Quality Improvement for Cardiovascular Disease Care in Low- and Middle-Income Countries: A Systematic Review.
BACKGROUND
The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care.


OBJECTIVE
As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs.


METHODS
We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD.


RESULTS
From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months.


CONCLUSIONS
The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.
Department of Medicine, Division of Geriatric, Hospital, Palliative and General Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California, United States of America.
Edward S
ES
Lee
Department of Medicine, Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America.
Rajesh
R
Vedanthan
Centre for Control of Chronic Conditions, Public Health Foundation of India, Kerala, India.
Panniyammakal
P
Jeemon
Moi University College of Health Sciences, Eldoret, Kenya.|Academic Model Providing Access to Healthcare, Eldoret, Kenya.
Jemima H
JH
Kamano
Health, Nutrition and Population Global Practice, The World Bank, Kathmandu, Nepal.
Preeti
P
Kudesia
The World Bank, Jakarta, Indonesia.
Vikram
V
Rajan
Center for Translation Research and Implementation Science, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, United States of America.
Michael
M
Engelgau
Department of Medicine, Division of General Medicine, Columbia University Medical Center, New York, New York, United States of America.
Andrew E
AE
Moran
D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000517:prevention & control* / Q000628:therapy; D003695:Delivery of Health Care; D003906:Developing Countries; D003920:Diabetes Mellitus / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy; D006282:Health Personnel; D006801:Humans; D058996:Quality Improvement; D012959:Socioeconomic Factors