Effectiveness of quality improvement interventions in improving cardiovascular disease-related outcomes in primary and tertiary care: A systematic review and meta-analyses

Hafiz et al. BMC Primary Care (2025) 26:366 https://doi.org/10.1186/s12875-025-03006-6 BMC Primary Care Open Access RESEARCH Effectiveness of quality improvement interventions in improving cardiovascular disease-related outcomes in primary and tertiary care: A systematic review and meta-analyses Nashid Hafiz1*, Karice Hyun1,2, Qiang Tu1, Deborah Manandi1, Wendan Shi3, Tim Usherwood4,5 and Julie Redfern1,5 Abstract Background Quality improvement strategies are increasingly being used across all healthcare settings to improve patient outcomes. However, the effectiveness of QI interventions in improving the care of cardiovascular (CVD) disease remains unclear. More evidence is needed to determine whether QI interventions can improve CVD medication use, manage risk factors, and enhance clinical outcomes. Therefore, this study aimed to systematically assess the effectiveness of QI interventions in improving CVD-related outcomes in both primary and tertiary healthcare services. Methods Six databases (Medline, Embase, PsycINFO, CENTRAL, CINAHL, and Scopus) were systematically searched for randomised and cluster randomised controlled trials from inception to 21st January 2025. Studies were included if they were randomised trials, included people with CVD, implemented a QI intervention focused on improving CVD care in either primary care services and hospitals, and measured at least one of the following outcomes: prescribed guideline-recommended CVD medications, risk factors, and clinical events. Three authors independently screened articles and extracted data from eligible studies. A random-effects model was used to estimate the pooled effects. Results Eighteen studies involving 438,285 individuals with CVD (72% male, pooled mean age [standard deviation]: 61.7 [12.8]). Commonly identified QI strategies were feedback reports (83%), decision support tools (72%), and QI teams (50%). Meta-analyses showed compared to usual care, QI interventions significantly improved lipid-lowering medications prescriptions (OR: 1.46, [95% CI: 1.08, 1.99]), reduced the rate of major cardiovascular events (MACE) (OR: 0.84, 95% CI: 0.71, 0.98) and total mortality (OR: 0.87, [95% CI: 0.77, 0.98]). Sensitivity analyses excluding one study showed significant improvements in ACEi/ARB/ARNI prescriptions (OR: 1.36, [95% CI: 1.10, 1.69]). Risk of bias analysis demonstrated significant improvements for lipid-lowering medications (OR: 1.63, [95% CI: 1.34, 2.00]), ACE/ARB/ARNI (OR: 1.90, [95% CI: 1.34, 2.71]) and beta-blockers (OR: 1.24, [95% CI:0.95, 1.61]). Subgroup analyses showed significant *Correspondence: Nashid Hafiz Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Hafiz et al. BMC Primary Care (2025) 26:366 Page 2 of 18 improvements in ACEi/ARB/ARNI (OR:1.35, [95% CI: 1.03, 1.77)]) and beta-blockers (OR:1.48, [95% CI: 1.31, 1.68)]) prescriptions along with reduced total mortality (OR: 0.86, [95% CI: 0.76, 0.98]) in hospitals. Lipid-lowering medication prescriptions improved in both primary care (OR: 1.58, [95% CI: 1.03, 2.40]) and hospitals (OR: 1.37, [95% CI: 1.08, 1.72]). In another subgroup analyses, shorter follow-up periods were associated with improvement in ACEi/ARB/ARNI (OR:1.38, [95% CI: 1.08, 1.77]), beta-blockers (OR: 1.45, [95% CI: 1.28, 1.61]) prescriptions and total mortality (OR: 0.86, [95% CI: 0.75, 0.99]). Longer follow-ups were more effective in reducing MACE (OR: 0.75, [95% CI: 0.63, 0.90]). Conclusion QI interventions can effectively improve lipid-lowering medication prescriptions, reduce MACE, and lower total mortality in CVD management. Interventions are particularly effective in hospital settings and with shorter follow-up periods for medication prescriptions, while longer follow-ups benefit MACE reduction. These findings highlight the potential of QI interventions to improve CVD management in both primary care services and hospitals, though tailored QI strategies may be needed for optimal effectiveness. Further studies are needed to fully evaluate the effectiveness of diverse QI interventions in healthcare. Systematic review registration PROSPERO registration number: CRD42021249907. Keywords Quality improvement, Primary care, Tertiary care, Cardiovascular health, Secondary prevention, Cardiovascular disease Introduction Cardiovascular disease (CVD) remains one of the leading causes of death and disease burden globally [1]. To reduce the burden, both primary and tertiary healthcare facilities globally have been increasingly adopting new, innovative strategies targeted to improve secondary prevention of CVD. Primary care serves as the frontline in secondary prevention in healthcare, which includes but is not limited to screening, diagnosis, increased adherence to guideline-recommended medications, risk factor assessment and management, among others [2–5]. Evidence from previous research found that increased adherence to guideline-recommended medications was associated with an 8% reduction in CVD events and a 12% reduction in all-cause mortality in people with coronary arterial disease [6]. Furthermore, previous research also found that effective management of risk factors not only slows the onset of CVD but also mitigate the risk of disease progression and related events and deaths [7]. Moreover, the integration of electronic health records in healthcare settings enables healthcare providers to seamlessly record, analyse and extract data to help facilitate accelerated decision-making and treatment processes [8, 9]. Leveraging the success of electronic health records integration in primary care [10]it is important to acknowledge its potential to improve healthcare providers’ capacity to efficiently monitor patients, support decision-making, and optimise care-coordination across all healthcare settings. As healthcare continues to evolve, the performance of healthcare systems in ensuring patient safety, improving efficien (...truncated)