Effect of a quality improvement intervention for acute heart failure in South India: An interrupted time series study
Introduction
The burden of heart failure (HF) is increasing worldwide and has disproportionately shifted toward low- and middle-income countries due to population growth, aging, and a greater prevalence of major heart failure risk factors, including hypertension, diabetes, and ischemic heart disease [[1], [2], [3]]. The outcomes of HF patients in low- and middle-income countries remain poor, with inpatient mortality rates around 8% (95% CI: 6% to 10%), which are almost triple to some high-income country groups [[4], [5], [6]]. Almost 50% of participants died at 3 years in the vanguard HF registry in India, reaching mortality rates observed much later in high-income country settings [7,8]. Improvements in HF mortality in high-income countries over time have been attributed to increased adherence to guideline-directed medical and device therapy which is a key heart failure performance measure [9,10]. Despite high-quality evidence that guideline-directed medical therapy reduces morbidity and mortality of patients with heart failure with reduced ejection fraction (HFrEF), only 25% of patients were discharged on guideline-directed medical therapy in the Trivandrum Heart Failure Registry in Kerala, India revealing a potential target for intervention [5].
Improving the quality and safety of health systems, which are increasingly recognized as key strategies for improving clinical outcomes, is a global health priority [11,12]. Quality improvement initiatives have been developed in high-income countries to improve health system quality and subsequent clinical outcomes in patients with HF with limited effect, but none have been studied in low- or middle-income countries where there is a greater potential effect in the setting of lower baseline quality of care [4,13]. Most quality improvement research in India has been focused on acute coronary syndrome care, and HF remains understudied despite the potential to improve clinical outcomes and population health [14,15]. To fill this gap, we developed, implemented, and evaluated a locally-contextualized HF quality improvement toolkit-based intervention compared to usual care for patients with acute HF in 8 hospitals in Kerala, India using an interrupted time series study design [16].
Section snippets
Study design
The Heart Failure Quality Improvement in Kerala (HF QUIK) study was a quasi-experimental study evaluating the effect of a locally-contextualized quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized for acute HF in 8 hospitals in Kerala, India from February 2018 to August 2018. The study utilized an interrupted time series study design. The pre-intervention period was from February 5th 2018 to May 6th 2018, and the post-intervention period was
Results
We recruited 1469 participants from 8 hospitals in Kerala, India. The hospitals varied in type, including government, non-profit, and private hospitals (Online Table 1). Participants were excluded if there were duplicate data entries for the same participant (n = 13), had missing data (n = 2), or were admitted to the hospital after the final date of study enrollment (n = 54). The complete case analysis was performed on 1400 participants with 758 participants in the control period and 642
Discussion
Among 1400 participants admitted with acute HF in Kerala, a locally-contextualized quality improvement toolkit significantly increased the prescription of guideline-directed medical therapy with 70% higher odds at hospital discharge among participants in the intervention period compared to the control period. The intervention also increased the rates of discharge process of care measures including tobacco cessation counseling, alcohol cessation counseling, diet counseling, weight monitoring
Conclusion
This quasi-experimental study in Kerala demonstrated improvements in guideline-directed medical therapy at hospital discharge using a HF-specific quality improvement toolkit. Implementation of this intervention may improve HF care in other settings in India and other low- or middle-income countries [13]. Although significant gains in process of care measures were demonstrated in this study, further investigation is needed to continue to improve clinical outcomes for patients with HF.
Summary
Funding
AA received funding from the Fogarty International Center of the National Institutes of Health, Duke Global Health Institute and Duke Hubert-Yeargan Center for Global Health for this research. Research reported in this publication was supported by the Fogarty International Center and National Institute of Mental Health, of the National Institutes of Health under Award Number D43TW010543. The other funders listed (Boeringher Ingelheim, Novartis, BUPA, AstraZeneca, American Heart Association,
Disclosures
MDH received funding from the World Heart Federation to serve as its senior program advisor for the Emerging Leaders program, which is supported by Boehringer Ingelheim and Novartis with previous support from BUPA and AstraZeneca. MDH also receives support from the American Heart Association, Verily, and AstraZeneca and American Medical Association for work unrelated to this research.
Author agreement form
This statement is to certify that all authors have seen and approved the manuscript.
We attest that the article is the Authors' original work, has not received prior publication and is not under consideration for publication elsewhere. We adhere to the statement of ethical publishing as appears in the International of Cardiology (citable as: Shewan LG, Rosano GMC, Henein MY, Coats AJS. A statement on ethical standards in publishing scientific articles in the International Journal of Cardiology
Acknowledgements
We acknowledge Alex Irudayaraj for his assistance with program management and study coordinators at each study site for their contributions.
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