Thielman, NathanAgarwal, Anubha2018-09-212020-08-302018https://hdl.handle.net/10161/17528<p>Importance: Quality improvement initiatives have been developed to improve clinical</p><p>outcomes in patients with heart failure (HF), but data from randomized trials of these</p><p>initiatives have not previously been synthesized.</p><p>Objective: To estimate the direction and magnitude of effect and quality of evidence for</p><p>hospital-based HF quality improvement interventions on process of care measures and</p><p>clinical outcomes among patients with acute HF.</p><p>Evidence Review: We performed a structured search to identify relevant randomized</p><p>trials through February 2017. Studies were independently reviewed in duplicate for key</p><p>characteristics, outcomes were summarized, and a qualitative synthesis was performed</p><p>due to substantial heterogeneity.</p><p>Findings: From 3,615 records, 14 randomized controlled trials were identified for</p><p>inclusion with multi-faceted interventions. The mean in-hospital mortality rate reported in</p><p>three trials (n = 75,164 participants) ranged from 3.4% to 5.6% in the intervention</p><p>compared to 3.4% to 15.4% in the comparator. There was a trend towards higher inhospital</p><p>use of angiotensin converting enzyme inhibitors (ACE-I; 57.9% versus 40.0%)</p><p>and beta-blockers (BB; 46.7% versus 10.2%) in the intervention than the comparator in</p><p>one trial (n = 429 participants). Five trials (n = 78,727 participants) demonstrated no</p><p>effect of the quality improvement intervention on use of ACE-I or angiotensin receptor</p><p>blocker (ARB) at discharge; whereas, one trial (n = 17,544 participants) demonstrated</p><p>an increase in ACE-I or ARB use at discharge (86.1% to 92.4%, absolute difference</p><p>5.9%; 95% CI 1.0, 10.7; P = 0.02). Three trials (n = 89,660 participants) reported no</p><p>effect on use of BB at discharge, and one trial (n = 71,829 participants) reported no</p><p>effect on use of aldosterone antagonist at discharge. Two trials (n = 419 participants)</p><p>demonstrated a trend towards lower hospital readmission up to 90 days after discharge.</p><p>There was no consistent effect of the quality improvement intervention on 30-day allcause</p><p>mortality, hospital length of stay, and patient-level health-related quality of life.</p><p>Conclusions and Relevance: Randomized trials of hospital-based HF quality</p><p>improvement interventions do not show a consistent effect on most process of care</p><p>measures and clinical outcomes. The overall quality of evidence for these outcomes is</p><p>very low to moderate, suggesting that future research will likely influence these</p><p>estimates.</p>MedicineMaster's thesis