Effectiveness of Quality Improvement Strategies Varied in Cardiovascular Outcomes


Data show variations in the type, effectiveness, and implementation of QI strategies for patients with CVD.

While clinical care quality improvement (QI) strategies work to control cardiovascular disease (CVD), there is limited data on which components of QI strategies work to impact the effects of CVD.

Investigators, led by Kavita Singh, PhD, Public Health Foundation of India, found substantial variations in the type, effectiveness, and implementation of QI strategies for patients with CVD.

They noted a need for a comprehensive map of cardiovascular QI strategies to identify potential areas of knowledge for improvement of cardiovascular outcomes.


In the study, the team aimed to identify and map evidence on effectiveness and implementation of cardiovascular QI strategies to improve outcomes.

The study population included adults ≥18 years old with established CVD, while intervention included studies that evaluated the effect of any QI intervention (health system-, clinician-, or patient-level) to improve outcomes for patients with CVD.

Further, the investigators considered standard CVD care as the control.

Outcomes included studies that evaluated primary outcomes of changes in cardiovascular risk factors (blood pressure, total cholesterol level) and major adverse cardiovascular events (MACEs).

Secondary outcomes included medication adherence, tobacco cessation, physical activity level, health-related quality of life, cost-effectiveness, hospital readmission, rates, all-cause deaths, and treatment satisfaction.

In addition, investigators included acceptability, fidelity, and feasibility in the outcomes. The study designs included randomized clinical trials (RCTs), cluster RCTs, quasi-randomized studies, and pre-intervention and post-intervention evaluations.

Thus, they performed a systemic scoping review that collected data from 8 electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library, ProQuest, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform).

Data was collected from studies published between January 2009 – October 2019, with eligible study designs of randomized trials and pre-intervention and post-intervention evaluations.


Investigators identified a total of 8066 publications, narrowing it down to 892 after screening abstracts.

Of this number, 456 studies met eligibility criteria, including 427 randomized trials, 21 quasi-randomized studies, and 8 pre-intervention and post-intervention.

They noted the studies included were from 45 countries involving 150,148 unique patients, with 61.9% men, mean age of 64.6 years, and 186 unique interventions.

Further, the most common CVD conditions were heart failure (37.9%), stroke (27.6%), post-myocardial infarction (14.0%), and stable coronary artery disease (10.1%).

Investigators found the most evaluated QI strategies were patient support (n = 311), information communication technology (ICT) for health (n = 78), community support (n = 18), supervision (n = 15), and high-intensity training (n = 14)

In addition, most strategies were found to use a combination of 6 elements of the chronic care model (n = 200), with decision support (n = 113), delivery system (n = 99), and self-management support (n = 68) following.

They found 422 studies investigated patient support, ICT for health, community support, and training measures, with 32 studies evaluating clinical outcomes of MACE and results ranging from positive to negative/neutral.

Investigators also noted in group problem-solving studies (n= 8), 3 studies demonstrated improvement in patient self-care and 1 study showed improvement in quality of life.

Strengthening infrastructure was also associated with improved treatment satisfaction.

However, they observed printed information and financial incentives had no meaningful effect on the patient.


In conclusion, the investigators observed variations in the type. effectiveness, and implementation of QI strategies for patients with CVD.

As a result, the team noted the usefulness of a comprehensive map of cardiovascular QI strategies for future identification of improvements in cardiovascular outcomes.

“Considering substantial variations in types, effectiveness, and implementation, future research should focus on high-quality, outcome-driven, and longer-term studies to understand the potential effect of QI strategies on cardiovascular health,” investigators wrote.

The study, “Assessment of Studies of Quality Improvement Strategies to Enhance Outcomes in Patients with Cardiovascular Disease,” was published online in JAMA Network Open.

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