Effectofa quality improvement interventionon clinical outcomes in patients in India with acute myocardial infarction the ACS QUIK randomized clinical trial

Mark D. Huffman, Padinhare P. Mohanan, Raji Devarajan, Abigail S. Baldridge, Dimple Kondal, Lihui Zhao, Mumtaj Ali, Mangalath N. Krishnan, Syam Natesan, Rajesh Gopinath, Sunitha Viswanathan, Joseph Stigi, Johny Joseph, Somanathan Chozhakkat, Donald M. Lloyd-Jones, Dorairaj Prabhakaran

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IMPORTANCE Wide heterogeneity exists in acutemyocardial infarction treatment and outcomes in India. OBJECTIVE To evaluate the effect of a locally adapted quality improvement tool kit on clinical outcomes and process measures in Kerala, a southern Indian state. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized, stepped-wedge clinical trial conducted between November 10, 2014, and November 9, 2016, in 63 hospitals in Kerala, India, with a last date of follow-up of December 31, 2016. During 5 predefined steps over the study period, hospitals were randomly selected to move in a 1-way crossover from the control group to the intervention group. Consecutively presenting patients with acutemyocardial infarction were offered participation. INTERVENTIONS Hospitals provided either usual care (control group; n = 10066 participants [step 0: n = 2915; step 1: n = 2649; step 2: n = 2251; step 3: n = 1422; step 4; n = 829; step 5: n = 0]) or care using a quality improvement tool kit (intervention group; n = 11 308 participants [step 0: n = 0; step 1: n = 662; step 2: n = 1265; step 3: n = 2432; step 4: n = 3214; step 5: n = 3735]) that consisted of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training. MAIN OUTCOMES AND MEASURES The primary outcomewas the composite of all-cause death, reinfarction, stroke, or major bleeding using standardized definitions at 30 days. Secondary outcomes included the primary outcome's individual components, 30-day cardiovascular death, medication use, and tobacco cessation counseling. Mixed-effects logistic regression models were used to account for clustering and temporal trends. RESULTS Among 21 374 eligible randomized participants (mean age, 60.6 [SD, 12.0] years; n = 16 183 men [76%] ; n = 13 689 [64%] with ST-segment elevationmyocardial infarction), 21 079 (99%) completed the trial. The primary composite outcome was observed in 5.3%of the intervention participants and 6.4%of the control participants. The observed difference in 30-day major adverse cardiovascular event rates between the groups was not statistically significant after adjustment (adjusted risk difference, -0.09% [95%CI, -1.32%to 1.14%]; adjusted odds ratio, 0.98 [95%CI, 0.80-1.21]). The intervention group had a higher rate of medication use including reperfusion but no effect on tobacco cessation counseling. There were no unexpected adverse events reported. CONCLUSIONS AND RELEVANCE Among patients with acutemyocardial infarction in Kerala, India, use of a quality improvement intervention compared with usual care did not decrease a composite of 30-day major adverse cardiovascular events. Further research is needed to understand the lack of efficacy.

Original languageEnglish
Pages (from-to)567-578
Number of pages12
JournalJAMA - Journal of the American Medical Association
Issue number6
StatePublished - Feb 13 2018


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