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

<p>Abstract</p> <p>Background</p> <p>Hypertension 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.</p> <p>Methods</p> <p>Semi-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.</p> <p>Results</p> <p>Of 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.</p> <p>Conclusions</p> <p>Patient 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.</p> <p>Trial registration</p> <p>National Clinical Trial Registry number NCT00265538</p

The Effect of Short and Long Term Endurance Training on Systemic, and Muscle and Prefrontal Cortex Tissue Oxygen Utilisation in 40 - 60 Year Old Women.

Aerobic endurance training (ET) increases systemic and peripheral oxygen utilisation over time, the adaptation pattern not being linear. However, the timing and mechanisms of changes in oxygen utilisation, associated with training beyond one year are not known. This study tested the hypothesis that in women aged 40-60 years performing the same current training load; systemic O2 utilisation (VO2) and tissue deoxyhaemoglobin (HHb) in the Vastus Lateralis (VL) and Gastrocnemius (GAST) would be higher in long term trained (LTT; > 5 yr) compared to a short term trained (STT; 6-24 months) participants during ramp incremental (RI) cycling, but similar during square-wave constant load (SWCL) cycling performed at the same relative intensity (below ventilatory turn point [VTP]); and that pre-frontal cortex (PFC) HHb would be similar between participant groups in both exercise conditions.Thirteen STT and 13 LTT participants performed RI and SWCL conditions on separate days. VO2, and VL, GAST, and PFC HHb were measured simultaneously.VO2peak was higher in LTT compared to STT, and VO2 was higher in LTT at each relative intensities of 25%, 80% and 90% of VTP in SWCL. HHb in the VL was significantly higher in LTT compared to STT at peak exercise (4.54 ± 3.82 vs 1.55 ± 2.33 μM), and at 25% (0.99 ± 1.43 vs 0.04 ± 0.96 μM), 80% (3.19 ± 2.93 vs 1.14 ± 1.82 μM) and 90% (4.62 ± 3.12 vs 2.07 ± 2.49 μM) of VTP in SWCL.The additional (12.9 ± 9.3) years of ET in LTT, resulted in higher VO2, and HHb in the VL at peak exercise, and sub-VTP exercise. These results indicate that in women 40-60 years old, systemic and muscle O2 utilisation continues to improve with ET beyond two years

Ramp Incremental (cycling); systemic oxygen utilisation, ventilatory and heart rate measures.

<p>Ramp Incremental (cycling); systemic oxygen utilisation, ventilatory and heart rate measures.</p

Square-Wave Constant Load (cycling); deoxygenated haemoglobin (HHb) group mean measures.

<p>Panel (A) HHb in the LVL. Panel (B) HHb in the GAST. Panel (C) HHb in the PFC at 90% VTP and peak exercise. Pattern fill STT, solid fill LTT. * Significant different between groups.</p

Square-Wave Constant Load (cycling); deoxygenated haemoglobin (HHb) measures.

<p>Panel (A) HHb in the LVL. Panel (B) HHb in the GAST. Panel (C) HHb in the PFC during the SW/CL.</p

Square–Wave Constant Load (cycling); systemic oxygen utilisation, ventilatory, heart rate and rate of perceived exertion measures.

<p>Square–Wave Constant Load (cycling); systemic oxygen utilisation, ventilatory, heart rate and rate of perceived exertion measures.</p

Ramp Incremental (cycling); deoxygenated haemoglobin HHb measures.

<p>Panel (A) HHb in the LVL. Panel (B) HHb in the GAST. Panel (C) HHb in the PFC. STT 0–8 min (n = 13); 8–9.5 min (n = 7–11); 9.5–13.5 min (n = 2–5). LTT 0–9 min (n = 13); 9–12 (n = 5–12); 12–14 (n = 3–5).</p

Participant characteristics for short term trained and long term trained older women.

<p>Participant characteristics for short term trained and long term trained older women.</p

Ramp Incremental (cycling); deoxygenated haemoglobin (HHb) group mean measures.

<p>Panel (A) HHb in the LVL. Panel (B) HHb in the GAST. Panel (C) HHb in the PFC at 90% VTP and peak exercise. Pattern fill STT, solid fill LTT. * Significant different between groups.</p