Quality Initiative Leads to More Evidence-Based ACS Care: BRIDGE ACS

Reed Miller

March 25, 2012

March 25, 2012 (Chicago, Illinois) — A program to improve the quality of acute coronary syndrome (A CS) care in Brazil has increased adherence to evidence-based practices, results of the Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes (BRIDGE-ACS) study show [1].

Today at the American College of Cardiology (ACC) 2012 Scientific Sessions, Dr Otavio Berwanger (Hospital do Coração, São Paolo, Brazil) presented results of the BRIDGE-ACS trial, which evaluated a multifaceted quality-improvement (QI) program intended to increase use of evidence-based therapies and reduce the incidence of major cardiovascular events among patients with ACS. The study results are simultaneously published online in the Journal of the American Medical Association.

Study cochair Dr Renato Lopes (Brazilian Clinical Research Institute, São Paolo, and Duke Clinical Research Institute, Durham, NC) told heartwire that "the types of tools and education that we provide are things that we should be doing anyway. Maybe we're not doing [them] or not doing those things as efficiently as we should be, but this trial showed that this type of intervention has an impact."

The QI program included distribution of printed educational materials explaining recommendations for clinical care, employment of a trained case manager responsible for ensuring that all the recommended interventions were used appropriately, reminder systems, and practical training. The primary end point was the percentage of eligible patients who received aspirin, clopidogrel, anticoagulants, and statins during the first 24 hours of treatment.

Among the 80.3% of patients eligible for all of the studied interventions, 67.9% of the patients in hospitals randomized to follow the QI program got all of the recommended acute interventions, compared with only 49.5% for patients treated at hospitals randomized to not participate in the QI program (p=0.01). Patients at the QI-participating hospitals were also significantly likely to receive all eligible acute and discharge medications, 50.9% vs 31.9% (p=0.03). The overall composite adherence scores were also significantly higher in the QI-participant hospitals than the control group (89% vs 81.4%; mean difference 8.6, p=0.01).

BRIDGE-ACS randomized 34 public hospitals in Brazil with a total of 1150 ACS patients treated in late 2011. About 80% of the centers were teaching hospitals in major urban areas, and 41% had 24-hour PCI capabilities. About 36% of the patients had non-ST-segment elevation MI, and 40% presented with STEMI. Almost 24% presented with unstable angina.

Berwanger and colleagues point out that this is the first randomized trial testing a QI intervention for ACS treatments in a "middle-income" country, which is important because more than 80% of the global burden of cardiovascular diseases is in low- or middle-income nations. The "background adherence rate" of about 40% is lower than what has been reported for most of Europe and North America but consistent with that of other middle- or low-income countries as well as that of the lowest quartile of North American hospitals, according to the authors.

The study focused on improving the quality of care in Brazil's public hospitals rather than cardiology institutes and private hospitals because, as in many low- and middle-income countries, public hospitals admit the majority of Brazilian patients but often struggle to implement the best evidence-based care, due to overcrowding, heavier individual clinical workloads, and fewer continuing-education personnel. The BRIDGE-ACS results show that QI initiatives are nevertheless feasible and effective in these challenging settings. Importantly, all of the components of the QI program tested in BRIDGE-ACS were simple and did not rely on expensive information technology or on complex human interventions, the authors note.

"If patient care can be improved when adoption rates are more in the 'middle range,' then our results are relevant to rest of world and to the United States for diseases other than ACS, for which evidence-based-medicine uptake is much less common," Berwanger et al explain.

Active Interventions Make the Difference

Berwanger told heartwire that the most effective components of the QI initiative were the "active interventions, which are the ones for which the power button is always on and never on standby. When the physician is about to make a decision, the intervention reminds them of what to do, because the reasons for this gap between what guidelines recommend and what physicians are doing in practice are complex."

For example, at the hospitals participating in the QI initiative, the triage nurse put a yellow sticker on the chart of chest-pain patients to remind the treating physician to review the checklist of recommended steps for treating these patients. Upon arrival, each patient also received a yellow, green, or red wristband indicating their risk or likelihood of suffering an ST-elevation MI.

"The ERs are often overcrowded, so even if you identify quickly and correctly a patient with ACS and you start using the checklist and give them the therapies you're supposed to, it's still easy to forget, or delays will happen due to overcrowding, so we wanted a simple way to identify the patients," Berwanger explained.

Probably the most important component of the QI program was the nurse or nurses tasked as ACS case coordinators at each center. Lopes explained that the case coordinators were critical "because [they] were making sure that whatever decision was being approved based on evidence-based medicine at the beginning [of the patient's care] would carry on through the whole hospitalization until the discharge."

Going Global

Although the in-hospital cardiovascular-event rates were 5.5% in the QI-participating group vs 7.0% in the control group, the study was not large enough to show a statistically significant difference in patient outcomes. Mortality rates at 30 days were 7% in patients at hospitals in the QI group and 8.4% in patients at control-group hospitals. As expected, the rate of bleeding events was slightly higher in the QI group, because more patients were on anticoagulant therapy, but the difference was not signicant.

Lopes and Berwanger are currently talking with the Brazilian Ministry of Health about possible funding for a larger trial of this QI program that would be large enough to show improvements in patient outcomes.

But they believe QI programs like the one demonstrated in BRIDGE-ACS could be effective beyond Brazil. "This collaboration and these results set up the perfect stage for a multinational effort, where each country could leverage these results for their country with their sources of funding and then come together in a multinational randomized study," Lopes said. He envisions a study that would examine the impact of the ACS QI program on patient outcomes and also measure the program's cost-effectiveness.

The study was funded by the Brazilian Ministry of Health in partnership with Hospital do Coração–Programa Hospitals de Excelência a Serviço do SUS. The authors report that they have no conflicts of interest.

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