Hospital-based quality improvement interventions for patients with heart failure: A systematic review
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Importance: Quality improvement initiatives have been developed to improve clinical
outcomes in patients with heart failure (HF), but data from randomized trials of these
initiatives have not previously been synthesized.
Objective: To estimate the direction and magnitude of effect and quality of evidence for
hospital-based HF quality improvement interventions on process of care measures and
clinical outcomes among patients with acute HF.
Evidence Review: We performed a structured search to identify relevant randomized
trials through February 2017. Studies were independently reviewed in duplicate for key
characteristics, outcomes were summarized, and a qualitative synthesis was performed
due to substantial heterogeneity.
Findings: From 3,615 records, 14 randomized controlled trials were identified for
inclusion with multi-faceted interventions. The mean in-hospital mortality rate reported in
three trials (n = 75,164 participants) ranged from 3.4% to 5.6% in the intervention
compared to 3.4% to 15.4% in the comparator. There was a trend towards higher inhospital
use of angiotensin converting enzyme inhibitors (ACE-I; 57.9% versus 40.0%)
and beta-blockers (BB; 46.7% versus 10.2%) in the intervention than the comparator in
one trial (n = 429 participants). Five trials (n = 78,727 participants) demonstrated no
effect of the quality improvement intervention on use of ACE-I or angiotensin receptor
blocker (ARB) at discharge; whereas, one trial (n = 17,544 participants) demonstrated
an increase in ACE-I or ARB use at discharge (86.1% to 92.4%, absolute difference
5.9%; 95% CI 1.0, 10.7; P = 0.02). Three trials (n = 89,660 participants) reported no
effect on use of BB at discharge, and one trial (n = 71,829 participants) reported no
effect on use of aldosterone antagonist at discharge. Two trials (n = 419 participants)
demonstrated a trend towards lower hospital readmission up to 90 days after discharge.
There was no consistent effect of the quality improvement intervention on 30-day allcause
mortality, hospital length of stay, and patient-level health-related quality of life.
Conclusions and Relevance: Randomized trials of hospital-based HF quality
improvement interventions do not show a consistent effect on most process of care
measures and clinical outcomes. The overall quality of evidence for these outcomes is
very low to moderate, suggesting that future research will likely influence these
CitationAgarwal, Anubha (2018). Hospital-based quality improvement interventions for patients with heart failure: A systematic review. Master's thesis, Duke University. Retrieved from https://hdl.handle.net/10161/17528.
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Rights for Collection: Masters Theses