Summary of findings
| In-hospital heart failure quality improvement interventions compared with usual care | ||||
|
Patient or population: hospitalised patients with heart failure Intervention: in-hospital heart failure quality improvement interventions Comparison: usual care | ||||
| Outcome | Effect on outcome | Number of hospitals and/or participants (studies) | Quality of the evidence (GRADE) | Comments |
| In-hospital mortality | Two of three trials (n=74 735) showed no effect of the intervention on in-hospital mortality (estimated treatment effect: −0.03, 95% CI −1.12 to 1.05; intervention effect: 1.0%, 95% CI −3.0% to 5.0%). One trial (n=429) had lower in-hospital mortality in the intervention (5.6%, 95% CI 2.5% to 8.7%) compared with usual care (15.4%, 95% CI 10.5% to 20.2%). | Hospitals=189. Participants=75 164. (three cluster RCTs). | ⨁⨁◯◯ Low*† | The point estimates vary, and the direction of effect is not consistent.* There are small number of included studies (n=3) but with high overall sample size.† |
| In-hospital medical therapy | One trial demonstrated a positive effect of the intervention towards increased in-hospital medical therapy for ACE-I (57.9% vs 40.0%) and BB (46.7% vs 10.2%) but no change in in-hospital diuretics (95.3% vs 95.8%). | Hospitals=14. Participants=429 (one cluster RCT). | ⨁⨁◯◯ Low*† | Although the magnitude of sample size is high, only one study reported this outcome.*† |
| Discharge medical therapy | Five out of six trials (n=78 727) showed no effect of the intervention on discharge medical therapy for ACE-I/ARB (estimated treatment effect: 0.75, 95% CI −2.66 to 4.16; 3% vs 3%; 86% vs 79%; 60% vs 41.7%; intervention effect: −7%, 95% CI −20% to 5%). Three out of three trials (n=89 660) showed no effect of the intervention on discharge medical therapy for BB (estimated treatment effect: 1.05, 95% CI −1.17 to 3.27; 65% vs 61%; absolute difference: 3.5%, 95% CI −6.1% to 13.1%). | Hospitals=307. Participants=96 271. (five cluster RCTs and one RCT). | ⨁⨁⨁◯ Moderate* | The direction of effect is inconsistent, and the point estimates vary across studies.* Magnitude of included studies is moderate (n=6) with high overall sample size. |
| Hospital readmission (up to 90 days after discharge) | Two out of three trials (n=419) showed a trend towards decreased hospital readmissions in the intervention compared with usual care (37% vs 67%; 7% vs 19%). | Participants=706 (three RCTs). | ⨁⨁◯◯ Low*† | The point estimates vary and the direction of effect is not consistent.* There are small number of included studies (n=3) with moderate overall sample size.† |
| 30-day all-cause mortality | Two out of two trials showed no effect of the intervention on 30-day all-cause mortality (7% vs 7%; absolute difference: −1.1%, 95% CI −3.2% to 0.9%). | Hospitals=86. Participants=17 681 (one cluster RCT, one RCT). | ⨁⨁◯◯ Low1 2 | Although the direction of effect is consistent, the point estimates vary in the setting of small number of included studies (n=2) with high overall sample size.1 2 |
| Hospital length of stay | The mean days in the intervention ranged from 6.2 to 10.4 days and in usual care from 7.0 to 11.4 days. | Hospitals=24. Participants=3335 (two cluster RCTs). | ⨁⨁◯◯ Low1 2 | The point estimates vary and the direction of effect is not consistent.* There are small number of included studies (n=2) with moderate overall sample size.† |
| Patient-level health-related quality of life | One out of three trials (n=282) showed a trend towards better quality of life in the intervention compared with usual care (mean change (SD): 22.1 (20.8) versus 11.3 (16.4)). | Hospitals=10. Participants=3411 (one cluster RCT, two RCTs). | ⨁◯◯◯ Very low1–3 | The direction of effect is not consistent* in the setting of small number of included studies (n=3). All studies likely have high risk of detection bias in use of questionnaires to assess self-reported outcomes.‡ |
*Downgraded due to inconsistency.
↵†Downgraded due to imprecision.
‡Downgraded due to study limitations.
GRADE Working Group grades of evidence (Guyatt et al. BMJ 2008; 336 (7650):924–926).
High quality: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
ACE-I, ACE inhibitor; ARB, angiotensin receptor blocker; BB, beta-blocker; cRCT, cluster randomised control trial; GRADE, Grading of Recommendations Assessment, Development and Evaluation; RCT, randomised control trial.