A nurse-led atrial fibrillation clinic: Impact on anticoagulation therapy and clinical outcomes

Understanding for whom, under what conditions, and how an integrated approach to atrial fibrillation service delivery works: a realist review

AIMS

To understand for whom, under what conditions, and how an integrated approach to atrial fibrillation (AF) service delivery works (or does not work).

METHODS AND RESULTS

A realist review of integrated approaches to AF service delivery for adult populations aged ≥18 years. An expert panel developed an initial programme theory, searched and screened literature from four databases until October 2022, extracted and synthesized data using realist techniques to create context-mechanism-outcome configurations for integrated approaches to AF service, and developed an integrated approach refined programme theory. A total of 5433 documents were screened and 39 included. The refined programme theory included five context-mechanism-outcome configurations for how clinical and system-wide outcomes are affected by the way integrated approaches to AF service delivery are designed and delivered. This review identifies core mechanisms underpinning the already known fundamental components of integrated care. This includes having a central coordinator responsible for service organization to provide continuity of care across primary and secondary care ensuring services are patient centred. Additionally, a fifth pillar, lifestyle and risk factor reduction, should be recognized within an AF care pathway.

CONCLUSION

It is evident from our provisional theory that numerous factors need to interlink and interact over time to generate a successfully integrated model of care in AF. Stakeholders should embrace this complexity and acknowledge that the learnings from this review are integral to shaping future service delivery in the face of an aging population and increased prevalence of AF.

Quality of services in health education nurse-led clinics: an Iranian service providers and service recipients experience

BACKGROUND

Patient education is a vital role of nurses in nurse-led clinics(NLCs). Since 2011, independent NLCs entitled health education Nurse-led clinics(HENLCs) have been established in Iran. In order for this newly developed service to be able to perform perfectly in implementation and evaluation, it should be explained based on one of the quality evaluation models. The objective of the study was to determine the dimension of service quality in HENLCs based on service providers' and service recipients' experience.

METHODS

This research is a qualitative study of directed content analysis type conducted between May and November 2020. Twenty-nine participants who had rich experiences in the patient education in HENLCs were interviewed in this study. Asarroodi et al.'s (2018) qualitative content analysis method was used for data analysis, and MaxQDA software was used for data management. We used credibility, dependability, and Confirmability to confirm the trustworthiness of the study's findings.

RESULTS

In this study service providers including managers, policymakers, decision-makers, nurses, physicians, and service recipients including patients and families participated. Seven generic categories, including (1) a competent and self-motivated nurse educator, (2) an easily accessible and comfortable environment, (3) informational-educational materials and health education equipment, (4) motivational facilities, (5) access to the health education support team, (6) organizational communication supporting the education process, and (7) receiving the patient education fee, constituted the main category of structure. Five generic categories, including (1) assessment and determination of the educational needs of the target group, (2) description of the nurse's duties, (3) teaching-learning methods, (4) patient referral, and (5) the process of preparing and publishing educational content, constituted the main category of process. One generic category called evaluation constituted the main category of outcome.

CONCLUSION

Based on the results of this study, it is suggested to managers to pay attention to the dimensions of the quality model of Donabedian (SPO) in setting up and developing the performance of HENLCs, it is recommended that future quantitative studies based on the categories formed in this study evaluate the observance of the dimensions of structure, process and outcome.

Does a nurse-led interventional program improve clinical outcomes in patients with atrial fibrillation? A meta-analysis

BACKGROUND

Being the most common type of arrhythmia, atrial fibrillation (AF) is progressively increasing with an annual rate of 5 million new cases. Recent guidelines highlight the importance of using collaborative multidisciplinary teams in order to improve outcomes during management of patients with AF. A nurse-led program including a nurse-directed education, counselling and intervention has shown to improve patients' outcomes in candidates with AF. In this analysis, we aimed to systematically compare the clinical outcomes observed in patients with AF who were assigned to a nurse-led interventional program versus a usual care group.

METHODS

EMBASE, MEDLINE, Http://www.

CLINICALTRIALS

gov , Web of Science; Google Scholar and Cochrane databases were the data sources. The clinical outcomes were considered as the endpoints in this study. This is a meta-analysis, and the statistical analysis was conducted by the RevMan software (version 5.4). Risk ratios (RR) with 95% confidence intervals (CI) were used to represent the data after statistical analysis.

RESULTS

Six studies with a total number 2916 participants were included whereby 1434 participants were assigned to a nurse-led intervention and 1482 participants were assigned to the usual care group. Our results showed that participants with AF who were assigned to the nurse-led interventional group had a significantly lower risk of composite endpoints (RR: 0.82, 95% CI: 0.70-0.96; P = 0.01), heart failure (RR: 0.66, 95% CI: 0.47-0.92; P = 0.02), atrial fibrillation (RR: 0.77, 95% CI: 0.63-0.94; P = 0.01) and re-admission (RR: 0.78, 95% CI: 0.62-0.99; P = 0.04). However, the risks of all-cause mortality (RR: 0.86, 95% CI: 0.68-1.09; P = 0.21), cardiac death (RR: 0.67, 95% CI: 0.33-1.39; P = 0.28), myocardial infarction (RR: 0.70, 95% CI: 0.35-1.42; P = 0.33), stroke (RR: 0.75, 95% CI: 0.44-1.26; P = 0.28), all bleeding events (RR: 1.11, 95% CI: 0.81-1.53; P = 0.51) and major bleeding events (RR: 0.91, 95% CI: 0.56-1.49; P = 0.71) were not significantly different.

CONCLUSIONS

The nurse-led interventional program significantly improved composite endpoints including heart failure and the recurrence of AF, resulting in a significantly lower admission rate compared to the usual care group. However, nurse-led interventional program did not affect mortality, stroke, myocardial infarction and bleeding events. Based on our current results, a nurse-led interventional programs apparently could be beneficial in patients with AF. Future larger trials would be able to confirm this hypothesis.

Oral anticoagulant switching in patients with atrial fibrillation: a scoping review

INTRODUCTION

Oral anticoagulants (OACs) prevent stroke in patients with atrial fibrillation (AF). Several factors may cause OAC switching.

OBJECTIVES

To examine the phenomenon of OAC switching in patients with AF, including all available evidence; frequency and patterns of switch, clinical outcomes, adherence, patient-reported outcomes, reasons for switch, factors associated with switch and evidence gaps.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, Embase and Web of Science, up to January 2022.

RESULTS

Of the 116 included studies, 2/3 examined vitamin K antagonist (VKA) to direct-acting OAC (DOAC) switching. Overall, OAC switching was common and the definition of an OAC switch varied across. Switching from VKA to dabigatran was the most prevalent switch type, but VKA to apixaban has increased in recent years. Patients on DOAC switched more to warfarin than to other DOACs. OAC doses involved in the switches were hardly reported and patients were often censored after the first switch. Switching back to a previously taken OAC (frequently warfarin) occurred in 5%-21% of switchers.The risk of ischaemic stroke and gastrointestinal bleeding in VKA to DOAC switchers compared with non-switchers was conflicting, while there was no difference in the risk of other types of bleeding. The risk of ischaemic stroke in switchers from DOAC versus non-switchers was conflicting. Studies evaluating adherence found no significant changes in adherence after switching from VKA to DOAC, however, an increase in satisfaction with therapy were reported. Reasons for OAC switch, and factors associated with OAC switch were mostly risk factors for stroke and bleeding. Clinical outcomes, adherence and patient-reported outcomes were sparse for switches from DOACs.

CONCLUSIONS

OAC switching is common in patients with AF and patients often switch back to an OAC they have previously been on. There are aspects of OAC switching that have received little study, especially in switches from DOACs.

A regional anticoagulation program improves safety and outcomes for both children and adults

BACKGROUND

Evidence-based anticoagulation programs usually serve a local, adult patient population. Here we report outcomes for a regional combined pediatric-adult program.

AIMS

The aims of this study were: (1) Compare the pre- vs. post-implementation quality of therapy (% time in therapeutic range (%TTR) and compliance). (2) Assess anticoagulant-relevant outcomes (bleeding and thrombotic complications).

METHODS

Data were collected for the years 2014-2019. Rosendaal linear interpolation was used to calculate %TTR. Bleeding complications were categorized using ISTH-SSC standard nomenclature and new thrombotic events were reviewed.

RESULTS

The patients were divided into a long-term warfarin group (N = 308), 80.2% of whom had cardiac-related therapeutic indications (median age 24y), and a second group (N = 114) comprised of short-term and non-warfarin long-term anticoagulation (median age 16y). Median %TTR for those on long-term warfarin was 78.9%. The incidence of major and clinically relevant non-major bleeding events was 1.65 and 2.43 /100 person-years of warfarin use, respectively. Thromboembolism (TE) incidence was 0.78/100 patient-years of warfarin use. Neither bleeding nor thrombosis was associated with %TTR (p = 0.48). Anticoagulant indication was the only variable associated with bleeding risk (p = 0.005). The second group had no on-therapy TE events but 7.9% experienced bleeding. Complete data were available for a randomly sampled pre-program warfarin group (N = 26). Median %TTR improved from 17.5 to 87% pre- vs. post-implementation. Similarly, compliance (defined as ≥ 1 INR/month) improved by 34.3%.

CONCLUSIONS

In conclusion, this program significantly improved and sustained %TTR and compliance. The lack of association between bleeding and thrombosis events and %TTR may be related to the high median %TTR (> 70%) achieved by this approach.

Nutrition nurse-led outpatient 'hot' clinics are efficient and cost-effective: a retrospective single-centre evaluation

BACKGROUND

Nutrition nurses work in multidisciplinary and nurse-led outpatient clinics. The daily nutrition nurse-led 'hot' clinic in this study sees patients for enteral or home parenteral nutritional support. Appointments may be for routine procedures or emergency reviews.

AIMS

This study aimed to identify activities and procedures performed in the nutrition nurse-led clinic, identifying admission avoidance activity.

METHODS

Nurse-held records for the period from April 2018 to March 2020 were reviewed retrospectively. Data were collated in an Excel spreadsheet for analysis and results are presented using descriptive statistics.

RESULTS

Records covered a total of 590 patients, 294 men and 296 women with a median age of 59 years, and 606 procedures. Key activities were troubleshooting enteral feeding tubes (29%), insertion of fine-bore nasogastric feeding tubes (18%) and management of home parenteral nutrition issues (11%). The presenting problem or issue was resolved in 90% of patients, with no need for hospital admission or additional medical review.

CONCLUSION

The nutrition nurse-led clinic provides an efficient and cost-effective service, preventing hospital admission and emergency department attendance in most cases.

Barriers to self-monitoring implementation in the oral anticoagulated population: A qualitative study

AIM

This study aimed to explore and understand the barriers perceived by Italian nurses to adopting self-monitoring for managing oral anticoagulation in real-life settings.

BACKGROUND

Barriers to self-monitoring implementation for managing oral anticoagulation have been poorly described.

DESIGN

The study had a qualitative descriptive and exploratory design with a hybrid approach.

METHODS

A literature review was conducted to identify a priori barriers (deductive approach), while a small and semi-structured focus group discussion was performed to explore the contextual barriers experienced by Italian nurses (inductive approach). A classic content analysis technique was adopted. Data were collected in 2019.

FINDINGS

Two main categories were identified. Organizational barriers referred to the lack of inter-professional collaboration and health-care system strategies to provide clinical pathways for self-monitoring. Individual barriers encompassed professional characteristics (e.g. university background, professional knowledge, continuum education and accountability/responsibility) and patient characteristics (e.g. patient health literacy and knowledge, engagement/empowerment and educational programmes). Finally, unwarranted clinical variation in oral anticoagulation management arose as a barrier determined by organizational and individual elements.

CONCLUSIONS

The results of this study pointed out an urgent public health issue in addressing barriers influencing self-monitoring practice and in sustaining care models that might enhance the quality improvement of self-monitoring for managing oral anticoagulation.

The Atrial Fibrillation Better Care (ABC) Pathway and Clinical Outcomes in Patients with Atrial Fibrillation: the Prospective Murcia AF Project Phase II Cohort

BACKGROUND

The Atrial fibrillation Better Care (ABC) pathway was proposed for a more holistic or integrated care approach to atrial fibrillation (AF) management. We investigated whether adherence with the ABC pathway reduced the risk of adverse clinical outcomes in real-world AF patients starting vitamin K antagonist (VKAs) therapy.

METHODS

Prospective cohort study including AF outpatients starting VKA therapy from July 2016 to June 2018. Patients were considered as adherent if all ABC pathway criteria (A: Avoid stroke; B: Better symptom control; and C: Cardiovascular risk factors/comorbidities management) were fulfilled. The primary endpoints were all-cause mortality, net clinical outcomes (NCOs), major adverse cardiovascular events (MACE), and composite thrombotic/thromboembolic events at 2 years.

RESULTS

We enrolled 1045 patients (51.6% female; median age 77 [70-83] years). Of these, 63.0% (658) were adherent to the ABC pathway and 37% (387) were considered non-adherent. Compared to non-adherent patients, those who were ABC adherent had lower event rates for all-cause mortality (13.76 vs. 6.56; p<0.001), NCOs (19.65 vs. 11.94; p<0.001), and MACE (11.88 vs. 7.75; p=0.006) during the follow-up. Adjusted Cox regression analyses demonstrated that the ABC pathway adherent care reduced the risks of all-cause mortality (aHR 0.57, 95% CI 0.42-0.78), NCOs (aHR 0.72, 95% CI 0.56-0.92), and cardiovascular mortality (aHR 0.54, 95% CI 0.32-0.90). Event-free survivals for all-cause mortality, NCOs (both log-rank p-values <0.001), and MACE (log-rank p-value = 0.004) were also higher in ABC pathway adherent patients.

CONCLUSIONS

In this real-world prospective cohort of AF patients starting VKA therapy, adherence to the ABC pathway management at baseline significantly reduced the risk of NCOs, all-cause mortality, and cardiovascular death at 2 years.

Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study

BACKGROUND

There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care.

METHODS

This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply.

RESULTS

Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]).

CONCLUSIONS

Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Role of telemedicine in the management of oral anticoagulation in atrial fibrillation: a practical clinical approach

Compared with face-to-face consultations, telemedicine has many advantages, including more efficient use of healthcare resources, partial relief of the burden of care, reduced exposure to COVID-19, treatment adjustment, organization of more efficient healthcare circuits and patient empowerment. Ensuring optimal anticoagulation in atrial fibrillation patients is mandatory if we want to reduce the thromboembolic risk. Of note, telemedicine is an excellent option for the long-term management of atrial fibrillation patients. Moreover, direct oral anticoagulants may provide an added value in telemedicine (versus vitamin K antagonists), as it is not necessary to monitor anticoagulant effect or make continuous dosage adjustments. In this multidisciplinary consensus document, the role of telemedicine in anticoagulation of this population is discussed and practical recommendations are provided.

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

OBJECTIVE

 The 'Atrial fibrillation Better Care' (ABC) pathway has been recently proposed as a holistic approach for the comprehensive management of patients with atrial fibrillation (AF). We performed a systematic review of current evidence for the use of the ABC pathway on clinical outcomes.

METHODS AND RESULTS

 We performed a systematic review and meta-analysis according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies reporting the prevalence of ABC-pathway-adherent management in AF patients, and its impact on clinical outcomes (all-cause death, cardiovascular death, stroke, and major bleeding). Meta-analysis of odds ratio (OR) was performed with random-effects models; subgroup analysis and meta-regression were performed to account for heterogeneity. Among the eight studies included, we found a pooled prevalence of ABC-adherent management of 21% (95% confidence interval, CI: 13-34%), with a high grade of heterogeneity, explained by the increasing adherence to each ABC criterion. Patients treated according to the ABC pathway showed a lower risk of all-cause death (OR: 0.42; 95% CI: 0.31-0.56), cardiovascular death (OR: 0.37; 95% CI: 0.23-0.58), stroke (OR: 0.55; 95% CI: 0.37-0.82) and major bleeding (OR: 0.69; 95% CI: 0.51-0.94), with moderate heterogeneity. Prevalence of comorbidities was moderators of heterogeneity for all-cause and cardiovascular death, while longer follow-up was associated with increased effectiveness for all outcomes.

CONCLUSION

 Adherence to the ABC pathway was suboptimal, being adopted in one in every five patients. Adherence to the ABC pathway was associated with a reduction in the risk of major adverse outcomes.