Optimizing primary care management of atrial fibrillation: The rationale and methods of the Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) study

Perceptions of primary care patients on the use of electronic clinical decision support tools to facilitate health care: A systematic review

OBJECTIVE

Electronic clinical decision support tools (eCDSTs) are interventions designed to facilitate clinical decision-making using targeted medical knowledge and patient information. While eCDSTs have been demonstrated to improve quality of care, there is a paucity of research relating to the acceptability of eCDSTs in primary care from the patients' perspective. This study aims to summarize current evidence relating to primary care patients' perceptions and experiences on the use of eCDSTs by their clinician to provide care.

METHODS

Four databases (Medline, Embase, CINAHL and Cochrane Library) were searched for qualitative and quantitative studies with outcomes relating to patients' perceptions of the use of clinician-facing or shared-eCDSTs. Data extraction and critical appraisal using the Johanna Briggs Institute Critical Appraisal checklists were carried out independently by reviewers. Qualitative and quantitative outcomes were synthesized independently. We used Richardson et al. 'Patient Evaluation of Artificial Intelligence (AI) in Healthcare' framework for qualitative analysis.

FINDINGS

20 papers were included for synthesis. eCDSTs were generally well-regarded by patients. The key facilitators for use were promoting informed decision-making, prompting discussions, aiding clinical decision-making, and enabling information sharing. Key barriers for use were lack of holistic care, 'medicalized' language, and confidentiality concerns.

CONCLUSION

Our study identified important aspects to consider in the development of future eCDSTs. Patients were generally positive regarding the use of eCDSTs; however, patient's perspectives should be included from the conception of new eCDSTs to ensure recommendations align with the needs of patients and clinicians.

PRACTICE IMPLICATIONS

The study results contribute to ensuring the acceptability of eCDSTs for patients and their unique needs. Encouragement is given for future development to adopt and build upon these findings. Additional research focusing on patients' perceptions of using eCDSTs for specific health conditions is deemed necessary.

Computerized clinical decision support to improve stroke prevention therapy in primary care management of atrial fibrillation: a cluster randomized trial

BACKGROUND

Despite guidelines supporting antithrombotic therapy use in atrial fibrillation (AF), under-prescribing persists. We assessed whether computerized clinical decision support (CDS) would enable guideline-based antithrombotic therapy for AF patients in primary care.

METHODS

This cluster randomized trial of CDS versus usual care (UC) recruited participants from primary care practices across Nova Scotia, following them for 12 months. The CDS tool calculated bleeding and stroke risk scores and provided recommendations for using oral anticoagulants (OAC) per Canadian guidelines.

RESULTS

From June 14, 2014 to December 15, 2016, 203 primary care providers (99 UC, 104 CDS) with access to high-speed Internet were recruited, enrolling 1,145 eligible patients (543 UC, 590 CDS) assigned to the same treatment arm as their provider. Patient mean age was 72.3 years; most were male (350, 64.5% UC, 351, 59.5% CDS) and from a rural area (298, 54.9% UC, 315, 53.4% CDS). At baseline, a higher than anticipated proportion of patients were receiving guideline-based OAC therapy (373, 68.7% UC, 442, 74.9% CDS; relative risk [RR] 0.97 (95% confidence interval [CI], 0.87-1.07; P = .511)). At 12 months, prescription data were available for 538 usual care and 570 CDS patients, and significantly more CDS patients were managed according to guidelines (415, 77.1% UC, 479, 84.0% CDS; RR 1.08 (95% CI, 1.01-1.15; P = .024)).

CONCLUSION

Notwithstanding high baseline rates, primary care provider access to the CDS over 12 months further optimized the prescribing of OAC therapy per national guidelines to AF patients potentially eligible to receive it. This suggests that CDS can be effective in improving clinical process of care.

TRIAL REGISTRATION

Clinical Trials NCT01927367. https://clinicaltrials.gov/ct2/show/NCT01927367?term=NCT01927367&draw=2&rank=1.

Resource use and cost associated with computerized decision support system and usual care in managing patients with atrial fibrillation: analysis of IMPACT-AF randomized trial data

BACKGROUND

IMPACT-AF is a prospective, randomized, cluster design trial comparing atrial fibrillation (AF) management with a computerized decision support system (CDS) to usual care (control) in the primary care setting of Nova Scotia, Canada. The objective of this analysis was to compare the resource use and costs between CDS and usual care groups.

METHODS

Case costing data, 12-month self-administered questionnaires, and monthly diaries from IMPACT-AF were used in this analysis. Descriptive statistics were used to compare costs and resource use between groups. All costs are presented in 2021 Canadian dollars and cover the 12-month period of participation in the study.

RESULTS

A total of 1,145 patients enrolled in the trial. Case costing data were available for 466 participants (41.1%), 12-month self-administered questionnaire data for 635 participants (56.0%) and monthly diary data for 223 participants (19.7%). Emergency department visits and hospitalizations comprised the most expensive component of AF care. Across all three datasets, there were no statistically significant differences in costs or resource use between CDS and usual care groups.

CONCLUSIONS

Although there were no significant differences in resource use or costs among CDS and usual care groups in the IMPACT-AF trial, this study provides insight into the methodology and practical challenges of collecting economic data alongside a trial.

REGISTRATION

Clinicaltrials.gov (registration number: NCT01927367, date of registration: 2013-08-20).

Assessment of atrial fibrillation in European emergency departments: insights from a prospective observational multicenter study

BACKGROUND

The diagnosis and management of atrial fibrillation (AF) in emergency departments (EDs) have not been well described in France, with limited EU research. This study aimed to describe the diagnosis, management, and prognosis of AF patients in French EDs.

METHODS

A prospective, observational 2-month study in adults diagnosed with AF was conducted at 32 French EDs. Data regarding patient characteristics, diagnosis, and treatment at EDs were collected, with 12-month follow-up.

RESULTS

The study included a total of 1369 patients diagnosed with AF at an ED: 279 patients (20.4%) with idiopathic AF (no identified cause of the AF) and 1090 (79.6%) with secondary AF (with a principal diagnosis identified as the cause of AF). Patients were aged 84 years (median) and 51.3% were female. Significantly more idiopathic AF patients than secondary AF patients underwent CHA<inf>2</inf>DS<inf>2</inf>-VASc assessment (67.8% vs. 52.1%,) or echocardiography (21.2% vs. 8.3%), or received an oral anticoagulant and/or antiarrhythmic (62.0% vs. 12.9%). Idiopathic AF patients also had significantly higher rates of discharge to home (36.4% vs. 20.4%) and 3-month cardiologist follow-up (67.0% vs. 41.1%). At 12 months, 96% of patients with follow-up achieved sinus rhythm. The estimated Kaplan-Meier 12-month mortality rate was significantly lower with idiopathic AF than secondary AF (11.9% vs. 34.5%).

CONCLUSIONS

Patients diagnosed with idiopathic or secondary AF at the ED presented heterogeneous characteristics and prognoses, with those with secondary AF having worse outcomes. Further studies are warranted to optimize patients' initial evaluation in EDs and provide appropriate follow-up.

Impact of a dedicated center for atrial fibrillation on resource utilization and costs

BACKGROUND

Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays.

HYPOTHESIS

We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care.

METHODS

The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics.

RESULTS

We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AF between October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days.

CONCLUSION

Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital.

Rhythm control versus rate control in a contemporary ambulatory atrial fibrillation cohort: Post-hoc analysis of the IMPACT-AF Trial

Background

We examined the characteristics and outcomes in a contemporary ambulatory population of patients with atrial fibrillation (AF), comparing rate control with rhythm control.

Methods

This is a post hoc analysis of a cluster-randomized trial (Integrated Management Program Advancing Community Treatment of Atrial Fibrillation [IMPACT-AF]) in ambulatory AF patients from 2016 to 2018, which compared use of a clinical decision support tool for general practitioners to usual care. This analysis compared patients managed with rate vs rhythm control, at entry into the study. Outcomes included AF-related emergency department (ED) visits, unplanned cardiovascular hospitalizations, and bleeding events at 12 months.

Results

A total of 870 patients were included in this analysis, 99 (11.4%) in the rhythm-control group, and 40% women. In the rhythm-control group, the mean age was younger (70 ± 11.4 vs 72.7 ± 9.5 years, P = 0.03), a higher number were paroxysmal (80% vs 43%, P < 0.001), and CHADS₂ scores were lower. The rate of AF-related ED visits was higher in the rhythm-control group (17.2 vs 7.3%, P = 0.003), and repeat visits (rate ratio 3.03, 95% confidence interval [1.99-4.52], P < 0.001). The number of repeat ED visits was independently associated with female sex and being in the rhythm-control group.

Conclusions

Both rate- and rhythm-control patients have recurrent ED visits, with a higher rate in patients treated with rhythm control. These findings are observational, but taken in the context of current guidelines could help develop further therapies aimed at improving symptom burden in both rhythm- and rate-control patients to broadly improve healthcare utilization in the AF population.

Lessons learned from Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): a pragmatic clinical trial of computerized decision support in primary care

Background

Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) was a pragmatic, cluster randomized trial assessing the effectiveness of a clinical decision support (CDS) tool in primary care, Nova Scotia, Canada. We evaluated if CDS software versus Usual Care could help primary care providers (PCPs) deliver individualized guideline-based AF patient care.

Methods

Key study challenges including CDS development and implementation, recruitment, and data integration documented over the trial duration are presented as lessons learned.

Results

Adequate resources must be allocated for software development, updates and feasibility testing. Development took longer than projected. End-user feedback suggested network access and broadband speeds impeded uptake; they felt further that the CDS was not sufficiently user-friendly or efficient in supporting AF care (i.e., repetitive alerts).

Integration across e-platforms is crucial. Intellectual property and other issues prohibited CDS integration within electronic medical records and provincial e-health platforms. Double login and data entry were impediments to participation or reasons for provider withdrawal. Data integration challenges prevented easy and timely data access, analysis, and reporting.

Primary care study recruitment is resource intensive. Altogether, 203 PCPs and 1145 of their patients participated, representing 25% of eligible providers and 12% of AF patients in Nova Scotia, respectively. The most effective provider recruitment strategy was in-office, small group lunch-and-learns. PCPs with past research experience or who led patient consent were top recruiters. The study office played a pivotal role in achieving patient recruitment targets.

Conclusions

A rapid growth in healthcare data is leading to widespread development of CDS. Our experience found practical issues to address for such applications to succeed. Feasibility testing to assess the utility of any healthcare CDS prior to implementation is recommended. Adequate resources are necessary to support successful recruitment for future pragmatic trials. CDS tools that integrate multiple co-morbid guidelines across eHealth platforms should be pursued.

Trial registration

ClinicalTrials.gov NCT01927367. Registered on August 22, 2013

Patient-Reported Outcomes and Patient-Reported Experience of Patients With Atrial Fibrillation in the IMPACT-AF Clinical Trial

Background

The IMPACT‐AF (Integrated Management Program Advancing Community Treatment of Atrial Fibrillation) trial is a prospective, randomized, cluster design trial comparing atrial fibrillation management with a computerized clinical decision support system with usual care (control) in the primary care setting of Nova Scotia, Canada. The objective of this analysis was to assess and compare patient‐reported health‐related quality of life and patient‐reported experience with atrial fibrillation care between clinical decision support and control groups.

Methods and Results

Health‐related quality of life was measured using the EuroQol 5‐dimensional 5‐level scale, whereas patient‐reported experience was assessed using a self‐administered satisfaction questionnaire, both assessed at baseline and 12 months. Health utilities were calculated using the Canadian EuroQol 5‐dimensional 5‐level value set. Descriptive statistics and generalized estimating equations were used to compare between groups. Among 1145 patients enrolled in the trial, 717 had complete EuroQol 5‐dimensional 5‐level data at baseline. The mean age of patients was 73.53 years, and 61.87% were men. Mean utilities at baseline were 0.809 (SD, 0.157) and 0.814 (SD, 0.157) for clinical decision support and control groups, respectively. At baseline, most patients in both groups reported being “very satisfied” with the care received for their atrial fibrillation. There were no statistically significant differences in utility scores or patient satisfaction between groups at 12 months.

Conclusions

Health‐related quality of life of patients remained stable over 12 months, and there was no significant difference in patient satisfaction or utility scores between clinical decision support and control groups.

Registration information

clinicaltrials.gov. Identifier: NCT01927367.

Nurse-led vs. usual-care for atrial fibrillation

BACKGROUND

Nurse-led integrated care is expected to improve outcome of patients with atrial fibrillation compared with usual-care provided by a medical specialist.

METHODS AND RESULTS

We randomized 1375 patients with atrial fibrillation (64 ± 10 years, 44% women, 57% had CHA2DS2-VASc ≥ 2) to receive nurse-led care or usual-care. Nurse-led care was provided by specialized nurses using a decision-support tool, in consultation with the cardiologist. The primary endpoint was a composite of cardiovascular death and cardiovascular hospital admissions. Of 671 nurse-led care patients, 543 (81%) received anticoagulation in full accordance with the guidelines against 559 of 683 (82%) usual-care patients. The cumulative adherence to guidelines-based recommendations was 61% under nurse-led care and 26% under usual-care. Over 37 months of follow-up, the primary endpoint occurred in 164 of 671 patients (9.7% per year) under nurse-led care and in 192 of 683 patients (11.6% per year) under usual-care [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.69 to 1.04, P = 0.12]. There were 124 vs. 161 hospitalizations for arrhythmia events (7.0% and 9.4% per year), and 14 vs. 22 for heart failure (0.7% and 1.1% per year), respectively. Results were not consistent in a pre-specified subgroup analysis by centre experience, with a HR of 0.52 (95% CI 0.37-to 0.71) in four experienced centres and of 1.24 (95% CI 0.94-1.63) in four less experienced centres (P for interaction <0.001).

CONCLUSION

Our trial failed to show that nurse-led care was superior to usual-care. The data suggest that nurse-led care by an experienced team could be clinically beneficial (ClinicalTrials.gov NCT01740037).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT01740037).

A virtual platform to deliver ambulatory care for patients with atrial fibrillation

Background

There are little data on the use of virtual care for patients with arrhythmia. We evaluated a virtual clinic platform, in conjunction with specialist care, for patients with symptomatic atrial fibrillation (AF).

Methods

This was a prospective, observational cohort study evaluating an online educational and treatment platform, with a randomized sub-study examining the use of an ambulatory single-lead electrocardiogram heart monitor (AHM). Follow-up was 6 months. The main outcome was patients’ platform use; success was defined as 90% of patients using the platform at least once, and 75% using it at least twice. The primary outcome in the AHM sub-study was Atrial Fibrillation Symptom Severity (AFSS) score. Other outcomes included patient satisfaction questionnaires, quality of life, emergency department visits, and hospitalizations for AF.

Results

We enrolled 94 patients between July 2018 and May 2019; 83% of patients logged in at least once and 54.3% more than once. Patients who were older, were male, or had new-onset AF were more likely to log in to the platform. Satisfaction scores were high; 70%–94% of patients responded favorably. Quality-of-life scores improved at 3 and 6 months. In the AHM sub-study (n = 71), those who received an AHM had lower AFSS scores (least square mean difference -2.52, 95% CI -4.48 to -0.25, P = .03). There was no difference in emergency department visits or hospitalizations.

Conclusion

The online platform did not reach our feasibility target but was well received. Allocation of an AHM was associated with improved quality of life. Virtual AF care shows promise and should be evaluated in further research.

A Conceptual Framework to Study the Implementation of Clinical Decision Support Systems (BEAR): Literature Review and Concept Mapping

Background

The implementation of clinical decision support systems (CDSSs) as an intervention to foster clinical practice change is affected by many factors. Key factors include those associated with behavioral change and those associated with technology acceptance. However, the literature regarding these subjects is fragmented and originates from two traditionally separate disciplines: implementation science and technology acceptance.

Objective

Our objective is to propose an integrated framework that bridges the gap between the behavioral change and technology acceptance aspects of the implementation of CDSSs.

Methods

We employed an iterative process to map constructs from four contributing frameworks—the Theoretical Domains Framework (TDF); the Consolidated Framework for Implementation Research (CFIR); the Human, Organization, and Technology-fit framework (HOT-fit); and the Unified Theory of Acceptance and Use of Technology (UTAUT)—and the findings of 10 literature reviews, identified through a systematic review of reviews approach.

Results

The resulting framework comprises 22 domains: agreement with the decision algorithm; attitudes; behavioral regulation; beliefs about capabilities; beliefs about consequences; contingencies; demographic characteristics; effort expectancy; emotions; environmental context and resources; goals; intentions; intervention characteristics; knowledge; memory, attention, and decision processes; patient–health professional relationship; patient’s preferences; performance expectancy; role and identity; skills, ability, and competence; social influences; and system quality. We demonstrate the use of the framework providing examples from two research projects.

Conclusions

We proposed BEAR (BEhavior and Acceptance fRamework), an integrated framework that bridges the gap between behavioral change and technology acceptance, thereby widening the view established by current models.

Clinical Decision Support and Implications for the Clinician Burnout Crisis

OBJECTIVES

This survey aimed to review aspects of clinical decision support (CDS) that contribute to burnout and identify key themes for improving the acceptability of CDS to clinicians, with the goal of decreasing said burnout.

METHODS

We performed a survey of relevant articles from 2018-2019 addressing CDS and aspects of clinician burnout from PubMed and Web of Science™. Themes were manually extracted from publications that met inclusion criteria.

RESULTS

Eighty-nine articles met inclusion criteria, including 12 review articles. Review articles were either prescriptive, describing how CDS should work, or analytic, describing how current CDS tools are deployed. The non-review articles largely demonstrated poor relevance and acceptability of current tools, and few studies showed benefits in terms of efficiency or patient outcomes from implemented CDS. Encouragingly, multiple studies highlighted steps that succeeded in improving both acceptability and relevance of CDS.

CONCLUSIONS

CDS can contribute to clinician frustration and burnout. Using the techniques of improving relevance, soliciting feedback, customization, measurement of outcomes and metrics, and iteration, the effects of CDS on burnout can be ameliorated.

Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF): A cluster randomized trial of a computerized clinical decision support tool

BACKGROUND

Clinical decision support (CDS) tools designed to digest, filter, organize, and present health data are becoming essential in providing clinical and cost-effective care. Many are not rigorously evaluated for benefit before implementation. We assessed whether computerized CDS for primary care providers would improve atrial fibrillation (AF) management and outcomes as compared to usual care.

METHODS

Overall, 203 primary care providers were recruited, randomized, and then cluster stratified by location (urban, rural) to usual care (n = 99) or CDS (n = 104). Providers recruited 1,145 adult patients with AF to participate. The intervention was access to an evidenced-based, point-of-care computerized CDS designed to support guideline-based AF management. The primary efficacy outcome was a composite of unplanned cardiovascular hospitalizations and AF-related emergency department visits; the primary safety outcome was major bleeding, both over 1 year. Patients were the units of intention-to-treat analysis.

RESULTS

No significant effects on the primary efficacy (130 control, 118 CDS, hazard ratio: 0.98 [95% CI 0.71-1.37], P = .926) or safety (n = 7 usual care, n = 8 CDS, 1.3% total, P = .939) outcomes were observed at 12-months.

CONCLUSIONS

IMPACT-AF rigorously assessed a CDS tool in a highly representative sample of primary care providers and their patients; however, no impact on outcomes was observed. Considering the proliferating use of CDS applications, this study highlights the need for efficacy assessments prior to adoption and clinical implementation.

The Admit-AF risk score: A clinical risk score for predicting hospital admissions in patients with atrial fibrillation

Aims

To develop and externally validate a risk score for all-cause hospital admissions in patients with atrial fibrillation.

Methods and results

We used a prospective cohort of 2387 patients with established atrial fibrillation as derivation cohort. Independent risk factors were selected from a broad range of variables using the least absolute shrinkage and selection operator method fit to a Cox model. The risk score was validated in a separate prospective cohort of 1300 atrial fibrillation patients. The incidence of all-cause hospital admission was 19.1 per 100 person-years in the derivation cohort and it was 26.1 per 100 person-years in the validation cohort. The most important predictors for admission were age (75–79 years: adjusted hazard ratio (aHR), 1.34; 95% confidence interval (CI), 1.01–1.78; 80–84 years: aHR, 1.50; 95% CI, 1.11–2.03; ≥85 years: aHR, 1.88; 95% CI, 1.36–2.62), prior pulmonary vein isolation (aHR, 0.72; 95% CI, 0.58–0.88), hypertension (aHR, 1.16; 95% CI, 0.99–1.36), diabetes (aHR, 1.38; 95% CI, 1.17–1.62), coronary heart disease (aHR, 1.17; 95% CI, 1.02–1.36), prior stroke/transient ischaemic attack (aHR, 1.26; 95% CI, 1.18–1.47), heart failure (aHR, 1.19; 95% CI, 1.03–1.39), peripheral artery disease (aHR, 1.35; 95% CI, 1.08–1.67), cancer (aHR, 1.33; 95% CI, 1.12–1.57), renal failure (aHR, 1.17; 95% CI, 0.99–1.37) and previous falls (aHR, 1.40; 95% CI, 1.13–1.74). A risk score with these variables was well calibrated, and achieved a C-index of 0.64 in the derivation and 0.59 in the validation cohort.

Conclusions

Multiple risk factors were associated with hospital admissions in atrial fibrillation patients. This prediction tool selects high-risk patients who may benefit from preventive interventions.

Do computerized clinical decision support systems improve the prescribing of oral anticoagulants? A systematic review

BACKGROUND

Serious adverse drug reactions have been associated with the underuse or the misuse of oral anticoagulant therapy. We systematically reviewed the impact of computerized clinical decision support systems (CDSS) on the prescribing of oral anticoagulants and we described CDSS features associated with success or failure.

METHODS

We searched Medline, Embase, CENTRAL, CINHAL, and PsycINFO for studies that compared CDSS for the initiation or monitoring of oral anticoagulants with routine care. Two reviewers performed study selection, data collection, and risk-of-bias assessment. Disagreements were resolved with a third reviewer. Potentially important CDSS features, identified from previous literature, were evaluated.

RESULTS

Sixteen studies were included in our qualitative synthesis. Most trials were performed in primary care (n = 7) or hospitals (n = 6) and included atrial fibrillation (AF) patients (n = 9). Recommendations mainly focused on anticoagulation underuse (n = 11) and warfarin-drug interactions (n = 5). Most CDSS were integrated in electronic records or prescribing and provided support automatically at the time and location of decision-making. Significant improvements in practitioner performance were found in 9 out of 16 studies, while clinical outcomes were poorly reported. CDSS features seemed slightly more common in studies that demonstrated improvement.

CONCLUSIONS

CDSS might positively impact the use of oral anticoagulants in AF patients at high risk of stroke. The scope of CDSS should now evolve to assist prescribers in selecting the most appropriate and tailored medication. Efforts should nevertheless be made to improve the relevance of notifications and to address implementation outcomes.

GARFIELD-AF model for prediction of stroke and major bleeding in atrial fibrillation: a Danish nationwide validation study

OBJECTIVES

To externally validate the accuracy of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) model against existing risk scores for stroke and major bleeding risk in patients with non-valvular AF in a population-based cohort.

DESIGN

Retrospective cohort study.

SETTING

Danish nationwide registries.

PARTICIPANTS

90 693 patients with newly diagnosed non-valvular AF were included between 2010 and 2016, with follow-up censored at 1 year.

PRIMARY AND SECONDARY OUTCOME MEASURES

External validation was performed using discrimination and calibration plots. C-statistics were compared with CHA₂DS₂VASc score for ischaemic stroke/systemic embolism (SE) and HAS-BLED score for major bleeding/haemorrhagic stroke outcomes.

RESULTS

Of the 90 693 included, 51 180 patients received oral anticoagulants (OAC). Overall median age (Q1, Q3) were 75 (66-83) years and 48 486 (53.5%) were male. At 1-year follow-up, a total of 2094 (2.3%) strokes/SE, 2642 (2.9%) major bleedings and 10 915 (12.0%) deaths occurred. The GARFIELD-AF model was well calibrated with the predicted risk for stroke/SE and major bleeding. The discriminatory value of GARFIELD-AF risk model was superior to CHA₂DS₂VASc for predicting stroke in the overall cohort (C-index: 0.71, 95% CI: 0.70 to 0.72 vs C-index: 0.67, 95% CI: 0.66 to 0.68, p<0.001) as well as in low-risk patients (C-index: 0.64, 95% CI: 0.59 to 0.69 vs C-index: 0.57, 95% CI: 0.53 to 0.61, p=0.007). The GARFIELD-AF model was comparable to HAS-BLED in predicting the risk of major bleeding in patients on OAC therapy (C-index: 0.64, 95% CI: 0.63 to 0.66 vs C-index: 0.64, 95% CI: 0.63 to 0.65, p=0.60).

CONCLUSION

In a nationwide Danish cohort with non-valvular AF, the GARFIELD-AF model adequately predicted the risk of ischaemic stroke/SE and major bleeding. Our external validation confirms that the GARFIELD-AF model was superior to CHA₂DS₂VASc in predicting stroke/SE and comparable with HAS-BLED for predicting major bleeding.

Integrated specialized atrial fibrillation clinics reduce all-cause mortality: post hoc analysis of a randomized clinical trial

Aims

An integrated chronic care programme in terms of a specialized outpatient clinic for patients with atrial fibrillation (AF), has demonstrated improved clinical outcomes. The aim of this study is to assess all-cause mortality in patients in whom AF management was delivered through a specialized outpatient clinic offering an integrated chronic care programme.

Methods and results

Post hoc analysis of a Prospective Randomized Open Blinded Endpoint Clinical trial to assess all-cause mortality in AF patients. The study included 712 patients with newly diagnosed AF, who were referred for AF management to the outpatient service of a University hospital. In the specialized outpatient clinic (AF-Clinic), comprehensive, multidisciplinary, and patient-centred AF care was provided, i.e. nurse-driven, physician supervised AF treatment guided by software based on the latest guidelines. The control group received usual care by a cardiologist in the regular outpatient setting.

After a mean follow-up of 22 months, all-cause mortality amounted 3.7% (13 patients) in the AF-Clinic arm and 8.1% (29 patients) in usual care [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.23–0.85; P = 0.014]. This included cardiovascular mortality in 4 AF-Clinic patients (1.1%) and 14 patients (3.9%) in usual care (HR 0.28; 95% CI 0.09–0.85; P = 0.025). Further, 9 patients (2.5%) died in the AF-Clinic arm due to a non-cardiovascular reason and 15 patients (4.2%) in the usual care arm (HR 0.59; 95% CI 0.26–1.34; P = 0.206).

Conclusion

An integrated specialized AF-Clinic reduces all-cause mortality compared with usual care. These findings provide compelling evidence that an integrated approach should be widely implemented in AF management.