Cluster-randomized trial to evaluate the effects of a quality improvement program on management of non–ST-elevation acute coronary syndromes: The European Quality Improvement Programme for Acute Coronary Syndromes (EQUIP-ACS)

Marcus D. Flather, Daphne Babalis, Jean Booth, Alfredo Bardaji, Jacques Machecourt, Grzegorz Opolski, Filippo Ottani, Héctor Bueno, Winston Banya, Anthony R. Brady, Mats Bojestig, Bertil Lindahl

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Background: Registries have shown that quality of care for acute coronary syndromes (ACS) often falls below the standards recommended in professional guidelines. Quality improvement (QI) is a strategy to improve standards of clinical care for patients, but the efficacy of QI for ACS has not been tested in randomized trials.

Methods: We undertook a prospective, cluster-randomized, multicenter, multinational study to evaluate the efficacy of a QI program for ACS. Participating centers collected data on consecutive admissions for non–ST-elevation ACS for 4 months before the QI intervention and 3 months after. Thirty-eight hospitals in France, Italy, Poland, Spain, and the United Kingdom were randomized to receive the QI program or not, 19 in each group. We measured 8 in-hospital quality indicators (risk stratification, coronary angiography, anticoagulation, β-blockers, statins, angiotensin-converting enzyme inhibitors, and clopidogrel loading and maintenance) before and after the intervention and compared composite changes between the QI and non-QI groups.

Results: A total of 2604 patients were enrolled. The absolute overall change in use of quality indicators in the QI group was 8.5% compared with 0.8% in the non-QI group (odds ratio for achieving a quality indicator in QI versus non-QI 1.66, 95% CI 1.43-1.94; P < .001). The main changes were observed in the use of risk stratification and clopidogrel loading dose.

Conclusions: The QI strategy resulted in a significant improvement in the quality indicators measured. This type of QI intervention can lead to useful changes in health care practice for ACS in a wide range of settings.

Original languageEnglish
Pages (from-to)700-707.e1
JournalAmerican Heart Journal
Issue number4
Publication statusPublished - Oct 2011


  • Acute Coronary Syndrome
  • Aged
  • Cluster Analysis
  • Female
  • Humans
  • Male
  • Outcome and Process Assessment (Health Care)
  • Prospective Studies
  • Quality Improvement

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