Brazilian inteRvention to Increase eviDence usaGe in practicE - Cardiovascular Prevention

Study Overview
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Brief Summary
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The purpose of the study is assess the impact of a multifaceted quality improvement intervention in adherence to evidence based therapies prescription (according to local guidelines) for cardiovascular prevention in high risk patients in 12 months.

Detailed Description
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The quality improvement strategy being assessed in this study will be applied to the healthcare team, thus any intervention that is not well established in the literature will not be prescribed to the patients. Thus, this trial does not imply any additional risk for patients. Furthermore, if this strategy is proved to be effective, it may be offered as a new clinical practice that might benefit brazilian patients. BRIDGE-CV consists of a quality improvement project by the incorporation of evidence based interventions in public and private hospitals in Brazil. The chosen setting is cardiovascular prevention in high risk patients since cardiovascular diseases represent the major cause of death in Brazil. It will be developed a cluster randomized trial, where hospitals will be allocated to receive or not the multifaceted intervention. The patients will be followed for 12 months in order to assess if the multifaceted intervention can increase the evidence based prescriptions. If this is the case, this tool package may be offered as a quality improvement intervention for all hospitals. Sites will be selected through the HCor investigators network. Invited sites must complete a screening form in order to verify eligibility and feasibility of application of the BRIDGE CV tools.Clusters will be randomized and allocated 1:1 to the Multifaceted Intervention Group or to the Control Group. Once the hospital/center is allocated to one of the groups every patient at that institution must be assisted following the same procedures. The randomization list will be created considering a random function with equal probability of being allocated to each of the groups. Each site will receive a code number and just this numbers will be used during randomization. This procedure will be performed by the HCor statistician ensuring allocation concealment. The study coordinator will inform the site what procedures must be taken, without revealing to the statistician which hospitals are allocated to the intervention group. The sample will be stratified considering primary care centers and secondary/tertiary outpatients' clinics. Considering the open nature of the study, treatment allocation will not be blinded to the investigators, health care providers and patients. However, clinical outcomes will be assessed and validated by a blinded committee.

Official Title
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A Cluster Randomized Trial Evaluating the Effect of a Multifaceted Intervention to Increase Evidence Based Strategies Usage for Cardiovascular Prevention.

Conditions
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Cardiovascular Diseases

Intervention / Treatment
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* Behavioral: Quality Improvement Intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients over 40 years old, with manifested atherothrombotic diseases ( coronary artery disease, stroke or transient ischemic attack, or peripheral artery disease) Exclusion Criteria: Patients from institutions that don't provide the Institutional Authorization Term, as well as patients that withdraw Inform Consent for Data Collection. Patients with a history of atrial fibrillation or that at the discretion of the physician needs anticoagulation, will be excluded.

Ages Eligible for Study
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Minimum Age: 40 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Control<br>Clusters randomized to the control group will keep their usual practice standards. Patient screening will be performed at the outpatient clinics and primary care centers. Both groups must complete the following forms: Admission, 06 months, and 12 months. Data collection will be performed from medical records by an independent professional not involved in patient care. Furthermore, study coordinator and data collectors from the sites, when asked, must provide appropriate documents for adjudication purposes. | |
| Experimental: Intervention<br>Educational multifaceted intervention can increase the evidence based prescriptions. If this is the case, this tool package may be offered as a quality improvement intervention for all hospitals. Health care professionals from each institution one being a physician (acting as a local leader) and the other being a research nurse (acting as a case manager) must attend the training course for high cardiovascular risk patients that will take place at HCor. | Behavioral: Quality Improvement Intervention<br>* The quality improvement intervention includes case management, reminders, check lists, educational materials, and audit and feedback reports<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Adherence to evidence based therapies | Adherence to evidence based therapies ( aspirin/antiplatelets , lipid lowering agents(statins) and ACE inhibitors/ARB) in an all or none model for patients without contra indication in a period of 12 months. | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Adherence to evidence based therapies | Adherence to aspirin/antiplatelets, lipid lowering agents(statins) and ACE Inhibitors/ARB in patients without contra indications (All or None Model). | six and twelve months | 
| LDL < 100mg/dL in 12 months | Percentage of eligible patients with LDL < 100mg/dL | 12 months | 
| LDL < 70mg/dL in 12 months | Percentage of eligible patients with LDL < 70mg/dL | 12 months | 
| Adherence to Lipid Lowering Agents (Statins) | Adherence to Lipid Lowering Agents (Statins) in patients without contraindications | 12 months | 
| Adherence to Antiplatelets | Adherence to Antiplatelets in Patients without contra-indications | 12 months | 
| Adherence to ACE inhibitors or ARBs | Adherence to ACE inhibitors or ARBs in patients without contra-indications | 12 Months | 
| Composite Outcome of Major Cardiovascular Events | Composite Outcome (death, non fatal myocardial infarction and non fatal stroke) | 12 months | 
| Adherence to Beta Blockers | Adherence to Beta Blockers in patients with a history of myocardial infarction and without contra-indications | 12 months | 
| Smoke Cessation Education | Smoke Cessation Education delivered to smokers | 12 Months | 
| Blood Pressure < 140 x 90 mmHg | Percentage of patients with blood pressure < 140 x 90 mmHg | 12 months | 
| Blood Pressure < 120 mmHg | Percentage of patients with blood pressure < 140 x 90 mmHg | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Quality Improvement, Cluster Analysis