PINNACLE India Quality Improvement Program Highlights Feasibility of QI Programs in Resource-Limited Countries

Programs designed to track and monitor the quality of outpatient care for patients with cardiovascular disease are feasible even in resource-limited environments, according to an analysis of data from the ACC’s PINNACLE India Quality Improvement Program (PIQIP) – India’s first national outpatient quality-improvement program focused on cardiovascular disease.

The analysis, published in the Journal of the American Heart Association, is based on performance measure data captured as part of PIQIP for 68,196 unique patients from 10 Indian cardiology outpatient departments from Jan. 1, 2011 to Feb. 5, 2014. Study authors estimated the prevalence of cardiovascular disease risk factors like hypertension, diabetes, dyslipidemia and current tobacco use, as well as examined adherence to performance measures for coronary artery disease, heart failure and atrial fibrillation (AFib).

Overall results found hypertension was present in 29.7 percent of patients, followed by diabetes (14.9 percent), current tobacco use (7.6 percent), and dyslipidemia (6.5 percent). Coronary artery disease was present in 14.8 percent of patients, while heart failure was noted in 4 percent and AFib was present in 0.5 percent of patients. In terms of medication use, patients with coronary artery disease reported use of aspirin (48.6 percent), clopidogrel (37.1 percent) and statin-based lipid-lowering therapy (50.6 percent), while 61.9 percent and 58.1 percent of heart failure patients reported use of RAAS antagonist and betablockers, respectively. Thirty-seven percent of AFib patients reported use of anticoagulants.

Study authors highlighted several important findings, including a seemingly significant difference by sex among cardiovascular disease encounters, with women composing only 7 percent and 3 percent of patients with coronary artery disease and heart failure, respectively. They also noted a younger mean age of the represented populations with cardiovascular disease and relatively lower prescription of evidence-based medications.

Despite the success, the study authors did note several challenges to PIQIP. Namely a lack of electronic health records; virtually non-existent outpatient record-keeping; the need for repeated training of staff regarding scanning software; and difficulty engaging physicians in using the web-based tracking tool due to their busy clinical schedules.  Moving forward the authors said several strategies are being considered, including enhanced data capture to include socioeconomic variables, medication contraindications and laboratory values; expansion of the program to more sites across India; and “progression to a model that enables [outpatient departments] to become self-sufficient in data collection and reporting and, consequently, less dependent on ACC staff.” 

In a country with a disproportionate provider/patient ratio and low levels of government funding for quality improvement, physician-driven initiatives for practice-based learning and improvement could be considered an unrealistic expectation,” the study authors said. “PIQIP demonstrates the feasibility of data acquisition in this challenging environment.”

Read more about the PIQIP project on the ACC in Touch Blog.


Keywords: Ambulatory Care, American Heart Association, Anticoagulants, Aspirin, Atrial Fibrillation, Coronary Artery Disease, Coronary Disease, Diabetes Mellitus, Dyslipidemias, Electronic Health Records, Government, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, India, Lipids, Outpatients, Quality Improvement, Risk Factors, Ticlopidine, Tobacco Use

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