Systematic collection of patient-reported outcomes in atrial fibrillation: feasibility and initial results of the Utah mEVAL AF programme

Discordant Treatment Goals for Patients With Atrial Fibrillation and Clinical Trials Metrics

BACKGROUND

Most clinical trials define successful atrial fibrillation (AF) treatment as no AF episodes longer than 30 seconds. Yet, there has been minimal study of how patients define successful treatment and whether their perspectives align with trial outcomes.

OBJECTIVES

Survey patients with AF to identify: 1) what aspect of AF is most important to address (frequency, duration, or severity of AF episodes); 2) what AF burden would be considered acceptable to consider treatment successful; and 3) to establish patient preferences for successful treatment thresholds for a validated patient-reported outcome (PRO) score.

METHODS

We surveyed patients receiving active care for AF at a single tertiary care center modeled after the Toronto AF Severity Scale (AFSS). The survey consisted of current and "successful treatment" AF frequency, burden, and symptom domains; and baseline socioeconomic information.

RESULTS

Of 7,000 invitations, 852 individuals completed the survey (12% response) with a mean age of 65 ± 13 years, 36.5% were female, and they had a mean CHA2DS2-VAsc score of 2.9 ± 1.9. Overall, 114 (13%) selected a decrease in AF episode duration as their top treatment priority, 505 (59%) episode frequency, and 230 (27%) episode severity. Overall, 207 (24%) patients would only consider a treatment successful if they never had AF again, whereas 645 (76%) patients considered success to be fewer AF episodes. A total of 341 (40%) patients would only consider a treatment successful if AF episodes lasted less than a few minutes, whereas 509 (60%) patients would accept AF episodes lasting >30 minutes. An AFSS symptom score ≤5 was considered a good outcome by 80% of respondents.

CONCLUSIONS

Patients prioritize decreased AF frequency over improvements in severity or duration, and an AFSS ≤5 would be a reasonable outcome of AF treatment. Most patients would consider treatment successful if they had more than 1 AF episode lasting longer than 30 seconds. Future clinical trial design should consider patients' perspectives when designing outcomes.

Comprehensive analysis of same day discharge after atrial fibrillation ablation: Clinical, cost, and patient reported outcomes

BACKGROUND

Same day discharge (SDD) following atrial fibrillation (AF) ablation procedure has emerged as routine practice, and primarily driven by operator discretion. However, the impacts of SDD on clinical outcomes, healthcare system costs, and patient reported outcomes (PROs) have not been systematically studied.

METHODS

We retrospectively analyzed patients undergoing routine AF ablation procedures with SDD versus overnight observation (NSDD). After propensity adjustment we compared postprocedure adverse events (AEs), healthcare system costs, and changes in PROs.

RESULTS

We identified 310 cases, with 159 undergoing SDD and 151 staying at least one midnight in the hospital (NSDD). Compared with NSDD, SDD patients were similar age (mean 64 vs. 66, p = 0.3), sex (26% female vs. 27%, p = 0.8), and with lower mean CHADS2-VA2Sc scores (2.0 vs. 2.7; p < 0.011). The primary outcome of AEs was noninferior in SDD versus NSDD patients (odds ratio 0.45, 95% confidence interval 0.21-0.99; noninferiority margin of 10%). There were also no differences in overall cost to the healthcare system between SDD and NSDD (p = 0.11). PROs numerically favored SDD (p = NS for all scores).

CONCLUSIONS

Physician selection for SDD appears at least as safe as NSDD with respect to clinical outcomes and SDD is not significantly less costly to the health system. There is a trend towards more favorable, general PROs among SDD patients. Routine SDD should be strongly considered for patients undergoing routine AF ablation procedures.

Patient-reported symptomatic events do not adequately reflect atrial arrhythmia

BACKGROUND

Management of atrial fibrillation is frequently geared toward improving symptoms. Yet, the magnitude of symptom-rhythm discordance is not well known in the setting of monitoring by ambulatory electrocardiography (AECG).

OBJECTIVE

We aimed to quantify the symptom-rhythm correlation (SRC) for atrial arrhythmia (atrial tachycardia/atrial fibrillation [AT/AF]) events.

METHODS

This was a retrospective cohort analysis of AECG data at a tertiary care center. All AECGs of ≥7 days with at least 1 AT/AF were included. Patient-triggered symptoms included shortness of breath, tiredness, palpitations, dizziness, or passing out with or without concurrent AT/AF. SRC was calculated for each patient. In addition, AT/AF-symptom association was evaluated at the event level by multivariable mixed effects logistic regression.

RESULTS

We identified 742 patients with qualifying AECG data; mean age was 64 years, 50% were female, and 22% had heart failure. The mean CHA2DS2-VASc score was 2.5. There were 6289 symptomatic events and 6900 AT/AF episodes. Of symptomatic events, 1013 (16%) had shortness of breath, 839 (13%) tiredness, 2640 (42%) palpitations, 783 (12%) dizziness, and 93 (1%) passing out. Overall SRC was 0.39 (range, 0-1.0), but presence of AT/AF increased odds of symptoms by ∼8.3 times in adjusted analyses (P < .01). In multivariable analysis, prior AF rhythm control treatment and lower heart rate were associated with worse SRC (P < .01).

CONCLUSION

Whereas AT/AF events increase the chances of symptoms, there is poor overall correlation between symptomatic events and documented AT/AF. Patient factors and prior treatments influence SRC. An improved understanding of this relationship correlation is needed to optimize clinical outcomes and to improve the rigor of AF research.

Performance of Off-the-Shelf Machine Learning Architectures and Biases in Detection of Low Left Ventricular Ejection Fraction

Artificial intelligence - machine learning (AI-ML) is a computational technique that has been demonstrated to be able to extract meaningful clinical information from diagnostic data that are not available using either human interpretation or more simple analysis methods. Recent developments have shown that AI-ML approaches applied to ECGs can accurately predict different patient characteristics and pathologies not detectable by expert physician readers. There is an extensive body of literature surrounding the use of AI-ML in other fields, which has given rise to an array of predefined open-source AI-ML architectures which can be translated to new problems in an "off-the-shelf" manner. Applying "off-the-shelf" AI-ML architectures to ECG-based datasets opens the door for rapid development and identification of previously unknown disease biomarkers. Despite the excellent opportunity, the ideal open-source AI-ML architecture for ECG related problems is not known. Furthermore, there has been limited investigation on how and when these AI-ML approaches fail and possible bias or disparities associated with particular network architectures. In this study, we aimed to: (1) determine if open-source, "off-the-shelf" AI-ML architectures could be trained to classify low LVEF from ECGs, (2) assess the accuracy of different AI-ML architectures compared to each other, and (3) to identify which, if any, patient characteristics are associated with poor AI-ML performance.

Major drivers of healthcare system costs and cost variability for routine atrial fibrillation ablation

Background

Catheter ablation is an effective treatment for atrial fibrillation (AF) but incurs significant financial costs to payers. Reducing variability may improve cost effectiveness.

Objectives

We aimed to measure (1) the components of direct and indirect costs for routine AF ablation procedures, (2) the variability of those costs, and (3) the main factors driving ablation cost variability.

Methods

Using data from the University of Utah Health Value Driven Outcomes system, we were able to measure direct, inflation-adjusted costs of uncomplicated, routine AF ablation to the healthcare system. Direct costs were considered costs incurred by pharmacy, disposable supplies, patient labs, implants, and other services categories (primarily anesthesia support) and indirect costs were considered within imaging, facility, and electrophysiology lab management categories.

Results

A total of 910 patients with 1060 outpatient ablation encounters were included from January 1, 2013, to December 31, 2020. Disposable supplies accounted for the largest component of cost with 44.8 ± 9.7%, followed by other services (primarily anesthesia support) with 30.4 ± 7.7% and facility costs with 16.1 ± 5.6%; pharmacy, imaging, and implant costs each contributed <5%. Direct costs were larger than indirect costs (82.4 ± 5.6% vs 17.6 ± 5.6%). Multivariable regression showed that procedure operator was the primary factor associated with AF ablation overall cost (up to 12% differences depending on operator).

Conclusions

Direct costs and other services (primarily anesthesia) drive the majority costs associated with AF ablations. There is significant variability in costs for these routine, uncomplicated AF ablation procedures. The procedure operator, and not patient characteristic, is the main driver for cost variability.

Patient‐reported Outcomes and Costs Associated with Vascular Closure and Same‐Day Discharge following Atrial Fibrillation Ablation

BACKGROUND

We aimed to measure patient-reported outcomes (PROs) and costs associated with same-day discharge (SDD) for atrial fibrillation (AF) ablation and vascular closure device implantation in clinical practice.

METHODS

PROs were prospectively measured in 50 AF ablation patients, comparing complete vascular device closure (n = 25) versus manual compression hemostasis (n = 25). Health-system costs for SDD patients receiving vascular device closure were compared to matched controls with one-night stays who did not receive any closure device.

RESULTS

Prospectively enrolled patients receiving vascular device closure for AF ablation had a mean age of 65 years, 17% were female, with a mean CHA₂ DS₂ -VASc score of 3. The mean number of venous sheaths was higher among patients receiving vascular device closure (3.8 vs. 3.1, p < 0.001), and there was one case of rebleeding in a patient receiving a vascular closure device (no other complications). Same-day discharge rates (76% vs. 8.3%, p < 0.001), patient satisfaction with bedrest time (8.5 vs. 6, p = 0.004) and with pain (8 vs. 5.1, p = 0.009) were significantly better among patients receiving vascular closure. In matched analyses of health-system costs, patients with vascular closure had mean age 66, 32% were female, and the mean CHA₂ DS₂ -VASc score was 2 (p = NS vs. controls). SDD with vascular closure was associated with the significantly lower facility, pharmacy, and disposable costs, but higher implant costs. Overall costs for ablation were not significantly different (mean difference 1.10%, 95% confidence interval [CI] -3.03 to 5.42).

CONCLUSIONS

Vascular closure for AF ablation improves patient experience in routine care. The use of vascular closure and SDD after AF ablation reduces several components of healthcare system costs, without an overall increase.

Adherence to a Multidisciplinary Lifestyle Program for Patients With Atrial Fibrillation and Obesity: Feasibility Study

Background

Atrial fibrillation is commonly associated with obesity. Observational studies have shown that weight loss is associated with improved prognosis and a decrease in atrial fibrillation frequency and severity. However, despite these benefits, nonadherence to lifestyle programs is common.

Objective

In this study, we evaluated adherence to and feasibility of a multidisciplinary lifestyle program focusing on behavior change in patients with atrial fibrillation and obesity.

Methods

Patients with atrial fibrillation and obesity participated in a 1-year goal-oriented cardiac rehabilitation program. After baseline assessment, the first 3 months included a cardiac rehabilitation intervention with 4 fixed modules: lifestyle counseling (with an advanced nurse practitioner), exercise training, dietary consultation, and psychosocial therapy; relaxation sessions were an additional optional treatment module. An advanced nurse practitioner monitored the personal lifestyle of each individual patient, with assessments and consultations at 3 months (ie, immediately after the intervention) and at the end of the year (ie, 9 months after the intervention). At each timepoint, level of physical activity, personal goals and progress, atrial fibrillation symptoms and frequency (Atrial Fibrillation Severity Scale), psychosocial stress (Generalized Anxiety Disorder–7), and depression (Patient Health Questionnaire–9) were assessed. The primary endpoints were adherence (defined as the number of visits attended as percentage of the number of planned visits) and completion rates of the cardiac rehabilitation intervention (defined as performing at least of 80% of the prescribed sessions). In addition, we performed an exploratory analysis of effects of the cardiac rehabilitation program on weight and atrial fibrillation symptom frequency and severity.

Results

Patients with atrial fibrillation and obesity (male: n=8; female: n=2; age: mean 57.2 years, SD 9.0; baseline weight: mean 107.2 kg, SD 11.8; baseline BMI: mean 32.4 kg/m2, SD 3.5) were recruited. Of the 10 participants, 8 participants completed the 3-month cardiac rehabilitation intervention, and 2 participants did not complete the cardiac rehabilitation intervention (both because of personal issues). Adherence to the fixed treatment modules was 95% (mean 3.8 sessions attended out of mean 4 planned) for lifestyle counseling, 86% (mean 15.2 sessions attended out of mean 17.6 planned) for physiotherapy sessions, 88% (mean 3.7 sessions attended out of mean 4.1 planned) for dietician consultations, and 60% (mean 0.6 sessions attended out of mean 1.0 planned) for psychosocial therapy; 70% of participants (7/10) were referred to the optional relaxation sessions, for which adherence was 86% (mean 2 sessions attended out of mean 2.4 planned). The frequency of atrial fibrillation symptoms was reduced immediately after the intervention (before: mean 35.6, SD 3.8; after: mean 31.2, SD 3.3), and this was sustained at 12 months (mean 24.8, SD 3.2). The severity of atrial fibrillation complaints immediately after the intervention (mean 20.0, SD 3.7) and at 12 months (mean 9.3, SD 3.6) were comparable to that at baseline (mean 16.6, SD 3.3).

Conclusions

A 1-year multidisciplinary lifestyle program for obese patients with atrial fibrillation was found to be feasible, with high adherence and completion rates. Exploratory analysis revealed a sustained reduction in atrial fibrillation symptoms; however, these results remain to be confirmed in large-scale studies.

Bimodal distribution of atrial fibrillation burden in 3 distinct cohorts: What is 'paroxysmal' atrial fibrillation?

BACKGROUND

Burden of atrial fibrillation (AF), as a continuous measure, is an emerging alternative classification often assumed to increase linearly with progression of disease. Yet there are no descriptions of AF burden distributions across populations.

METHODS

We examined patterns of AF burden (% time in AF) across 3 different cohorts: outpatients with AF undergoing Holter monitoring in a national registry (ORBIT-AF II), routine outpatients undergoing Holter monitoring in a tertiary healthcare system (UHealth), and patients >= 65 years with cardiac implantable electronic devices (Merlin.netTM linked to Medicare).

RESULTS

We included 2,058 ORBIT-AF II patients, 4,537 UHealth patients, and 39,710 from Merlin.net. Mean age ranged from 56 to 77 years, sex ranged from 40% to 61% male, and mean CHA2DS2-VASc scores ranged from 2.2 to 4.9. Across all cohorts, AF burden demonstrated skewed frequency towards the extremes, with the vast majority of patients having either very low or very high AF burden. This bimodal distribution was consistent across cohorts, across clinically-documented AF types (paroxysmal v persistent), patients with or without a known AF diagnosis, and among patients with different types of cardiac implantable electronic devices.

CONCLUSIONS

Across 3 broad, diverse cohorts with continuous monitoring, distribution of AF burden was consistently skewed towards the extremes without an even, linear distribution or progression. As AF burden is increasingly recognized as a descriptor and potential risk-stratifier, these findings have important implications for future research and patient care.

Quantifying the Impact of Atrial Fibrillation on Heart Failure-Related Patient-Reported Outcomes in the Utah mEVAL Program

BACKGROUND

Atrial fibrillation (AF) frequently complicates heart failure (HF), and each is associated with lower overall health-related quality of life. We aimed to quantify the incremental burden of AF on the health-related quality of life of patients with HF in clinical practice.

METHODS AND RESULTS

We used data from the Utah mEVAL program to analyze patient-reported outcomes (PROs) among patients with HF with and without AF. The primary outcome was the HF-specific Kansas City Cardiomyopathy Questionnaire, with generic PROs as secondary outcomes. Among 1707 patients with HF, 36% had AF (n = 616). Those with HF and AF were older (mean age 69 years vs 58 years, P < .001), more likely to have prior stroke (29% vs 17%, P < .001) and ischemic cardiomyopathy (28% vs 23%, P = .01), but had similar ejection fractions (mean 44% each, P = .6). After adjustment, and compared with HF alone, HF with AF was associated with worse Kansas City Cardiomyopathy Questionnaire scores (adjusted mean difference -3.45, 95% confidence interval [CI] -6.24 to -0.65), and worse Patient-Reported Outcomes Measurement Information System physical function scores (adjusted mean difference -1.63, 95% CI -2.59 to -0.67). The difference in visual analog scale general health was borderline (adjusted mean difference -2.01, 95% CI -4.51 to 0.49), and Patient-Reported Outcomes Measurement Information System depression scores were similar (adjusted mean difference 0.54, 95% CI -0.48 to 1.57).

CONCLUSIONS

AF complicates nearly one-third of HF cases, and patients with HF and AF are substantially older and sicker. After adjustment, AF was independently associated with worse disease-specific and overall health-related quality of life than HF alone. Whether maintaining sinus rhythm can improve the HF-related health status of patients with HF in clinical practice should be explored further.

The impact of patient-reported outcomes on loss to follow-up care after bariatric surgery

BACKGROUND

High rates of attrition to post-bariatric surgical care continue to be common, despite recommendations for lifelong follow-up. There is little available work focusing on the etiology of attrition to post-bariatric surgical follow-up. Patient-reported outcomes (PROs) are metrics of patients' perceptions of their own health and have been used for their predictive value in other specialties. The relationships between PROs and loss to follow-up have not been explored.

METHODS

PRO data from patients who met the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) definition of loss to follow-up at 1-year postoperatively were reviewed and compared to patients who were compliant with 1-year follow-up. Patient-reported outcomes measurement information system (PROMIS) measures are routinely collected pre- and postoperatively at our institution using a series of validated computer-adaptive tests that assess depression, satisfaction with social roles, pain interference, and physical function. A series of univariate logistic regressions tested whether baseline PROs or change in PROs from baseline to 6-month postoperatively predicted loss to follow-up at 1 year.

RESULTS

Neither baseline PROs nor change in depression, satisfaction with social roles, pain interference, or physical function were significant predictors of loss to follow-up. Similarly, patient state of residence, Charlson Comorbidity Index, BMI, and percent excess weight loss were not significant predictors of follow-up attrition.

CONCLUSION

The PROs in this study were not significant predictors of loss to follow-up at 1-year postoperatively. The rate of bariatric procedures continues to increase nationally, so does the potential for late post-surgical complications. Given the potential impact of loss to follow-up on adverse late post-surgical outcomes, there is a need to facilitate long-term post-surgical follow-up and more investigation is needed to identify and intervene on underlying causes of bariatric patient follow-up attrition.

The CHA2DS2-VASc score and Geriatric Multidimensional Assessment tools in elderly patients with persistent atrial fibrillation undergoing electrical cardioversion. A link with arrhythmia relapse?

INTRODUCTION

The CHA₂DS₂-VASc score is widely used for stroke risk stratification in patients with atrial fibrillation (AF). Our endpoints were to evaluate in an old population undergoing electrical cardioversion (ECV) of persistent AF if the CHA₂DS₂-VASc was associated with some of the Geriatric Multidimensional Assessment tools and with the presence of sinus rhythm at the follow-up.

METHODS

We enrolled all the consecutive patients admitted in a day-hospital setting aged ≥60 years. The Mini-Mental State Examination (MMSE; neurocognitive function), the 15-item Geriatric Depression Scale (GDS; depressive symptoms) and the Short Physical Performance Battery (SPPB; physical functioning) were administered before ECV.

RESULTS

Between 2017 and 2019, 134 patients were enrolled (mean age: 77±9 years, range: 60-96; men: 63.4%; EF: 60±12%). Hypertension was the most frequent comorbid condition (82.1%). The CHA₂DS₂-VASc score was 3.8±1.6. Abnormal values of MMSE, GDS and SPPB were observed in 7.9, 19.8 and 22.3% of cases, respectively. There were significant correlations between the CHA₂DS₂-VASc score and the MMSE (p=0.008), the GDS (p<0.001) and the SPPB (p<0.001). Depressive symptoms increased CHA₂DS₂-VASc correlation with SPPB of about 20%. CHA₂DS₂-VASc score was higher in patients with arrhythmia relapse (p=0.048; mean length of follow-up: 195 days). This association persisted even after adjustment for amiodarone therapy.

CONCLUSIONS

The CHA₂DS₂-VASc score significantly correlated with neuro-cognitive performance, depressive symptoms and physical functioning. It was also associated with AF relapse. Accordingly, in the elderly, the CHA₂DS₂-VASc could help quantify thrombo-embolic risk, give an indication of frailty status and help to choose between a rate- and a rhythm-control strategy.

Patient-reported outcomes and subsequent management in atrial fibrillation clinical practice: Results from the Utah mEVAL AF program

BACKGROUND

Atrial fibrillation (AF) significantly reduces health-related quality of life (HRQoL), previously measured in clinical trials using patient-reported outcomes (PROs). We examined AF PROs in clinical practice and their association with subsequent clinical management.

METHODS

The Utah My Evaluation (mEVAL) program collects the Toronto AF Symptom Severity Scale (AFSS) in AF outpatients at the University of Utah. Baseline factors associated with worse AF symptom score (range 0-35, higher is worse) were identified in univariate and multivariable analyses. Secondary outcomes included AF burden and AF healthcare utilization. We also compared subsequent clinical management at 6 months between patients with better versus worse AF HRQoL.

RESULTS

Overall, 1338 patients completed the AFSS symptom score, which varied by sex (mean 7.26 for males vs. 10.27 for females; p < .001), age (<65, 9.73; 65-74, 7.66; ≥75, 7.58; p < .001), heart failure (9.39 with HF vs. 7.67 without; p < .001), and prior ablation (7.28 with prior ablation vs. 8.84; p < .001). In multivariable analysis, younger age (mean difference 2.92 for <65 vs. ≥75; p < .001), female sex (mean difference 2.57; p < .001), pulmonary disease (mean difference 1.88; p < .001), and depression (mean difference 2.46; p < .001) were associated with higher scores. At 6-months, worse baseline symptom score was associated with the use of rhythm control (37.1% vs. 24.5%; p < .001). Similar cofactors and results were associated with increased AF burden and health care utilization scores.

CONCLUSIONS

AF PROs in clinical practice identify highly-symptomatic patients, corroborating findings in more controlled, clinical trials. Increased AFSS score correlates with more aggressive clinical management, supporting the utility of disease-specific PROs guiding clinical practice.

Atrial arrhythmias and patient-reported outcomes in adults with congenital heart disease: An international study

BACKGROUND

Atrial arrhythmias (ie, intra-atrial reentrant tachycardia and atrial fibrillation) are a leading cause of morbidity and hospitalization in adults with congenital heart disease (CHD). Little is known about their effect on quality of life and other patient-reported outcomes (PROs) in adults with CHD.

OBJECTIVE

The purpose of this study was to assess the impact of atrial arrhythmias on PROs in adults with CHD and explore geographic variations.

METHODS

Associations between atrial arrhythmias and PROs were assessed in a cross-sectional study of adults with CHD from 15 countries spanning 5 continents. A propensity-based matching weight analysis was performed to compare quality of life, perceived health status, psychological distress, sense of coherence, and illness perception in patients with and those without atrial arrhythmias.

RESULTS

A total of 4028 adults with CHD were enrolled, 707 (17.6%) of whom had atrial arrhythmias. After applying matching weights, patients with and those without atrial arrhythmias were comparable with regard to age (mean 40.1 vs 40.2 years), demographic variables (52.5% vs 52.2% women), and complexity of CHD (15.9% simple, 44.8% moderate, and 39.2% complex in both groups). Patients with atrial arrhythmias had significantly worse PRO scores with respect to quality of life, perceived health status, psychological distress (ie, depression), and illness perception. A summary score that combines all PRO measures was significantly lower in patients with atrial arrhythmias (-3.3%; P = .0006). Differences in PROs were consistent across geographic regions.

CONCLUSION

Atrial arrhythmias in adults with CHD are associated with an adverse impact on a broad range of PROs consistently across various geographic regions.

Accuracy of Patient Identification of Electrocardiogram-Verified Atrial Arrhythmias

This cross-sectional study describes the sensitivity and specificity of patient self-assessment for atrial arrhythmia compared with 12-lead electrocardiogram and describes the association of patient perception of arrhythmia with symptom burden.