Effect of a Quality Improvement Intervention on Clinical Outcomes in Patients in India With Acute Myocardial Infarction: The ACS QUIK Randomized Clinical Trial

• Published in: JAMA : the journal of the American Medical Association 2018-02, Vol.319 (6), p.567-578
• Main Authors: Huffman, Mark D, Mohanan, Padinhare P, Devarajan, Raji, Baldridge, Abigail S, Kondal, Dimple, Zhao, Lihui, Ali, Mumtaj, Krishnan, Mangalath N, Natesan, Syam, Gopinath, Rajesh, Viswanathan, Sunitha, Stigi, Joseph, Joseph, Johny, Chozhakkat, Somanathan, Lloyd-Jones, Donald M, Prabhakaran, Dorairaj
• Format: Article
• Language: English
• Subjects: Aged; Bleeding; Cerebral infarction; Check lists; Clinical outcomes; Clinical trials; Clustering; Drugs; Female; Heart attacks; Hospitals; Humans; India; Intention to Treat Analysis; Intervention; Logistic Models; Male; Middle Aged; Myocardial infarction; Myocardial Infarction - complications; Myocardial Infarction - mortality; Myocardial Infarction - therapy; Original Investigation; Patients; Practice Guidelines as Topic; Quality; Quality control; Quality Improvement; Regression analysis; Regression models; Reperfusion; Research Design; Statistical analysis; Tobacco; Treatment Outcome
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2017.21906

IMPORTANCE: Wide heterogeneity exists in acute myocardial infarction treatment and outcomes in India. OBJECTIVE: To evaluate the effect of a locally adapted quality improvement tool kit on clinical outcomes and process measures in Kerala, a southern Indian state. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized, stepped-wedge clinical trial conducted between November 10, 2014, and November 9, 2016, in 63 hospitals in Kerala, India, with a last date of follow-up of December 31, 2016. During 5 predefined steps over the study period, hospitals were randomly selected to move in a 1-way crossover from the control group to the intervention group. Consecutively presenting patients with acute myocardial infarction were offered participation. INTERVENTIONS: Hospitals provided either usual care (control group; n = 10 066 participants [step 0: n = 2915; step 1: n = 2649; step 2: n = 2251; step 3: n = 1422; step 4; n = 829; step 5: n = 0]) or care using a quality improvement tool kit (intervention group; n = 11 308 participants [step 0: n = 0; step 1: n = 662; step 2: n = 1265; step 3: n = 2432; step 4: n = 3214; step 5: n = 3735]) that consisted of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training. MAIN OUTCOMES AND MEASURES: The primary outcome was the composite of all-cause death, reinfarction, stroke, or major bleeding using standardized definitions at 30 days. Secondary outcomes included the primary outcome’s individual components, 30-day cardiovascular death, medication use, and tobacco cessation counseling. Mixed-effects logistic regression models were used to account for clustering and temporal trends. RESULTS: Among 21 374 eligible randomized participants (mean age, 60.6 [SD, 12.0] years; n = 16 183 men [76%] ; n = 13 689 [64%] with ST-segment elevation myocardial infarction), 21 079 (99%) completed the trial. The primary composite outcome was observed in 5.3% of the intervention participants and 6.4% of the control participants. The observed difference in 30-day major adverse cardiovascular event rates between the groups was not statistically significant after adjustment (adjusted risk difference, −0.09% [95% CI, −1.32% to 1.14%]; adjusted odds ratio, 0.98 [95% CI, 0.80-1.21]). The intervention group had a higher rate of medication use including reperfusion but no effect on tobacco cessation counseling. There were no unexpected adverse events reported. CONCLUSIONS A