Effectiveness of motivational interviewing in patients with dyslipidemia treated in primary care...

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

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.

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

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 disease, captured by their GPs with

consecutive sampling.

Study subjects

• 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

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

• 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

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

• 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

Results

Flowchart of included general

practitioners and patients

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

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

Evolution of the mean levels of Triglyceridesthroughout the study by group

Trig

lyce

rides

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

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.

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).