CHICAGO – A very active, low-technology quality improvement program can improve the uptake of evidence-based therapies for acute coronary syndrome in public hospitals, results of the BRIDGE-ACS study show.
Patients at hospitals randomized to the multiphase program were twice as likely to receive all evidence-based therapies including aspirin, clopidogrel (Plavix), anticoagulants, and statins within the first 24 hours.
Although BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) was not powered to evaluate clinical outcomes, all trended in the right direction, co-principal investigator Dr. Otávio Berwanger said at the annual meeting of the American College of Cardiology.
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Dr. Otávio Berwanger
"Because it is simple and feasible, the tools tested in the BRIDGE-ACS trial can become the basis for developing quality-improvement programs to maximize the use of evidence-based interventions for the management of acute coronary syndromes," he said.
Registries in several countries have shown consistently that the translation of research findings into practice is suboptimal. These care gaps are an even bigger problem in low- and middle-income countries, where up to 80% of the global burden of cardiovascular disease resides, observed Dr. Berwanger of the Hospital do Coração, São Paulo, Brazil.
BRIDGE-ACS randomized 34 public general hospitals from major urban areas in Brazil to routine practice or the intervention. A total of 1,150 consecutive ACS patients were treated during March-November 2011. Their mean age was 62 years, and about 40% presented with ST-segment elevation myocardial infarction (STEMI), 36% presented with non-STEMI, and 24% had unstable angina.
For the intervention, triage nurses identified ACS patients by placing a yellow "chest pain" sticker on their chart, and evaluating physicians were given a checklist consistent with national guidelines. The charts were coded green, yellow, and red to denote a scale from no chest pain to severe pain, and patients were given colored bracelets that matched the risk category to serve as simple reminders throughout their hospital stay, Dr. Berwanger explained.
The most important element of the intervention program was the use of specially trained nurse–case managers to ensure that all components of the intervention were being used and who followed the patients from the emergency room until discharge, he said.
Less-active components of the program included providing educational materials such as pocket guidelines, posters, and websites that contained evidence-based recommendations for the management of patients with ACS.
"As you see, it’s complex, but it doesn’t rely on complex and expensive technology," Dr. Berwanger remarked.
Among the 80% of patients without contraindications, adherence to all evidence-based therapies in the first 24 hours was 67.9% at the intervention hospitals and 49.5% at the control hospitals, a significant difference. The results remained significant when the analysis excluded statins (78% vs. 58%), which are not critical in the first 24 hours, he said.
Eligible patients were also significantly more likely at the intervention hospitals to receive all acute and discharge medications (51% vs. 32%), even after excluding statins.
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Dr. Erik Magnus Ohman
"One of the key findings of your study is not the 24-hour results, but that more patients at discharge are actually on the right therapy," said discussant Dr. Erik Magnus Ohman of Duke University, Durham, N.C. "It tells us that if you get it right from the beginning, the patients are going to stay on the right track. It’s very important."
The mean Composite Adherence Score was significantly higher at the intervention hospitals, at 89%, than at the control hospital, at 81.4%.
A subgroup analysis showed that the intervention had a larger effect in hospitals with percutaneous coronary intervention capabilities (odds ratio, 7.97) and in patients with a final diagnosis of non-STEMI (OR, 3.47), Dr. Berwanger said.
Session co-moderator Dr. Robert Harrington, director of Duke Clinical Research Institute, asked which component of the intervention really made the difference and whether a case manager who follows ACS patients throughout the hospital is sustainable.
Dr. Berwanger replied that the dedicated nurse–case manager is the key. He acknowledges that this is challenging and costly to sustain because he or she should be exempt from performing other duties, but says hospital managers and chief operating officers may become convinced and hire such staff if they start seeing the difference in quality.
At 30 days, there was a nonsignificant trend favoring the intervention hospitals over controls for major cardiovascular adverse events (5.5% vs. 7%), cardiovascular mortality (6.6% vs. 7.1%), and total mortality (7.0% vs. 8.4%).
Rates of in-hospital major bleeding events higher in the intervention group, driven largely by higher use of anticoagulants and statins, but was not significant (1.2% vs. 0.2%), Dr. Berwanger reported.