effectiveness of a medical education intervention to treat hypertension in primary care

EFFECTIVENESS OF A MEDICAL EDUCATION EFFECTIVENESS OF A MEDICAL EDUCATION INTERVENTION TO TREAT HYPERTENSION IN INTERVENTION TO TREAT HYPERTENSION IN

PRIMARY CARE PRIMARY CARE

AuthorsAuthors: Silvia Martínez-Valverde MSc1, 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. InstitutionsInstitutions:1Center for Social and Economic Studies on Health. Hospital Infantil de México Federico Gómez

2Center for Health Systems Research, National Institute of Public Health 3Epidemiology and Health Services Research Unit, Instituto Mexicano del

Seguro Social

MexicoNational Institute of Public National Institute of Public

Health, MexicoHealth, MexicoHospital Infantil de Hospital Infantil de

México Federico GómezMéxico Federico Gómez

Introduction Introduction In México, hypertension is among the top five causes of In México, hypertension is among the top five causes of visit to primary care clinics, and its complications are visit to primary care clinics, and its complications are among the main causes of emergency services and among the main causes of emergency services and hospital care. hospital care.

The interventions to tackle this growing problem The interventions to tackle this growing problem comprise public health programs that include prevention comprise public health programs that include prevention and health promotion activities and screening.and health promotion activities and screening.

Public healthcare systems have developed evidence-Public healthcare systems have developed evidence-based clinical guidelines in accordance with international based clinical guidelines in accordance with international recommendations, but suitable for local use during their recommendations, but suitable for local use during their daily practice.daily practice.

National Institute of National Institute of Public Health, MexicoPublic Health, Mexico

Hospital Infantil de Hospital Infantil de México Federico GómezMéxico Federico Gómez

Introduction Introduction

The guidelines have been used as a tool in The guidelines have been used as a tool in continuing medical education programs, and it is continuing medical education programs, and it is expected that practitioners would use them.expected that practitioners would use them.

Continuing medical education (CME) consists of Continuing medical education (CME) consists of educational activities that serve to maintain, develop, educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional or increase the knowledge, skills, and professional performance and relationships that a medical doctor performance and relationships that a medical doctor uses to provide services to the patients.uses to provide services to the patients.



ObjectiveObjective

To evaluate the effectiveness of a continuing To evaluate the effectiveness of a continuing

medical education (CME) intervention to improve medical education (CME) intervention to improve

appropriate care for hypertension, on blood pressure appropriate care for hypertension, on blood pressure

control of hypertensive patients in primary care control of hypertensive patients in primary care

clinics. clinics.



MethodsMethods Design:Design: A secondary data analysis was carried out A secondary data analysis was carried out

using data of hypertensive patients treated by family using data of hypertensive patients treated by family

physicians who participated in the Continuing physicians who participated in the Continuing

Medical Education intervention.Medical Education intervention.

Setting:Setting: The study was conducted at a national level The study was conducted at a national level

in six family medical clinics belonging to the Mexican in six family medical clinics belonging to the Mexican

Institute of Social Security (IMSS), the largest public Institute of Social Security (IMSS), the largest public

health care system in Mexico.health care system in Mexico.



Methods Methods

Study Population: Study Population: The analysis included 193 The analysis included 193

patients with hypertension (intervention group: n = patients with hypertension (intervention group: n =

101 patients; control group: n = 92 patients), who 101 patients; control group: n = 92 patients), who

were treated by 90 physicians. were treated by 90 physicians.

Intervention: Intervention: The intervention was based on three The intervention was based on three

sequential stages that lasted 3 months. In each sequential stages that lasted 3 months. In each

setting, a general internal medicine specialist was setting, a general internal medicine specialist was

trained to coordinate the interventions and to work as trained to coordinate the interventions and to work as

a clinical instructor. a clinical instructor.



Methods Methods An evidence-based clinical guideline was An evidence-based clinical guideline was

previously designed and adapted to the family previously designed and adapted to the family

medicine context and served as the groundwork for medicine context and served as the groundwork for

the intervention.the intervention.

Analysis: Analysis: The effect of the CME intervention was The effect of the CME intervention was

analyzed using multiple logistic regression modeling analyzed using multiple logistic regression modeling

in which the dependent variable was uncontrolled in which the dependent variable was uncontrolled

blood pressure in the post-intervention patient blood pressure in the post-intervention patient

measurement. measurement.


Hospital Infantil de Hospital Infantil de México Federico Gómez México Federico Gómez

Methods Methods

The operational definition of uncontrolled blood The operational definition of uncontrolled blood

pressure states that the systolic/diastolic figures pressure states that the systolic/diastolic figures

should be ≥140/90 mmHg5. should be ≥140/90 mmHg5.

Outcome measure : Outcome measure : Proportion of patients with Proportion of patients with

uncontrolled blood pressure in the intervention and uncontrolled blood pressure in the intervention and

control groups at baseline and final stages. control groups at baseline and final stages.



Results: Results: Baseline characteristics Baseline characteristics

National Institute of National Institute of Public Health, MexicoPublic Health, Mexico Hospital Infantil de Hospital Infantil de

México Federico GómezMéxico Federico Gómez

* p <0.05

General characteristics Intervention Control

n=101 n=92

Mean (SD) Mean (SD)Age (years) 58.8 (12.9) 58.7 (9.3)

% %

Sex Men 19.8 20.7Women 80.2 79.4

Civil status Single, widowed* 45.5 25.0Married or consensual union 54.5 75.0

Literacy Up to 3 years of primary school 63.4 67.4Elementary school completed 12.9 18.5Secondary school 18.8 7.6High school 3.0 2.2

College graduates 2.0 4.4

Results:Results: Baseline Clinical Data Baseline Clinical Data Variables Intervention Control

n=101 n=92Clinical 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)

ComorbidityDiabetes 8.91 11.96Cardiopathy 10.89 4.35

Duration of hypertension (years)≤ 5 38.5 33.05-9 27.1 26.110-14 14.6 23.915-19 8.3 13.6≥20 11.5 3.4

Blood pressure controlControlled patients 38.6 30.4

Nutritional status Normal 19.8 9.8Overweight 33.7 37.0Obesity 46.5 53.3

Results:Results: Patients with uncontrolled blood pressure in both Patients with uncontrolled blood pressure in both

groups at baseline and final evaluation stages groups at baseline and final evaluation stages



pp: percentage pointspp: percentage points p: p value between groups p: p value between groups

.



Multiple Logistic Regression Model: CME Multiple Logistic Regression Model: CME intervention with uncontrolled blood pressureintervention with uncontrolled blood pressure

Variables included in the Variables included in the

final modelfinal modelOdds ratioOdds ratio 95% confidence 95% confidence

intervalintervalp > zp > z

CME educational CME educational

intervention intervention 0.470.47 0.240.24 0.900.90 0.020.02

Baseline uncontrolled blood Baseline uncontrolled blood

pressurepressure2.662.66 1.311.31 5.385.38 0.010.01

Baseline body mass index Baseline body mass index 1.071.07 1.0011.001 1.1431.143 0.040.04

WomenWomen 0.460.46 0.200.20 1.061.06 0.070.07

Age (years)Age (years) 1.031.03 0.990.99 1.061.06 0.110.11

Dietary recommendations at Dietary recommendations at

the baseline evaluation the baseline evaluation 0.430.43 0.220.22 0.870.87 0.020.02

Hosmer-Lemeshow goodness of fit, Prob > Hosmer-Lemeshow goodness of fit, Prob > 22 = 0.5683 = 0.5683

ConclusionsConclusions



The analysis demonstrated that a multifaceted The analysis demonstrated that a multifaceted

intervention of CME increase the probability to intervention of CME increase the probability to

control blood pressure in hypertensive patients. control blood pressure in hypertensive patients.

The results highlight the importance of providing The results highlight the importance of providing

dietary recommendations. Dietary recommendations dietary recommendations. Dietary recommendations

are a proxy that can be used to ascertain whether are a proxy that can be used to ascertain whether

patients change their dietary habits to control their patients change their dietary habits to control their

body weight and decrease their blood pressure.body weight and decrease their blood pressure.

effectiveness of a medical education intervention to treat hypertension in primary care

Documents

public health programs

health systems research

health promotion activities

health services research

family medical clinics

primary care clinics

public healthcare systems

hospital care