Centre for Chronic Disease Control, New Delhi, India.
Public Health Foundation of India, Gurgaon, India.
Implement Sci. 2019 Feb 6;14(1):12. doi: 10.1186/s13012-019-0857-7.
The ACS QUIK trial showed that a multicomponent quality improvement toolkit intervention resulted in improvements in processes of care for patients with acute myocardial infarction in Kerala but did not improve clinical outcomes in the context of background improvements in care. We describe the development of the ACS QUIK intervention and evaluate its implementation, acceptability, and sustainability.
We performed a mixed methods process evaluation alongside a cluster randomized, stepped-wedge trial in Kerala, India. The ACS QUIK intervention aimed to reduce the rate of major adverse cardiovascular events at 30 days compared with usual care across 63 hospitals (n = 21,374 patients). The ACS QUIK toolkit intervention, consisting of audit and feedback report, admission and discharge checklists, patient education materials, and guidelines for the development of code and rapid response teams, was developed based on formative qualitative research in Kerala and from systematic reviews. After four or more months of the center's participation in the toolkit intervention phase of the trial, an online survey and physician interviews were administered. Physician interviews focused on evaluating the implementation and acceptability of the toolkit intervention. A framework analysis of transcripts incorporated context and intervening mechanisms.
Among 63 participating hospitals, 22 physicians (35%) completed online surveys. Of these, 17 (77%) respondents reported that their hospital had a cardiovascular quality improvement team, 18 (82%) respondents reported having read an audit report, admission checklist, or discharge checklist, and 19 (86%) respondents reported using patient education materials. Among the 28 interviewees (44%), facilitators of toolkit intervention implementation were physicians' support and leadership, hospital administrators' support, ease-of-use of checklists and patient education materials, and availability of training opportunities for staff. Barriers that influenced the implementation or acceptability of the toolkit intervention for physicians included time and staff constraints, Internet access, patient volume, and inadequate understanding of the quality improvement toolkit intervention.
Implementation and acceptability of the ACS QUIK toolkit intervention were enhanced by hospital-level management support, physician and team support, and usefulness of checklists and patient education materials. Wider and longer-term use of the toolkit intervention and its expansion to potentially other cardiovascular conditions or other locations where the quality of care is not as high as in the ACS QUIK trial may be useful for improving acute cardiovascular care in Kerala and beyond.
NCT02256657.
ACS QUIK 试验表明，多组分质量改进工具包干预措施可改善喀拉拉邦急性心肌梗死患者的护理流程，但在护理背景改善的情况下并未改善临床结局。我们描述了 ACS QUIK 干预措施的制定，并评估了其实施、可接受性和可持续性。
我们在印度喀拉拉邦进行了一项混合方法的过程评估，同时进行了一项集群随机、阶梯式试验。ACS QUIK 干预措施旨在与常规护理相比，降低 30 天内主要不良心血管事件的发生率，涉及 63 家医院（n=21374 例患者）。ACS QUIK 工具包干预措施由在喀拉拉邦进行的形成性定性研究和系统评价组成，包括审核和反馈报告、入院和出院清单、患者教育材料以及制定代码和快速反应团队的指南。在中心参与试验的工具包干预阶段四个月或更长时间后，进行了在线调查和医生访谈。医生访谈侧重于评估工具包干预措施的实施和可接受性。对转录本的框架分析纳入了背景和干预机制。
在 63 家参与医院中，有 22 名医生（35%）完成了在线调查。其中，17 名（77%）答复者报告其医院有心血管质量改进团队，18 名（82%）答复者报告阅读过审核报告、入院清单或出院清单，19 名（86%）答复者报告使用过患者教育材料。在 28 名受访者（44%）中，工具包干预措施实施的促进因素包括医生的支持和领导力、医院管理人员的支持、清单和患者教育材料的易用性，以及为员工提供培训机会。影响医生对工具包干预措施实施或接受的障碍包括时间和人员限制、互联网接入、患者量和对质量改进工具包干预措施的理解不足。
医院层面的管理支持、医生和团队支持以及清单和患者教育材料的有用性增强了 ACS QUIK 工具包干预措施的实施和可接受性。更广泛和更长期地使用工具包干预措施，并将其扩展到潜在的其他心血管疾病或其他护理质量不如 ACS QUIK 试验的地区，可能有助于改善喀拉拉邦及其他地区的急性心血管护理。
NCT02256657。
