Hospital-Based Quality Improvement Interventions for Patients With Acute Coronary Syndrome: A Systematic Review

Multicomponent Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Protocol for a Pilot Implementation Trial

BACKGROUND

Although the incidence of acute myocardial infarction (AMI) is rising in sub-Saharan Africa, the uptake of evidence-based care for the diagnosis and treatment of AMI is limited throughout the region. In Tanzania, studies have revealed common misdiagnosis of AMI, infrequent administration of aspirin, and high short-term mortality rates following AMI.

OBJECTIVE

This study aims to evaluate the implementation and efficacy outcomes of an intervention, the Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC), which was developed to improve the delivery of evidence-based AMI care in Tanzania.

METHODS

This single-arm pilot trial will be conducted in the emergency department (ED) at a referral hospital in northern Tanzania. The MIMIC intervention will be implemented by the ED staff for 1 year. Approximately 400 adults presenting to the ED with possible AMI symptoms will be enrolled, and research assistants will observe their care. Thirty days later, a follow-up survey will be administered to assess mortality and medication use. The primary outcome will be the acceptability of the MIMIC intervention, which will be measured by the Acceptability of Intervention Measurement (AIM) instrument. Acceptability will further be assessed via in-depth interviews with key stakeholders. Secondary implementation outcomes will include feasibility and fidelity. Secondary efficacy outcomes will include the following: the proportion of participants who receive electrocardiogram and cardiac biomarker testing, the proportion of participants with AMI who receive aspirin, 30-day mortality among participants with AMI, and the proportion of participants with AMI taking aspirin 30 days following enrollment.

RESULTS

Implementation of MIMIC began on September 1, 2023. Enrollment is expected to be completed by September 1, 2024, and the first results are expected to be published by December 31, 2024.

CONCLUSIONS

This study will be the first to evaluate an intervention for improving AMI care in sub-Saharan Africa. If MIMIC is found to be acceptable, the findings from this study will inform a future cluster-randomized trial to assess effectiveness and scalability.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04563546; https://clinicaltrials.gov/study/NCT04563546.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59917.

Provider attitudes towards quality improvement for myocardial infarction care in northern Tanzania

INTRODUCTION

Myocardial Infarction (MI) is a leading cause of death worldwide. In high income countries, quality improvement strategies have played an important role in increasing uptake of evidence-based MI care and improving MI outcomes. The incidence of MI in sub-Saharan Africa is rising, but uptake of evidence-based care in northern Tanzania is low. There are currently no published quality improvement interventions from the region. The objective of this study was to determine provider attitudes towards a planned quality improvement intervention for MI care in northern Tanzania.

METHODS

This study was conducted at a zonal referral hospital in northern Tanzania. A 41-question survey, informed by the Theoretical Framework for Acceptability, was developed by an interdisciplinary team from Tanzania and the United States. The survey, which explored provider attitudes towards MI care improvement, was administered to key provider stakeholders (physicians, nurses, and hospital administrators) using convenience sampling.

RESULTS

A total of 140 providers were enrolled, including 82 (58.6%) nurses, 56 (40.0%) physicians, and 2 (1.4%) hospital administrators. Most participants worked in the Emergency Department or inpatient medical ward. Providers were interested in participating in a quality improvement project to improve MI care at their facility, with 139 (99.3%) strongly agreeing or agreeing with this statement. All participants agreed or strongly agreed that improvements were needed to MI care pathways at their facility. Though their facility has an MI care protocol, only 88 (62.9%) providers were aware of it. When asked which intervention would be the single-most effective strategy to improve MI care, the two most common responses were provider training (n = 66, 47.1%) and patient education (n = 41, 29.3%).

CONCLUSION

Providers in northern Tanzania reported strongly positive attitudes towards quality improvement interventions for MI care. Locally-tailored interventions to improve MI should include provider training and patient education strategies.

Benchmarking System Monitoring on Quality Improvement in Percutaneous Coronary Intervention: A Nationwide Registry in Japan

Background

Quality indicators (QIs) have been developed to improve and standardize care quality in percutaneous coronary intervention (PCI). In Japan, consecutive PCI procedures are registered in a nationwide database (the Japanese Percutaneous Coronary Intervention registry), which introduces a benchmarking system for comparing individual institutional performance against the national average.

Objectives

The aim of this study was to assess the impact of the benchmarking system implementation on QI improvement at the hospital level.

Methods

A total of 734,264 PCIs were conducted at 1,194 institutions between January 2019 and December 2021. In January 2018, a web-based benchmarking system encompassing 7 QIs for PCI at the institutional level, including door-to-balloon time and rate of transradial intervention, was introduced. The process by which institutions tracked their QIs was centrally monitored.

Results

During the 3-year study period, the benchmarking system was reviewed at least once at 742 institutions (62.1%) (median 4 times; Q1-Q3: 2-7 times). The institutions that reviewed their records had higher PCI volumes. Among these institutions, although door-to-balloon time was not directly associated, the proportion of transradial intervention increased by 2.3% in the system review group during the initial year compared with 0.7% in their counterparts. However, in the subsequent year, the association between system reviews and QI improvement was attenuated.

Conclusions

The implementation of a benchmarking system, reviewed by participating institutions in Japan, was partially associated with improved QIs during the first year; however, this improvement was attenuated in the subsequent year, highlighting the need for further efforts to develop effective and sustainable interventions to enhance care quality in PCI.

Improving acute myocardial infarction care in northern Tanzania: barrier identification and implementation strategy mapping

BACKGROUND

Evidence-based care for acute myocardial infarction (AMI) reduces morbidity and mortality. Prior studies in Tanzania identified substantial gaps in the uptake of evidence-based AMI care. Implementation science has been used to improve uptake of evidence-based AMI care in high-income settings, but interventions to improve quality of AMI care have not been studied in sub-Saharan Africa.

METHODS

Purposive sampling was used to recruit participants from key stakeholder groups (patients, providers, and healthcare administrators) in northern Tanzania. Semi-structured in-depth interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview transcripts were coded to identify barriers to AMI care, using the 39 CFIR constructs. Barriers relevant to emergency department (ED) AMI care were retained, and the Expert Recommendations for Implementing Change (ERIC) tool was used to match barriers with Level 1 recommendations for targeted implementation strategies.

RESULTS

Thirty key stakeholders, including 10 patients, 10 providers, and 10 healthcare administrators were enrolled. Thematic analysis identified 11 barriers to ED-based AMI care: complexity of AMI care, cost of high-quality AMI care, local hospital culture, insufficient diagnostic and therapeutic resources, inadequate provider training, limited patient knowledge of AMI, need for formal implementation leaders, need for dedicated champions, failure to provide high-quality care, poor provider-patient communication, and inefficient ED systems. Seven of these barriers had 5 strong ERIC recommendations: access new funding, identify and prepare champions, conduct educational meetings, develop educational materials, and distribute educational materials.

CONCLUSIONS

Multiple barriers across several domains limit the uptake of evidence-based AMI care in northern Tanzania. The CFIR-ERIC mapping approach identified several targeted implementation strategies for addressing these barriers. A multi-component intervention is planned to improve uptake of evidence-based AMI care in Tanzania.

Factors Associated With Medical Staff's Engagement and Perception of a Quality Improvement Program for Acute Coronary Syndromes in Hospitals: A Nationally Representative Mixed-Methods Study in China

Background Medical staff represent critical stakeholders in the process of implementing a quality improvement (QI) program. Few studies, however, have examined factors that influence medical staff engagement and perception regarding QI programs. Methods and Results We conducted a nationally representative survey of a QI program in 6 cities in China. Quantitative data were analyzed using multilevel mixed-effects linear regression models, and qualitative data were analyzed using the framework method. The engagement of medical staff was significantly related to knowledge scores regarding the specific content of chest pain center accreditation (β=0.42; 95% CI, 0.27-0.57). Higher scores for inner motivation (odds ratio [OR], 1.79; 95% CI, 1.18-2.72) and resource support (OR, 1.52; 95% CI, 1.02-2.24) and lower scores for implementation barriers (OR, 0.81; 95% CI, 0.67-0.98) were associated with improved treatment behaviors among medical staff. Resource support (OR, 4.52; 95% CI, 2.99-6.84) and lower complexity (OR, 0.81; 95% CI, 0.65-1.00) had positive effects on medical staff satisfaction, and respondents with improved treatment behaviors were more satisfied with the QI program. Similar findings were found for factors that influenced medical staff's assessment of QI program sustainability. The qualitative analysis further confirmed and supplemented the findings of quantitative analysis. Conclusions Clarifying and addressing factors associated with medical staff's engagement and perception of QI programs will allow further improvements in quality of care for patients with acute coronary syndrome. These findings may also be applicable to other QI programs in China and other low- and middle-income countries. Registration URL: https://www.chictr.org.cn/; Unique identifier: Chi-CTR2100043319.

Quality Improvement and Public Reporting in STEMI Care

Mortality rates for patients with ST-segment elevation myocardial infarction (STEMI) remain high despite development of novel drugs and interventions over the past several decades. There is significant variability between hospitals in use of evidence-based treatments, and substantial opportunities exist to optimize care pathways and reduce disparities in care delivery. Quality improvement interventions implemented at local, regional, and national levels have improved care processes and patient outcomes. This article reviews evidence for quality improvement interventions along the spectrum of STEMI care, describes existing systems for quality measurement, and examines local and national policy interventions, with special attention to public reporting programs.

Health Care Quality Improvement for ST-Segment Elevation Myocardial Infarction: A Retrospective Study Based on Propensity-Score Matching Analysis

Reducing the treatment delay by organizing delivery of care on a regional basis is a priority for improving the quality of ST-segment elevated myocardial infarction (STEMI) care. This study aimed to evaluate the impact of the combined measures on quality metrics of healthcare delivery in Suzhou. The data were collected from the National Chest Pain Center (CPC) Data Reporting Database. 4775 patients were recruited, and after propensity-score matching, 1078 pairs were finally included for analysis. We examined the changes in quality metrics of care including prehospital and in-hospital processes, and clinic outcomes. Quality improvement (QI) implementation improved most process indicators. However, these improvements did not yield decreased in-hospital mortality. The door-to-balloon and the FMC-to-device time decreased from 85.0 and 98.0 min to 78 and 88 min, respectively (p < 0.001). Cases transferred directly via EMS had a greater improvement in most of process indicators. The proportion of patients transferred directly via EMS was 10.3%, much lower than that of self-transported patients at 58.3%. Tertiary hospitals showed greater performance improvement in process indicators than secondary hospitals. The percentage of cases using EMS remained low for suburban areas. The establishment of coordinated STEMI care needs to be accompanied with solving the fragmented situation of the prehospital and hospital care, and patient delay should be addressed, especially in suburban areas and on transferred-in inpatients.

Assessment of Studies of Quality Improvement Strategies to Enhance Outcomes in Patients With Cardiovascular Disease

IMPORTANCE

Clinical care quality improvement (QI) strategies are critical to prevent and control cardiovascular disease (CVD). However, there is limited evidence regarding which components of the health system-, clinician-, and patient-based QI strategies contribute to their impact on CVD.

OBJECTIVES

To identify, map, and organize evidence on the effectiveness and implementation of cardiovascular QI strategies that seek to improve outcomes in patients with CVD.

EVIDENCE REVIEW

Eight electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library, ProQuest, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform) were searched for studies published between January 1, 2009, and October 25, 2019. Eligible study designs included randomized trials and preintervention and postintervention evaluations. Descriptive findings of included studies were reported using several frameworks to map the intervention components stratified by target population, setting, outcomes, and overall results.

FINDINGS

From 8066 screened titles and abstracts, 456 unique studies with 150 148 unique patients (38.1% women and 61.9% men; mean [SD] age, 64.6 [7.1] years) were identified, including 427 randomized trials, 21 quasi-randomized studies, and 8 preintervention and postintervention studies. Of 336 studies from 45 countries that were classified, 255 (75.9%) were from high-income countries; 68 (20.2%), upper-middle-income countries; 13 (3.9%), lower-middle-income countries; and 0, low-income countries, with diverse clinical settings and target patient populations (post-myocardial infarction, stroke, heart failure). Patient support (311 studies), information communication technology (ICT) for health (78 studies), community support (18 studies), supervision (15 studies), and high-intensity training (14 studies) were the most commonly evaluated QI strategies. Other strategies were group problem-solving (7 studies), printed information (5 studies), strengthening infrastructure (4 studies), and financial incentives (3 studies). Patient support, ICT for health, training, and community support were strategies that had been evaluated the most for clinical end points and showed modest associations with several clinical outcomes. The other strategies did not have outcome-driven evaluations reported. Group problem-solving was associated with improved patient self-care and quality of life. Strengthening infrastructure was associated with improved treatment satisfaction. Printed information and financial incentives showed no meaningful effect.

CONCLUSIONS AND RELEVANCE

This systematic review found that substantial variations exist in the types, effectiveness, and implementation of QI strategies for patients with CVD. A comprehensive map of QI strategies created by this study would be useful for researchers to identify where new knowledge is needed to improve cardiovascular outcomes. Outcome-driven evaluations and long-term studies are needed, particularly in low-income settings, to better understand the effects of QI strategies on prevention and control of CVD.

Sharing and Teaching Electrocardiograms to Minimize Infarction (STEMI): reducing diagnostic time for acute coronary occlusion in the emergency department

BACKGROUND

Limits to ST-Elevation Myocardial Infarction (STEMI) criteria may lead to prolonged diagnostic time for acute coronary occlusion. We aimed to reduce ECG-to-Activation (ETA) time through audit and feedback on STEMI-equivalents and subtle occlusions, without increasing Code STEMIs without culprit lesions.

METHODS

This multi-centre, quality improvement initiative reviewed all Code STEMI patients from the emergency department (ED) over a one-year baseline and one-year intervention period. We measured ETA time, from the first ED ECG to the time a Code STEMI was activated. Our intervention strategy involved a grand rounds presentation and an internal website presenting weekly local challenging cases, along with literature on STEMI-equivalents and subtle occlusions. Our outcome measure was ETA time for culprit lesions, our process measure was website views/visits, and our balancing measure was the percentage of Code STEMIs without culprit lesions.

RESULTS

There were 51 culprit lesions in the baseline period, and 64 in the intervention period. Median ETA declined from 28.0 min (95% confidence interval [CI] 15.0-45.0) to 8.0 min (95%CI 6.0-15.0). The website garnered 70.4 views/week and 27.7 visitors/week in a group of 80 physicians. There was no change in percentage of Code STEMIs without culprit lesions: 28.2% (95%CI 17.8-38.6) to 20.0% (95%CI 11.2-28.8%). Conclusions Our novel weekly web-based feedback to all emergency physicians was associated with a reduction in ETA time by 20 min, without increasing Code STEMIs without culprit lesions. Local ECG audit and feedback, guided by ETA as a quality metric for acute coronary occlusion, could be replicated in other settings to improve care.

Effect of a Triage-Based Screening Protocol on Diagnosis and Treatment of Acute Coronary Syndrome in a Tanzanian Emergency Department: A Prospective Pre-Post Study

Background Evidence suggests that acute coronary syndrome (ACS) is underdiagnosed in sub-Saharan Africa. Triage-based interventions have improved ACS diagnosis and management in high-income settings but have not been evaluated in sub-Saharan African emergency departments (EDs). Our objective was to estimate the effect of a triage-based screening protocol on ACS diagnosis and care in a Tanzanian ED. Methods and Results All adults presenting to a Tanzanian ED with chest pain or shortness of breath were prospectively enrolled. Treatments and clinician-documented diagnoses were observed and recorded. In the preintervention phase (August 2018 through January 2019), ACS testing and treatment were dictated by physician discretion, as per usual care. A triage-based protocol was then introduced, and in the postintervention phase (January 2019 through October 2019), research assistants performed ECG and point-of-care troponin I testing on all patients with chest pain or shortness of breath upon ED arrival. Pre-post analyses compared ACS care between phases. Of 1020 total participants (339 preintervention phase, 681 postintervention phase), mean (SD) age was 58.9 (19.4) years. Six (1.8%) preintervention participants were diagnosed with ACS, versus 83 (12.2%) postintervention participants (odds ratio [OR], 7.51; 95% CI, 3.52-19.7; P<0.001). Among all participants, 3 (0.9%) preintervention participants received aspirin, compared with 50 (7.3%) postintervention participants (OR, 8.45; 95% CI, 3.07-36.13; P<0.001). Conclusions Introduction of a triage-based ACS screening protocol in a Tanzanian ED was associated with significant increases in ACS diagnoses and aspirin administration. Additional research is needed to determine the effect of ED-based interventions on ACS care and clinical end points in sub-Saharan Africa.