Effect of a Multifaceted Intervention on Use of Evidence-Based Therapies in Patients With Acute Coronary Syndromes in Brazil: The BRIDGE-ACS Randomized Trial

Study Questions:

What is the effect of a multifaceted quality improvement (QI) intervention on the use of evidence-based therapies and the incidence of major cardiovascular events among patients with acute coronary syndrome (ACS) in a middle-income country?


BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes), a cluster-randomized (concealed allocation) trial, was conducted among 34 clusters (public hospitals) in Brazil and enrolled a total of 1,150 patients with ACS from March 15, 2011, through November 2, 2011, with follow-up through January 27, 2012. Multifaceted QI intervention including educational materials for clinicians, reminders, algorithms, and case manager training, versus routine practice (control) was conducted. The primary endpoint was the percentage of eligible patients who received all evidence-based therapies (aspirin, clopidogrel, anticoagulants, and statins) during the first 24 hours in patients without contraindications.


Mean age of the patients enrolled was 62 [standard deviation, 13] years; 68.6% were men, and 40% presented with ST-segment elevation myocardial infarction, 35.6% with non–ST-segment elevation myocardial infarction, and 23.6% with unstable angina. The randomized clusters included 79.5% teaching hospitals, all from major urban areas, and 41.2% with 24-hour percutaneous coronary intervention capabilities. Among eligible patients (923/1,150 [80.3%]), 67.9% in the intervention versus 49.5% in the control group received all eligible acute therapies (population average odds ratio [ORPA], 2.64; 95% confidence interval [CI], 1.28-5.45). Similarly, among eligible patients (801/1,150 [69.7%]), those in the intervention group were more likely to receive all eligible acute and discharge medications (50.9% vs. 31.9%; ORPA , 2.49; 95% CI, 1.08-5.74). Overall composite adherence scores were higher in the intervention clusters (89% vs. 81.4%; mean difference, 8.6%; 95% CI, 2.2%-15.0%). In-hospital cardiovascular event rates were 5.5% in the intervention group versus 7.0% in the control group (ORPA, 0.72; 95% CI, 0.36-1.43); 30-day all-cause mortality was 7.0% versus 8.4% (ORPA, 0.79; 95% CI, 0.46-1.34).


The authors concluded that a multifaceted educational intervention resulted in significant improvement in the use of evidence-based therapies.


In this cluster-randomized trial, a multifaceted QI intervention including reminders, checklists, case management, and educational materials, was effective in improving quality of ACS care in public hospitals. The intervention increased the uptake of evidence-based therapies during the first 24 hours, mainly driven by increased prescription rates of antithrombotic therapies and statins. However, the study was not powered for the evaluation of clinical outcomes, and the low number of events and the wide confidence intervals around point estimates make the interpretation of the clinical endpoint results inconclusive. Larger studies with adequate power are warranted to assess the effect of QI interventions on clinical outcomes as well as on cost-effectiveness.

Clinical Topics: Acute Coronary Syndromes, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Nonstatins, Novel Agents, Statins, Interventions and ACS

Keywords: Odds Ratio, Myocardial Infarction, Cost-Benefit Analysis, Acute Coronary Syndrome, Follow-Up Studies, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Ticlopidine, Hospitals, Public, Hospitals, Teaching, Percutaneous Coronary Intervention, Incidence, Quality Improvement, Brazil, Cardiology, Case Management, Cardiovascular Diseases, Confidence Intervals

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