ABC | Volume 115, Nº1, July 2020

93 Original Article Taniguchi et al. Best practice in cardiology (BPC) program Arq Bras Cardiol. 2020; 115(1):92-99 care provided to patients with cardiovascular disease (CVD). 6,7 Thus, a well-aligned clinical intervention such as a multiyear QI program like the American Heart Association (AHA) Get With The Guidelines (GWTG) program, if adapted to the guidelines and health care delivery system of Brazil, might have a significant impact on treatment and outcomes of CVD patients and practice patterns of their caregivers. GWTG is a QI program created by the AHA and the American Stroke Association (ASA) with the aim of improving the care of patients hospitalized with CVD. It was created to assist hospitals in redesigning the care delivered for heart conditions of high economic burden such as acute coronary syndrome (ACS), atrial fibrillation (AF), heart failure (HF) and stroke and has been validated in the United States over the past 17 years. It has been shown to improve in-hospital quality of care, patient outcomes, and costs. 8 It is within this context, after appropriate adaptation to the Brazilian healthcare system, that this novel program is being launched. Its main objective is to assess the adherence rates of hospital health professionals to the latest AHA/SBC guidelines’ recommendations on HF, AF and ACS and its effect on patient outcomes and quality of life before and after the implementation of a Best Practice in Cardiology (BPC) program adapted from the GWTG initiative. This initiative in Brazil is the result of a tripartite collaboration of the AHA, the SBC and the Brazilian Ministry of Health, with participation of the Hospital do Coração (HCor), to be tested in selected public hospitals and if proven effective, to be further implemented countrywide. Methods BPC is a QI program that was adapted from GWTG and approved by the Institutional Review Board (IRB) of the Coordinating Center under the number 48561715.5.1001.0060. It will be implemented in selected tertiary hospitals of the Brazilian public health system in the five macro-regions of Brazil. The study steering committee and coordination groups are described in Appendix 1. After acceptance to participate and local IRB approval, the project management group will make an initial visit to make sure that the center meets the infrastructure requirements to participate in the program and to present it to local leadership. The effect of the program on measures of institutional performance, quality of life and clinical outcomes will be evaluated in a cohort quasi-experimental study design combined with a cohort design, through data collection before and after the implementation of the BPC Program. Before the intervention, evaluation will occur over a period of approximately two months prior to the implementation of the BPC program in the institution or after the inclusion of the first 15 patients in each arm. Post-intervention evaluation will be conducted after the first intervention and will last approximately 18 months. Patients will be followed through telephone contact at one and six months after discharge by local trained interviewers. A multidisciplinary team composed of a local leader, doctors, nurses, and patient educators will be responsible for establishing local strategies for improvement and driving the efforts to the local program. Population Eligible patients will be consecutive patients aged 18 years or older, admitted to the selected hospitals with a primary diagnosis of acute HF (ICD-10 code I50; I50.0; I50.1 or I50.9), ACS (ICD10 codes: I20.0 to I21.9 and I22.0 to I22.9) or AF/ Atrial Flutter (ICD-10 code I-48), regardless of a previous history of any of these conditions, and agree to participate in the study by signing an informed consent form. Screening for AF/flutter patients may be performed in the outpatient clinic. The details of eligibility criteria can be found in Appendix 2. Definition of performance measures and quality metrics Performance measures and quality metrics were selected from the American College of Cardiology (ACC)/AHA care metrics on HF, 9 ACS 10 and AF 11 to compose two sets of indicators for each of these conditions. As previously reported, the former set of indicators were derived from class I recommendations of the latest ACC/AHA guidelines and included public comment and a peer review process whereas the latter was derived from other recommendations not following a strict methodology. 12,13 These performance and quality metrics have then been reviewed and adapted to be consistent with current guidelines in Brazil. Twenty-one performance measures were selected, five for HF, nine for ACS and seven for AF (Table 1). Twenty-two other quality metrics were included in the three arms of the program, nine for HF, six for ACS and seven for AF (Appendix 3). Eligible patients are defined as those patients without documented intolerance or contraindications for that specific measure. The overall rates of adherence to recommendations will be measured using an opportunity-based approach according to ACC/AHA methodology. 14 Outcome measures Length of stay, in-hospital mortality, cardiac mortality at one month and at six months, and readmission within one month and six months due to a cause related to the index admission will be computed. In addition, quality of life and health perception will be measured using the WHOQOL-BREF questionnaire 15 and the Numering Rating Scale (NRS), 16 respectively, at discharge and at six months. Identification of barriers at baseline Possible causes of non-adherence to guidelines that require specific interventions will be identified through discussion with the institutions, via a semi-structured interview (Appendix 4). The semi-structured interviewwill be held before the start of the project for mapping institutional processes and flow of care in each arm in which the institution is enrolled. These interviews aim to identify specific behavioral changes needed to encourage participation in the BPC program as well as adherence to guideline recommendations. Thus, when care processes lead to failure to implement recommended therapies, changes can be implemented to improve a specific process or care.