Diuretic Comparison Project
- Conditions
- Hypertension
- Interventions
- Registration Number
- NCT02185417
- Lead Sponsor
- VA Office of Research and Development
- Brief Summary
The Diuretic Comparison Project aimed to evaluate whether chlorthalidone, as compared with hydrochlorothiazide, would reduce the risk of major nonfatal cardiovascular disease outcomes and non-cancer-related deaths in older patients with hypertension who were receiving hydrochlorothiazide at baseline. The investigators incorporated the pragmatic methods used by the Department of Veterans Affairs (VA) Healthcare System to provide a real-world assessment of the effectiveness of chlorthalidone as compared with hydrochlorothiazide in routine clinical care.
- Detailed Description
Thiazide-type diuretics have been in use for more than 50 years and are considered as the first-line treatment for hypertension. Of the more than 1 million Veterans prescribed a thiazide-type diuretic each year, more than 95% receive hydrochlorothiazide, and fewer than 2.5% receive chlorthalidone. However, indirect evidence has been accumulating for many years that chlorthalidone may be more effective than hydrochlorothiazide at preventing cardiovascular events.
The Diuretic Comparison Project was conducted with a clinically integrated design (termed a "point of care" or "pragmatic embedded" trial). The key feature of our design was that, instead of employing local investigators, the investigators developed centralized trial procedures and implemented into the VA electronic health record (EHR) and healthcare delivery systems. This approach enabled us to conduct trial-related interactions and randomization with the use of data in the EHRs, centralize recruitment efforts without the use of site staff, eliminate the need for trial-related visits and procedures, and centralize data capture from administrative databases.
This study was performed to answer a question of whether chlorthalidone is more effective than hydrochlorothiazide at preventing cardiovascular outcomes. Consent was obtained from eligible participants who were willing to participate and their primary care providers. With provider assented to the patient undergoing randomization, 3,523 older patients with hypertension were randomized across 72 VA health care systems. Patients across the US (including Puerto Rico and District of Columbia) were enrolled. Participants were randomly assigned to continue with existing hydrochlorothiazide treatment regimen (25/50mg daily) or switch to a dose equivalent chlorthalidone (12.5/25 mg daily).
The primary outcome was the first occurrence of a composite outcome consisting of a nonfatal cardiovascular event or non-cancer related death. Nonfatal cardiovascular events included nonfatal myocardial infarction, stroke, hospitalization for heart failure, or urgent coronary revascularization for unstable angina.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 20723
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Hydrochlorothiazide Hydrochlorothiazide (HCTZ) Participants remained on the existing hydrochlorothiazide treatment regimen (a daily dose of 25 or 50 mg). Chlorthalidone Chlorthalidone (CTD) Participants switched to an equivalent dose of chlorthalidone (a daily dose of 12.5 or 25 mg).
- Primary Outcome Measures
Name Time Method Proportion of Participants Had a Composite Primary Outcome Outcome data collection was performed from study randomization until the participants deceased, withdrawn, or reached end of study (Up to 5.4 years for the first patient enrolled and an average of 2.4 years for all participants). The primary outcome was the first occurrence of a composite endpoint consisting of a nonfatal cardiovascular event or non-cancer related death. Nonfatal cardiovascular events included nonfatal myocardial infarction, stroke, hospitalization for heart failure, or urgent coronary revascularization for unstable angina. Time to the first event was computed based on the earliest hospital admission or death dates. Ascertainment of study outcomes was made with the use of administrative and clinical data obtained from VA EHRs through June 1, 2022, from records of Medicare claims obtained from the Centers for Medicare and Medicaid Services through 2021, and from National Death Index records through 2019. Trial outcomes were ascertained with the use of validated EHR phenotypes and, when needed, manual adjudication. Manually adjudicated outcomes were evaluated by investigators and staff who were unaware of group assignment.
Time From Randomization to Composite Primary Outcome Outcome data collection was performed from study randomization until the participants deceased, withdrawn, or reached end of study (Up to 5.4 years for the first patient enrolled and an average of 2.4 years for all participants). Time to study primary outcome was defined as years from randomization to the first occurrence of a composite endpoint, consisting of a nonfatal cardiovascular event or non-cancer related death. Nonfatal cardiovascular events included nonfatal myocardial infarction, stroke, hospitalization for heart failure, or urgent coronary revascularization for unstable angina. For participants who had a primary outcome, time to event was determined as the earliest admission or death date. Ascertainment of study outcomes was made with the use of administrative and clinical data obtained from VA EHRs through June 1, 2022, from records of Medicare claims obtained from the Centers for Medicare and Medicaid Services through 2021, and from National Death Index records through 2019. Trial outcomes were ascertained with the use of validated EHR phenotypes and, when needed, manual adjudication. Manually adjudicated outcomes were evaluated by investigators and staff who were unaware of group assignment.
- Secondary Outcome Measures
Name Time Method Proportion of Participants Had Nonfatal Myocardial Infarction Outcome data collection was performed from study randomization until the participants deceased, withdrawn, or reached end of study (Up to 5.4 years for the first patient enrolled and an average of 2.4 years for all participants). Secondary outcomes were the individual components of the primary outcome. Ascertainment of study outcomes was made with the use of administrative and clinical data obtained from VA EHRs through June 1, 2022, from records of Medicare claims obtained from the Centers for Medicare and Medicaid Services through 2021, and from National Death Index records through 2019. Trial outcomes were ascertained with the use of validated EHR phenotypes and, when needed, manual adjudication. Manually adjudicated outcomes were evaluated by investigators and staff who were unaware of group assignment.
Proportion of Participants Deceased and Not Related to Cancer Outcome data collection was performed from study randomization until the participants deceased, withdrawn, or reached end of study (Up to 5.4 years for the first patient enrolled and an average of 2.4 years for all participants). Secondary outcomes were the individual components of the primary outcome. Ascertainment of study outcomes was made with the use of administrative and clinical data obtained from VA EHRs through June 1, 2022, from records of Medicare claims obtained from the Centers for Medicare and Medicaid Services through 2021, and from National Death Index records through 2019. Trial outcomes were ascertained with the use of validated EHR phenotypes and, when needed, manual adjudication. Manually adjudicated outcomes were evaluated by investigators and staff who were unaware of group assignment.
Proportion of Participants Had Nonfatal Stroke Outcome data collection was performed from study randomization until the participants deceased, withdrawn, or reached end of study (Up to 5.4 years for the first patient enrolled and an average of 2.4 years for all participants). Secondary outcomes were the individual components of the primary outcome. Ascertainment of study outcomes was made with the use of administrative and clinical data obtained from VA EHRs through June 1, 2022, from records of Medicare claims obtained from the Centers for Medicare and Medicaid Services through 2021, and from National Death Index records through 2019. Trial outcomes were ascertained with the use of validated EHR phenotypes and, when needed, manual adjudication. Manually adjudicated outcomes were evaluated by investigators and staff who were unaware of group assignment.
Proportion of Participants Had Hospitalization for Heart Failure Outcome data collection was performed from study randomization until the participants deceased, withdrawn, or reached end of study (Up to 5.4 years for the first patient enrolled and an average of 2.4 years for all participants). Secondary outcomes were the individual components of the primary outcome. Ascertainment of study outcomes was made with the use of administrative and clinical data obtained from VA EHRs through June 1, 2022, from records of Medicare claims obtained from the Centers for Medicare and Medicaid Services through 2021, and from National Death Index records through 2019. Trial outcomes were ascertained with the use of validated EHR phenotypes and, when needed, manual adjudication. Manually adjudicated outcomes were evaluated by investigators and staff who were unaware of group assignment.
Proportion of Participants Had Unstable Angina Leading to Urgent Coronary Revascularization Collection of outcome data were performed from randomization until participants deceased, withdrawn, or reached end of study (Up to 5.4 years for the first patient enrolled and an average of 2.4 years for all participants). Secondary outcomes were the individual components of the primary outcome. Ascertainment of study outcomes was made with the use of administrative and clinical data obtained from VA EHRs through June 1, 2022, from records of Medicare claims obtained from the Centers for Medicare and Medicaid Services through 2021, and from National Death Index records through 2019. Trial outcomes were ascertained with the use of validated EHR phenotypes and, when needed, manual adjudication. Manually adjudicated outcomes were evaluated by investigators and staff who were unaware of group assignment.
Trial Locations
- Locations (68)
Maine VA Medical Center, Augusta, ME
🇺🇸Togus, Maine, United States
VA Southern Oregon Rehabilitation Center and Clinics, White City, OR
🇺🇸White City, Oregon, United States
New Mexico VA Health Care System, Albuquerque, NM
🇺🇸Albuquerque, New Mexico, United States
VA Gulf Coast Veterans Health Care System, Biloxi, MS
🇺🇸Biloxi, Mississippi, United States
Hampton VA Medical Center, Hampton, VA
🇺🇸Hampton, Virginia, United States
Tomah VA Medical Center, Tomah, WI
🇺🇸Tomah, Wisconsin, United States
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
🇺🇸Bedford, Massachusetts, United States
Aleda E. Lutz VA Medical Center, Saginaw, MI
🇺🇸Saginaw, Michigan, United States
VA Roseburg Healthcare System, Roseburg, OR
🇺🇸Roseburg, Oregon, United States
Memphis VA Medical Center, Memphis, TN
🇺🇸Memphis, Tennessee, United States
Sheridan VA Medical Center, Sheridan, WY
🇺🇸Sheridan, Wyoming, United States
Manhattan Campus of the VA NY Harbor Healthcare System, New York, NY
🇺🇸New York, New York, United States
Dayton VA Medical Center, Dayton, OH
🇺🇸Dayton, Ohio, United States
Jackson C. Montgomery VA Medical Center, Muskogee, OK
🇺🇸Muskogee, Oklahoma, United States
St. Louis VA Medical Center John Cochran Division, St. Louis, MO
🇺🇸Saint Louis, Missouri, United States
Huntington VA Medical Center, Huntington, WV
🇺🇸Huntington, West Virginia, United States
VA Caribbean Healthcare System, San Juan, PR
🇵🇷San Juan, Puerto Rico
Rehabilitation R&D Service, Baltimore, MD
🇺🇸Baltimore, Maryland, United States
Albany VA Medical Center Samuel S. Stratton, Albany, NY
🇺🇸Albany, New York, United States
St. Cloud VA Health Care System, St. Cloud, MN
🇺🇸Saint Cloud, Minnesota, United States
VA North Texas Health Care System Dallas VA Medical Center, Dallas, TX
🇺🇸Dallas, Texas, United States
Syracuse VA Medical Center, Syracuse, NY
🇺🇸Syracuse, New York, United States
Louis Stokes VA Medical Center, Cleveland, OH
🇺🇸Cleveland, Ohio, United States
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
🇺🇸Philadelphia, Pennsylvania, United States
Wm. Jennings Bryan Dorn VA Medical Center, Columbia, SC
🇺🇸Columbia, South Carolina, United States
Alaska VA Healthcare System, Anchorage, AK
🇺🇸Anchorage, Alaska, United States
Veterans Health Care System of the Ozarks, Fayetteville, AR
🇺🇸Fayetteville, Arkansas, United States
VA Central California Health Care System, Fresno, CA
🇺🇸Fresno, California, United States
Central Arkansas VHS John L. McClellan Memorial Veterans Hospital, Little Rock, AR
🇺🇸Little Rock, Arkansas, United States
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
🇺🇸West Los Angeles, California, United States
VA Palo Alto Health Care System, Palo Alto, CA
🇺🇸Palo Alto, California, United States
VA Long Beach Healthcare System, Long Beach, CA
🇺🇸Long Beach, California, United States
Grand Junction VA Medical Center, Grand Junction, CO
🇺🇸Grand Junction, Colorado, United States
Wilmington VA Medical Center, Wilmington, DE
🇺🇸Wilmington, Delaware, United States
Washington DC VA Medical Center, Washington, DC
🇺🇸Washington, District of Columbia, United States
Bay Pines VA Healthcare System, Pay Pines, FL
🇺🇸Bay Pines, Florida, United States
Captain James A. Lovell Federal Health Care Center, North Chicago, IL
🇺🇸North Chicago, Illinois, United States
VA Illiana Health Care System, Danville, IL
🇺🇸Danville, Illinois, United States
Boise VA Medical Center, Boise, ID
🇺🇸Boise, Idaho, United States
Edward Hines Jr. VA Hospital, Hines, IL
🇺🇸Hines, Illinois, United States
Iowa City VA Health Care System, Iowa City, IA
🇺🇸Iowa City, Iowa, United States
Richard L. Roudebush VA Medical Center, Indianapolis, IN
🇺🇸Indianapolis, Indiana, United States
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
🇺🇸Boston, Massachusetts, United States
Michael E. DeBakey VA Medical Center, Houston, TX
🇺🇸Houston, Texas, United States
Cincinnati VA Medical Center, Cincinnati, OH
🇺🇸Cincinnati, Ohio, United States
Fargo VA Healthcare System, Fargo, ND
🇺🇸Fargo, North Dakota, United States
Minneapolis VA Health Care System, Minneapolis, MN
🇺🇸Minneapolis, Minnesota, United States
Durham VA Medical Center, Durham, NC
🇺🇸Durham, North Carolina, United States
South Texas Health Care System, San Antonio, TX
🇺🇸San Antonio, Texas, United States
Birmingham VA Medical Center, Birmingham, AL
🇺🇸Birmingham, Alabama, United States
VA Portland Health Care System, Portland, OR
🇺🇸Portland, Oregon, United States
Rocky Mountain Regional VA Medical Center, Aurora, CO
🇺🇸Aurora, Colorado, United States
Clement J. Zablocki VA Medical Center, Milwaukee, WI
🇺🇸Milwaukee, Wisconsin, United States
Omaha VA Nebraska-Western Iowa Health Care System, Omaha, NE
🇺🇸Omaha, Nebraska, United States
Coatesville VA Medical Center, Coatesville, PA
🇺🇸Coatesville, Pennsylvania, United States
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
🇺🇸Pittsburgh, Pennsylvania, United States
Wilkes-Barre VA Medical Center, Wilkes-Barre, PA
🇺🇸Wilkes-Barre, Pennsylvania, United States
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
🇺🇸West Haven, Connecticut, United States
Tennessee Valley Healthcare System Nashville Campus, Nashville, TN
🇺🇸Nashville, Tennessee, United States
Manchester VA Medical Center, Manchester, NH
🇺🇸Manchester, New Hampshire, United States
White River Junction VA Medical Center, White River Junction, VT
🇺🇸White River Junction, Vermont, United States
VA Black Hills Health Care System Fort Meade Campus, Fort Meade, SD
🇺🇸Sturgis, South Dakota, United States
North Florida/South Georgia Veterans Health System, Gainesville, FL
🇺🇸Gainesville, Florida, United States
VA Pacific Islands Health Care System, Honolulu, HI
🇺🇸Honolulu, Hawaii, United States
VA Central Iowa Health Care System, Des Moines, IA
🇺🇸Des Moines, Iowa, United States
Kansas City VA Medical Center, Kansas City, MO
🇺🇸Kansas City, Missouri, United States
Ralph H. Johnson VA Medical Center, Charleston, SC
🇺🇸Charleston, South Carolina, United States
William S. Middleton Memorial Veterans Hospital, Madison, WI
🇺🇸Madison, Wisconsin, United States