1. EFFECTIVENESS OF A MEDICAL EDUCATION INTERVENTION TO TREAT HYPERTENSION IN PRIMARY CARE Authors Institutions 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

2. 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

3. Introduction  The guidelines have been used as a tool in continuing 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

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

5. 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.  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 at a national level 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

6. 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.  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 lasted 3 months. In each setting, a general internal medicine specialist was trained to coordinate the interventions and to work as a clinical instructor. Hospital Infantil de México Federico Gómez National Institute of Public Health, Mexico

7. 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

8. 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

9. Results: Baseline characteristics National Institute of Public Health, Mexico Hospital Infantil de México Federico Gómez * p <0.05 General characteristicsInterventionControl n=101n=92 Mean (SD) Age (years)58.8 (12.9)58.7 (9.3) % Sex Men19.820.7 Women80.279.4 Civil status Single, widowed*45.525.0 Married or consensual union54.575.0 Literacy Up to 3 years of primary school63.467.4 Elementary school completed12.918.5 Secondary school18.87.6 High school3.02.2 College graduates2.04.4

10. Results: Baseline Clinical Data VariablesInterventionControl n=101n=92 Clinical dataMean (SD) Blood pressure (mmHg) Systolic135.5 (15.8)136.6 (13.6) Diastolic83.7 (8.6)84.8 (7.9) Biochemical indicators (mg/dL) Glucose108.5 (29.5)110.8 (39.7) Total Cholesterol211.9 (44.8)214.7 (50.0) Triglycerides227.5 (131.7)215.0 (98.0) Comorbidity Diabetes8.9111.96 Cardiopathy10.894.35 Duration of hypertension (years) ≤ 538.533.0 5-927.126.1 10-1414.623.9 15-198.313.6 ≥2011.53.4 Blood pressure control Controlled patients38.630.4 Nutritional status Normal19.89.8 Overweight33.737.0 Obesity46.553.3

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

12. Hospital Infantil de México Federico Gómez National Institute of Public Health, Mexico Multiple Logistic Regression Model: CME intervention with uncontrolled blood pressure Variables included in the final model Odds ratio 95% confidence interval p > z CME educational intervention 0.470.240.900.02 Baseline uncontrolled blood pressure 2.661.315.380.01 Baseline body mass index 1.071.0011.1430.04 Women0.460.201.060.07 Age (years) 1.030.991.060.11 Dietary recommendations at the baseline evaluation 0.430.220.870.02 Hosmer-Lemeshow goodness of fit, Prob >  2 = 0.5683

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