effectiveness of motivational interviewing in patients with dyslipidemia treated in primary care...
TRANSCRIPT
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Julia Bóveda José M ª BoschNieves Barragán José A. PradosManuel 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
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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.
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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
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25 Primary Health Centers located in four regions of Spain.
Study site
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• 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
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• 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
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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
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• 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
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TARGET POPULATIONSTUDY POPULATION
Patients attending health centers and meet inclusion criteria:
Adults 40-75 years old, both sexes withDyslipidemia
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 GROUPInical evaluation
CONTROL GROUPInical evaluation
InterventionMOTIVATIONAL 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 analysisConclusions
TRAINING MI
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• 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
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Results
Flowchart of included general
practitioners and patients
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Evolution of the mean levels of Total Cholesterol throughout the study by group
Tota
l Cho
lest
erol
m
g/dl
Visits
F=0,021; p=0,996
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Evolution of the mean levels of LDL- cholesterolthroughout the study by group
LDL
Chol
este
rol
mg/
dl
Visits
F=0,067; p=0,977
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Evolution of the mean levels of Triglyceridesthroughout the study by group
Trig
lyce
rides
mg/
dl
Visits
F = 0,216; p=0,886
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Lipid disorder type at the beginning and end of the study
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CV risk score: evolution for groups
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Evolution weight grades
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Bode Mass Index in obese and overweight patients
(F=0,567, p=0,452
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Initial and final level of physical activity groups (IPAQ)
Low
Medium
High
Chi square =23,3; p<0.01
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Score questionnaire mediterranean diet
Diet questionnaire score
Score ≥ 9: high compliance
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Use of lipid-lowering drugs
Chi square= 5,042, p=0,025
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Conclusions1. 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.
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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).