While multiple randomised controlled trials have outlined the optimal care for patients with acute coronary syndromes (ACS), evidence-based therapies are not always applied, particularly in low- and middle-income countries. In this Brazilian study, the authors hypothesised that a multifaceted quality improvement (QI) intervention could improve the use of evidence-based therapies and improve ACS outcomes.
BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) was a cluster-randomised trial that enrolled a total of 1150 ACS patients between March and and November 2011. The multifaceted QI intervention used included reminders, a checklist, case management, and educational materials; clusters were randomly allocated to the use of these or to a routine strategy. The main outcome measure was the percentage of all eligible patients who received all evidence-base therapies during the first 24 hours of treatment, where no contraindications were present.
40% of patients presented with ST-elevation myocardial infarction (STEMI), 35.6% with non-ST-segment myocardial infarction, and 23.6% with unstable angina. Almost 80% of the hospitals included were from major urban areas, and 41.2% had 24-hour PCI facilities available. In the intervention group, 67.9% of all eligible patients received all the appropriate acute therapies, compared to 49.5% in the control group. This also translated into an increased likelihood of receiving appropriate discharge medications (51.0% vs. 31.9%). In-hospital cardiovascular event rates were 5.5% in the intervention group vs 7.0% in the control group, and 30-day all-cause mortality was also reduced (7.0% vs 8.4%).
A multifaceted educational intervention in Brazil led to a significant improvement in the use of evidence-based therapies, suggesting that this approach may improve outcomes following ACS for patients in low- and middle-income countries.
- Berwanger O, Guimaraes HP, Laranjeira LN et al. Effect of a Multifaceted Intervention of Use of Evidence-Based Therapies in Patients With Acute Coronary Syndromes in Brazil. The BRIDGE-ACS Randomized trial. JAMA 2012;307:2041-2049