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): 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, ß-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. Clinical guidelines recommend several evidence-based strategies for the early care of patients with acute coronary syndromes (ACS), [1] and [2] but a number of registries indicate that many of these strategies are not used effectively, which results in suboptimal care and puts patients at risk. [3], [4], [5], [6], [7] and 8 Quality improvement (QI) in health care is a broad strategy that aims to identify and measure indicators of good practice and ensure that those indicators are achieved through behavioral change, education, and appropriate incentives. [9], [10] and [11] The management of ACS is a complex multifactorial process that involves a wide range of professionals and resources. Improvements in early management of ACS patients are known to lead to better outcomes, and QI programs have therefore been developed to improve the care of ACS patients. [12], [13], [14] and [15] Many of these programs have been evaluated in observational studies, which can lead to an overoptimistic interpretation of their efficacy, may not take into account background improvements in care that occur over time and may not be generalizable to different health care systems. Accordingly, we undertook a rigorous proof of concept, cluster-randomized evaluation of a QI intervention for ACS in 5 countries to determine if measurable improvements in quality of care could occur.
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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