CHICAGO – A multifaceted quality initiative that consists of staff education, patient reminders and a feedback loop may help to improve therapy adherence and encourage lifestyle changes of at-risk cardiovascular patients in settings with limited resources, according to results of a clinical trial from Brazil presented at the American Heart Association scientific sessions 2018.
“In patients at high cardiovascular risk – in this case patients with established cardiovascular disease – a multifaceted quality-improvement intervention resulted in significant improvement in the use of evidence-based therapies,” said Otavio Berwanger, MD, PhD, of the Heart Hospital in Sao Paolo. He reported results of the BRIDGE Cardiovascular Prevention Cluster Randomized Trial. “The tools used in our trial can become the basis for developing quality-improvement programs to maximize the use of evidence-based therapies for the management of these high-risk patients with, especially in limited-resource settings.”
BRIDGE-CV included 1,619 patients from 40 care settings. Institutions that adopted the multifaceted intervention adhered to 73.5% of the evidence-based therapies (antiplatelet agents, statins and ACE inhibitors) while those in the control group adhered to 58.7% of the performance measures, Dr. Berwanger said. That represents a gain of 25%. The study employed an “all-or-none” model. That is, participating sites were required to adopt all components of the quality-improvement initiative or none.
Dr. Otavio Berwanger
He noted that although the evidence supporting the use of platelet therapies, statins, and ACE inhibitors is strong, “translation of these findings in practice is clearly suboptimal.” He added, “It seems to be an even larger problem in settings like mine in Brazil, so quality-improvement interventions, especially in lower-resource settings such as low- and middle-income countries, are definitely needed.”
The quality-improvement model the trial evaluated involved two levels of intervention. The first level comprised three steps: a case manager evaluating the patient’s treatment needs with the aid of a checklist; then an evaluation by the physician; and then providing physicians with what Dr. Berwanger described as “a physician support tool” – a one-page summary of major guideline recommendations. The second level comprised monthly audit and feedback reports to the providers and patient education about lifestyle modification. Staff education and training was also provided to sites that adopted the model. “Our intervention was sort of based on behavioral marketing,” Dr. Berwanger said.
The trial also identified a number of trends among secondary endpoints, although the populations were too small to reach statistical significance. For example, Dr. Berwanger noted that intervention sites had higher use of high-dose statins and more than double the rate of smoking cessation. He also noted a 24% relative risk reduction in major cardiovascular events in the intervention group vs. controls. Among the intervention sites, teaching institutions seems to have a notable improvement in adherence outcomes than other settings, Dr. Berwanger said, but the study did not fully analyze that trend.
“We see this study not as the final word but as the first step,” he said. “More studies are needed.”
Dr. Berwanger reported receiving research support and/or honoraria from Astra Zeneca, Amgen, Bayer, Eurofarma, Servier, Novartis and NovoNordisk. Amgen sponsored the investigator-initiated trial.
SOURCE: Berwanger O, et al. AHA 2018 Abstr.19360.