March 25, 2012 – ACC Late-breaking clinical trial BRIDGE-ACS found simple educational programs boost adherence to evidence-based medicine
Cardiovascular disease, particularly acute coronary syndrome (ACS), is a global health threat and, in many countries, it is the leading cause of death. Despite the proven effectiveness of evidence-based treatments, studies have found that adherence to these treatments drops significantly in low- to middle-income countries, or even in poorer parts of the United States.
During a late-breaking session at the American College of Cardiology Annual Scientific Sessions in Chicago, researchers presented findings that showed how a simple, low-cost intervention program significantly increased hospitals’ rates of adherence to evidence-based therapies for patients with ACS.
“Guideline therapies work if given to the right patients in time, yet studies highlight gaps between guidelines and what physicians do in practice − not just in Brazil but in the United States, Europe, Australia, and elsewhere,” said study co-chair Otavio Berwanger, MD, PhD, director of the Research Institute HCor (Hospital do Coração) at the Cardiac Hospital of São Paulo.
The DCRI’s Renato Lopes, MD, PhD, was a co-chair of the BRIDGE-ACS study and is also the director of the Brazilian Clinical Research Institute (BCRI). Close collaboration between the BCRI and DCRI has been ongoing throughout several projects, with the BCRI being an extension of the DCRI in Brazil. However, this is the first DCRI/BCRI/HCor partnership in which study research efforts were led and conducted in Brazil by the HCor and BCRI.
BRIDGE-ACS enrolled more than 1100 patients at 34 public hospitals in Brazil between March 2011 and November 2011. Half of the hospitals provided routine care to patients, while the other half participated in a three-pronged intervention program designed to improve evidence-based care for patients with ACS.
Among the intervention hospitals, researchers observed an 18 percent improvement in adherence to the Brazilian Society of Cardiology guidelines for treating ACS. “Although the study was not statistically powered to detect clinical outcomes, there was a trend toward a 20 percent reduction in the rates of death, heart attacks, serious bleeding events, and non-fatal heart attacks or stroke,” said Dr. Berwanger.
The hospitals participating in the intervention arm of the trial were provided with simple educational tools and reminded about ACS guidelines of care; in addition, one or two nurses at each hospital were selected as case managers and followed patients from admission through discharge. The educational tools included patient chart color-coded stickers to indicate level of chest pain, matching colored bracelets for easier patient identification, and checklists of recommended treatments for mild, moderate, and severe ACS.
All physicians at the intervention hospitals also received pocket-sized copies of ACS recommendations, posters and other educational materials about ACS guidelines, and links to a website offering lectures on the latest in ACS care.
Researchers chose the most conservative endpoint for the trial—eligible patients with ACS had to receive every evidence-based treatment (100 percent) within the first 24 hours of hospital admittance for a case to be considered a successful intervention, as defined for this project. This included the use of aspirin, clopidogrel, statins, and anticoagulation therapy to break up and prevent blood clots. Lopes noted that the trial results would have been even greater if patients were required to receive 75 percent of the recommended therapies to be counted successfully.
“BRIDGE-ACS is an exciting trial because our results could be applied wherever ACS is undertreated, such as in lower-income countries and lower-income areas of the United States,” said Lopes. “The results reinforce the idea that a simple, feasible educational intervention, combined with evidence-based treatments, is effective and can make a significant difference in patient care.”
The secondary outcome for the trial was adherence to guideline-based care when patients were discharged from the hospital. This includes prescribing aspirin, beta-blockers, statins, and angiotensin-converting enzyme inhibitors. Compared with the control group, the intervention group had significantly higher guideline-adherence rates, and the impact remained high even when researchers excluded statin use as a discharge criterion.
“These findings could really benefit patients in countries where ACS is undertreated,” said Berwanger. “For every 10 percent increase in the use of evidence-based medicines, there is a significant reduction in adverse clinical outcomes. We saw trends indicating an approximate 20 percent reduction in adverse outcomes. These types of interventions are cost-effective and simple to implement.”
“There is a need for a large international, intervention trial that has enough patients to statistically assess the impact of these quality improvement interventions on clinical outcomes,” added both Drs. Berwanger and Lopes.