Julia Bóveda José M ª Bosch
Nieves Barragán José A. Prados
Manuel Campíñez Luis A. Pérula
Effectiveness of motivational
in...
Objective of the study
To verify the effectiveness of a multifactorial
intervention based on motivational intervention by
...
Multicenter, open, controlled and randomized
cluster, with two parallel arms formed by two
groups of population with a fol...
25 Primary
Health
Centers
located in
four regions
of Spain.
Study site
• 227 adults aged 40 to 75 years with uncontrolled
dyslipidemia in situation of primary prevention of
cardiovascular disea...
• 38 GPs were randomized to an intervention with their patients based on MI
or informative advice usual.
• MI was delivere...
Both Groups GPs:
Explained guide clinical
performance in
dyslipidemia and
training video
recording
Workshop
training MI 16...
• Main outcome measures :
• Reduction of lipid levels: total cholesterol, LDL-cholesterol,
Trglycerides.
• Other outcomes ...
TARGET POPULATION
STUDY POPULATION
Patients attending health centers and meet inclusion
criteria:
Adults 40-75 years old, ...
• An intention to treat analysis has been conducted. To check the
effect of the intervention a comparison of means test (A...
Results
Flowchart of
included
general
practitioners
and patients
Evolution of the mean levels of Total Cholesterol
throughout the study by groupTotalCholesterol
mg/dl
Visits
F=0,021; p=0,...
Evolution of the mean levels of LDL- cholesterol
throughout the study by groupLDLCholesterol
mg/dl
Visits
F=0,067; p=0,977
Evolution of the mean levels of Triglycerides
throughout the study by groupTriglycerides
mg/dl
Visits
F = 0,216; p=0,886
Lipid disorder type at the beginning and end of
the study
CV risk score: evolution for groups
Evolution weight grades
Bode Mass Index in obese and overweight
patients
(F=0,567, p=0,452
Initial and final level of physical activity
groups (IPAQ)
Low
Medium
High
Chi square =23,3; p<0.01
Score questionnaire mediterranean diet
Diet questionnaire score
Score ≥ 9: high compliance
Use of lipid-lowering drugs
Chi square= 5,042, p=0,025
Conclusions
1. An approach based on Motivational Interviewing conducted by
primary care physicians aimed at improving the ...
This project has been funded by the Consejería de Salud de la Junta de Andalucía (PI-0100/2008, resolution No. BOJA. 12th
...
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Effectiveness of motivational interviewing in patients with dyslipidemia treated in primary care consultations: randomized controlled trial by cluster (Dislip-EM study)

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  • Diagrama de flujo de los participantes según la Declaración CONSORT
    Inicialmente fueron aleatorizados 54 médicos de familia, en 34 centros de salud.
    Finalmente fueron 38 ( 25 centros de salud) los que incluyeron pacientes en el estudio.
  • La cifra media de colesterol total disminuyó de forma significativa en ambos grupos a lo largo del periodo de 12 meses de seguimiento (Diferencia de medias=-19,60; IC95%:-15,33 a -23,87 mg/dl; test de Friedman=91,756; p&amp;lt;0,001), sin que se hayan apreciado diferencias significativas entre ambos grupos (F=0,021; p=0,996)
  • La cifra media de c-LDL ha disminuido significativamente en el total de la muestra (diferencia de medias=-13,78; IC95%:-9,77 a -17,79 mg/dl; test de Friedman=58,856; p&amp;lt;0,001), sin diferencias significativas entre ambos grupos (F=0,067; p=0,977).
  • Del mismo modo, la cifra media de triglicéridos ha disminuido de forma significativa en ambos grupos (diferencia de medias=-19,14; IC95%:-11,29 a -26,99 mg/dl; test de Friedman=23,390; p&amp;lt;0,001), sin que hayamos encontrado diferencias entre los mismos (F = 0,216; p=0,886)
  • Hemos observado descensos significativos para el total de la muestra en la puntuación del RCV medido con las tablas Score, Regicor y Framingham, sin diferencias significativas entre GE y GC
  • En el momento de su inclusión en el estudio, el 80.4% en el GE y el 79,2% en el GC tenían sobrepeso u obesidad. Se ha observado una tendencia positiva del porcentaje de pacientes que perdieron peso en ambos grupos sin que las diferencias sean estadísticamente significativas. El porcentaje de obesos se ha reducido un 8,4% (de un 35,5% a un 27,1%) en el GE y un 6,7% (de un 31,7% a un 25%) en el GC.
  • El IMC en los pacientes con sobrepeso u obesidad, ha disminuido de 29,79±3,53 a 29,17±3,54 (Figura 12). Aún cuando este descenso no presenta una diferencia significativa entre ambos grupos (F=0,567, p=0,452), sí es significativo en el total de la muestra (diferencia de medias=-0,61; IC95%;-0,34 a -0,88; test de Friedman=59,050, p&amp;lt;0,001).
  • En cuanto al nivel de actividad física, valorado utilizando el cuestionario IPAQ, evidenciamos un aumento en ambos grupos (p=0,030), con una diferencia significativa favorable al GE (Ji cuadrado=23,3 p&amp;lt;0.01). Como se representa en la figura 15, en el GE de 24 sujetos (25,5%) que eran sedentarios o con nivel de actividad física bajo al inicio, solo 2 (6,3%) continuaban siéndolo al final del estudio.
  • El cuestionario de adherencia a la dieta mediterránea arroja una puntuación media al inicio de 8,30±2,43 (DT) y una puntuación final tras un año de seguimiento de 9,41±2,47 (DT), diferencia estadísticamente significativa (diferencia de medias=1,11: IC95:1,42-7,29; test de Friedman=44,366; p&amp;lt;0,001).
    En ambos grupos existe una modificación en el sentido positivo en la visita final: de 8,27±2,24 (DT) a 9,37±2,19 (DT) en el GE y de 8,33±2,59 (DT) a 9.45 ±2,70 (DT) en el GC, sin diferencias significativas entre ellos (IC 95% de la diferencia de medias: -0,626 a 0,582)
  • Hemos de destacar que hemos observado que existe una mayor prescripción de estatinas en el grupo control. Aunque se trata de una muestra pequeña , hemos visto que en 23 de 120 en GC frente a 10 de 107 en GE se ha instaurado tratamiento con estatinas, siendo esta diferencia estadísticamente significativa (Ji cuadrado 5,042, p=0,025).
  • Effectiveness of motivational interviewing in patients with dyslipidemia treated in primary care consultations: randomized controlled trial by cluster (Dislip-EM study)

    1. 1. Julia Bóveda José M ª Bosch Nieves Barragán José A. Prados Manuel Campíñez Luis A. Pérula Effectiveness of motivational interviewing in patients with dyslipidemia treated in primary care consultations: randomized controlled trial by cluster (Dislip-EM study) ICMI 2014 Amsterdam
    2. 2. Objective of the study To verify the effectiveness of a multifactorial intervention based on motivational intervention by General Practitioners (GPs) trained in motivational interviewing (MI), to improve the control of lipid levels in patients with dyslipidemia, compared with standard medical advice.
    3. 3. Multicenter, open, controlled and randomized cluster, with two parallel arms formed by two groups of population with a follow-up over 12 months in primary health care. Study design
    4. 4. 25 Primary Health Centers located in four regions of Spain. Study site
    5. 5. • 227 adults aged 40 to 75 years with uncontrolled dyslipidemia in situation of primary prevention of cardiovascular disease, captured by their GPs with consecutive sampling. Study subjects
    6. 6. • 38 GPs were randomized to an intervention with their patients based on MI or informative advice usual. • MI was delivered in the Experimental Group (EG), and usual intervention in the Control Group (CG). • A specific training plan was designed and implemented in the EG. • The fidelity of the MI intervention was checked with video recordings of real consultations with a scale designed and validated in this study (EVEM questionnaire). • Follow-up: 1 year. Intervention
    7. 7. Both Groups GPs: Explained guide clinical performance in dyslipidemia and training video recording Workshop training MI 16h Booster training: micropills, videorecording feedback with expert… No specific training in MI EVEM questionnaire Control Group Intervention Group Performance in GPs
    8. 8. • Main outcome measures : • Reduction of lipid levels: total cholesterol, LDL-cholesterol, Trglycerides. • Other outcomes variables: • Reduction of cardiovascular risk • Degree of improvement in diet • Increase of physical activity and weight loss in overweight patients. Determinations
    9. 9. TARGET POPULATION STUDY POPULATION Patients attending health centers and meet inclusion criteria: Adults 40-75 years old, both sexes with Dyslipidemia Exclusion criteria: • Secondary dyslipidemia or with lipid-lowering drug therapy •CVD. Diabetes. Severe COPD. Severe renal or hepatic disease •Mental illness or substance abuse •Be sick for an extended period •Pregnancy or lactation Randomisation 38 GPs (n=436 patients) EXPERIMENTAL GROUP Inical evaluation CONTROL GROUP Inical evaluation Intervention MOTIVATIONAL INTERVIEWING Intervention USUAL CARE Monitoring, assessment and motivational intervention at 2, 4, 8 and 12 meses Level blood lipids and CV risk Monitoring, assessment and usual care at 2, 4, 8 and 12 meses Level blood lipids and CV risk Data analysis Conclusions TRAINING MI
    10. 10. • An intention to treat analysis has been conducted. To check the effect of the intervention a comparison of means test (ANOVA, Kruskal-Wallis) and proportions (Chi-square, McNemar) was used, and a multivariate analysis was done. Using Multiple Linear Regression or Logistic Regression (p ≤ 0.05). Statistical Analysis
    11. 11. Results Flowchart of included general practitioners and patients
    12. 12. Evolution of the mean levels of Total Cholesterol throughout the study by groupTotalCholesterol mg/dl Visits F=0,021; p=0,996
    13. 13. Evolution of the mean levels of LDL- cholesterol throughout the study by groupLDLCholesterol mg/dl Visits F=0,067; p=0,977
    14. 14. Evolution of the mean levels of Triglycerides throughout the study by groupTriglycerides mg/dl Visits F = 0,216; p=0,886
    15. 15. Lipid disorder type at the beginning and end of the study
    16. 16. CV risk score: evolution for groups
    17. 17. Evolution weight grades
    18. 18. Bode Mass Index in obese and overweight patients (F=0,567, p=0,452
    19. 19. Initial and final level of physical activity groups (IPAQ) Low Medium High Chi square =23,3; p<0.01
    20. 20. Score questionnaire mediterranean diet Diet questionnaire score Score ≥ 9: high compliance
    21. 21. Use of lipid-lowering drugs Chi square= 5,042, p=0,025
    22. 22. Conclusions 1. An approach based on Motivational Interviewing conducted by primary care physicians aimed at improving the lipid profile in patients with dyslipidemia, has not proven to be more effective than usual intervention. 2. Both Motivational Interviewing and the usual care, significantly reduces total cholesterol, LDL cholesterol, triglycerides and cardiovascular risk after a one-year monitoring program. 3. Motivational Interviewing gets to make the patients increase their level of physical exercise to a greater degree than the usual approach. 4. Professionals who perform a motivational approach use less lipid-lowering drugs than the control group in patients with dyslipidemia.
    23. 23. This project has been funded by the Consejería de Salud de la Junta de Andalucía (PI-0100/2008, resolution No. BOJA. 12th January 20, 2009), and has received a grant from the Spanish Society of Family and Community Medicine (Helps for doctoral theses Isabel Fernández 2011).

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