Team-Based Quality Improvement Strategy Boosts Chronic Heart Care in India, Trial Finds

Heart disease, stroke, and heart failure are chronic conditions that demand lifelong attention, yet the quality of long-term care for these illnesses remains strikingly poor in many parts of the world. Now, a randomized feasibility trial conducted in India offers a promising answer to one of global health’s most stubborn problems: how to make sure that people who have already survived a cardiovascular event actually receive the proven medicines and follow-up care that could prevent the next one. The trial, known as C-QIP, tested a multicomponent quality improvement strategy in routine outpatient clinics and found that the approach was not only deliverable in real-world settings but also meaningfully improved prescribing and patient behaviors.

The scale of the underlying problem is enormous. Cardiovascular diseases caused an estimated 20.5 million deaths and 300 million disability-adjusted life years in 2024, with a disproportionate burden falling on low- and middle-income countries where these diseases strike working-age adults. Secondary prevention, the use of evidence-based drugs and lifestyle management in people with established disease, is one of the most powerful tools available to blunt this burden. Yet the international PURE study, which followed patients across 17 countries, documented alarmingly low use of proven secondary prevention drugs: antiplatelets in just 25 percent of eligible patients, beta-blockers in 17 percent, ACE inhibitors or ARBs in 20 percent, and statins in a mere 15 percent, with the lowest use in low-income settings where only 3 percent of patients took statins.

Updated analyses from PURE, published in 2025, revealed that the situation is not improving. Globally, the use of at least one recommended drug class among people with cardiovascular disease hovered around 41 percent in 2007, peaked near 43 percent, and then fell to roughly 31 percent by 2019. Even in high-income countries, use declined from about 89 percent to 77 percent. In India, the picture was particularly sobering: use of at least one secondary prevention medication class stood at 21.4 percent at baseline, rose to a mid-period peak of 43 percent, and then slid back to 21.6 percent by the last visit. These figures describe a stalled, or even worsening, implementation gap, driven by fragmented healthcare delivery, clinical inertia, limited insurance coverage, poor patient awareness, and weak long-term adherence.

To confront this gap, researchers led by Kavita Singh of the Centre for Chronic Disease Control and Public Health Foundation of India, together with senior co-authors Mark Huffman and Dorairaj Prabhakaran, designed the C-QIP trial as a pragmatic, individual-level randomized controlled feasibility study. The strategy was not dreamed up in a conference room. It emerged from a co-design process involving patients living with heart disease, their caregivers, nurses, pharmacists, physicians, cardiologists, healthcare administrators, and policy makers, informed by a systematic scoping review, qualitative interviews, and a modified Delphi consensus survey among experts. The result was a five-part intervention: trained non-physician cardiovascular care coordinators who each managed 50 to 60 patients; an electronic health record with an embedded clinical decision support system that generated guideline-recommended prompts for physicians; tailored text-message reminders promoting healthy behaviors, clinic attendance, and medication adherence; a patient diary with a visual medication adherence tool; and quarterly audit-and-feedback reports for providers built around Plan-Do-Study-Act cycles.

Between September 2022 and September 2023, the team screened 492 adults at four hospitals, two public and two private, in Delhi and Karnataka, and randomized 410 patients with ischemic heart disease, ischemic stroke, or heart failure to either the C-QIP strategy or usual care. The control arm received a printed leaflet on healthy behaviors and routine care, delivered by separate staff to minimize contamination. The trial’s primary goal was explicitly about implementation rather than definitive clinical effectiveness: could such a strategy be delivered with high fidelity in busy outpatient clinics, and would patients and providers accept it? The answer, on both counts, was a resounding yes. At the end of the study, with a median follow-up of about 15 months, retention was 93.2 percent in the intervention arm and 91.7 percent in usual care, far exceeding the prespecified 80 percent threshold.

Fidelity to the intervention was equally impressive. Cardiovascular care coordinators delivered lifestyle counseling to 94.4 percent of intervention participants at the final visit, including counseling on healthy diet for 99.5 percent, exercise for 98.4 percent, stress avoidance for 90.9 percent, and home blood pressure monitoring for 90.4 percent. Adoption of the electronic decision support system was universal, with prompts reviewed at 100 percent of follow-up visits, though physician acceptance varied by prompt type. Acceptability was striking: 98.4 percent of patients reported that the strategy made medication adherence easier, and 97.9 percent wanted to continue using it beyond the trial. On the provider side, 98.4 percent found decision-support-enabled care satisfactory, and every single provider said the system made it easy to follow guidelines.

The preliminary effectiveness signals were the trial’s most consequential findings. Use of guideline-directed medical therapy, the evidence-based combination of drugs proven to prevent recurrent events, rose dramatically in the intervention arm. Among patients with ischemic heart disease, 58.3 percent in the C-QIP group received the full recommended bundle compared with 32.4 percent under usual care, a relative risk of 1.45. For ischemic stroke, the effect was even larger: 76.7 percent versus 31.8 percent, a relative risk of 2.41. Heart failure was the exception, with no significant difference between groups, a result the authors suggest may reflect the higher cost and more complex access pathways for newer heart failure medications, which decision support and coordination alone cannot overcome. Patient behaviors also shifted favorably, with self-reported adherence higher in the intervention arm for medications, diet, and physical activity, the last showing a particularly large gap of 91.4 percent versus 70.4 percent.

The intervention also transformed the texture of care itself. Patients in the C-QIP arm averaged 7.1 outpatient visits in the past year compared with 2.0 in usual care, and 7.6 clinic blood pressure checks versus 1.6. Reminder systems were transformed: 70.7 percent of intervention patients received phone calls after missed appointments versus 4.4 percent of controls, and 41.4 percent received calls prompting laboratory tests versus 0.5 percent. Consultations lasted longer, treatment satisfaction scores were significantly higher across all domains, and family involvement in self-care, from healthy eating to smoking cessation support, increased markedly. Exploratory clinical measures showed a small but significant reduction in diastolic blood pressure, with non-significant favorable trends in systolic pressure, though the trial was never powered to detect differences in risk factors or clinical events.

The authors are careful about what these results do and do not prove. Individual randomization within shared clinics raises the possibility of contamination, since providers exposed to decision-support prompts may have altered care for control patients, and future confirmatory trials should use cluster randomization. The trial was unblinded, relied partly on self-reported adherence, and examined multiple secondary outcomes without adjustment for multiplicity, so some findings could reflect chance. Implementation also occurred under research-supported conditions with dedicated coordinators, and real-world rollout may face resource and workload challenges. Still, sensitivity analyses using inverse probability weighting supported the robustness of the main findings, and the consistency of effects across implementation measures, prescribing, and behavior lends credibility to the overall picture.

The significance of C-QIP extends well beyond its four hospitals. It builds on a lineage of Indian implementation research, including the ACS-QUIK trial for acute coronary syndrome care, the SPREAD trial of community health worker support after heart attacks, and the CARRS Translation Trial in diabetes, and it aligns squarely with India’s updated National Programme for Prevention and Control of Noncommunicable Diseases, which emphasizes team-based care, digital health tools, and task-sharing with non-physician workers. Compared with international efforts such as COORDINATE-Diabetes in the United States and BRIDGE in Brazil, C-QIP provides unusually granular implementation data from a resource-constrained setting. The next step, the authors argue, is a large, cluster-randomized hybrid effectiveness-implementation trial with long enough follow-up to determine whether these gains in care processes translate into fewer heart attacks, strokes, and deaths. If they do, the humble combination of a care coordinator, a decision-support prompt, a text message, and a quarterly feedback report could become one of the most cost-effective weapons in the global fight against cardiovascular disease.

Subject of Research: A multicomponent quality improvement strategy for chronic cardiovascular disease care in India

Article Title: Assessing a multicomponent quality improvement strategy for chronic care of cardiovascular diseases in India: The C-QIP randomized feasibility trial

Article References: Singh, K., Roy, A., Kondal, D., Nikhare, K., Gandral, M., Patil, S. G., Aithal, K., Girish, M. P., Gupta, M., Madan, K., Sawhney, J. P. S., Ali, K., Jain, M., Kushwaha, S., Jindal, D., Mendenhall, E., Patel, S. A., Narayan, K. M. V., Tandon, N., … Prabhakaran, D. (2026). Assessing a multicomponent quality improvement strategy for chronic care of cardiovascular diseases in India: The C-QIP randomized feasibility trial. PLOS Medicine, 23(9), e1004932. https://doi.org/10.1371/journal.pmed.1004932

Image Credits: AI Generated

DOI: 10.1371/journal.pmed.1004932

Keywords: cardiovascular disease, quality improvement, India, randomized controlled trial, guideline-directed medical therapy, clinical decision support, secondary prevention, care coordination, implementation science, heart failure, ischemic stroke, medication adherence