Introduction

Systemic Arterial Hypertension (SAH) is defined as a chronic degenerative disease characterized by increased Blood pressure (BP) above 140/90 mmHg is known as a silent disease, since it does not always have a clinical presentation and its identification is late, which can cause damage to the target organ without being diagnosed in a timely manner; It is the main risk factor for cardiovascular diseases, which has a greater impact on their morbidity and mortality. [1,2]

According to the World Health Organization (WHO) and the Pan American Health Organization (PAHO), there are 1.28 billion adults between the ages of 30 and 79 with SAH equivalent to 30% of the population, most of them living in low- and middle-income countries. 46% of adults are unaware that they have hypertension and only one in five who are under treatment (21%) are under control. [3,4]

According to Mexico’s National Health and Nutrition Survey 2022 (ENSANUT 2022), the prevalence of SAH in adults over 20 years of age was 26.4% (27.7% in women and 31.3% in men), increasing in line with the age of the population [5] Likewise, it mentions that the prevalence of adults over 20 years of age with controlled BP (blood pressure) (<130/80mmHg) was 33.7%, and the female sex with greater control was 37.9% 95% CI (22.6-34.0) [6]. The diagnosis of SAH is clinical, with several separate BP measurements in the office or by home monitoring, ambulatory BP monitoring (ABPM) to improve the subject’s conditions, at different times with a number >140/90 mmHg [7–10].

The Mexican Institute of Social Security (IMSS) is the largest social security agency in Latin America, for the year 2023 it had more than 500 thousand workers, seven National Medical Centers (CMN), 25 High Specialty Medical Units (UMAE), 251 hospitals, 1526 Family Medicine Units (UMF), 123 Social Security Centers, five Centers and 41 Medical Research Units,  Biomedical, Epidemiology and Health Services; 12 sports units, 38 theatres, 60 shops, 18 wakes, 1323 nurseries and 4 resorts [11].

Based on the Comprehensive Care Protocols (PAI), a subject is considered to be under hypertensive control when he or she has BP <130/80 mmHg and no less than 110/70 mmHg in the medium and long term. In patients with type 2 diabetes (T2D) or kidney damage no greater than 30 ml/min/1.73m2, the target should also be <130/80mmHg. Finally, in senile patients with carotid atherosclerosis, the goal is <150/90 mmHg [1,8]. Modification of the lifestyle of subjects with SAH is the main management, the three main ones being the DASH diet, decreasing salt intake to <5 g/day (2g of sodium) and losing weight [12,13].

As of 2014, the UNIFILA initiative was created in the IMSS with the aim of reducing the waiting time, without distinction of sex, age, acute or chronic pathology, workers, minors in daycare centers, thus contributing to improving the quality of medical care and chronic non-communicable diseases, such as SAH. It is described for patients without an appointment, transferring patients to a different clinic where an appointment was cancelled, to improve their satisfaction, so that they receive medical care in the first available office, thus reducing the waiting time, which previously had an average of more than one hour. Its general implementation began in 2016 [14].

In the FMUs at the IMSS, the time allocated for first-level outpatient consultation is modified by multiple factors. Among others, due to the transfer of the patient to an assigned office of the UNIFILA initiative, to personal factors of the patients, such as: personality, education, age, sex, mental state and communication. The personality and work style of the primary care physician, such as: mood, motivation, communication skills, clinical interviewing, paternalism, and problem-solving skills [15].

This can alter therapeutic adherence, hypertensive control, and in general, Agreed recommendations from a healthcare provider. [16–18]. It has been documented that follow-up with the same family doctor (secondment office) to provide continuity and establish a better communication and doctor-patient relationship, so that the patient is in a comfortable, receptive and comfortable environment, where he or she has greater confidence to express his or her doubts, concerns and insecurities, can be reflected in better hypertensive control. Likewise, the continuity and longitudinality of medical care can allow the first-level physician to detect the external factors that influence poor therapeutic adherence and hypertensive lack of control and implement solution strategies [19].

The present work aims to respond to the association of hypertensive control and medical care in UNIFILA clinics in a firstlevel unit at the IMSS. The above association is not yet documented in the scientific literature, so it is essential to demonstrate it as a risk or protective factor for the control of chronic non-communicable diseases, such as SAH.

Materials and Methods Type of study and objective

An observational, cross-sectional and analytical study was conducted. During the period from November 2022 to November 2023. The primary objective was to associate hypertensive control in subjects with SAH with follow-up in secondment clinics compared to UNIFILA clinics.

Subject

A sample size was calculated using the statistical calculator EPIINFO v. 7.2 [20]. An alpha of 0.05% and a 1-B of 20% were used, with an uncontrolled prevalence of SAH with follow-up in the referral clinic of 40% and a prevalence of uncontrolled SAH without follow-up in the referral clinic of 60%. It was considered a 1:1 exposed/unexposed ratio. An n=200 was obtained. The type of sampling used was non-probabilistic, for consecutive cases in the Family Medicine Unit No. 64 “Tequexquinahuac”.

Subjects aged 20 to 60 years with a diagnosis of SAH with a period of more than 6 months of diagnosis were included, likewise, subjects with comorbidities such as T2D and Chronic Kidney Disease (CKD) with glomerular filtration rate greater than 30ml/min/1.73m2 were admitted to the study. Subjects with pharmacological therapy for single, dual, or triple SAH were admitted. Subjects with secondary hypertension, attributed to pregnancy, hyperthyroidism, and subjects with emotional disorders were excluded.

Ethical Issues and Informed Consent

Subjects were informed about the details of the study, the main objective, and the questionnaire used. Those who agreed to participate were granted an informed consent and privacy notice for the use of the information provided by them. The procedures carried out in this research were authorized with registration number R-2022-1408-039, approved by the Local Research Committee 1408 and the Local Research Ethics Committee 14088 of the IMSS.

Measurement

Blood pressure

The blood pressure figure was obtained from the electronic medical record in previously diagnosed subjects, taking the blood pressure values from the last consultation. The outcome variable, hypertensive control, was defined as a blood pressure figure <130/80 mmHg [1,6].

Data Sheet and Therapeutic Adherence

A questionnaire was carried out in which sociodemographic and clinical variables of the subjects were identified, likewise, the 8-item Morisky Green Levine Test was applied, with Cronbach’s coefficient of alpha (alpha = 0.80), sensitivity 86% and specificity 56% [17,21,22]. The therapeutic adherence variable was dichotomized into adherent and non-adherent according to the score obtained, less than 8 points non-adherent and adherent 8 points [23,24].

Statistics

Frequencies and percentages were obtained using the SPSS version 27 in a descriptive analysis phase, for the qualitative variables (sex, hypertensive control, medical care office, comorbidities and therapeutic adherence). For the quantitative variables (age, systolic blood pressure and diastolic blood pressure) their type of distribution was determined using form criteria such as asymmetry (-0.05 to 0.05), kurtosis (-0.02-0.02) and statistical criteria using the Kolmogorov-Smirnov test, considering p > 0.05 as a non-Gaussian distribution, median and interquartile ranges (IQR) were used 25.75. As well as mean and standard deviation (SD) in the case of Gaussian distribution.

In the bivariate phase, Pearson’s Chi-square (value expected by chance >5) was used for the association of dichotomous variables (second-guess clinic and UNIFILA clinic) with hypertensive control and lack of control and was considered statistically significant with a p < 0.05. RMP and 95% CI were calculated.

A multivariate model was constructed, which considered possible confounding factors that had an impact on hypertensive lack of control (UNIFILA clinic, male sex and comorbidities), through an RLM, taking into consideration clinical relevance, statistical significance and/or risk tendency. Considering the variables previously analyzed in the unadjusted model. Crude and adjusted RMPs were obtained with a 95% CI and p-value. The results were represented by a Forest Plot using GraphPad Software, LLC, 2365 Northsi-de Dr., Suite 560, San Diego, CA 92108, USA.

Results

Of the 200 subjects studied with a diagnosis of systemic arterial hypertension, 73.1% were female. The median age was 53 years (46, 58). Regarding schooling, basic education predominated with 66.6% and subjects with a partner in 81.7%. Subjects with some comorbidity were 45.3%. 49.3% of those who attend follow-up at the UNIFILA initiative clinic; 55.7% had lack of control and 46.8% had low adherence (Table 1).

Table 1. Characteristics of subjects with SAH who are treated in a first-level unit.

The baseline characteristics of the subjects were contrasted with the follow-up in the UNIFILA clinic and the secondment clinic. Regarding sex, a predominance of men was found, with 52.8% attending the UNIFILA clinic. The median age of the subjects attending the UNIFILA clinic for follow-up was 54 years (IQR) (26.65). 30.5% of the subjects are married and attend the clinic. Primary schooling was found in 19.5% of the subjects who attended the clinic. Comorbidity was present in 28.5% of the subjects who were followed up at UNIFILA. In 24% of the subjects who attended the UNIFILA clinic, the treatment was single, with 20% of the subjects with dual treatment both in the UNIFILA clinic and in the secondment clinic. Low adherence of 30.5% was found in subjects who attended UNIFILA.  (Table 2)

Table 2: Characteristics of Subjects with SAH According to Follow-Up Clinics The baseline characteristics of the study subjects were contrasted with the outcome (hypertensive lack of control). The median age of subjects with uncontrolled SAH was 53 years (46,58). Regarding sex, it was found that 42.5% of the female subjects had hypertensive lack of control. When the age variable is dichotomized, 48.5% of the population is in the range of 41-60 years. Poor adherence was found in 55% with hypertensive lack of control (Table 3).

Table 3. Characteristics of subjects with SAH according to hypertensive control.

A total of 38% of subjects with hypertensive lack of control presented 38% of patients attending the UNIFILA clinic, with an odds ratio (OR) of 5.9 (3.12-11.08) and a p <0.05 (Table 4).

Table 4: Follow-up in the UNIFILA clinic and hypertensive control in subjects with SAH.

Multivariate Results

Multivariate analysis was performed using multiple logistic regression adjusted for hypertensive decontrol, finding an OR and 95% CI of 1.51 (0.75-3.06); for the presence of comorbidities in subjects with SAH, an OR and 95% CI of 1.36 (0.71-2.55) was obtained, and a 95% OR and 95% CI of 6.32 (3.36-11.9) were obtained for the presence of comorbidities in subjects with SAH. (Table 5) (Figure 1)

Table 5: Multivariate analysis. Risk Factors for Hypertensive Dyscontrol in Subjects with Systemic Arterial Hypertension of FMU 64.