2022, Number S3
The mexican health-care system and high blood pressure
Full text
10.35366/105194
Language: English
References: 11
Page: s259-265
PDF size: 266.15 Kb.
ABSTRACT
High blood pressure (HBP) is the most prevalent risk factor in the Mexican population. The Mexican Social Security Institute (IMSS) has more than 69 million recorded affiliated populations. HBP is the second most important disease that financially impacts the IMSS. It has been estimated that the cost to treat HBP is 52,284 million Mexican pesos, which is only exceeded by diabetes and cancer. HBP represents a financial burden and reinforces the need to focus on promoting healthy lifestyles, prevention, timely detection, and treatment adherence. Some studies have shown costly-effective interventions, especially when standardization of treatment protocols, risk-based treatments, and task sharing with healthcare providers. The Comprehensive Care Protocol is one of the first strategies for health services in Mexico that includes evidence-based, multidisciplinary activities within all care settings, particularly the primary one for the treatment of HBP, which is discussed in length in this paper.INTRODUCTION
High blood pressure (HBP) is the most prevalent risk factor in the Mexican population. Approximately 1/3 of the Mexican population older than 20 years of age have this condition. Furthermore, its frequency is greater than 50% when a subject had an acute coronary syndrome. Cardiovascular diseases (CVD) have been the leading cause of death for 20 years. In 2020, according to information from the National Institute of Statistics and Geography (INEGI), there was estimated excess mortality of 43%, where more than 218,000 deaths were attributable to cardiovascular causes. This impressive burden represents 62 thousand more than in 2019, exceeding the deaths observed for COVID-19.1
It has been estimated that more than 1.04 billion people live with the disease. The highest prevalence of HBP is reported in low-to-middle-income countries.2 In Latin America, the prevalence of HBP is 44% (ranging between 17.7 to 52.5%), of which only 53.3% receive treatment and 37.6% had blood pressure goals (< 140/90 mmHg). Moreover, better arterial pressure control has been reported within urban populations compared to rural communities (39.6 vs 32.4%). Of all the patients living with the disease, only 36.4% use two or more antihypertensive drugs.3
The Mexican Social Security Institute (IMSS) has more than 69 million recorded affiliated populations. This represents 54% of the national population estimated by the National Council of Population for 2021, as the number of adults requiring health services has consistently increased (Figure 1). The IMSS has reported a population older than 20 years of 37,515,011, of which 7,749,578 have a previous medical diagnosis of HBP, which represents an estimated prevalence of 20.7%. 59.3% are women in this group, and 40.7% are men Table 1 .
HBP is the second most important disease that financially impacts the IMSS. It has been estimated that the cost to treat HBP is 52,284 million Mexican pesos, which is only exceeded by diabetes mellitus (96,823 million pesos) and cancer (19,951 million pesos). Therefore, it represents a financial burden and reinforces the need to focus on promoting healthy lifestyles, prevention, timely detection, and treatment adherence. Some studies have shown costly-effective interventions, especially when standardization of treatment protocols, risk-based treatments, and task sharing with healthcare providers.4,5
COMPREHENSIVE CARE PROTOCOL FOR SYSTEMIC HIGH BLOOD PRESSURE
The IMSS standardizes and systematizes care for all its patients living with HBP with the Comprehensive Care Protocol (PAI; abbreviation in Spanish). This protocol includes multidisciplinary activities that are integrated into all care levels. Particularly at primary care levels, it focuses on strengthening all healthcare workers' preventive strategies. Furthermore, there is the active participation of medical personnel, nursing, nutrition, social work, psychology, dentistry, and medical assistants, who specifically carry out promotion actions and identify risk factors for hypertensive-related complications in all people aged 20.
The Comprehensive Care Protocol for HBP highlights evidence-based activities related to adequate blood pressure measurement at clinical visits and home and ambulatory blood pressure monitors (ABPM). This strategy also seeks to replace dual or triple combination therapies using a single pill approach and promote non-pharmacological strategies. Additionally, the model seeks to empower every patient, focusing on improving self-control, self-care, promoting lifestyle changes, and closer interaction with healthcare providers.6 Furthermore, this method to treat HBP is also based on a matrix model in which healthcare experts from the three levels of care coordinate and participate for the benefit of patients. The level of demand of the activities was classified according to the scientific evidence as Essential (activities derived from clinical trials, meta-analyses, systematic reviews, and international and national guidelines), Optional (activities that can be chosen among several with the same effectiveness the resource is not available) and Evitable (activities that are not useful/effective and in some cases can be harmful) (Figure 2).
Risk stratification is highly relevant within the Comprehensive Care Protocol. This approach is based on risk estimations that emphasize target organ damage, the number of risk factors, the presence of established cardiovascular and renal disease, and prevalent diabetes mellitus. The risk stratification also considers the degree of HBP to implement dual or triple antihypertensive treatments (Table 2). The final objective of this approach is to implement diverse actions to promote healthy lifestyle habits, prioritize primary prevention, make a prompt diagnosis, and assure an adequate classification and stratification of cardiovascular risk.7-9
Finally, the Comprehensive Care Protocol for HBP attaches to the most relevant modifications proposed in the European and American HBP guidelines that prioritize dual antihypertensive therapies with Angiotensin-II Receptor Antagonists (ARA2) or Angiotensin Enzyme Inhibitors (ACEI) plus an antagonist of calcium (CaA). In particular cases, an optimal strategy would be using a triple therapy using ARA2/ACE inhibitors plus CaA plus first-line thiazide diuretic in patients without blood pressure goals (< 130/80 mmHg). It is essential to mention that monotherapy is always encouraged in mild HBP, low cardiovascular risk in older adults with faility or pregnant women (Figure 3).8,10,11
SUMMARY OF ESSENTIAL ACTIVITIES IN MEDICINE
- 1. Promotes and participates in health promotion.
- 2. Promotes primary prevention in patients at risk of HBP.
- 3. Appropriately measures blood pressure in all health-care units.
- 4. It adequately stratifies cardiovascular risk in patients with HBP into low, medium, and high risk to establish pharmacological and non-pharmacological treatment goals according to the stratification.
- 5. Detects and treats comorbidities associated with cardiovascular risk.
- 6. Intentionally looks for target organ damage.
- 7. Use combined first-line therapies (Use step 1, step 2, step 3 of this protocol) in all hypertensive patients of medium/high risk and reserve monotherapy for cases of mild SAH or very sensitive patients or frail patients.
- 8. Promotes the use of Home Blood Pressure Monitoring and the use of the logbook.
- 9. Provides appropriate follow-up of the patient with HBP to guarantee the achievement of goals in the short, medium and long term.
- 10. Indicates Ambulatory Blood Pressure Monitoring in cases of diagnostic doubt or difficult control.
- 11. Detects and sends to the corresponding level the cases of major hypertensive emergencies with repercussions on the target organ.
- 12. Detects possible cases of secondary HBP and sends to the corresponding level with all the basic studies including ABPM or MDPA.
- 13. Detect cases of true resistance and send to third level, which will proceed according to the case.
- 14. Receive training in HBP, at least once a year
- 15. Various
CONCLUSIONS
The Comprehensive Care Protocol is one of the first strategies for health services in Mexico that includes evidence-based, multidisciplinary activities within all care settings, particularly the primary one. Additionally, this approach gets the benefit that all three care levels are highly coordinated to give standardize, preventive, diagnostic, and therapeutic approaches. In the latter, emphasis is placed on dual and triple therapy as the first line according to cardiovascular risk with the use of "one-single" pill approach, allocating monotherapy to low-risk patients, frail, and pregnant women. Non-pharmacological strategies are a fundamental part of the Comprehensive Care Protocol, as these should be emphasized along with the patient contribution, self-care, and empowerment to prevent hypertensive-related complications.
REFERENCES
Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation 2019; 140: e596-646. Available in: https://doi.org/10.1161/CIR.0000000000000678
Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertens Dallas Tex 1979. 2018; 71: 1269-1324. Available in: https://doi.org/10.1161/HYP.0000000000000066
AFFILIATIONS
1 Former President of National Association of Cardiologists of Mexico (ANCAM), Member of GREHTA.
Author contributions: Each author contributed important intellectual content during manuscript drafting or revision and accepted accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
Funding: The authors received no specific funding for this work.
Conflict of interest/financial disclosure: The authors declare that they have no conflict of interests.
CORRESPONDENCE
Gabriela Borrayo-Sánchez, MD. E-mail: gborrayos@yahoo.com.mx