Quality improvement intervention not linked to improved outcomes after myocardial infarction in India

1. A locally adapted quality improvement tool kit was not sufficient to improve the rate of 30-day major adverse cardiovascular events in patients with acute MI in Kerala, India

Evidence Rating Level: 1 (Excellent)

Study Rundown: Ischemic heart disease represents the leading cause of deaths world-wide, and while developed countries have programs to improve access and outcomes after acute myocardial infarction (MI), this same infrastructure is not in place in low- and middle-income countries. Furthermore, South Asia is estimated to have the highest age-standardized incident rate of MI in the world. This study looked to determine the effect of a locally adapted quality improvement tool kit for acute coronary syndrome, consisting of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training on major cardiovascular events at multiple sites in Kerala, India. The quality improvement intervention did not decrease 30-day major adverse cardiovascular events, including all-cause death, reinfarction, or major bleeding.

Overall, this study suggests that a locally adapted quality improvement tool kit was not sufficient to improve the rate of 30-day major adverse cardiovascular events compared to usual care in patients with acute MI in Kerala, India. This study built on previous observational data from the region and collaborated with a local organization to ensure its methods were appropriate for the area. However, the intervention included several evidence-based components, such as audit, feedback, and checklists, that may not have been fully implemented at all sites and would have affected results. Additionally, recruitment bias may have been present in patients who provided informed consent for 3-day follow-up.

Click to read the study in JAMA

Relevant Reading: Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015

In-Depth [randomized controlled trial]: This study randomized 21 374 patients in 63 hospitals in Kerala, India with either non-ST-segment elevation MI (NSTEMI) or ST-segment elevation MI (STEMI) to usual care or care using a quality improvement tool kit. This tool kit consisted of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training. 76% of participants were men, 31% had a history of tobacco use, 44% had diabetes, and 65% presented with a STEMI. The unadjusted rate of 30-day major adverse cardiovascular events was 5.3% in the intervention group vs. 6.4% in the control group, which was not statistically significant after adjustment (OR 0.98 [CI_95% 0.80-1.21]). The rate of death at 30-days was also not significantly different (adjusted OR 0.94 [CI_95% 0.74-1.19]).

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