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Electronic Health Record as a Source of Information to Assess Quality of Healthcare for Hypertensives: Mexico

Author(s): Svetlana Doubova1, Ricardo Pérez-Cuevas2, Magdalena Suárez1,  Dennis Ross-Degnan3, Anita Wagner3
Affiliation(s): 1Epidemiology and Health Services Research Unit, Mexican Institute of Social Security, Mexico, 2Ministry of Health, Mexico, 3Harvard University, United States
1st country of focus: Mexico
Relevant to the conference theme: Health information and technologies
Summary (max 100 words): The objectives of this study were a) development of quality of care indicators (QCI) for hypertensives in Mexico; b) to determine the feasibility of constructing QCI using electronic health record data; and c) to evaluate the quality of care (QC) provided to hypertensives.   Methods: The study had a mixed method approach which included 48,048 hypertensives.  Results: 14 QCI emerged by using the available EHR (Electronic Health Record) data. The study demonstrated that it is feasible to evaluate QC for hypertensives using the EHR data yet substandard quality in processes and clinical outcomes was observed.
Background (max 200 words): In low and middle-income countries (LMIC) the growing prevalence of hypertension and premature mortality from its complications is a public health problem. Blood pressure control in hypertensives reduces mortality and morbidity, however, more than half of them are untreated and only 23% -46% achieved recommended blood pressure levels. It has been reported that the higher QC for patients with hypertension is associated with better control of their blood pressure, highlighting the importance of measuring QC, in order to identify failures and implement improvement strategies. One of the tools to improve QC is the use of EHR; which is 'a longitudinal collection of information about patient’s general characteristics, medical history, healthcare received and health outcomes. The use of EHR can improve the QC through its continuous monitoring, increased adherence to clinical guidelines, decreased medication errors, and other strategies.  In order to facilitate and improve the QC, the EHR is widely deployed in developed countries but in LMIC the experiences are limited. Only a few LMIC countries like Argentina, Costa Rica and Peru introduced EHR for research in small-scale settings. Mexico introduced the EHR at institutional level in the Mexican Institute of Social Security (IMSS). The IMSS is responsible for the care of 47% of the Mexican population and has a network of 1,516 family medicine clinics (FMC). In the IMSS, hypertension and other cardiovascular diseases are among top causes of ambulatory and hospital care. Nevertheless little is know about the QC that patients with hypertension receive. Currently the EHR information is not available on a routine basis to measure QC for this population.
Objectives (max 100 words): The objectives of this study were a) development of QCI in the Mexican Institute of Social Security (IMSS) health system; b) to determine the feasibility of constructing QCI using the IMSS EHR data; and c) to evaluate the QC provided to IMSS patients with hypertension.
Methodology (max 400 words): Methods: The study had a mixed method approach consisting of: 1) Development of QCI for hypertensive patients using the RAND-UCLA method; 2) Extraction of routine EHR data and construction of predefined QCI; 3) Evaluation of quality of care for hypertensive patients who received healthcare at Family medicine clinics in 2009. Setting: 4 FMCs in Mexico City. Study Population: 48,048 patients with hypertension who received care in 2009.
Results (max 400 words): Results: We developed 20 QCI, of which 14 were possible to construct using available EHR data. QCI comprised both process of care and health outcomes. Among 48,048 patients with hypertension, 64% were women, 66.7% were ≥60 years of age; 70% were overweight or obese (BMI ≥25.0 kg/m2); 30.9% had diabetes and 7.4% arteriosclerotic diseases. 51% of patients were prescribed one antihypertensive drug, 19.2% two, 4.3% received 3 or more antihypertensive drugs and 25.5% had no antihypertensive drugs prescriptions. The most frequently prescribed drugs were inhibitors of angiotensin converting enzyme (50%). The indicators of QC showed that during 2009, only in 15% of patients with newly diagnosed hypertension (in 2009) the diagnosis was based on the records of at least three blood pressure (BP) measurements with systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg. Just 10% of them were ordered urinalysis, serum creatinine, fasting plasma glucose and total cholesterol. Regarding timely detection of complications: 39.8% of subsequent hypertensive patients without diabetes had fasting plasma glucose measurement at least once in the last 12 months; 37.8% of them had serum creatinine test; 43.2 had total cholesterol measurement and 10.0% were referred to the ophthalmologist. Regarding non-pharmacological and pharmacological treatment only 3.3% of obese hypertensive patients received nutritional counseling; 53% of patients with total cholesterol >= 240mg/dl or total cholesterol 200-239mg/dl and one or more of the following CV risk factors: smoking, diabetes or established atherosclerotic diseases were prescribed statins. 61.3% of patients with systolic BP ≥ 140 mmHg or diastolic ≥ 90 mmHg in the last 3 consultations and with 3 antihypertensive drugs were referred to the second level of care. Regarding health outcomes: 62.8% of hypertensive patients without diagnosis of diabetes and / or chronic kidney disease had blood pressure below 140/90 mmHg in the last 3 measurements; nevertheless 7.4% of  hypertensive patients with type 2 diabetes or chronic kidney disease had blood pressure below 130/80 mmHg in the last 3 measurements. Furthermore, 1.5% of patients had a cardiovascular event (myocardial infarction, cerebral vascular event, arterial thrombosis) in the last year.
Conclusion (max 400 words): The study demonstrated that it is feasible to evaluate QC for hypertensive patients using the IMSS EMR data. The results highlight the need to improve processes and clinical outcomes of guideline-based care for hypertensive patients in Mexico.

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