Hospital-based quality improvement interventions for patients with heart failure: A systematic review

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

estimates.