension now. Honestly, because of your letter I look at it, I look at why is he not on hydrochlorothiazide.' (emphasis added).
Providers who felt the intervention did not change their thiazide prescribing behavior beyond the intervention mostly emphasized that it was because they already prescribed thiazides regularly:
'I don't think it changed, I don't see how it could change...because I, uh, I like thiazides...I'm already a believer.'
Barriers
Providers suggested a number of barriers to the influence of the intervention that are likely to restrict concordance with hypertension guidelines more generally. They can be categorized according to three common themes: guidelines are not universally applicable, reluctance to 'rock the boat', and cost and inconvenience.
Guidelines are not universally applicable
Some providers described the influence of the intervention--and guideline concordance more generally--as limited according to the characteristics of each particular patient:
'Each patient is individual...and...they need individual attention. And, uh, sometimes they fall into guidelines sometimes they don't. You know, for example, I have an eighty-five year old patient, uh, who has a blood pressure of 170, 180, and I cannot lower that to 140, patient becomes dizzy and light-headed, I cannot use the guidelines. So I have to accept higher blood pressure. You know, I have patients that they have supine hypertension. Their blood pressure is 200 when they lay down, when they stand up they're up to 120. And uh, every time they go to the hospital, their blood pressure is high. They put them on a bunch of blood pressure medications. They come out and they fall down...I cannot use the guideline for such [a] patient like that.'
Many other providers explained that, especially at the VA, they often see geriatric patients that are more likely to have multiple co-morbidities or contra-indications that make thiazides unsuitable or indicate a greater benefit from another anti-hypertensive:
'You know, my patients are older. They have prostate issues, and they go to bathroom too often, they have arthritis, they have difficulty to get to the bathroom...some they had problems with hypokalemia or renal issues that they were not a candidate for the medication...and, uh, my patients are diabetic, they have coronary artery disease, they have, you know, metabolic syndrome, so I think ACE inhibitors and ARBs are more selective for them than you know, just, uh, hydrochlorothiazide.'
Reluctance to 'rock the boat'
Many providers explained that, while they understand the benefit of a thiazide, they or often their patients were nevertheless hesitant to add or switch to a thiazide if the patient's blood pressure was already at or near goal. In the RCT, patients who were not controlled at the time of their primary care visit were 3.3 times more likely to be prescribed a thiazide than those who were controlled:
'I think [it] kind of depended where their blood pressure was at, you know, if their numbers were controlled without side effects on the regimen that they were on, I think there was, you know, a little bit of uh, um, kind of a sentiment on the part of the patient and maybe a little reluctance to kind of rock the boat.'
This was particularly an issue with new or co-managed patients:
'The...difficulty with being prescribed...are those patients that [have] been on...another medication for years by the previous provider or by their private...physician, and so it's hard for you to convince them to change to something different because they say 'Well I've been on this for like, ten years now and my blood pressure is controlled, why do you want to change it now?"
Cost and inconvenience
Several providers also mentioned cost and inconvenience to patients as a barrier. Some discussed patients for whom travel to their VA clinic was lengthy or difficult, so they didn't want to be switched if it required an extra visit for labs. Another provider explained that, although the co-pay at the VA is a flat eight dollars for each medication, patients often have many prescriptions, so the cost of adding one more can be prohibitive. Based on a similar rationale, another provider described looking to other anti-hypertensives with a broader range of indications, thus possibly eliminating the need for another prescription:
'Diuretics, like thiazide...sometimes I say 'why I should make this guy spend eight dollars?' Let me just give an ACE and get two things [hypertension and diabetes treatment] done.'
Acceptability of the intervention
Almost all providers (20/21) had a positive opinion of the intervention strategy, but many expressed nuanced opinions, highlighting positive aspects and sometimes noting reservations.
Positives
When asked their opinion of the intervention, some providers discussed its positive effect on their approach to hypertension, but many more focused on the way it educated patients and facilitated discussion during the consultation. About one-third stated they had a positive opinion of the intervention at least in part because it prompted a positive change in their management of hypertension for some patients. About one-third of providers also expressed a favorable opinion of the intervention because it made patients more informed about their hypertension and different therapy options. Finally, most providers had a positive opinion of the intervention because it promoted among patients a greater interest and involvement in their hypertension management. These first three themes were often expressed in various combinations by providers:
'I really liked and, as I said it brought up, it made me think about things a little differently in some cases and it brought up great conversations with the patients.'
'I think it's good...it makes patients a little more pro-active about their healthcare...they were interested in it and it made them actually, you know, talk to you about their blood pressure.'
'I think it's a great idea...for many reasons. The actual subject matter, of course, is very pressing. Poorly-controlled hypertension is a well-recognized problem, and under-utilization of diuretics, and it's also um, a nice intervention to involve patients and empower them...it's...wonderful to get the patients involved directly in their care, and uh, inform them of the goals and the methods of achieving those goals.'
A few providers also explained that a necessary condition for the acceptability of this intervention was the 'well-established profile' and sometimes the 'cost-effectiveness' of thiazide diuretics:
'For hydrochlorothiazide, it is good...an enduring medication, a good medication...you just need the doctors to be aware of the effectiveness. But if you start promoting...all these fancy new medications [with this type of intervention]...I wouldn't encourage it.'
Negatives/reservations
Despite their overall receptivity to the patient activation approach, a number of providers expressed some concern or reservations about certain aspects of the intervention, a majority of which were focused on the use of incentives. Most reservations were expressed in the context of a positive opinion of the overall intervention strategy, as only one provider articulated a negative view of the intervention in general. Almost all the negatives/reservations expressed fit into two themes, with a third theme mentioned.
Financial incentives can create a conflict of interest
Four providers suggested the use of financial incentives created conflicting motivations for patients. A couple expressed this as a normative statement, suggesting simply that patients should be motivated not by money, but by what is good for their health; interestingly, a similar opinion was expressed by patients involved in the study. Two other providers suggested that the motivation created by the incentives could push patients to seek out a diuretic regardless of its suitability for them, thus compromising some of the provider's autonomy: 'If they are more interested in getting [the incentive], that kind of put pressure on us not to say no.'
A couple of providers also suggested that incentives may not be cost-effective, and one was concerned that patients might think the VA had an 'alternative motive' for offering an incentive because it is not typical practice at the VA.
However, it is worth noting that 13 of 17 providers asked actually had a positive or neutral view of the use of incentives. Most of these providers explained that if the incentives enhanced the patients' interest in their hypertension care, then they were fine with their inclusion, saying 'if it's going to work, I'm all for it.' Also, most providers said some patients seemed motivated by the $20 incentive to have a discussion, while providers felt few patients seemed motivated by the six-month co-pay reimbursement or pushed for a prescription because of it.
The intervention might undermine patient trust
Two providers expressed a concern that the intervention might suggest providers are giving inadequate care:
'As a physician...I often have a good reason for the decisions I make, and...I worry about it giving the message to, uh, the patient that 'your doctor should be doing this, and your doctor is not'.'
This concern was hypothetical for one provider, who also had a negative overall view of the intervention strategy. However, the other provider that expressed the concern did report a patient coming in with the impression that he received the letter because his provider had not prescribed the correct medication. This provider reported that the patient's concern was appeased in discussing the intervention further:
'I explained the situation to him...I told him why I didn't put him on hydrochlorothiazide, and why I would not put him on hydrochlorothiazide, and he was happy.'
This second provider had a positive view of the intervention, but was concerned that trust might still be undermined if a patient was not so easily appeased. It is worth noting that several other providers specifically volunteered that they didn't feel the intervention prompted any distrust:
'I did not have any...challenging interactions in the sense that somebody was either questioning my judgment, or upset, or thought there was an oversight...it was a very non-threatening conversation...and there wasn't any distrust, so they pretty well just believed my explanation if I said 'I don't think this is appropriate.' And they also, I didn't get the feeling of, you know, having them lose confidence in me if I said 'Yup...let's do it. Thanks for bring it to my attention.'
The wrong patients might be 'activated'
Similar to the previously described prescribing barrier--thiazides may not be a universally acceptable therapy--a couple of providers were also concerned that the intervention strategy might be targeted at patients that should not be on the promoted therapy. For example, one cautioned against targeting geriatric patients for thiazides, explaining that too often there are too many complications, and another explained if clinic rather than home blood pressure readings are used to identify target patients, it may create confusion in patients with controlled hypertension.
Broader acceptability
In all, 18 of 20 providers asked had a positive opinion about using patient activation strategies on a broader basis for implementing hypertension or other therapy guidelines:
'I wouldn't mind seeing either more studies like this or even just having that be part of our practice of care...where the patient's getting letters...hypertension is a great idea or cholesterol would be another.'
As with explaining their opinions of the intervention itself, providers most often discussed how the patient activation strategy informs patients and facilitates discussions:
Interviewer: 'What do you think in general about promoting things such as new guideline therapies through patient-initiated interventions...taking information to the patient and having them bring it in?'
Provider one: 'I think that is actually a good idea...you can educate patient...and again...it make the job of physician easier, you know, when they come to the doctor they said, 'Is this right for me?' So then you don't have to start up the whole conversation again.'
Provider two: 'I think that's really kind of forming an alliance with your patient as, as you together determine what the best therapy is, so I don't, I don't see any problem with that. There's probably much to be gained.'
Provider three: 'I think that...would be...a wonderful idea, I think like I said earlier that, um, maybe prompting patients this way, uh, might...make them more interested and proactive with their healthcare.'
In explaining their opinion, other providers re-iterated the strategy had prompted useful changes in their management of some patients, and a few mentioned that they thought the strategy would prove cost-effective.
Two providers had negative or ambivalent views about using patient activation strategies on a larger scale. One supported broader use of the intervention to promote thiazides, but was hesitant to endorse its use for any other therapy, particularly for medications that were not as 'well-established' as thiazides. The other expressed concern that if the strategy was used for too many therapies, providers would quickly become saturated and the strategy would become ineffective.