IMPROVE HF: Implementation of practice-specific improvement programs linked with better care for patients with HF
Fonarow G. Circulation. 2010;doi: 10.1161/CIRCULATIONAHA.109.934471.
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The implementation of practice-specific performance improvement interventions was associated with improved use of guideline-recommended therapies for patients with chronic HF, primary results from the IMPROVE HF trial suggested.
“Despite compelling scientific evidence and readily accessible national guidelines, beneficial therapies for HF remain underused in many care settings,” the researchers wrote in their study. “IMPROVE HF is the first large-scale outpatient performance improvement initiative designed to assess the effects of a practice-specific, process-of-care improvement intervention on HF patient care.”
Researchers collected data on 34,810 participants with HF or post-MI and reduced ejection fraction (≤35%) from 167 U.S. outpatient cardiology practices. Participants were followed longitudinally for intervention at 12 and 24 months, including single-point-in-time cohorts measured at 6 and 18 months. The researchers then measured adherence to a set of practice-specific guideline-recommended performance improvement interventions designed to improve the quality of HF care delivery.
According to the study results, the performance improvement interventions were associated with improvement in five of seven quality measures at 24 months after implementation (P<.001). The researchers reported that adherence to evidence-based, guideline-recommended care among practices was associated with an absolute increase of 25.1% for aldosterone antagonist use, a 29.9% increase for cardiac resynchronization therapy use and a 27.4% increase in the use of implantable cardioverter defibrillators vs. baseline (P<.001). The use of beta-blockers (6.2%) and HF education tools (12.6%) also increased after implementation.
The use of anticoagulation in patients with permanent, paroxysmal or persistent atrial fibrillation, however, decreased, and the increased use of ACE inhibitors and angiotensin receptor blockers was not statistically significant. When analyzed at an aggregate level, improvements in six of seven improvement measures were reported. The 20% or more absolute improvement in at least three of the seven quality measures met the study’s primary endpoint, according to the researchers.
“The results of this study suggest a favorable impact of applying performance improvement techniques of clinical decision support, reminder systems, guideline-driven care improvement tools, educational outreach, collaborative support, performance profiling and feedback in real-world cardiology practices,” they concluded. “Implementation of this defined and scalable practice-specific intervention may enhance use of guideline-recommended HF therapies previously demonstrated to improve outcomes.”
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ARMYDA-5 PRELOAD: Clopidogrel administered in advance of PCI yielded similar outcomes to cath lab administration
Di Sciascio G. J Am Coll Cardiol. 2010;56:550–557.
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Dosage of clopidogrel in the catheterization lab was shown to produce similar clinical outcomes as the standard 4- and 8-hour preloads in patients who underwent percutaneous coronary intervention, according to results of the ARMYDA-5 PRELOAD trial.
The Italian researchers enrolled 409 patients in the study and randomly assigned them to receive either a 600 mg clopidogrel loading dose 4 to 8 hours prior to PCI (n=204) or a 600 mg loading dose given in the catheterization lab after coronary angiography, but prior to PCI (n=205). The primary endpoint was the 30-day incidence of the following major adverse cardiac events: cardiac death, MI or unplanned target vessel revascularization.
Researchers reported no significant difference in the primary endpoint between the two arms (8.8% in-lab vs. 10.3% pre-load), which was driven mainly by periprocedural MI. There was a minor increased risk of bleeding or vascular complications in the pre-load arm (7.8%) vs. the in-lab arm (5.4%). Additional findings showed that patients in the in-lab group showed higher platelet reactivity during PCI (P=.043) and 2 hours after intervention (P=.01) vs. those in the pre-load group, but the levels became similar at 8 and 24 hours.
The trial, the researchers wrote, “indicates that a strategy of 600-mg in-lab clopidogrel load pre-PCI may have similar clinical outcomes as routine 4- to 8-hour pre-load. Thus, when indicated, in-lab clopidogrel administration can be a safe alternative to routine pre-treatment given before knowing patients’ coronary anatomy.”
Goran Stankovic, MD, PhD, and Milorad Zivkovic, MD, both with the Medical School of Belgrade in Belgrade, Serbia, explained in an accompanying editorial that the study addresses a clinically relevant question with a randomized controlled trial, and that the results support the in-lab administration of clopidogrel as a safe alternative to routine pre-treatment given before knowing a patient’s anatomy.
“This study serves the purpose of stimulating more and larger efforts to study the issue of clopidogrel platelet reactivity by developing either new regimens of the same drug or new drugs that have different, more predictable and more powerful effects on platelet function, such as prasugrel or ticagrelor,” they concluded.