Efficacy of Patient Activation Interventions With or Without Financial Incentives to Promote Prescribing of Thiazides and Hypertension Control

Peter J Kaboli; M. Bryant Howren; Areef Ishani; Barry Carter; Alan J Christensen; Mark W Vander Weg

doi:10.1001/jamanetworkopen.2018.5017

Importance Evidence-based guidelines recommend thiazide diuretics as a first-line therapy for uncomplicated hypertension; however, thiazides are underused, and hypertension remains inadequately managed. Objective To test the efficacy of a patient activation intervention with financial incentives to promote thiazide prescribing. Design, Setting, and Participants The Veterans Affairs Project to Implement Diuretics, a randomized clinical trial, was conducted at 13 Veterans Affairs primary care clinics from August 1, 2006, to July 31, 2008, with 12 months of follow-up. A total of 61 019 patients were screened to identify 2853 eligible patients who were not taking a thiazide and not at their blood pressure (BP) goal; 598 consented to participate. Statistical analysis was conducted from December 1, 2017, to September 12, 2018. Interventions Patients were randomized to a control group (n = 196) or 1 of 3 intervention groups designed to activate patients to talk with their primary care clinicians about thiazides and hypertension: group A (n = 143) received an activation letter, group B (n = 128) received a letter plus a financial incentive, and group C (n = 131) received a letter, financial incentive, and a telephone call encouraging patients to speak with their primary care clinicians. Main Outcomes and Measures Primary outcomes were thiazide prescribing and BP control. A secondary process measure was discussion between patient and primary care clinician about thiazides. Results Among 598 participants (588 men and 10 women), the mean (SD) age for the combined intervention groups (n = 402) was 62.9 (8.8) years, and the mean baseline BP was 148.1/83.8 mm Hg; the mean (SD) age for the control group (n = 196) was 64.1 (9.2) years, and the mean baseline BP was 151.0/83.4 mm Hg. At index visits, the unadjusted rate of thiazide prescribing was 9.7% for the control group (19 of 196) and 24.5% (35 of 143) for group A, 25.8% (33 of 128) for group B, and 32.8% (43 of 131) for group C (P < .001). Adjusted analyses demonstrated an intervention effect on thiazide prescribing at the index visit and 6-month visit, which diminished at the 12-month visit. For BP control, there was a significant intervention effect at the 12-month follow-up for group C (adjusted odds ratio, 1.73; 95% CI, 1.06-2.83; P = .04). Intervention groups exhibited improved thiazide discussion rates in a dose-response fashion: group A, 44.1% (63 of 143); group B, 56.3% (72 of 128); and group C, 68.7% (90 of 131) (P = .004). Conclusions and Relevance This patient activation intervention about thiazides for hypertension resulted in two-thirds of patients having discussions and nearly one-third initiating a prescription of thiazide. Adding a financial incentive and telephone call to the letter resulted in incremental improvements in both outcomes. By 12 months, improved BP control was also evident. This low-cost, low-intensity intervention resulted in high rates of discussions between patients and clinicians and subsequent thiazide treatment and may be used to promote evidence-based guidelines and overcome clinical inertia. Trial Registration ClinicalTrials.gov Identifier: NCT00265538 This randomized clinical trial tests the efficacy of patient activation interventions with or without financial incentives to promote prescribing of thiazide diuretics in patients with hypertension and improve the quality of hypertension management. Key Points Question What is the effect of a patient activation intervention using patient education, financial incentives, and reminder telephone calls to improve care for hypertension? Findings In this randomized clinical trial of 598 patients, those who received the intervention were more likely to discuss hypertension treatment with their primary care clinicians and receive evidence-based care. In a dose-response manner, adding financial incentives and reminder telephone calls had incremental effects, and significantly improved rates of attainment of goal blood pressure were achieved after 12 months. Meaning To attain high levels of blood pressure control and guideline-concordant therapy, engaging patients through patient activation interventions appears to be an effective, low-cost intervention.

Efficacy of Patient Activation Interventions With or Without Financial Incentives to Promote Prescribing of Thiazides and Hypertension Control

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