ABC | Volume 115, Nº1, July 2020

96 Original Article Taniguchi et al. Best practice in cardiology (BPC) program Arq Bras Cardiol. 2020; 115(1):92-99 The longitudinal effect of the program on HF, ACS and AF will be assessed by comparing the overall rates of adherence to the recommendations before and after its implementation in the participating institutions on a quarterly basis, using a generalized linear mixed-effect model (GLMM) for time trend analysis over a time horizon of 18 months. It will be expressed by means of proportions and their respective 95% confidence intervals. It is expected that the random effect approach used by GLMM will account for between-site differences at baseline. 29 Quality of life scores will be calculated using the methodology reported in the WHOQOL-BREF questionnaire manual. 30 The total score consists of the average of the scores of the four domains of the instrument (physical health, psychological health, social relationships and environment). 30 The internal consistency of the instrument will be calculated using the Cronbach’s alpha coefficient. It shall be considered appropriate a value above 0.7. The results observed over time in the participating institutions on the dependent variables of mortality, readmission rate, length of stay, variation in quality of life and in health perception will be adjusted by multivariable GLMM for demographic, clinical and socioeconomic variables, disease severity, risk factors, initial self-perception of health (NRS), level of health literacy and degree of specific and overall adherence of the institution to clinical recommendations. The variables will be included in the model when associated in the univariate or bivariate analysis (p <0.20) and according to clinical relevance. Odds ratios or relative risks will be calculated, as appropriate, with respective 95% CI. All analyses will be two-tailed and performed independently for each arm of the protocol using a 0.05 significance level. Discussion Why is this project needed? In Brazil, a large country with a complex universal healthcare system, 1 the quality of cardiovascular care has been the subject of evaluation and concern. Patient access to the various levels of healthcare varies throughout the country and the quality of care delivered is highly heterogeneous. 1,2 As in other parts of the world and in spite of medical society efforts in publishing clinical guidelines, mortality related to CVD remains high, reflecting the difficulty of patients having access to recommended therapies and care at appropriate times. 31,32 Registries performed by SBC in multiple regions of Brazil have shown a high variation in the quality of care delivered for cardiovascular conditions of high economic burden, 32,33 such as coronary artery disease (CAD) 3,34 HF, 4 stroke, and AF. 35 These registries have shown that adherence to evidence- based therapies remains suboptimal and, at least for HF, the lack of optimal therapies is more critical in the public non- academic institutions of the poorest regions of Brazil. 4 It was also observed that morbidity and mortality related to HF are much higher than those observed in developed countries, even when adjusting for region, number of hospital beds and type of institution. The Brazilian registries have contributed enormously in demonstrating how these highly prevalent conditions are being approached across the country, but they have not addressed the gap in the implementation of interventions that may have prevented improvements in the quality of care. Furthermore, they have not controlled for situations where specific therapies are not recommended or are contraindicated. 3,4,34,35 The two randomized trials (BRIDGE-ACS and IMPACT‑AF) performed in Brazil for testing multifaceted interventions to promote adherence to guideline recommendations have shown that the implementation of QI interventions is feasible and can be effective. 6,7 However, these studies did not consider barriers related to local context, did not test if the results observed on adherence to recommendations are sustained over time or the effect of the interventions on patients’ quality of life. 6,7 The BRIDGE-ACS trial, for example, which was performed mostly in academic institutions, 36 achieved at most 68% adherence to acute therapies and only 51% adherence if all acute and discharge therapies were considered, with no impact on 30-day mortality. 6 The GWTG program show that hospitals achieving at least 85% of compliance to evidence-based therapies reached better results on clinical outcomes. 37,38 These findings provide a compelling argument in support of the implementation of a QI initiative in Brazilian hospitals that considers the complexity of the local reality and that has already been tested and proven effective elsewhere. The GWTG program, implemented in nearly 50% of all U.S. hospitals, has shown a sustained effect on mortality, length of stay and costs. 39 There is thus the potential to decrease the economic burden imposed by ACS, HF and AF on the Brazilian health system. What is different in the Brazilian program? Despite the fact that the GTWG program has been deployed in the U.S. for more than 15 years, only as recently as 2016 has another country (China) taken advantage of a similar ACS program. 36 In Brazil we are starting the program in three different dimensions: ACS, AF and HF. A nationwide quality program focusing on multiple conditions, including outpatient clinics has never been tested within the GWTG experience. 8,22 Also, the notion of patient-reported outcomes including quality of life has been contemplated for the BPC program and may help ministries and cardiology societies in directing health policies to local needs. The identification of barriers and facilitators in each hospital is considered one of the key steps in the success of clinical implementation strategies. In this project, we are using as a conceptual model a didactic framework proposed by Michie, Stralen and West, 24 which integrates dynamic and interactive mechanisms to promote behavioral changes resulting from the interaction between the individual (capability and motivation) and the environment (opportunities). 24 This model will also help the coordinating center in identifying and acting on specific institutional needs during the course of the project. In doing so, in some institutions, intervention will be focused on improving capacity, in others on increasing