Part II, Provider perspectives: should patients be activated to request evidence-based medicine? a qualitative study of the VA project to implement diuretics (VAPID)

Abstract

BackgroundHypertension guidelines recommend the use of thiazide diuretics as first-line therapy for uncomplicated hypertension, yet diuretics are under-prescribed, and hypertension is frequently inadequately treated. This qualitative evaluation of provider attitudes follows a randomized controlled trial of a patient activation strategy in which hypertensive patients received letters and incentives to discuss thiazides with their provider. The strategy prompted high discussion rates and enhanced thiazide-prescribing rates. Our objective was to interview providers to understand the effectiveness and acceptability of the intervention from their perspective, as well as the suitability of patient activation for more widespread guideline implementation.MethodsSemi-structured phone interviews were conducted with 21 primary care providers. Interviews were transcribed verbatim and reviewed by the interviewer before being analyzed for content. Interviews were coded, and relevant themes and specific responses were identified, grouped, and compared.ResultsOf the 21 providers interviewed, 20 (95%) had a positive opinion of the intervention, and 18 of 20 (90%) thought the strategy was suitable for wider use. In explaining their opinions of the intervention, many providers discussed a positive effect on treatment, but they more often focused on the process of patient activation itself, describing how the intervention facilitated discussions by informing patients and making them more pro-active. Regarding effectiveness, providers suggested the intervention worked like a reminder, highlighted oversights, or changed their approach to hypertension management. Many providers also explained that the intervention 'aligned' patients' objectives with theirs, or made patients more likely to accept a change in medications. Negative aspects were mentioned infrequently, but concerns about the use of financial incentives were most common. Relevant barriers to initiating thiazide treatment included a hesitancy to switch medications if the patient was at or near goal blood pressure on a different anti-hypertensive.ConclusionsPatient activation was acceptable to providers as a guideline implementation strategy, with considerable value placed on the activation process itself. By 'aligning' patients' objectives with those of their providers, this process also facilitated part of the effectiveness of the intervention. Patient activation shows promise for wider use as an implementation strategy, and should be tested in other areas of evidence-based medicine.Trial registrationNational Clinical Trial Registry number NCT00265538

Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012

“…167 Many strategies to enhance uptake of evidence into practice have been investigated including use of didactic education sessions, audit and feedback, reminders, opinion leaders, educational materials, patient mediated interventions, financial incentives and interventions tailored to identified barriers-the median improvements of these strategies is approximately 10%. [168][169][170][171][172] Recently, the use of multiple rather than single interventions, particularly those which are specifically tailored to identified barriers, has been associated with approximately double the improvement than those of single interventions. 173 174 There is other evidence in the medical behaviour change literature which can inform strategies to enhance adoption of evidence into practice.…”

Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare

“…In prior work, veterans expressed concern over cost burdens to VHA, suggesting a sense of "stewardship" of limited resources. [21][22][23] This may reflect the unique place veterans have in society, having served in the military and now being recipients of a promised benefit. Ultimately, fee-basis care has been used to improve access, but unlimited fee-basis care would turn VHA into an insurance benefit and not the integrated healthcare system it is currently.…”

Maximising the value of combining qualitative research and randomised controlled trials in health research: the QUAlitative Research in Trials (QUART) study – a mixed methods study

“…53 Mihaylov et al 53 were able to explain the failure to recruit in a trial of constipation treatment according to the strongly held beliefs about appropriate or favourite existing treatment and a reluctance to change behaviour as required by entering the trial. Buzza et al 52 described…”