ACC: Quality interventions may be the BRIDGE to adherence
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CHICAGO—Integrating low-cost, quality improvement interventions that include checklists, nurse champions and educational materials, can help bridge the gap in terms of physician adherence to evidence-based protocols for treating acute coronary syndrome (ACS) patients, according to the results of the late-breaking clinical BRIDGE-ACS trial presented this morning at the 61st annual American College of Cardiology (ACC) scientific session. While the strategies worked, larger studies should be conducted to evaluate whether these types in strategies will be effective in the long term.

Important gaps still exist between what the guidelines say and what is applied in clinical practice, said Otavio Berwanger, MD, PhD, co-chair of the study and director of the Research Institute HCor at the Cardiac Hospital of São Paulo. “Even a simple intervention such as aspirin is still not at 100 percent.”

Because these types of interventions are rarely assessed, particularly in lower income countries, Berwanger and colleagues set out to evaluate techniques that could help stamp out the cardiovascular disease burden by improving quality adherence for ACS patients in the BRIDGE-ACS trial.

While Berwander acknowledged that previous randomized clinical trials, cost-effective analyses and reviews have outlined the possible benefits of these types of interventions to treat and manage ACS patients, “translation of research findings into practice is suboptimal and that these care gaps are even greater in low- and middle-income countries.”

Therefore to look at how these interventions could work in Brazil, Berwander et al conducted a pragmatic cluster randomized trial at 34 public hospitals in urban areas of Brazil that had an emergency department who accepted ACS patients.  

BRIDGE-ACS had a “very pragmatic, very flexible design," so it could be replicated, noted Berwander.

The study enrolled 1,150 ACS patients who were randomized to receive a multifaceted quality improvement intervention (602 patients at 17 hospitals) and routine practice (548 patients at 17 hospitals). Private hospitals, cardiac institutions and hospitals located in rural areas were excluded.

The researchers assessed the adherence to evidence-based therapies during the first 24 hours post-hospitals admission as the primary endpoint.

“Behavior modification is difficult,” Berwander said. But, the interventional component used during the study attempted to implement strategies to keep the physician in check in the hope of improving adherence.

“We used a patient reminder, as a rapid triage tool, that was attached to the clinical evaluation form as soon as a patient was thought to have ACS,” Berwander. After a patient was deemed an ACS patients, they were sent immediately to the physician who were equipped with a checklist outlining algorithms for the risk stratifications and recommendations of evidence-based therapies for patients at a high-, moderate- or low-risk. 

“We also developed a bracelet according to the risk category (red=high risk, yellow=moderate risk, and green=low risk),” Berwander said. “This is an inexpensive technology.”

In addition, the multifaceted treatment included a trained nurse, who acted as the case manager,  whose job was to ensure that the aforementioned tools were being used correctly and frequently and to ensure that evidence-based therapies were being prescribed. “These are active interventions,” Berwander offered. “These tend to work better than passive interventions.”

Posters also were displayed around the hospitals and pocket guidelines were distributed.

Adherence to all evidence-based therapies (aspirin, clopidogrel, anticoagulants and statins) during the first 24 hours in patients without contraindications was assessed.  

“To reach this endpoint the patient must receive all of them [strategies listed above] for the endpoint to be achieved,” Berwander said. “It was an all or none approach, which some may criticize.” The researchers found that patients in the intervention group did 18.4 percent better in terms of adherence to all evidence-based therapies within the first 24 hours compared with the control group, 67.9 percent vs. 49.5 percent, respectively. When statins were taken out of this equation, these numbers were 78.1 percent vs. 57.7 percent, respectively.

While Berwander noted that the study did not have enough statistical power to reach conclusions, he said that all inhospital clinical outcomes were going in the right direction, expect major bleeding, which he said was expected because of anticoagulant use. Prior to the study, Berwander said that less than half of the patients were receiving less than half of the therapies.

“In conclusion, a simple multifaceted educational intervention resulted in significant improvement in the use of evidence-based medications,” Berwander said. “It is simple and feasible, at least in Brazil.

“We consider the BRIDGE-ACS trial a first step,” said Berwander, who offered that a larger analysis is necessary to look at larger endpoints. “We need to see more trials testing implementation science.”

Berwander said that the case manager was “key” to the success of this trial; however, he noted that putting these case managers in place will be costly. “This is what was most challenging,” he said. “How do we sustain these costs?” He said that once a hospital CEO begins to see the improvement in quality and adherence, perhaps they will be more apt to get on board.

“The findings are that more patients are on adherence,” said Erik M. Ohman, MD, director of the program for advanced coronary disease at the Duke University Medical Center in Durham, N.C., and a member of the study discussant panel. “If you get [adherence] right at the beginning, you will stay on the right track.”

In the long term, Berwander said that clinical decision support systems (CDS) and the EMR could help take these interventional strategies a step forward. However, in Brazil, there is no unified EMR system across public hospitals.

“It would be expensive and quite challenging to adopt a CDS system,” Berwander summed. “It would be quite hard to design that at the moment.” He noted that use of these tools could improve adherence even further than just use of the case manager.