Effectiveness of quality improvement interventions in improving cardiovascular disease-related outcomes in primary and tertiary care: A systematic review and meta-analyses

BACKGROUND: Quality improvement strategies are increasingly being used across all healthcare settings to improve patient outcomes. However, the effectiveness of QI interventions in improving the care of cardiovascular (CVD) disease remains unclear. More evidence is needed to determine whether QI interventions can improve CVD medication use, manage risk factors, and enhance clinical outcomes. Therefore, this study aimed to systematically assess the effectiveness of QI interventions in improving CVD-related outcomes in both primary and tertiary healthcare services.

METHODS: Six databases (Medline, Embase, PsycINFO, CENTRAL, CINAHL, and Scopus) were systematically searched for randomised and cluster randomised controlled trials from inception to 21st January 2025. Studies were included if they were randomised trials, included people with CVD, implemented a QI intervention focused on improving CVD care in either primary care services and hospitals, and measured at least one of the following outcomes: prescribed guideline-recommended CVD medications, risk factors, and clinical events. Three authors independently screened articles and extracted data from eligible studies. A random-effects model was used to estimate the pooled effects.

RESULTS: Eighteen studies involving 438,285 individuals with CVD (72% male, pooled mean age [standard deviation]: 61.7 [12.8]). Commonly identified QI strategies were feedback reports (83%), decision support tools (72%), and QI teams (50%). Meta-analyses showed compared to usual care, QI interventions significantly improved lipid-lowering medications prescriptions (OR: 1.46, [95% CI: 1.08, 1.99]), reduced the rate of major cardiovascular events (MACE) (OR: 0.84, 95% CI: 0.71, 0.98) and total mortality (OR: 0.87, [95% CI: 0.77, 0.98]). Sensitivity analyses excluding one study showed significant improvements in ACEi/ARB/ARNI prescriptions (OR: 1.36, [95% CI: 1.10, 1.69]). Risk of bias analysis demonstrated significant improvements for lipid-lowering medications (OR: 1.63, [95% CI: 1.34, 2.00]), ACE/ARB/ARNI (OR: 1.90, [95% CI: 1.34, 2.71]) and beta-blockers (OR: 1.24, [95% CI:0.95, 1.61]). Subgroup analyses showed significant improvements in ACEi/ARB/ARNI (OR:1.35, [95% CI: 1.03, 1.77)]) and beta-blockers (OR:1.48, [95% CI: 1.31, 1.68)]) prescriptions along with reduced total mortality (OR: 0.86, [95% CI: 0.76, 0.98]) in hospitals. Lipid-lowering medication prescriptions improved in both primary care (OR: 1.58, [95% CI: 1.03, 2.40]) and hospitals (OR: 1.37, [95% CI: 1.08, 1.72]). In another subgroup analyses, shorter follow-up periods were associated with improvement in ACEi/ARB/ARNI (OR:1.38, [95% CI: 1.08, 1.77]), beta-blockers (OR: 1.45, [95% CI: 1.28, 1.61]) prescriptions and total mortality (OR: 0.86, [95% CI: 0.75, 0.99]). Longer follow-ups were more effective in reducing MACE (OR: 0.75, [95% CI: 0.63, 0.90]).

CONCLUSION: QI interventions can effectively improve lipid-lowering medication prescriptions, reduce MACE, and lower total mortality in CVD management. Interventions are particularly effective in hospital settings and with shorter follow-up periods for medication prescriptions, while longer follow-ups benefit MACE reduction. These findings highlight the potential of QI interventions to improve CVD management in both primary care services and hospitals, though tailored QI strategies may be needed for optimal effectiveness. Further studies are needed to fully evaluate the effectiveness of diverse QI interventions in healthcare.

SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number: CRD42021249907.