448-Martínez Valverde-_c.pdf - INRUD

EFFECTIVENESS OF A MEDICAL EDUCATION
INTERVENTION TO TREAT HYPERTENSION IN
PRIMARY CARE
Authors: Silvia Martínez-Valverde MSc 1 , Hortensia
Reyes-Morales MD, MSc, DrSc. 2 , Angélica Castro-Ríos
MHE. 3 , Ricardo Pérez-Cuevas MD, MSc, DrSc. 3 , Miguel
Klunder-Klunder MSc. 1 , Guillermo Salinas-Escudero
MSc. 1 .
Institutions:
1
Center for Social and Economic Studies on Health. Hospital Infantil de
México Federico Gómez
2
Center for Health Systems Research, National Institute of Public Health
3
Epidemiology and Health Services Research Unit, Instituto Mexicano del
Seguro Social
Mexico
National Institute of Public
Health, Mexico
Hospital Infantil de
México Federico Gómez

Introduction
• In México, hypertension is among the top five causes of
visit to primary care clinics, and its complications are
among the main causes of emergency services and
hospital care.
• The interventions to tackle this growing problem
comprise public health programs that include prevention
and health promotion activities and screening.
• Public healthcare systems have developed evidence-
based clinical guidelines in accordance with international
recommendations, but suitable for local use during their
daily practice.
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

Introduction
•The guidelines have been used as a tool in
continuing i medical education programs, and it is
expected that practitioners would use them.
• Continuing medical education (CME) consists of
educational activities that serve to maintain, develop,
or increase the knowledge, skills, and professional
performance and relationships that a medical doctor
uses to provide services to the patients.
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

Objective
• To
evaluate
the
effectiveness
of a continuing
medical education (CME) intervention to improve
appropriate care for hypertension, on blood pressure
control
clinics.
of
hypertensive
patients
in
primary
care
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

Methods
• Design: A secondary data analysis was carried out
using data of hypertensive patients treated by family
physicians who participated in the Continuing
Medical Education intervention.
• Setting: The study was conducted d at a national level
l
in six family medical clinics belonging to the Mexican
Institute of Social Security (IMSS), the largest public
health care system in Mexico.
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

Methods
• Study Population: The analysis included 193
patients with hypertension (intervention group: n =
101 patients; control group: n = 92 patients), who
were treated by 90 physicians.
• Intervention: The intervention was based on three
sequential stages that t lasted 3 months. In each
setting, a general internal medicine specialist was
trained to coordinate the interventions and to work as
a clinical instructor.
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

Methods
• An evidence-based clinical guideline was
previously designed and adapted to the family
medicine context and served as the groundwork for
the intervention.
• Analysis: The effect of the CME intervention was
analyzed using multiple logistic regression modeling
in which the dependent variable was uncontrolled
blood pressure in the post-intervention patient
measurement.
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

Methods
• The operational definition of uncontrolled blood
pressure states that the systolic/diastolic figures
should be ≥140/90 mmHg5.
• Outcome measure : Proportion of patients with
uncontrolled blood pressure in the intervention and
control groups at baseline and final stages.
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

Results: Baseline characteristics
General characteristics Intervention Control
n=101 n=92
Mean (SD) Mean (SD)
Age (years) 58.88 (12.9) 58.7 (9.3)
% %
Sex
Men 19.8 20.7
Women 80.2 79.4
Civil status
Single, widowed* 45.5 25.0
Married or consensual union 54.55 75.0
Literacy
Up to 3 years of primary school 63.4 67.4
Elementary school completed 12.9 18.5
Secondary school 18.8 7.6
High school 3.0 2.2
College graduates 2.0 4.4
National Institute of
Public Health, Mexico
* p

Results: Baseline Clinical Data
Variables Intervention Control
n=101 n=92
Clinical data Mean (SD) Mean (SD)
Blood pressure (mmHg)
Systolic 135.5 (15.8) 136.6 (13.6)
Diastolic 83.7 (8.6) 84.8 (7.9)
Biochemical indicators (mg/dL)
Glucose 108.5 (29.5) 110.8 (39.7)
Total Cholesterol 211.9 (44.8) 214.7 (50.0)
Triglycerides 227.5 (131.7) 215.0 (98.0)
Comorbidity
Diabetes 8.91 11.96
Cardiopathy 10.89 4.35
Duration of hypertension (years)
≤ 5 38.5 33.0
5-9 27.1 26.1
10-14 14.6 23.9
15-19 19 8.3 13.6
≥20 11.5 3.4
Blood pressure control
Controlled patients 38.6 30.4
Nutritional status
Normal 19.8 9.8
Overweight 33.7 37.0
Obesity 46.5 53.3

Results:
Patients with uncontrolled blood pressure in both
groups at baseline and final evaluation stages
.
pp: percentage points
p: p value between groups
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

Multiple Logistic Regression Model: CME
intervention with uncontrolled blood pressure
Variables included in the
final model
Odds ratio 95% confidence
p > z
interval
CME educational
0.47 0.24 0.90 0.02
intervention
Baseline uncontrolled blood
2.66 1.31 5.38 0.01
pressure
Baseline body mass index 1.07 1.001 1.143 0.04
Women 0.46 0.20 1.06 0.07
Age (years) 1.03 0.99 1.06 0.11
Dietary recommendations at
the baseline evaluation
Hosmer-Lemeshow
goodness of fit, Prob > χ 2 = 0.5683
0.43 0.22 0.87 0.02
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez

• The
intervention
Conclusions
analysis demonstrated that a multifaceted
of
CME
increase
the
probability
control blood pressure in hypertensive patients.
to
• The results highlight the importance of providing
dietary recommendations. Dietary recommendations
are a proxy that can be used to ascertain whether
patients t change their dietary habits to control their
body weight and decrease their blood pressure.
National Institute of
Public Health, Mexico
Hospital Infantil de
México Federico Gómez