Application of the simple atrial fibrillation better care pathway for integrated care management in frail patients with atrial fibrillation: A nationwide cohort study

Abstract

Background The benefit of integrated care management was unknown in frail atrial fibrillation (AF) patients. This study evaluated whether compliance with the atrial fibrillation Better Care (ABC) pathway for integrated care management would improve clinical outcomes in frail AF patients. Methods From the Korea National Health Insurance Service database, 262,987 nonvalvular AF patients were enrolled between 1 January 2005 and 31 December 2015. For each patient, the Hospital Frailty Risk Score and category were calculated retrospectively using all available ICD‐10 diagnostic codes. Patients were divided into three frailty‐based risk categories: low (<5 points, n = 221,542), intermediate (5‐15 points, n = 37,341), and high risk (>15 points, n = 4,104). Results Over a mean follow‐up of 5.9 (interquartile range 3.2, 9.4) years, in high frailty risk patients, the ABC group had lower rates of all‐cause death (6.5 vs 17.5 per 100 person‐years, P < .001; hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.56‐0.97) but was nonsignificant for the composite outcome (10.5 vs 26.0 per 100 person‐years, P = .101; HR 0.79; 95% CI 0.59‐1.05) compared with the Non‐ABC group. When the three frailty categories were compared, the greatest benefit on mortality was seen in the high frailty group (pint < 0.001), but for the composite outcome, there was no statistical interaction for the three frailty categories (pint = 0.063). Conclusions Compliance with the simple ABC pathway is associated with improved outcomes in AF patients with high frailty risk. Given the high healthcare burden associated with frail AF patients, integrated AF management should be implemented to improve outcomes in these patients.

Integrated care and outcomes in patients with atrial fibrillation and comorbidities

“…30 All the observational studies consistently reported an association with a significant reduction in the risk of cardiovascular events and all-cause death, ranging from 10% to 60% per cent reduction in risk according to the various cohorts studied, together with a reduction in the risk of hospitalization. [8][9][10][11][28][29][30] In a contemporary Europeanwide AF cohort, clinical management adherent to the ABC pathway was associated with a 40% to 50% reduction in the major clinical outcomes. 28 In the recent mAFA randomized clinical trial, ABC pathway use resulted in a 60% reduction in the composite outcome of thromboembolic events/rehospitalization/all-cause death over a 1 year follow-up.…”

“…Since its proposal, the ABC pathway has been evaluated in observational retrospective studies 8‐10,28,29 and one randomized controlled trial 13 . Also, ABC pathway adherent care was associated with a reduced risk of adverse events even in clinically complex AF patients (those with multimorbidity, polypharmacy and hospitalized ones), 11 as well as in those AF patients found to be frail 30 . All the observational studies consistently reported an association with a significant reduction in the risk of cardiovascular events and all‐cause death, ranging from 10% to 60% per cent reduction in risk according to the various cohorts studied, together with a reduction in the risk of hospitalization 8‐11,28‐30 .…”

Adherence to the ‘Atrial Fibrillation Better Care’ Pathway in Patients with Atrial Fibrillation: Impact on Clinical Outcomes—A Systematic Review and Meta-Analysis of 285,000 Patients

“…After the titles and abstracts screening, 14 full texts were evaluated, and eight studies were included in the final systematic review and meta-analysis(16-23) (Table 1) [Figure S1], with a total of 285,253 AF patients included (23). Four studies were based in Europe (17,18,20,24), two in Asia (22,23), one in North America (19) and one was multinational (21).…”

“…Among the eight included studies, two were post-hoc subgroup analyses of previously performed RCTs (19,21), four were based on observational registries (16)(17)(18)20) while the last one was derived from a nationwide claims registry (22). One study did not include a follow-up phase (17).…”

“…The only RCT, the 'mobile Atrial Fibrillation Application II' (mAFA-II), a cluster-randomized study conducted in China, implemented the ABC pathway through a mobile phone application. Six out of eight studies(17-21,23) enrolled both out-and inpatients, while the remaining two only considered hospitalised patients (16,22).…”