AHA 2018: Multifaceted interventions improve adherence to evidence-based measures in high-risk CV disease

November 10, 2018 – The DCRI’s Renato Lopes, MD, MHS, PhD, contributed to two late-breaking clinical trials from the BRIDGE initiative.

Cardiovascular diseases remain the leading cause of death globally–particularly in low and middle-income countries, where 80 percent of the burden resides–yet research has shown that patients with high cardiovascular risk often fail to receive evidence-based therapies in community practice.

It is well established that statins, antiplatelet therapy, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) lower the long-term risk of cardiovascular events in patients with atherothrombotic disease. However, registries have shown that utilization of these therapies in practice is suboptimal and that care gaps are even wider in low- and middle-income countries. Trials studying the effects of quality improvement interventions on the use of these therapies have rarely been conducted in lower-resource settings.

To help address this evidence gap, BRIDGE (Brazilian Intervention to Increase Evidence Usage in Practice), a quality improvement initiative, was launched 10 years ago. This initiative conducts randomized trials to examine the impact of multifaceted quality improvement interventions on use of evidence-based therapies and clinical outcomes. The DCRI’s Renato Lopes MD, MHS, PhD, was co-chair of the BRIDGE-Acute Coronary Syndrome (ACS) trial, which revealed in 2012 that this type of intervention can improve the use of evidence-based therapies and clinical outcomes in ACS patients.

Results from two additional studies, BRIDGE-Cardiovascular Prevention and BRIDGE-Stroke, were presented Saturday at the 2018 American Heart Association Scientific Sessions in Chicago. Lopes was an investigator on both of these studies, testing the same concept as BRIDGE-ACS — this time in patients with stroke and high cardiovascular risk.

“The two studies, led by Brazilian investigators, showed that in general, multifaceted quality improvement interventions resulted in significant improvement in the use of evidence-based therapies, although they were not powered to assess impacts on clinical outcomes,” Lopes said. “Our interventions are relatively simple and feasible, so they could form the basis of quality improvement programs to maximize use of evidence-based interventions to manage patients with stroke and high cardiovascular risk.”

BRIDGE-CV was a cluster-randomized clinical trial including 1,619 patients with established atherothrombotic disease from 40 outpatient clinics or primary care units. The intervention tested involved case management, audit and feedback reports, and distribution of educational materials to health care providers and patients. The primary endpoint was the adherence to combined evidence-based therapies. Institutions that received a multifaceted intervention adhered to 73.5 percent of evidence-based therapies while the control group that received routine care adhered to just 58.7 percent.

The BRIDGE-Stroke trial examined the impact of a multifaceted quality improvement intervention to increase the adherence to 10 evidence-based performance metrics therapies for acute ischemic stroke and transient ischemic attack patients. This two-arm, cluster-randomized trial included 1,624 patients from 36 hospitals in Brazil, Argentina, and Peru. The intervention group adhered to 85.3 percent of the evidence-based performance measures, and the control group adhered to 77.8 percent, a difference that was not statistically significant. Although the intervention did not result in an overall improvement in adherence to evidence-based performance measures relative to standard of care, individual care elements did improve, including a significant increase in the use of thrombolysis and smoking cessation.

Additional DCRI contributors to BRIDGE-Stroke included Ying Xian, Janet Prvu Bettger, and Eric Peterson.

BRIDGE-CV is funded by Amgen as an investigator-initiated trial. BRIDGE-Stroke is funded by the Brazilian Ministry of Health in partnership with Hospital do Coração (HCor) – Programa Hospitais de Excelência à Serviço do SUS (PROADI-SUS). This study also received educational support from Boehringer Ingelheim and Lepetit Pharma.