PINNACLE India Program Demonstrates Feasibility of Quality Improvement in Resource-Limited Countries

Journal Wrap | While the burden of cardiovascular disease (CVD) in India continues to grow, there are limited data available on the quality of outpatient care. There has also been an increase in risk factors for coronary artery disease (CAD) such as smoking, physical inactivity, and unhealthy diets, along with low levels of awareness, treatment, and control of CAD risk factors. The number of cardiologists for the highly-populated country is low and busy practitioners are often too overwhelmed to report or attempt to improve the quality of cardiovascular care.

According to new research from the ACC’s PINNACLE India Quality Improvement Program (PIQIP), it is possible to collect and study the quality of outpatient cardiovascular care in research-limited environments. The pilot study, published May 20 in the Journal of the American Heart Association, examines performance measures and outlines areas for further improvements in the delivery of cardiovascular care.

Researchers studied PIQIP data from 10 Indian cardiology outpatient departments between January 1, 2011, and February 5, 2014, and examined the prevalence of CAD, heart failure (HF), and atrial fibrillation (AFib) for 68,196 patients. Hypertension was the most prevalent CAD factor in 29.7% of patients, followed by diabetes (14.9%), tobacco use (7.6%) and dyslipidemia (6.5%). CAD was present in 14.8% of patients, HF in 4.0% patients, and AFib in 0.5% of patients. Aspirin (48.6%), clopidogrel (37.1%), and statin-based, lipid-lowering therapies (50.6%) were taken by CAD patients, while RAAS antagonists (61.9%) and beta-blockers (58.1%) were used by HF patients. Anticoagulants were taken by 37% of AFib patients.

The PIQIP data revealed a significant difference by sex among cardiovascular disease prevalence, with women comprising only 7% of patients with CAD and 3% of patients with HF. Additionally, the authors also found that a younger mean age of the represented populations with CVD and a relatively lower prescription of evidence-based medications for CAD, HF, and AFib.

The study authors also report several challenges related to the implementation of the PIQIP. Most of the outpatient departments did not use electronic health records, outpatient record-keeping was mostly nonexistent, and the system in place made it difficult to track patients from one visit to another. There was also reluctance from busy physicians to use the web-based tracking tool, and staff required repeated training for the software. The authors report that several strategies are being considered for the future, including a model that allows outpatient departments to become self-sufficient in data collection and reporting; enhanced data capture, including socioeconomic variables, medication contraindication, and laboratory values; and expansion of the program to other sites across India.

“This paper demonstrates the high potential for the American College of Cardiology and the PINNACLE Registry to partner with cardiologists and help them improve the quality of outpatient cardiovascular care across the globe,” said William Oetgen, MD, ACC executive vice president of science, education, and quality and one of the study authors.

The PIQIP is the first cardiovascular disease care data-collection and reporting program implemented in India. This study demonstrates that it is feasible to study the quality of outpatient cardiovascular care in this and other countries with limited resources.


  1. Kalra A, Pokharel Y, Hira RS, et al. J Am Heart Assoc. 2015;4:e001910.

Keywords: CardioSource WorldNews, ACC Publications, India, Cardiovascular Diseases, Coronary Artery Disease, Coronary Disease

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