Effectiveness of motivational interviewing in patients with dyslipidemia: a randomized cluster trial

Adapted motivational interviewing for brief healthcare consultations: A systematic review and meta-analysis of treatment fidelity in real-world evaluations of behaviour change counselling

BACKGROUND

Behaviour change counselling (BCC) is an adaptation of motivational interviewing (MI) designed to maximize the effectiveness of time-limited health behaviour change consultations. To improve intervention quality and understanding of treatment effects, it is recommended that evaluations of health behaviour change interventions incorporate existing fidelity frameworks (e.g. The National Institutes of Health [NIH] Behaviour Change Consortium) and ensure that treatment fidelity is assessed and reported.

PURPOSE

This systematic review was designed to examine (a) adherence to NIH fidelity recommendations, (b) provider fidelity to BCC and (c) impact of these variables on the real-world effectiveness of BCC for adult health behaviours and outcomes.

METHODS AND RESULTS

Searches of 10 electronic databases yielded 110 eligible publications describing 58 unique studies examining BCC delivered within real-world healthcare settings by existing providers. Mean study adherence to NIH fidelity recommendations was 63.31% (Range 26.83%-96.23%). Pooled effect size (Hedges g) for short-term and long-term outcomes was .19 (95% CI [.11, .27]) and .09 (95% CI [.04, .13]), respectively. In separate, random-effects meta-regressions, neither short-term nor long-term effect sizes were significantly modified by adherence to NIH fidelity recommendations. For the subgroup of short-term alcohol studies (n = 10), a significant inverse relationship was detected (Coefficient = -.0114, 95% CI [-.0187, -.0041], p = .0021). Inadequate and inconsistent reporting within the included studies precluded planned meta-regression between provider fidelity and BCC effect size.

CONCLUSIONS

Further evidence is needed to clarify whether adherence to fidelity recommendations modifies intervention effects. Efforts to promote transparent consideration, evaluation and reporting of fidelity are urgently needed. Research and clinical implications are discussed.

Dietary outcomes of community-based CVD preventive interventions: a systematic review and meta-analysis

OBJECTIVE

We aimed to synthesise available evidence on the effects of community-based interventions in improving various dietary outcome measures.

DESIGN

Systematic review and meta-analysis.

SETTING

We searched databases including Medline, EMBASE, PSYCINFO, CINAHL and the Cochrane registry for studies reported between January 2000 and June 2022. The methodological quality of the included studies was evaluated using the Cochrane risk of bias tools for each study type. For some of the outcomes, we pooled the effect size using a random-effects meta-analysis.

PARTICIPANTS

A total of fifty-one studies, thirty-three randomised and eighteen non-randomised, involving 100 746 participants were included.

RESULTS

Overall, thirty-seven studies found a statistically significant difference in at least one dietary outcome measure favouring the intervention group, whereas fourteen studies found no statistically significant difference. Our meta-analyses indicated that, compared with controls, interventions were effective in decreasing daily energy intake (MJ/d) (mean difference (MD): -0·25; 95 % CI: -0·37, -0·14), fat % of energy (MD: -1·01; 95 % CI: -1·76, -0·25) and saturated fat % of energy (MD: -1·54; 95 % CI: -2·01, -1·07). Furthermore, the interventions were effective in improving fibre intake (g/d) (MD: 1·08; 95 % CI: 0·39, 1·77). Effective interventions use various strategies including tailored individual lifestyle coaching, health education, health promotion activities, community engagement activities and/or structural changes.

CONCLUSION

This review shows the potential of improving dietary patterns through community-based CVD preventive interventions. Thus, development and implementation of context-specific preventive interventions could help to minimise dietary risk factors, which in turn decrease morbidity and mortality due to CVD and other non-communicable diseases.

Effectiveness of a brief motivational intervention in the management of risky alcohol use in primary care: ALCO-AP20 study protocol

Background

Motivational interviewing (MI) could be a method for minimizing alcohol-related harm. The study aims to assess the effectiveness of a brief intervention, based on a MI, in patients with risky alcohol use attended in Primary Care (PC).

Materials and methods

A cluster-randomized, two-arm parallel, multicenter, open-label, controlled clinical trial. Fifty PC healthcare professionals from the province of Córdoba (Spain) will be randomized to one of the two study groups: (1) Experimental Group (EG): MI-based approach; (2) Control Group (CG): Usual care based on health advice. EG intervention: Professionals will receive a training program focused on MI, consisting of a training workshop and the use of pre- and post-workshop questionnaires to measure knowledge and skills acquired, as well as the degree of empathy, with a videotape of the health professionals with standardized patients, before and after the workshop, and subsequent training feedback. CG intervention: Workshop on the management of risky alcohol use based on health advice; participants will also complete the pre-and post-workshop questionnaires and be videotaped. Study population: Patients ≥ 14 years old with risky alcohol consumption (28 Standard Drink Units-SDU-/week in men and 17 SDU/week in women) or excessive alcohol use (≥ 6 SDU in men or ≥ 4 SDU in women, in less than 2 h). It would be necessary to include 110 subjects/group to find a difference of 20% between the percentage of patients in abstinence between EG (37%) and CG (20%), alpha error of 5%, and statistical power of 80%. Assuming a loss rate of 5% and the cluster design effect, the number of subjects to be recruited is estimated at 197/group. The follow-up period will be 12 months. The primary outcome variables will be the self-reported alcohol use level and the Alcohol Use Disorders Identification Test (AUDIT) questionnaire score.

Discussion

The study aims to demonstrate the effectiveness of the motivational approach in the comprehensive treatment of the patient with risky alcohol use, improving the empathy of the healthcare professionals and strengthening the healthcare professional-patient relationship to achieve the behavioral change of the patients with this problem in primary care consultations.

Clinical trial registration

ClinicalTrials.gov.

Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review

OBJECTIVE

Clinical inertia, the absence of treatment initiation or intensification for patients not achieving evidence-based therapeutic goals, is a primary contributor to poor clinical outcomes. Effectively combating clinical inertia requires coordinated action on the part of multiple representatives including patients, clinicians, health systems, and the pharmaceutical industry. Despite intervention attempts by these representatives, barriers to overcoming clinical inertia in cardiovascular disease (CVD) risk factor control remain.

METHODS

We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia.

RESULTS

Effective interventions included dynamic forms of patient and clinician education, monitoring of real-time patient data to facilitate shared decision-making, or a combination of these approaches. Based on findings, we describe three possible multi-level approaches to counter clinical inertia - a collaborative approach to clinician training, use of a population health manager, and use of electronic monitoring and reminder devices.

CONCLUSION

To reduce clinical inertia and achieve optimal CVD risk factor control, interventions should consider the role of multiple representatives, be feasible for implementation in healthcare systems, and be flexible for an individual patient's adherence needs.

PRACTICE IMPLICATIONS

Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.

The 'miracle cure': how do primary care physicians prescribe physical activity with the aim of improving clinical outcomes of chronic disease? A scoping review

Objectives

To identify how primary care physicians (PCPs) prescribe physical activity for patients with chronic disease, and to determine characteristics of physical activity interventions with improved clinical outcomes of chronic disease.

Design

A scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews 2018 was completed.

Data sources

Four bibliographic databases (Medline, EMBASE, SPORTDiscus, CINAHL) and four grey literature/unpublished databases (Proquest, National Institute for Health and Care Excellence, Canadian Health Research Collections, Clinical Trials) were searched from inception to 7 March 2022.

Eligibility criteria for selecting studies

Studies involving PCP-delivered physical activity prescriptions or counselling for participants with a chronic disease or mental health condition, which reported clinical outcomes were included. Opinion papers, news and magazine articles and case reports were excluded, as were studies in which a physical activity intervention was provided for primary prevention of chronic disease, prescribed by healthcare providers or researchers other than PCPs, or for healthy participants without chronic disease.

Results

An initial search identified 4992 records. Fifteen studies met inclusion criteria. Characteristics of physical activity prescriptions that improved clinical outcomes included: personalised advice; brief intervention; behavioural supports (handouts and/or referrals) and physician follow-up. Reported adverse events were rare. Research gaps include optimal timing and length of follow-up, and the long-term and cost-effectiveness of interventions.

Summary/Conclusion

Several characteristics of physical activity counselling by PCPs for patients with chronic disease may improve clinical outcomes, although research gaps remain. Studies exploring the effectiveness of physical activity prescription for individuals with chronic conditions are urgently needed.

Effectiveness of Motivational Interviewing in Managing Overweight and Obesity : A Systematic Review and Meta-analysis

BACKGROUND

Motivational interviewing (MI) is potentially useful in management of overweight and obesity, but staff training and increased delivery time are barriers, and its effectiveness independent of other behavioral components is unclear.

PURPOSE

To assess the independent contribution of MI as part of a behavioral weight management program (BWMP) in controlling weight and improving psychological well-being.

DATA SOURCES

6 electronic databases and 2 trial registries, searched from database inception through 24 September 2021.

STUDY SELECTION

Randomized controlled trials in adults or adolescents aimed at weight loss or maintenance and comparing programs incorporating MI versus interventions without MI.

DATA EXTRACTION

Two reviewers independently screened studies, extracted data, and assessed risk of bias. Outcomes included weight, anxiety, depression, quality of life, and other aspects of psychological well-being. Pooled mean differences or standardized mean differences were obtained using random- and fixed-effects meta-analyses.

DATA SYNTHESIS

Forty-six studies involving 11 077 participants, predominantly with obesity, were included. At 6 months, BWMPs using MI were more effective than no/minimal intervention (-0.88 [95% CI, -1.27 to -0.48] kg; I ² = 0%) but were not statistically significantly more effective than lower-intensity (-0.88 [CI, -2.39 to 0.62] kg; I ² = 55.8%) or similar-intensity (-1.36 [CI, -2.80 to 0.07] kg; I ² = 18.8%) BWMPs. At 1 year, data were too sparse to pool comparisons with no/minimal intervention, but MI did not produce statistically significantly greater weight change compared with lower-intensity (-1.16 [CI, -2.49 to 0.17] kg; I ² = 88.7%) or similar-intensity (-0.18 [CI, -2.40 to 2.04] kg; I ² = 72.7%) BWMPs without MI. Studies with 18-month follow-up were also sparse; MI did not produce statistically significant benefit in any of the comparator categories. There was no evidence of subgroup differences based on study, participant, or intervention characteristics. Too few studies assessed effects on psychological well-being to pool, but data did not suggest that MI was independently effective.

LIMITATIONS

High statistical heterogeneity among studies, largely unexplained by sensitivity and subgroup analyses; stratification by comparator intensity and follow-up duration resulted in pooling of few studies.

CONCLUSION

There is no evidence that MI increases effectiveness of BWMPs in controlling weight. Given the intensive training required for its delivery, MI may not be a worthwhile addition to BWMPs.

PRIMARY FUNDING SOURCE

National Institute for Health Research Biomedical Research Centre. (PROSPERO: CRD42020177259).

Effectiveness of Written Dietary Advice for Improving Blood Lipids in Primary Care Adults-A Pragmatic Randomized Controlled Trial (MYDICLIN)

Lifestyle management is the first line of treatment for moderately elevated blood lipids in healthy individuals. We investigated the effectiveness of providing food-based written advice for lowering low-density lipoprotein (LDL) cholesterol (intervention) or triglycerides (control) in a pragmatic randomized controlled trial with two parallel arms from 2018-2019 at a rural primary health care center. We sent feedback letters after 3 weeks and 6 months. Out of the 113 adult primary care patients randomized, 112 completed the study. There were no differences between the intervention and control groups for changes in LDL cholesterol after 3 weeks (mean ± standard deviation -0.21 ± 0.38 vs. -0.11 ± 0.34 mmol/L, p = 0.45) or 6 months (-0.05 ± 0.47 vs. 0.02 ± 0.41 mmol/L, p = 0.70) (primary outcome). Following the advice to consume plant sterols and turmeric was associated with a reduction in LDL cholesterol after 3 weeks. Following the advice to consume less carbohydrates was associated with reduced triglycerides. In the intervention arm, 14 individuals (25%) reduced their LDL cholesterol by ≥10% after three weeks. Their reduction was attenuated but maintained after six months (-7.1 ± 9.2% or -0.31 ± 0.38 mmol/L, p = 0.01 compared with baseline). They differed only in higher adherence to the advice regarding turmeric. In conclusion, this undemanding intervention had little effect on blood lipids for most individuals.

Effectiveness of community-based cardiovascular disease prevention interventions to improve physical activity: A systematic review and meta-regression

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality globally. Despite preventive community-based interventions (CBIs) seem efficacious in reducing CVD risks, a comprehensive up-to-date synthesis on the effectiveness of such interventions in improving physical activity (PA) is lacking. We performed a systematic review and meta-analysis of community-based CVD preventive interventions aimed at improving PA level. MEDLINE, EMBASE, CINAHL, Cochrane register and PSYCINFO databases were searched in October 2019 for studies reported between January 2000 and June 2019. We assessed the methodological quality of included studies using the Cochrane risk of bias tools. We performed a random-effects meta-analysis and meta-regression to pool estimates of various effect measures. Results are reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline. Our study protocol was registered in the PROSPERO database (CRD42019119885). A total of 44 randomized and 20 non-randomized controlled studies involving 98,919 participants were included. Meta-analyses found that CBIs improved the odds of attaining the recommended PA level (at least 150 min of moderate and vigorous PA (MVPA)/week) at 12 month (OR: 1.62; 95%CI: 1.25-2.11) and 18 to 24 months of follow-up (OR: 1.46; 95%CI: 1.12-1.91). Furthermore, interventions were effective in improving metabolic equivalents of task at 12 month (standardized mean difference (SMD): 0.28; 95% CI: 0.03-0.53), MVPA time at 12 to 18 months (SMD: 0.34; 95%CI: 0.05-0.64), steps per day (SMD: 0.32; 95%CI: 0.08-0.55), and sitting time (SMD: -0.25; 95%CI: -0.34 to -0.17). Subgroup analyses found that interventions in low- and middle-income countries showed a greater positive effect on attainment of recommended PA level (OR: 1.40; 95%CI: 1.02-1.92) than those in high-income countries (OR: 1.31; 95%CI: 0.96-1.78). Moreover, interventions targeting high-risk groups showed greater effectiveness than those targeting the general population (OR: 1.76; 95%CI: 1.30-2.39 vs. 1.17; 95%CI: 0.89-1.55). In conclusion, community-based CVD preventive interventions have a positive impact on improving the PA level, albeit that relevant studies in lower-middle and low-income countries are limited. With the rising burden of CVDs, rolling out CBIs targeting the general population and high-risk groups are needed to control the growing CVD-burden.

Promoting Successful Cognitive Aging: A Ten-Year Update

A decade has passed since we published a comprehensive review in this journal addressing the topic of promoting successful cognitive aging, making this a good time to take stock of the field. Because there have been limited large-scale, randomized controlled trials, especially following individuals from middle age to late life, some experts have questioned whether recommendations can be legitimately offered about reducing the risk of cognitive decline and dementia. Despite uncertainties, clinicians often need to at least make provisional recommendations to patients based on the highest quality data available. Converging lines of evidence from epidemiological/cohort studies, animal/basic science studies, human proof-of-concept studies, and human intervention studies can provide guidance, highlighting strategies for enhancing cognitive reserve and preventing loss of cognitive capacity. Many of the suggestions made in 2010 have been supported by additional research. Importantly, there is a growing consensus among major health organizations about recommendations to mitigate cognitive decline and promote healthy cognitive aging. Regular physical activity and treatment of cardiovascular risk factors have been supported by all of these organizations. Most organizations have also embraced cognitively stimulating activities, a heart-healthy diet, smoking cessation, and countering metabolic syndrome. Other behaviors like regular social engagement, limiting alcohol use, stress management, getting adequate sleep, avoiding anticholinergic medications, addressing sensory deficits, and protecting the brain against physical and toxic damage also have been endorsed, although less consistently. In this update, we review the evidence for each of these recommendations and offer practical advice about behavior-change techniques to help patients adopt brain-healthy behaviors.

Motivational interviewing to support modifiable risk factor change in individuals at increased risk of cardiovascular disease: A systematic review and meta-analysis

BACKGROUND

Programmes using motivational interviewing show potential in facilitating lifestyle change, however this has not been well established and explored in individuals at risk of, yet without symptomatic pre-existent cardiovascular disease. The objective of this systematic review and meta-analysis was to determine the effectiveness of motivational interviewing in supporting modifiable risk factor change in individuals at an increased risk of cardiovascular disease.

METHODS

Systematic review and meta-analysis with results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-related databases were searched for randomised controlled trials from 1980 to March 2020. Criteria for inclusion included; preventive programmes, motivational interviewing principles, modification of cardiovascular risk factors in adults of both genders, different ethnicities and employment status, and having at least 1 or more modifiable cardiovascular risk factor/s. Two reviewers independently extracted data and conducted a quality appraisal of eligible studies using an adapted Cochrane framework. The Cochrane framework supports to systematically identify, appraise and synthesize all the empirical evidence that meets the pre-specified eligibility criteria to answer a specific question.

FINDINGS

A total of 12 studies met the inclusion criteria. While completeness of intervention reporting was found to be adequate, the application of motivational interviewing was found to be insufficiently reported across all studies (mean overall reporting rate; 68%, 26% respectively). No statistical difference between groups in smoking status and physical activity was reported. A random effects analysis from 4 studies was conducted, this determined a synthesized estimate for standardised mean difference in weight of -2.00kg (95% CI -3.31 to -0.69 kg; p = 0.003), with high statistical heterogeneity. Pooled results from 4 studies determined a mean difference in LDL-c of -0.14mmol/l (5.414mg/dl), which was non-significant. The characteristics of interventions more likely to be effective were identified as: use of a blended approach delivered by a nurse expert in motivational interviewing from an outpatient-clinic. The application of affirmation, compassion and evocation, use of open questions, summarising, listening, supporting and raising ambivalence, combining education and barrier change identification with goal setting are also important intervention characteristics.

CONCLUSIONS

While motivational interviewing may support individuals to modify their cardiovascular risk through lifestyle change, the effectiveness of this approach remains uncertain. The strengths and limitations of motivational interviewing need to be further explored through robust studies.

Motivational support programme to enhance health and well-being and promote weight loss in overweight and obese adolescents: A randomized controlled trial in Turkey

AIM

The aim of this study is to investigate the effect on health, well-being and weight loss of a motivational support programme provided for adolescents who were overweight and obese.

METHODS

This was a randomized controlled trial. Sixty-four adolescents (39 girls and 25 boys) who were overweight and obese and consulted at our polyclinic from January 2015 to February 2016 comprised the study population. The sociodemographic characteristics, well-being levels and physical parameters of the adolescents were evaluated. Routine follow-ups were practiced for both groups. The adolescents in the experimental group had motivational interviews and were sent reminder messages over a 6-month period, and education programmes were conducted with the parents.

RESULTS

After 6 months, the body mass index values had decreased in the experimental group compared with baseline, with no decrease in the controls. Scores for the Paediatric Quality of Life total scale and physical health and psychosocial health subscale points were increased in experimental and control groups, but the quality of life scale points of the experimental group were higher than the control group. In the experimental group, aspartate aminotransferase, alanine aminotransferase, insulin, homeostasis model assessment of insulin resistance (HOMA-IR) and total cholesterol were decreased.

CONCLUSION

The motivational support programme affected the adolescents' health positively and can be recommended as a routine nursing intervention.

Impact of a primary care training program on the prevention and management of unhealthy alcohol use: A quasi-experimental study

OBJECTIVE

To assess the impact of a training program targeted to Primary Care (PC) professionalson the acquisition of communication skills, attitudes, and knowledge about the prevention and management of unhealthy alcohol use.

METHODS

A quasi-experimental, pre- and post-intervention study was performed in PC centers of Cordoba (Spain). Family doctors, residents and nurses participated in the study. The intervention was based on a motivational interviewing training program, which consisted in a workshop on learning skills, attitudes and knowledge about the alcohol management. PC providers were videotaped with a standardized patient in order to check the clinical and communication competencies acquired. A descriptive, bivariate and multivariate analysis was carried out (p < 0.05).

RESULTS

PC providers' communication skills and attitudes showed significant improvements in the variables studied (p < 0.001), as well as in the clinical interview evaluation parameters.

CONCLUSION

The present study reveals the impact of a training program targeted to PC professionals on communication skills, attitudes, and knowledge about the prevention and management of patients with unhealthy alcohol use.

PRACTICE IMPLICATIONS

Training activities targeted to PC providers represent a valuable strategy to improve communication skills, attitudes and knowledge of these professionals in their clinical practice.

The effectiveness of a proven chronic disease prevention and screening intervention in diverse and remote primary care settings: an implementation study on the BETTER 2 Program

Background

The Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) randomised control trial (RCT) showed that the BETTER Program improved chronic disease prevention and screening (CDPS) by 32.5% in urban team-based primary care clinics.

Aim

To evaluate outcomes from implementation of BETTER in diverse clinical settings.

Design & setting

An implementation study was undertaken to apply the CDPS intervention from the BETTER trial to diverse settings in BETTER 2. Patients aged 40–65 years were invited to enrol in the study from three clinics in Newfoundland and Labrador, Canada.

Method

At baseline, eligibility for 27 CDPS actions (for example, cancer, diabetes and hypertension screening, lifestyle) was determined. Patients then met with a trained provider and prioritised goals to address their eligible CDPS actions. Providers received training in behaviour change theory and practice. Descriptive analysis of clinical outcomes and success factors were reported.

Results

A total of 154 patients (119 female and 35 male) had a baseline visit; 106 had complete outcome assessments, and the remainder had partial outcome assessments. At baseline, patients were eligible for a mean of 12.3 CDPS actions and achieved a mean of 6.0 (49%, 95% confidence intervals [CI] = 24% to 74%) at 6-month follow-up, including reduced hypertension (86% of eligible patients, 95% CI = 67% to 96%), weight control (51% of eligible patients, 95% CI = 42% to 60%), and smoking cessation (36% of eligible patients, 95% CI = 17% to 59%). Male, highly educated, and lower income individuals achieved a higher proportion of CDPS manoeuvers than their counterparts.

Conclusion

Clinical outcomes from this implementation study were comparable with those of the prior BETTER RCT, providing support for the BETTER Program as an effective approach to CDPS in more diverse general practice settings.

Patient-Centered Care: Lifestyle Modifications Among Adult Participants With Dyslipidemia

BACKGROUND

Dyslipidemia, a risk factor for coronary heart disease (CHD), is a burden due to morbidity, mortality, and CHD-related costs. Patient-centered clinical interventions improve adherence to lifestyle modifications among adults with dyslipidemia.

OBJECTIVE

The study's objectives were to (a) promote participants' safety through increased knowledge on the risks and prevention of CHD, (b) help participants identify their own barriers to lifestyle modifications, and (c) develop strategies with participants on individualized plans to adhere to healthy living.

METHODS

Seventeen participants with dyslipidemia enrolled in a quality improvement over 6 weeks. Participants were from one employee health clinic in Mississippi. Measures are Heart Disease Fact Questionnaire (HDFQ), Framingham Tool, pre- and poststudy lipid panels, and physiologic measurements. Interventions include motivational technique-led interviews as a tool for behavioral change.

RESULTS

Pre- and post-HDFQ responses indicated an 18% increase in knowledge attainment because of the patient-centered care interventions. Postinterventions, mean plasma lipid panels were 29% lower, weight loss ranged from 0 to 10.1 pounds, and body mass indexes were 0.4 to 1.2 less. Blood pressures (BPs) preintervention ranged from 120/70 to 159/89. Postinterventions BP ranged from 107/82 to 146/70.

CONCLUSIONS

Patient-centered clinical interventions improve management of dyslipidemia through increased knowledge on risks and prevention of CHD and also through finding own barriers to healthy living.

IMPLICATIONS

Healthcare providers can make a difference in people's lives through exploring the unhealthy behaviors and discovering ways for better health outcomes.

Efficacy of a Combined Strategy to Improve Low-density Lipoprotein Cholesterol Control Among Patients With Hypercholesterolemia: A Randomized Clinical Trial

INTRODUCTION AND OBJECTIVES

Several interventions can improve low-density lipoprotein cholesterol (LDL-C) control. Our main objective was to evaluate the efficacy of a combined intervention to improve LDL-C control in patients with hypercholesterolemia. The study also assessed the efficacy of the intervention in improving adherence (pharmacological, diet, and exercise).

METHODS

A multicenter, parallel group, randomized clinical trial (primary care) was conducted in 358 adults diagnosed with hypercholesterolemia, whether receiving prior drug therapy or not. We compared 178 participants who received the combined intervention (written material, self-completed registration cards, and messages to mobile telephones) with 178 controls. The main outcome variable was the proportion of participants with adequate LDL-C control (target levels of the European guidelines on dyslipidemia and cardiovascular risk) at 24 months.

RESULTS

At 24 months, the mean reduction in LDL-C was significantly higher in the intervention group (23.8mg/dL [95%CI, 17.5-30.1]) than in the control group (14.6mg/dL [95%CI, 8.9-20.4]; P=.034). The mean LDL-C decrease was 13.1%±28.6%. At 1 year, the proportion of participants with adequate control was significantly higher in the intervention group than in the control group (43.7% vs 30.1%; P=.011; RR, 1.46). Adherence was significantly higher in the intervention group, both to drug therapy (77.2% vs 64.1%; P=.029) and exercise (64.9% vs 35.8; P<.001), but not to diet.

CONCLUSIONS

The combined intervention significantly reduced LDL-C (by more than 13% at 2 years) and improved the degree of LDL-C control in patients with hypercholesterolemia at 1 year.

[Map of resources and healthcare needs for patients with dyslipidaemia in Spain: The MADI study]

INTRODUCTION

Dyslipidaemia is a major modifiable determining factor of vascular risk and, despite this, a significant number of patients do not achieve lipid goals. The aim of this study is to describe the resources and current needs in clinical practice in Spain, through an analysis of management, organisation and the patient care circuit of dyslipidaemia patient.

METHODS

A descriptive, cross-sectional, multicentre study, using a questionnaire, was conducted on physicians, 266 in primary care (PC) and 258 in specialised care (SC), who attended patients with dyslipidaemia in hospitals and centres within the National Health System. Probabilistic analyses were performed, stratifying by care-level, existence of a lipid unit (LU), and geographic area.

RESULTS

Observed differences were mostly due to geographic location, rather than the existence of LU in the referral hospitals. Most system deficiencies were found in the southern provinces of the country. Nearly all primary care physicians declared that they diagnose, manage and control dyslipidaemia patients, but a general agreement was lacking for diagnostic and referral criteria. The scarce use of a shared protocol between PC and SC showed evidence of poor coordination between health care providers. Furthermore, there was a remarkably low proportion of patients receiving health care education for their disease.

CONCLUSIONS

This study emphasises the need to identify weaknesses in the dyslipidaemia patient care circuit, and to perform the appropriate remedial actions, in particular, to promote coordination between levels of care and to foster patient education about their disease.

Measuring the quality of motivational interviewing in primary health care encounters: The development and validation of the motivational interviewing assessment scale (MIAS)

BACKGROUND

Motivational interviewing (MI) is a collaborative, goal-oriented method to help patients change behaviour. Tools that are often used to measure MI are the motivational interviewing skills code' (MISC), the 'motivational interviewing treatment integrity' (MITI) and the 'behaviour change counselling index' (BECCI). The first two instruments have not been designed to be used in primary healthcare (PHC) settings. The BECCI actually is time-consuming. The motivational interviewing assessment scale (MIAS, 'EVEM' in Spanish) was developed to measure MI in PHC encounters as an alternative to the previous instruments.

OBJECTIVES

To validate MIAS as an instrument to assess the quality of MI in PHC settings.

METHODS

(a)

DEVELOPMENT

Sixteen experts in MI participated in the design, face and consensus validity, using a Delphi-type methodology. (b)

VALIDATION

SETTING

27 PHC centres located in Spain.

SUBJECTS

four experts in MI tested its psychometric properties with 332 video recordings coming from the Dislip-EM study (consultations provided by 37 practitioners).

MEASUREMENTS

dimensionality, internal consistency, reliability (intra-class correlation coefficient-ICC), sensitivity to change and convergent validity with the BECCI scale.

RESULTS

A 14-item scale was obtained after the validation process. Factor analysis: two factors explained 76.6% of the total variance. Internal consistency, α = 0.99. Reliability: intra-rater ICC = 0.96; inter-rater ICC = 0.97. Sensitivity to change: means before and after training were 23.63 versus 38.57 (P < 0.001). Spearman's coefficient between the MIAS and the BECCI scale was 0.98 (P < 0.001).

CONCLUSION

The MIAS is a consistent and reliable instrument to assess the use of MI in PHC settings. [Box: see text].