Quality Improvement in Cardiovascular Disease Care

This chapter reviews the diagnosis and treatment of cardiovascular disease in low- and middle-income countries (LMICs) with a view to improving the quality of care. In keeping with the Institute of Medicine’s definition of quality as the “degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr 1990, 4), the focus is on studies of specific interventions and measurable health outcomes. Because the resources available to support health care delivery in LMICs are scarce, this chapter seeks to improve clinical quality by getting the most out of known effective interventions within the limits of available resources rather than recommending unproven interventions that require early-phase studies or substantial investment to scale up. Clinical quality can be improved anywhere and at any time and doing so need not be expensive. Quality standards and measures contain principles that can be compared and shared across countries and local settings. However, quality care delivery in low-resource settings does not necessarily mean dissemination and implementation of a universal set of standards—especially those formulated for cardiovascular diseases in high-income countries (HICs). Standards and interventions should be dictated by context and community capacity. Adaptation to the local setting is necessary for achieving optimal clinical outcomes and patient satisfaction. A conceptual framework guided this chapter. The authors specified four domains, cutting across two distinct phases of cardiovascular disease (acute versus chronic) and two levels of intervention (health system versus patient-provider) (table 18.1). Health system–level interventions include those directly targeting one or more of the six “building blocks of a health system” as defined by the World Health Organization (2007). Patient-provider-level interventions are focused on influencing patient or provider behavior. Acute phases of cardiovascular disorders, such as acute myocardial infarction, stroke, and limb ischemia, occur unpredictably. Good outcomes demand timely clinical responses, which require adequate and accessible facilities, functional transportation networks, providers prepared to treat cases that present at all hours, and patient awareness of when and how to seek medical attention. In contrast, chronic phases of cardiovascular disorders, such as diabetes mellitus, hypertension, and congestive heart failure, require screening for preclinical risk factors, systematic monitoring for complications, and substantial patient self-care and engagement to initiate and maintain treatment adherence. Good-quality, chronic-phase care may prevent or delay onset of acute-phase manifestations, thereby preventing or delaying disability or death. Quality interventions are examined at the health care system and patient-provider levels. The authors populated the four domains of this two-by-two framework with potential quality improvement levers based on previous knowledge of the field and examples gleaned from other chapters in this volume. Once the framework was established, a systematic literature review was conducted to identify evidence supporting specific interventions within it. The results are accompanied by detailed narratives of clinical quality improvement efforts for cardiovascular diseases, including the story of a comprehensive community-based cardiovascular disease primary prevention program in Kenya, the experience of an acute coronary syndrome (ACS) clinical pathways intervention in China, and a spotlight on mobile health (m-health) applications around the world.