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Guía de Práctica Clínica

Hipertensión Arterial Primaria o Esencial en personas de 15 años y más.

T8 – Recomendación / Juicio del Panel y Evidencia

T8.- En personas mayores de 15 años con diagnóstico de hipertensión arterial, el Ministerio de Salud RECOMIENDA realizar el seguimiento con toma de presión arterial en domicilio por sobre seguimiento con toma de presión arterial en consulta.
Comentarios del Panel de Expertos:
►Las personas hipertensas y/o familiares deben ser capacitados para relizar la toma de presión arterial de forma correcta.

El Panel de Expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.

A continuación se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.

 1.- ¿El problema es una prioridad?
No Probablemente no Probablemente sí Varía No lo sé

El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.

 2.- ¿Qué tan significativos son los efectos deseables anticipados?
Trivial Pequeño Moderado Grande Varía No lo sé

Grandes: El equipo elaborador de la Guía estimó que los efectos deseables de “realizar el seguimiento con toma de presión arterial en domicilio” en comparación a “realizar seguimiento con toma de presión arterial en consulta” son grandes, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.

Evidencia de investigación

  seguimiento de personas mayores de 15 años con diagnóstico de hipertensión arterial, con toma de presión arterial en domicilio en comparación con toma de presión arterial en consulta

Población

Personas mayores de 15 años con diagnóstico de hipertensión arterial

Intervención

Seguimiento con toma de presión arterial en domicilio o Automedida de la Presión Arterial (AMPA)

Comparación

Seguimiento con toma de presión arterial en consulta

Desenlaces

Efecto relativo

(IC 95%)

Estudios/

pacientes

Efecto absoluto estimado*

Certeza de la evidencia

(GRADE)

Mensajes clave en términos sencillos

domicilio

consulta

Diferencia

(IC 95%)

Personas con presión arterial controlada (presión arterial bajo 140/90 o 130/80 en diabéticos)

RR: 1,34

(1,11 a 1,6)

11 ensayos/ 3.210 pacientes [14, 20, 22, 26, 32, 41, 46, 52, 53, 64, 76]

400 por 1000

536 por 1000

Diferencia: 136 pacientes más por 1000

(44 a 240 más)

⊕⊕⊕1,2

Moderada

Probablemente un mayor número de personas logra un control de la hipertensión cuando se realiza el seguimiento de la presión arterial en la consulta que cuando se realiza en el domicilio

RR: Riesgo relativo /IC 95%: Intervalo de confianza del 95%
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo CON seguimiento con toma de presión en domicilio está basado en el riesgo del grupo control en los estudios. El riesgo CON seguimiento con toma de presión en consulta (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
1 Se disminuyó en un nivel la certeza de la evidencia por riesgo de sesgo por razones variadas en los ensayos: algunos no era clara la secuencia de aleatorización ni el ocultamiento de ésta [14, 20, 22, 46, 64, 76].
Fecha de elaboración de la tabla: Julio, 2018

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Búsqueda y Síntesis de Evidencia

 3.- ¿Qué tan significativos son los efectos indeseables anticipados?
Grande Moderado Pequeño Trivial Varía No lo sé

Triviales: El equipo elaborador de la Guía estimó que los efectos indeseables de “realizar el seguimiento con toma de presión arterial en domicilio” en comparación a “realizar seguimiento con toma de presión arterial en consulta” son triviales o no relevantes, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.

Evidencia de investigación

No se reportaron efectos indeseables de la intervencion ni de la comparación.

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Búsqueda y Síntesis de Evidencia

 4.- ¿Cuál es la certeza general de la evidencia sobre efectos?
Muy baja Baja Moderada Alta Ningún estido incluído

Moderada: Existe confianza respecto del efecto de “realizar el seguimiento con toma de presión arterial en domicilio” en comparación a “realizar seguimiento con toma de presión arterial en consulta”.

Evidencia de investigación

Desenlaces

Importancia

Certainty of the evidence
(GRADE)

Pacientes con presión arterial controlada (presión arterial bajo 140/90 o 130/80 en diabéticos)

CRÍTICO

⨁⨁⨁
MODERADOa

a. Se disminuyó en un nivel la certeza de la evidencia por riesgo de sesgo por razones variadas en los ensayos: algunos no era clara la secuencia de aleatorización ni el ocultamiento de ésta [14, 20, 22, 46, 64, 76].

 5.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
Incertidumbre o variabilidad importantes Posiblemente hay incertidumbre o variabilidad importantes Probablemente no hay incertidumbre ni variabilidad importantes No hay variabilidad o incertidumbre importante

Probablemente no hay incertidumbre ni variabilidad importantes: En función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud, el equipo elaborador de la Guía consideró que probablemente no hay incertidumbre o ni variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de “realizar el seguimiento con toma de presión arterial en domicilio” y “realizar seguimiento con toma de presión arterial en consulta”. La mayoría de las personas escogerían el seguimienro de la toma de presión arterial en el domicilio.

Evidencia de investigación

No se encontraron estudios de valores y preferencias de pacientes o cuidadores que abordara específicamente la pregunta. Sí se identificaron estudios relacionados con opiniones de personas hipertensas con respecto a auto monitoreo de presión arterial en el hogar.
Un estudio cualitativo (1) realizado en 527 personas hipertensas de 24 consultas (edad 35-85 años), en tratamiento, con presiones deficientemente controladas, se asignaron al azar a autocontrol con autovaloración de medicación antihipertensiva más telemonitorización y a atención habitual. El objetivo fue explorar puntos de vista de ellos sobre autocontrol de presión arterial y “autogestión” de la terapia medicamentosa antihipertensiva. Los resultados demostraron que las personas confiaban en el autocontrol de presión arterial y consideraron que sus múltiples lecturas en el hogar eran más válidas que una sola lectura en consulta tomada por su médico. Aunque muchos hipertensos auto-dosificaron su medicamento cuando fue necesario, otros carecían de la confianza para aumentar la dosis del medicamento sin consultar con su médico.
Otro estudio realizado con el objetivo de explorar experiencias de autocontrol de presión arterial en 26 personas hipertensas que habían sufrido un accidente cerebrovascular, realizó entrevistas semi-estructuradas. Informó que la técnica fue bienvenida, aceptada y exitosa para las personas, incluso para aquellos con discapacidades. Concluye que el control de la presión arterial en el hogar puede conducir a un mejor control de ésta y que esta intervención simple y pragmática podría ser más ampliamente utilizada (2).

Referencia
1. Jones MI, Greenfield SM, Bray EP, Baral-Grant S, Hobbs FDR, Holder R, et al. Patients’ experiences of self-monitoring blood pressure and self-titration of medication: the TASMINH2 trial qualitative study. Br J Gen Pract. 2012; 62: e135–42.
2. Ovaisi S, Ibison J, Leontowitsch M, et al. A qualitative study of stroke patients’ perceptions of home blood pressure monitoring. Br J Gen Pract 2011; 61: e604-10.

Búsqueda y Síntesis de Evidencia

 6.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
Favorece la comparación Probablemente favorece la comparación No favorece la intervención ni la comparación Probablemente favorece la intervención Favorece la intervención Varía No lo sé

Favorece la intervención: Considerando que la intervención es “realizar el seguimiento con toma de presión arterial en domicilio” y la comparación es “realizar seguimiento con toma de presión arterial en consulta”, el equipo elaborador de la Guía opinó que el balance entre efectos deseables e indeseables claramente favorece “realizar el seguimiento con toma de presión arterial en domicilio”.

 7.- ¿Qué tan grandes son los recursos necesarios (costos)?
Costos extensos Costos moderados Costos y ahorros despreciables Ahorros moderados Ahorros extensos Varía No lo sé

Costos moderados: El equipo elaborador de la Guía consideró que los costos de “realizar el seguimiento con toma de presión arterial en domicilio” son moderados si se compara con los costos de “realizar seguimiento con toma de presión arterial en consulta”, en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.

Evidencia de investigación

Tabla. Precios referenciales *

Ítem

Toma de presión arterial en domicilio

Toma de presión arterial en consulta

Consulta o control por enfermera, matrona o nutricionista* 1

—–

$ 5.153x 2 consultas

Control de presión arterial con aparato digital de control de presión arterial**

—–

—–

Total

$ 29.9901

$ 10.3062

El porcentaje de cobertura del seguro de salud sobre el precio de la(s) prestación(es) sanitaria(s), dependerá del tipo de seguro de cada paciente.

Referencias
1. Rango de precio equipo: $29.990-$69.000 (Cotización en farmacias privadas). https://salcobrand.cl/products/toma-presion-brazalete; http://smarthealth.cl/site/productos/25
2. Precio obtenido de la base de datos del Estudio de Verificación de Costos 2015 MINSAL. El precio fue actualizado utilizando la UF al 1 de julio 2018.

Búsqueda y Síntesis de Evidencia

 8.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
Favorece la comparación Probablemente favorece la comparación No favorece la intervención ni la comparación Probablemente favorece la intervención Favorece la intervención Varía Ningún estudio incluido

Probablemente favorece la comparación: Considerando que la intervención es “realizar el seguimiento con toma de presión arterial en domicilio” y la comparación es “realizar seguimiento con toma de presión arterial en consulta”, el equipo elaborador de la Guía opinó que probablemente la alternativa más costo-efectiva es “realizar seguimiento con toma de presión arterial en consulta”.
El panel considera que la intervención probablemente es costoefectiva en términos de los ahorros a largo plazo en morbimortalidad.

Evidencia de investigación

No se realizó la búsqueda de estudios que abordaran la costo-efectividad de esta intervención ya que no es considerado un test diagnóstico de alto costo (Anual $2.418.399 y Mensual $201.533).*

Referencia
*Ministerio de Salud. Decreto 80: Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la Ley 20.850 [Internet]. Santiago; 2015 Nov.Evidencia de investigación

Búsqueda y Síntesis de Evidencia

 9.- ¿Cuál sería el impacto en equidad en salud?
Reducido Probablemente reducido Probablemente ningún impacto Probablemente aumentado Aumentado Varía No lo sé

Probablemente reducida: El equipo elaborador de la Guía consideró que la equidad en salud se probablemente se reduciría si se recomendase “realizar el seguimiento con toma de presión arterial en domicilio”, dado que identificó grupos o contextos que actualmente tiene barreras de acceso importantes, ya sea en términos económicos, geográficos u otros.

 10.- ¿La intervención es aceptable para las partes interesadas?
No Probablemente no Probablemente sí Varía No lo sé

Sí: El equipo elaborador de la Guía consideró que “realizar el seguimiento con toma de presión arterial en domicilio” SÍ es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos de centros de salud, pacientes, cuidadores, seguros de salud, otros).

 11.- ¿Es factible implementar la intervención?
No Probablemente no Probablemente sí Varía No lo sé

Probablemente sí: El equipo elaborador de la Guía consideró que “realizar el seguimiento con toma de presión arterial en domicilio” probablemente SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.
El panel considera que es necesario educar a las personas hipertensas en la toma estandarizada de la Presión Arterial.