Primary Care Intervention Fails to Cut Heart Disease Risks

A data-driven quality improvement program focused on improving cardiovascular outcomes implemented in primary care practices did not result in better care quality in an Australian cluster randomized trial.

Patients with coronary heart disease (CHD) in practices assigned to the intervention came out statistically just as likely to have unplanned cardiovascular disease hospitalizations at 24 months as controls (10.6% vs 11.5%, adjusted RR 0.91, 95% CI 0.75-1.10), according to a group led by Julie Redfern, PhD, of Bond University in Robina, Australia.

There was also no improvement in the incidence of major adverse cardiovascular events (MACE; 5.5% vs 6.4%, adjusted RR 0.81, 95% CI 0.61-1.07) or other measured outcomes, they reported in Circulation: Population Health and Outcomes.

“The QUEL trial included a large patient cohort and robust end points such as hospitalizations and MACE, and taken together, it is argued that the QUEL trial adds to the body of evidence suggesting data-driven and collaborative quality improvement may not be effective in improving clinical outcomes for people with complex health conditions in primary care,” the researchers wrote.

A major public health challenge thus stands: despite the variety and availability of efficacious therapies that reduce cardiovascular risk, broad implementation remains somehow out of reach.

“It is estimated that only a third of guideline-eligible patients for statin therapy receive a prescription, and roughly half of those started will stop within a year. Hypertension and diabetes metrics fare even worse, with around only 20% reaching control targets. … Though having evidence-based treatments available is essential, it is only half the battle in the fight to improve patient outcomes,” commented Joseph Ebinger, MD, and two colleagues from Cedars-Sinai Medical Center in Los Angeles, in an accompanying editorial.

As for QUEL’s education-heavy intervention, part of the issue could have been the assumption that the primary care providers need more knowledge or engagement in the first place, the trio suggested.

“[W]hen asked, primary care providers themselves say this is often not the case. They are often aware of the clinical evidence and want to provide high-quality care to all their patients. The problem more frequently stems from competing demands, misaligned incentives, patient preferences, and a system that is designed to optimize billing, not building healthier communities,” Ebinger and colleagues argued.

Asking more and more from clinicians — more tasks, more electronic health record clicks — may not be realistic when it is already time-consuming to check all the boxes in preventative care services.

“Expecting providers to perform all of these services is not only mathematically impossible, but also fuels burnout, a condition reported by 58% of primary care providers and contributing to a shortage of ≈70,000 primary care physicians, particularly in rural and underserved communities, as providers continue to leave clinical practice for nonclinical roles,” the editorialists wrote.

“Future iterations of implementation should include policy changes, realignment of incentives, improving the patient experience, and reducing burnout in our primary care colleagues,” they suggested.

The single-blind, cluster-randomized QUEL trial was conducted in the Australian primary care setting from 2019 to 2022. There were 51 practices (selected on the basis of having at least 200 adult patients annually with CHD) randomized 1:1 to a 12-month quality improvement intervention or standard care.

For the intervention, staff representatives from each participating practice attended learning workshops and were tasked with disseminating the information and leading quality improvement activities. Monthly feedback reports were generated for each practice based on their electronic health record data. Additionally, each practice was supposed to prepare and submit “plan-do-study-act” improvement plans between workshops.

The study included 7,864 adults with CHD who had visited their general practitioner in the past 12 months. The cohort had a mean age of 71.9 years and was 68% men. One in four had a prior myocardial infarction.

Data extracted from electronic health records showed no care quality metric favoring the intervention group over usual care:

• Prescription of antiplatelet: 17.0% vs 17.9% (adjusted RR 0.94, 95% CI 0.79-1.13)
• Prescription of statin: 66.6% vs 65.1% (adjusted RR 1.03, 95% CI 0.97-1.09)
• Prescription of angiotensin-converting enzyme or angiotensin receptor blocker: 54.6% for both (adjusted RR 1.00, 95% CI 0.93-1.07)
• LDL cholesterol ≥2.0 mmol/L: 38.2% for both (adjusted RR 0.99, 95% CI 0.86-1.13)
• Systolic blood pressure >130 mmHg: 51.8% vs 53.9% (adjusted RR 0.97, 95% CI 0.87-1.09)
• Current smoking: 14.6% vs 13.0% (adjusted RR 0.96, 95% CI 0.57-1.59)
• Management plan or team care arrangement review: 14.1% vs 14.9% (adjusted RR 1.02, 95% CI 0.64-1.63)

Not all patients had data available at 12- and 24-month follow-up, however, due to changes in their clinic’s electronic medical record software, Redfern and colleagues acknowledged. Moreover, their analysis was limited to the quality of data entered at the point of care.

“It is possible that the COVID-19 pandemic negatively impacted the ability of intervention practices to prioritize data-driven quality improvement for secondary prevention of CHD. The pandemic may also have impacted hospitalization rates and study power given the observed rate of the primary outcome being much lower than anticipated,” the authors added.

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