Effectiveness of data-driven quality improvement on hospitalizations and health outcomes for people with coronary heart disease in primary care (QUEL): a cluster randomised controlled trial with 24-month follow-up
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Background
Using data to drive improved health outcomes offers an healthcare approach that has potential to benefit secondary prevention of coronary heart disease (CHD). The aim of this trial was to test the effectiveness of a data-driven quality improvement program in primary care on cardiovascular hospitalizations, major adverse cardiovascular events (MACE), risk factor profiles and medication prescriptions at 24 months in people with CHD.
Methods
Single-blind, cluster randomised controlled trial conducted in 51 Australian primary care practices. Practices having ≥200 adult patients annually with CHD were the units of randomization and people with CHD the units of analysis. Practices were randomised (1:1) to intervention (12-month data-driven quality improvement including benchmarking, monthly reporting, improvement planning) or control (standard care). Primary outcome was proportion of people with CHD who had unplanned CVD hospitalizations at 24-months.
Secondary outcomes were MACE, guideline-recommended medication prescription, risk factor targets, and management planning. Data were extracted from electronic records linked to administrative data and analysed using intention-to-treat log-binomial regression within the framework of generalized estimating equations accounting for clustering of patients within practices. Trial was registered with ANZCTR (ACTRN12619001790134).
Results
Between November 2019 and November 2021, 51 primary care practices participated, resulting in a patient cohort of 7864 (4524 from control practices, 3340 from intervention practices). The practices in control and intervention groups were well balanced for practice characteristics, socioeconomic status according to postcode, and median number of patients per practice. Mean age of the patient cohort was 71·9 (±11·8) years, 68% were male and 24% had a prior myocardial infarction. At 24-months, there was no significant in between the control (11·5%) and intervention (10·6%) groups for unplanned CVD hospitalizations (relative risk: 0·91, 95% CI 0·75 to 1·10). Similarly, there was no evidence that secondary outcomes of MACE, clinical measures, or medication prescriptions were different between the groups at 24 months.
Conclusions
A primary care, 12-month data-driven quality improvement program did not improve unplanned hospitalizations, MACE or medication prescriptions for people with CHD at 24-month follow-up. Robust evidence for use of a data-driven, collaborative approach to improving care for people with coronary heart disease in primary care remains elusive.
CONDENSED ABSTRACT
The QUEL cluster randomized controlled trial tested the effectiveness of data-driven quality improvement on secondary prevention of coronary heart disease in primary care with 24-month follow-up. It is arguably one of the largest and most robust studies evaluating the effectiveness of this type of intervention in primary care or an acute hospital setting. No significant improvement was found in unplanned cardiovascular disease hospitalizations, major adverse cardiovascular events, cardiovascular disease risk factors or medication prescriptions at 12- and 24-months. Evidence for use of a data-driven, collaborative approach to improving care for people with coronary heart disease in primary care remains elusive.
