A Nationwide Initiative to Improve Cardiology Quality: The Best Practice in Cardiology Program in Brazil

Taniguchi, Fabio Papa; Bernardez-Pereira, Sabrina; Ribeiro, Antônio Luiz Pinho; Morgan, Louise; Curtis, Anne B.; Taubert, Kathryn; Albuquerque, Denilson Campos de; Smith Jr, Sidney C; Paola, Angêlo Amato Vincenzo de

Acessibilidade / Reportar erro

Brasil

Arquivos Brasileiros de Cardiologia

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Original Article • Arq. Bras. Cardiol. 120 (10) • Nov 2023 • https://doi.org/10.36660/abc.20230375 copy

A Nationwide Initiative to Improve Cardiology Quality: The Best Practice in Cardiology Program in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Central Illustration

: A Nationwide Initiative to Improve Cardiology Quality: The Best Practice in Cardiology Program in Brazil

ACEI/ARB: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker; LVEF: left ventricular ejection fraction; LVSD: left ventricular systolic dysfunction; AF: atrial fibrillation; PT/INR: prothrombin time/international normalized ratio.

Abstract

Background

Despite significant progress in improving the quality of cardiovascular care, persistent gaps remain in terms of inconsistent adherence to guideline recommendations.

Objective

This study evaluates the effects of implementing a quality improvement program adapted from the American Heart Association’s Get with the Guidelines™ initiative on adherence to guideline-directed medical therapy for acute coronary syndrome (ACS), atrial fibrillation (AF), and heart failure (HF).

Methods

We examined demographics, quality measures, and short-term outcomes in patients hospitalized with ACS, AF, and HF enrolled in the Best Practice in Cardiology (BPC) Program from 2016 to 2022.

Results

This study included 12,167 patients in 19 hospitals in Brazil. Mean age was 62.5 [53.8-71] y/o; 61.1% were male, 68.7% had hypertension, 32.0% diabetes mellitus, and 24.1% had dyslipidemia. Composite score had a sustainable performance in the period from baseline to the last quarter: 65.8±36.2% to 73± 31.2% for AF (p=0.024), 81.0± 23.6% to 89.9 ± 19.3% for HF (p<0.001), and from 88.0 ± 19.1 to 91.2 ±14.9 for ACS (p<0.001).

Conclusions

The BPC program is a quality improvement program in Brazil in which real-time data, obtained using cardiology guideline metrics, were implemented in a quality improvement program resulting in an overall sustained improvement in AF, HF, and ACS management.

Cardiology; Quality Improvement; Evidence-Based Practice

Atrial Fibrillation
ARB/ACEI Prescribed Prior to Discharge (When LVEF ≤40)
CHA2DS2–VASc risk Score Documented Prior to Discharge
β-blocker Prescribed Prior to Discharge (when LVEF ≤ 40)
Anticoagulation Prescription Prior to Discharge
PT/INR Planned Follow-Up Documented Prior to Discharge for Warfarin TreatmenT
HAS-BLED risk Score Documented Prior to Discharge
Statin at discharge in AF patients with CAD, CVA/TIA, PVD, or Diabetes
Acute coronary syndrome
Aspirin within 24 hours of admission
Aspirin at discharge
β-blockers at discharge
ARB/ACEI Prescribed Prior to Discharge (When LVEF ≤40)
Statin at discharge
Adult smoking cessation advice/counseling
High Blood Pressure control
30 - Minute Door- to - Needle Time
90 -Minute Door-to- Balloon Time
Heart Failure
ARB/ACEI at discharge for patients with LVSD
β-blockers at discharge for patients with LVSD, no contraindications
LVEF assessment
Post-discharge appointment
Aldosterone antagonist prescription

	AF (n=2,503)	HF (n=3,574)	ACS(n=6090)	Total (n=12,167)
Age; median [IQR]	66 [57.3 - 74.2]	61 [51 - 70.8]	61.7 [54.3-69.1]	62.5 [53.8 - 71]
Gender; male (%)	52.5	58.4	66.3	61.1
Race; White (%)	49.7	31.5	38.4	38.7
Race; Brown (%)	36.9	52.2	47.7	46.7
Race; Black (%)	12.0	15.4	12.8	13.4
Race; Asian (%)	0.9	0.8	0.7	0.8
Hypertension (%)	71.5	70.6	82.5	68.7
Diabetes mellitus (%)	24.1	35.1	41.5	32.0
Dyslipidemia (%)	26.3	21.8	30.3	24.1
Previous stroke (%)	14.3	9.8	6.6	8.3
Coronary artery disease (%)	10.5	14	18	13.5
Peripheral artery disease (%)	4.9	3.8	2.5	3.1
Myocardial Infarction (%)	11.7	18.7	20.7	16.2
Permanent Atrial Fibrillation / Atrial flutter (%)	81.9	25.4	3.2	24.8
Rheumatic valvular disease (%)	6.6	6	0.3	3.1
Valvular disease (%)	13.5	15.9	1.1	8.0
Dialysis (%)	0.8	1.8	1.5	1.3
Kidney failure (Cr>2.0)(%)	5.4	14.6	3.6	6.6
Previous angioplasty (%)	5.5	10.9	11.4	10
Previous CABG (%)	4.2	5.7	3.4	4.2
Valvular prosthesis (%)	9.4	9.1	0.6	4.9
Current smoking (%)	5.2	7.6	25.5	15.2
BMI, median [IQR]	25.3 [21.9 - 28.9]	25.7 [22.2 - 29.6]	26.3 [23.7 - 29.3]	25.4 [22.3 - 28.9]
LVEF, median [IQR]	61 [46 - 67]	36 [26 - 53]	54 [42 - 62]	51 [36 - 63]

Atrial fibrillation
Quarter	Mean Value	Difference from baseline	p value
Baseline	52.92 (42.53; 63.3)	-	-
Quarter 2	59.24 (50.18; 68.31)	6.33 (2.93; 9.72)	< 0.001
Quarter 3	63.83 (55.33; 72.32)	10.91 (4.93; 16.89)	< 0.001
Quarter 4	66.66 (58.28; 75.04)	13.74 (5.69; 21.79)	< 0.001
Quarter 5	67.74 (58.86; 76.62)	14.83 (4.76; 24.89)	0.004
Quarter 6	67.08 (56.55; 77.61)	14.16 (1.59; 26.74)	0.027
Heart Failure
Quarter	Mean Value	Difference from baseline	p value
Baseline	79.94 (74.78; 85.1)	-	-
Quarter 2	83.02 (78.43; 87.61)	3.08 (1.09; 5.06)	0.002
Quarter 3	85.24 (80.8; 89.69)	5.3 (2.1; 8.5)	0.001
Quarter 4	86.61 (82.34; 90.88)	6.67 (2.88; 10.46)	< 0.001
Quarter 5	87.12 (83.01; 91.24)	7.18 (3.08; 11.29)	< 0.001
Quarter 6	86.78 (82.15; 91.41)	6.84 (2.02; 11.66)	0.005
Acute Coronary Syndrome
Quarter	Mean Value	Difference from baseline	p value
Baseline	87.72 (83.89; 91.54)	-	-
Quarter 2	87.31 (83.69; 90.94)	-0.4 (-2.72; 1.92)	0.734
Quarter 3	88.16 (84.64; 91.69)	0.45 (-2.58; 3.47)	0.773
Quarter 4	89.19 (85.44; 92.94)	1.48 (-2.27; 5.22)	0.44
Quarter 5	89.34 (84.97; 93.71)	1.62 (-3.08; 6.32)	0.499
Quarter 6	87,53 (82,36; 92,71)	-0,18 (-5,98; 5,61)	0,951

Performance measures for AF*	Baseline (n=364)	at 6 continuos quarters (n=181)	p
ARB/ACEI at discharge	83.7	80.6	0.973
CHADS-VASC2 score	47.4	43.1	0.461
β-Blockers at discharge	81	91.8	0.101
Anticoagulation	78.4	82.8	0.318
PT/INR Planned Follow-Up	87.1	97.7	0.002
HAS-BLED score	23.6	38.1	0.001
Statin at discharge	64.8	82.1	0.006
Composite score	65.8 ± 36.2	73 ± 31.2	0.024
Performance Measures for HF**	Baseline (n=326)	at 6 continuous quarters (n=224)	p
ARB/ACEI at discharge for patients with LVSD	72.9	87.2	0.008
β-Blockers at discharge for patients with LVSD	86.8	91.9	0.263
LVEF assessment	90.8	94.9	0.128
Postdischarge appointment	82.5	88.8	0.077
Aldosterone Antagosnist	64.2	82.8	0.004
Composite score	81 ± 23.6	89.9 ± 19.3	<0.001
Performance Measures for ACS***	Baseline (n=485)	at 6 continuous quarters (n=394)	p
Aspirin within 24 h of admission	90.2	94.7	0.035
Aspirin at discharge	94.4	96.2	0.281
β-Blockers at discharge	82.1	88.6	0.013
ARB/ACEI at discharge for patients with LVEF < 40%	79.6	83.8	0.546
Statin at discharge	87.3	95.2	<0,001
Blood pressure control at discharge	95.4	96.5	0.682
Adult smoking cessation advice/counseling	92	75.3	0.004
Door-to-needle time	55.6	33.3	1
Door-to-balloon time	64.4	68.3%	0.621
Composite score	88 ± 19.1	91.2 ± 14.9	<0.001

	Atrial fibrillation	Heart failure	Acute coronary syndrome
Hospital mortality
n/N (% [CI95%])	9/135 (6.67%)*	120/1305 (9.2%)	44/1959 (2.25%)
Mortality
Rate per 100 patient-year (95%CI)	28/518 (5.4 [3.4 - 8.4])	146/440 (32.9 [27.0 - 40.1])	70/764 (9.1 [6.8 - 12.1])
Hospitalization
Rate per 100 patient-year (95%CI)	34/508 (6.5 [4.3 - 9.8])	189/389 (42.6 [35.8 - 50.7])	167/715 (21.7 [18.1 - 26.1])
Hospitalization or death
Rate per 100 patient-year (95%CI)	57/508 (10.9 [8.0 - 15.0])	312/389 (70.4 [61.5 - 80.5])	222/715 (28.9 [24.6 - 33.9])

Sociedade Brasileira de Cardiologia - SBC Avenida Marechal Câmara, 160, sala: 330, Centro, CEP: 20020-907, (21) 3478-2700 - Rio de Janeiro - RJ - Brazil, Fax: +55 21 3478-2770 - São Paulo - SP - Brazil
E-mail: revista@cardiol.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Mailing Address: Fabio Papa Taniguchi • Hospital do Coração - HCor - R. Des. Eliseu Guilherme, 147. Postal Code 04004-030, Paraíso, São Paulo, SP - Brazil. E-mail: ftaniguchi@hcor.com.br