Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial

Abstract

ObjectivesThe primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF).DesignAppropriate ED attendance was defined by the requirement for an electrical or chemical cardioversion and/or an attendance resulting in hospitalisation or administration of intravenous medications for ventricular rate control. Quantitative and qualitative responses were recorded and analysed using descriptive statistics and content analysis, respectively. Random effects logistic regression was performed to estimate the OR of inappropriate ED attendance based on clinically relevant patient characteristics.ParticipantsParticipants ≥18 years with a documented history of AF were approached in one of eight centres partaking in the study across Canada (Ontario, Nova Scotia, Alberta and British Columbia).ResultsOf the 356 patients enrolled (67±13, 45% female), the majority (271/356, 76%) had inappropriate reasons for presentation and did not require urgent ED treatment. Approximately 50% of patients(172/356, 48%) were driven to the ED due to symptoms, while the remainder presented on the basis of general fear or anxiety (67/356, 19%) or prior medical advice (117/356, 33%). Random effects logistic regression analysis showed that patients with a history of congestive heart failure were significantly more likely to seek urgent care for appropriate reasons (p=0.03). Likewise, symptom-related concerns for ED presentation were significantly less likely to result in inappropriate visitation (p=0.02). When patients were surveyed on alternatives to ED care, the highest proportion of responses among both groups was in favour of specialised rapid assessment outpatient clinics (186/356, 52%). Qualitative content analysis confirmed these results.ConclusionsImproved education focused on symptom management and alleviating disease-related anxiety as well as the institution of rapid access arrhythmias clinics may reduce the need for unnecessary healthcare utilisation in the ED and subsequent hospitalisation.Trial registration numberNCT03127085

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association

“…Symptoms also are the rea-son for presentation in 50% of patients presenting to the emergency department for AF. 103…”

Engagement of atrial fibrillation patients with the AF-EduApp, a new mobile application to support AF management

“…Moreover, communication is crucial for patient satisfaction with their care, which was shown by others before ( 26 , 27 ) and confirmed in our study. The possibility to easily ask questions can comfort patients and reduce emergency department (ED) visits or early consultations, as was shown by Hong KL et al When looking at the reasons for ED attendance of AF patients in Canada, they noted that 271 of the 356 ED visits were, in fact, unnecessary and could have been managed more effectively outside the ED setting ( 28 ). Therefore, accessible communication can help patients explore whether an urgent visit is needed.…”

Trends in Atrial Fibrillation Management—Results from a National Multi-Center Urgent Care Network Registry

“…It is estimated that approximately a third of the population will experience AF lifelong [23]. AF is a major cause of ED visits worldwide [11,21], and some of these visits are unnecessary [24]. In addition, there is growing consensus that AF can be optimally managed following discharge from an ED in outpatient settings [25][26][27][28].…”