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Hospital-based quality improvement interventions for patients with heart failure: a systematic review
  1. Anubha Agarwal1,
  2. Ehete Bahiru2,
  3. Sang Gune Kyle Yoo3,
  4. Mark A Berendsen4,
  5. Sivadasanpillai Harikrishnan5,
  6. Adrian F Hernandez6,7,
  7. Dorairaj Prabhakaran8,9,
  8. Mark D Huffman3,10
  1. 1 Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  2. 2 Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
  3. 3 Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  4. 4 Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  5. 5 Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum Medical College, Trivandrum, Kerala, India
  6. 6 Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
  7. 7 Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
  8. 8 Centre for Chronic Disease Control, New Delhi, India
  9. 9 Public Health Foundation of India, Gurugram, Haryana, India
  10. 10 The George Institute for Global Health, Sydney, New South Wales, Australia
  1. Correspondence to Dr Anubha Agarwal, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago IL 60611, USA; anubha.agarwal{at}


Objective To estimate the direction and magnitude of effect and quality of evidence for hospital-based heart failure (HF) quality improvement interventions on process of care measures and clinical outcomes among patients with acute HF.

Review methods We performed a structured search to identify relevant randomised trials evaluating the effect of in-hospital quality improvement interventions for patients hospitalised with HF through February 2017. Studies were independently reviewed in duplicate for key characteristics, outcomes were summarised and a qualitative synthesis was performed due to substantial heterogeneity.

Results From 3615 records, 14 randomised controlled trials were identified for inclusion with multifaceted interventions. There was a trend towards higher in-hospital use of ACE inhibitors (ACE-I; 57.9%vs40.0%) and beta-blockers (BBs; 46.7%vs10.2%) in the intervention than the comparator in one trial (n=429 participants). Five trials (n=78 727 participants) demonstrated no effect of the intervention on use of ACE-I or angiotensin receptor blocker at discharge. Three trials (n=89 660 participants) reported no effect on use of BB at discharge. Two trials (n=419 participants) demonstrated a trend towards lower hospital readmission up to 90 days after discharge. There was no consistent effect of the quality improvement intervention on 30-day all-cause mortality, hospital length of stay and patient-level health-related quality of life.

Conclusions Randomised trials of hospital-based HF quality improvement interventions do not show a consistent effect on most process of care measures and clinical outcomes. The overall quality of evidence for the prespecified primary and key secondary outcomes was very low to moderate, suggesting that future research will likely influence these estimates.

Trial registration number CRD42016049545.

  • heart failure
  • quality and outcomes of care
  • systemic review

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  • Contributors AA, EB, MAB, AFH, DP and MDH conceived and designed the study. MAB did the scientific literature search. AA, EB, SGKY and MDH screened abstracts and full texts. AA, SGKY and MDH performed data extraction, risk of bias and graded the quality of evidence. All authors contributed to the data analysis and critically revised the manuscript. AA is the study guarantor.

  • Funding AA received funding from the Fogarty International Center of the National Institutes of Health, Duke Global Health Institute and Duke Hubert-Yeargan Center for Global Health for this research. Research reported in this publication was supported by the Fogarty International Center and National Institute of Mental Health of the National Institutes of Health under Award Number D43TW010543. The authors are independent from the funders.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

  • Competing interests MDH receives funding from the World Heart Federation to serve as its senior programme advisor for the Emerging Leaders programme, which is supported by Boehringer Ingelheim and Novartis with previous support from BUPA and AstraZeneca. MDH also receives support from the American Heart Association, Verily and AstraZeneca for work unrelated to this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data are freely available within the appendices in the data supplement. No additional data available.

  • Patient consent for publication Not required.

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