Adherence to the Atrial fibrillation Better Care pathway and the risk of adverse health outcomes in older care home residents with atrial fibrillation: a retrospective data linkage study 2003-18

BACKGROUND

The Atrial fibrillation Better Care (ABC) pathway is the gold-standard approach to atrial fibrillation (AF) management, but the effect of implementation on health outcomes in care home residents is unknown.

OBJECTIVE

To examine associations between ABC pathway adherence and stroke, transient ischaemic attack, cardiovascular hospitalisation, major bleeding, mortality and a composite of all these outcomes in care home residents.

METHODS

A retrospective cohort study of older care home residents (≥65 years) in Wales with AF was conducted between 1 January 2003 and 31 December 2018 using the Secure Anonymised Information Linkage Databank. Adherence to the ABC pathway was assessed at care home entry using pre-specified definitions. Cox proportional hazard and competing risk models were used to estimate the risk of health outcomes according to ABC adherence.

RESULTS

From 14,493 residents (median [interquartile range] age 87.0 [82.6-91.2] years, 35.2% male) with AF, 5,531 (38.2%) were ABC pathway adherent. Pathway adherence was not significantly associated with risk of the composite outcome (adjusted hazard ratio, 95% confidence interval [CI]: 1.01 [0.97-1.05]). There was a significant independent association observed between ABC pathway adherence and a reduced risk of myocardial infarction (0.70 [0.50-0.98]), but a higher risk of haemorrhagic stroke (1.59 [1.06-2.39]). ABC pathway adherence was not significantly associated with any other individual health outcomes examined.

CONCLUSION

An ABC adherent approach in care home residents was not consistently associated with improved health outcomes. Findings should be interpreted with caution owing to difficulties in defining pathway adherence using routinely collected data and an individualised approach is recommended.

Pharmacist-led intervention for older people with atrial fibrillation in long-term care (PIVOTALL study): a randomised pilot and feasibility study

BACKGROUND

Older care home residents are a vulnerable group of people with atrial fibrillation (AF) at high risk of adverse health events. The Atrial Fibrillation Better Care (ABC: Avoid stroke; Better symptom management; Cardiovascular and other comorbidity management) pathway is the gold-standard approach toward integrated AF care, and pharmacists are a potential resource with regards to its' implementation. The aim of this study was to determine the feasibility of pharmacist-led medicines optimisation in care home residents, based on the ABC pathway compared to usual care.

METHODS

Individually randomised, prospective pilot and feasibility study of older (aged ≥ 65 years) care home residents with AF (ISRCTN14747952); residents randomised to ABC pathway optimised care versus usual care. The primary outcome was a description of study feasibility (resident and care home recruitment and retention). Secondary outcomes included the number and type of pharmacist medication recommendations and general practitioner (GP) implementation.

RESULTS

Twenty-one residents were recruited and 11 (mean age [standard deviation] 85.0 [6.5] years, 63.6% female) were randomised to receive pharmacist-led medicines optimisation. Only 3/11 residents were adherent to all three components of the ABC pathway. Adherence was higher to 'A' (9/11 residents) and 'B' (9/11 residents) components compared to 'C' (3/11 residents). Four ABC-specific medicines recommendations were made for three residents, and two were implemented by residents' GPs. Overall ABC adherence rates did not change after pharmacist medication review, but adherence to 'A' increased (from 9/11 to 10/11 residents). Other ABC recommendations were inappropriate given residents' co-morbidities and risk of medication-related adverse effects.

CONCLUSIONS

The ABC pathway as a framework was feasible to implement for pharmacist medication review, but most residents' medications were already optimised. Low rates of adherence to guideline-recommended therapy were a result of active decisions not to treat after assessment of the net risk-benefit.

1208 FEASIBILITY OF A PHARMACIST-LED INTERVENTION FOR ATRIAL FIBRILLATION IN LONG-TERM CARE: THE PIVOTALL STUDY

Introduction

Older people in care homes with atrial fibrillation (AF) have complex health needs and would benefit from taking part in research. This study assessed the feasibility of pharmacist implementation of the Atrial Fibrillation Better Care (ABC: Anticoagulation; Better symptoms; Cardiovascular comorbidity management) pathway, and collection of an AF-specific, resident-centred outcome.

Methods

Older residents (aged ≥65 years) with AF were recruited from care homes within Liverpool and Sefton and randomised to receive the pharmacist intervention, or continue their existing treatment. Resident quality of life was assessed using the Atrial Fibrillation Effect on Quality of Life Questionnaire (AFEQT).

Results

Twenty-two care homes were approached about the study, and seven signed up to take part between 28 September 2020 and 29 April 2021. Time taken to recruit care homes ranged from 0 to 122 days. There were 83 residents identified as potentially eligible to take part, but after screening only 28 residents (34%) were invited. Overall, 21 residents were recruited. Eleven residents received the pharmacist intervention and three had ABC recommendations made to their GPs. Two out of four recommendations were implemented. The pharmacist administered the AFEQT questionnaire to 17 residents with capacity and completion rates were 94% and 93% at baseline and six-months, respectively. Residents found the questionnaire difficult; most were unable to distinguish if symptoms were AF-related (n=3), or did not know they had AF (n=8), and questions related to physical activity were not applicable to any of the residents who were bed bound (n=5) or had severely limited mobility (n=12).

Conclusion

There were procedural (encountered before research starts), system (encountered during research) and resident-specific barriers that impacted this study. Barriers need addressing before wider implementation, and AF-specific quality of life measures need to be developed and validated for care home residents. A detailed commentary has been submitted for publication.

Stop and Go: Barriers and Facilitators to Care Home Research

Barriers to care home research have always existed, but have been thrown into sharp relief by the COVID-19 pandemic. Existing infrastructure failed to deliver the research, or outcomes, which care home residents deserved and we need to look, again, at how these barriers can be taken down. Barriers can be categorised as procedural (encountered before research starts), system (encountered during research) or resident-specific. To tackle these, research regulatory bodies need to adopt a standardised approach to how care home research is developed and designed, reviewed and regulated, and how such approaches can enable recruitment of as wide a range of residents and their representatives as possible, including those without the mental capacity to consent for research. Establishment of local, inter-disciplinary collaborations between universities, general practices, health and social care providers and care homes is another priority. This should be based on pre-existing models such as the 'Living lab' model developed in The Netherlands and now being implemented in the UK and Austria. These changes are critical to develop a sustainable research model. If well designed this will deliver better outcomes for residents and align with the individual and organisational priorities of those who care for them.

Prevalence and outcomes of atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003-2018

OBJECTIVE

To determine atrial fibrillation (AF) prevalence and temporal trends, and examine associations between AF and risk of adverse health outcomes in older care home residents.

METHODS

Retrospective cohort study using anonymised linked data from the Secure Anonymised Information Linkage Databank on CARE home residents in Wales with AF (SAIL CARE-AF) between 2003 and 2018. Fine-Gray competing risk models were used to estimate the risk of health outcomes with mortality as a competing risk. Cox regression analyses were used to estimate the risk of mortality.

RESULTS

There were 86,602 older care home residents (median age 86.0 years [interquartile range 80.8-90.6]) who entered a care home between 2003 and 2018. When the pre-care home entry data extraction was standardised, the overall prevalence of AF was 17.4% (95% confidence interval 17.1-17.8) between 2010 and 2018. There was no significant change in the age- and sex-standardised prevalence of AF from 16.8% (15.9-17.9) in 2010 to 17.0% (16.1-18.0) in 2018. Residents with AF had a significantly higher risk of cardiovascular mortality (adjusted hazard ratio [HR] 1.27 [1.17-1.37], P < 0.001), all-cause mortality (adjusted HR 1.14 [1.11-1.17], P < 0.001), ischaemic stroke (adjusted sub-distribution HR 1.55 [1.36-1.76], P < 0.001) and cardiovascular hospitalisation (adjusted sub-distribution HR 1.28 [1.22-1.34], P < 0.001).

CONCLUSIONS

Older care home residents with AF have an increased risk of adverse health outcomes, even when higher mortality rates and other confounders are accounted for. This re-iterates the need for appropriate oral anticoagulant prescription and optimal management of cardiovascular co-morbidities, irrespective of frailty status and predicted life expectancy.

Integrated Care for Atrial Fibrillation Management: The Role of the Pharmacist

Within Europe and the Asia-Pacific, the Atrial Fibrillation Better Care (ABC) pathway is the gold standard integrated care strategy for atrial fibrillation management. Atrial fibrillation diagnosis should be confirmed and characterized (CC) prior to implementation of ABC pathway components: 1) "A"- Anticoagulation/Avoid stroke; 2) "B"- Better symptom management; and 3) "C"- Cardiovascular and other comorbidity optimization. Pharmacists have the potential to expedite integrated care for atrial fibrillation across the health care continuum: hospital, community pharmacy, and general practice. This review summarizes the available evidence base for pharmacist-led implementation of the "CC to ABC" model.

Prevalence and outcomes of atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003–2018

Background

Older care home residents are a high-risk group of people with atrial fibrillation (AF) who are under-represented in clinical trials. Improved understanding of AF epidemiology and management in this population is paramount for health and social care organisations to strategically plan services.

Purpose

To determine the trends in AF prevalence and compare adverse health outcomes in older care home residents aged ≥65 years with AF compared to those without AF.

Methods

Retrospective cohort study of people entering a care home between 2003–2018 using nationwide, population-scale anonymised health and administrative data, provisioned from the Secure Anonymised Information Linkage (1 January 2000–31st December 2018). Direct standardisation was used to calculate AF prevalence by year of care entry (2010–2018). Cox regression analyses were used to estimate the risk of adverse health outcomes.

Results

Between 2003 and 2018, 86,602 people aged ≥65 years became new residents in care homes in Wales. Residents with AF (n=14,493) had a significantly higher risk (adjusted hazard ratio [aHR], 95% confidence interval [CI]) of cardiovascular (aHR 1.27 [1.17 to 1.37], p&lt;0.001) and all-cause mortality (aHR 1.14 [1.11 to 1.17], p&lt;0.001), Figure 1. The risk (sub-distribution hazard ratio [sHR], 95% CI) of ischaemic stroke (adjusted sHR 1.55 [1.36 to 1.76], p&lt;0.001) and cardiovascular hospitalisation (adjusted sHR 1.28 [1.22 to 1.34], p&lt;0.001) was also higher in residents with AF, even when mortality was considered a competing event, Figure 1. There was no significant change in age- and sex-standardised prevalence of AF between 2010 and 2018, 16.79% (95% CI 15.85 to 17.94) and 17.02% (95% CI 16.05 to 17.98), respectively (absolute change 2010–2018: 0.06% [95% CI: −1.38 to 1.50], p=0.93), Figure 2.

Conclusions

This study demonstrates unique data on the epidemiology of AF and associated outcomes in older care home residents. Whilst the prevalence of AF remained stable between 2010–2018, residents with AF had significantly higher risk of adverse health events. Treatment of AF in accordance with guidelines is critical in this population to optimise management and reduce adverse health outcomes.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial Hemorrhage: Systematic Review and Meta-Analysis

BACKGROUND:

For patients with atrial fibrillation who survive an intracranial hemorrhage (ICrH), the decision to offer oral anticoagulation (OAC) is challenging and necessitates balancing risk of thromboembolic events with risk of recurrent ICrH.

METHODS:

This systematic review assesses the effectiveness and safety of OAC and/or antiplatelets in patients with atrial fibrillation with nontraumatic ICrH. Bibliographic databases CENTRAL, MEDLINE, EMBASE, and CINAHL were searched. Articles on adults with atrial fibrillation with spontaneous ICrH (intracerebral, subdural, and subarachnoid), receiving antithrombotic therapy for stroke prevention were eligible for inclusion.

RESULTS:

Twenty articles (50 470 participants) included 2 randomized controlled trials (n=304)‚ 8 observational studies, 8 cohort studies, and 2 studies that meta-analyzed individual-level data from observational studies. OAC therapy was associated with a significant reduction in thromboembolic events (summary relative risk [sRR], 0.51 [95% CI, 0.30–0.86], heterogeneity I 2 =2%; P =0.39, n=5 studies) and all-cause mortality (sRR, 0.52 [95% CI, 0.38–0.71], heterogeneity I 2 =0; P =0.44, n=3 studies). OAC therapy was not associated with an increased risk of recurrent ICrH (sRR, 1.44 [95% CI, 0.38–5.46], heterogeneity I 2 =70%, P =0.02, n=5 studies). Nonvitamin K antagonist OACs were more effective at reducing the risk of thromboembolic events (sRR, 0.65 [95% CI, 0.44–0.97], heterogeneity I 2 =72%, P =0.03, n=3 studies) and were associated with a lower risk of recurrent ICrH (sRR, 0.52 [95% CI, 0.40–0.67], heterogeneity I 2 =0%, P =0.43, n=3 studies) than warfarin.

CONCLUSIONS:

In nontraumatic ICrH survivors with atrial fibrillation, OAC therapy is associated with a reduced risk of thromboembolic events and all-cause mortality without significantly increasing risk of recurrent ICrH. This finding is primarily based on observational data, and further larger randomized controlled trials are needed to corroborate or refute these findings.

Stroke in Older Adults Living in Care Homes: Results From a National Data Linkage Study in Wales

OBJECTIVES

To determine the proportion of older people moving to care homes with a recent stroke, incidence of stroke after moving to a care home, mortality following stroke, and secondary stroke prevention management in older care home residents.

DESIGN

Retrospective cohort study using population-scale individual-level linked data sources between 2003 and 2018 in the Secure Anonymized Information Linkage (SAIL) Databank.

SETTING AND PARTICIPANTS

People age ≥65 years residing in long-term care homes in Wales.

METHODS

Competing risk models and logistic regression models were used to examine the association between prior stroke, incident stroke, and mortality following stroke.

RESULTS

Of 86,602 individuals, 7.0% (n = 6055) experienced a stroke in the 12 months prior to care home entry. The incidence of stroke within 12 months after entry to a care home was 26.2 per 1000 person-years [95% confidence interval (CI) 25.0, 27.5]. Previous stroke was associated with higher risk of incident stroke after moving to a care home (subdistribution hazard ratio 1.83, 95% CI 1.57, 2.13) and 30-day mortality following stroke (odds ratio 2.18, 95% CI 1.59, 2.98). Severe frailty was not significantly associated with risk of stroke or 30-day mortality following stroke. Secondary stroke prevention included statins (50.5%), antiplatelets (61.2%), anticoagulants (52.4% of those with atrial fibrillation), and antihypertensives (92.1% of those with hypertension).

CONCLUSIONS AND IMPLICATIONS

At the time of care home entry, individuals with history of stroke in the previous 12 months are at a higher risk of incident stroke and mortality following an incident stroke. These individuals are frequently not prescribed medications for secondary stroke prevention. Further evidence is needed to determine the optimal care pathways for older people living in long-term care homes with history of stroke.

Oral anticoagulants and outcomes in adults ≥80 years with atrial fibrillation: A global federated health network analysis

BACKGROUND

The objective of this study was to determine associations between use of oral anticoagulation (OAC) and stroke and bleeding-related outcomes for older people ≥80 years with atrial fibrillation (AF), and to determine trends over time in prescribing of OAC for this population.

METHODS

A retrospective cohort study was conducted. People aged ≥80 years with AF receiving (1) no OAC; (2) warfarin; or (3) a non-vitamin-K antagonist oral anticoagulant (NOAC) between 2011 and 2019 were included. Propensity score matching was used to balance cohorts (no OAC, warfarin or a NOAC) on characteristics including age, sex, ethnicity, and co-morbidities. Cox proportional hazard models were used to derive hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

The proportion of people aged ≥80 years receiving any OAC increased from 32.4% (n = 27,647) in 2011 to 43.6% (n = 110,412) in 2019. After propensity score matching, n = 169,067 individuals were included in the cohorts receiving no OAC or a NOAC. Compared to no OAC, participants receiving a NOAC had a lower risk of incident dementia (hazHR 0.68, 95% CI 0.65-0.71), all-cause mortality (HR 0.49, 95% CI 0.48-0.50), first-time ischaemic stroke (HR 0.87, 95% CI 0.83-0.91), and a higher risk of major bleeding (HR 1.08, 95% CI 1.05-1.11). Compared to participants receiving warfarin, participants receiving a NOAC had a lower risk of dementia (HR 0.90, 95% CI: 0.86-0.93), all-cause mortality (HR 0.74, 95% CI: 0.72-0.76), ischaemic stroke (HR 0.86, 95% CI: 0.82-0.90) and major bleeding (HR 0.88, 95% CI: 0.85-0.90). Similar results were observed when only including people with additional bleeding risk factors.

CONCLUSIONS

The proportion of people aged ≥80 years receiving OAC has increased since the introduction of NOACs, but remains low. Use of a NOAC was associated with improved outcomes compared to warfarin, and compared to no OAC, except for a small but statistically significant higher risk of major bleeding.

Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review

BACKGROUND

anticoagulation is integral to stroke prevention for atrial fibrillation (AF), but there is evidence of under-treatment in older people in long-term care (LTC).

OBJECTIVE

to synthesise evidence on the prevalence and outcomes (stroke, mortality or bleeding) of AF in LTC and the factors associated with the prescription of anticoagulation.

METHODS

studies were identified from Medline, CINAHL, PsycINFO, Scopus and Web of Science from inception to 31 October 2019. Two reviewers independently applied the selection criteria and assessed the quality of studies using the Newcastle Ottawa Scale.

RESULTS

twenty-nine studies were included. Prevalence of AF was reported in 21 studies, ranging from 7 to 38%. Two studies reported on outcomes based on the prescription of anticoagulation or not; one reported a reduction in the ischaemic stroke event rate associated with anticoagulant (AC) prescription (2.84 per 100 person years, 95% confidence interval [CI]: 1.98-7.25 versus 3.95, 95% CI: 2.85-10.08) and a non-significant increase in intracranial haemorrhage rate (0.71 per 100 person years, 95% CI: 0.29-2.15 versus 0.65, 95% CI: 0.29-1.93). The second study reported a 76% lower chance of ischaemic stroke with AC prescription and a low incidence of bleeding (n = 4 events). Older age, dementia/cognitive impairment and falls/falls risk were independently associated with the non-prescription of anticoagulation. Conversely, previous stroke/transient ischaemic attack and thromboembolism were independently associated with an increased prescription of anticoagulation.

CONCLUSION

estimates of AF prevalence and factors associated with AC prescription varied extensively. Limited data on outcomes prevent the drawing of definitive conclusions. We recommend panel data collection and systems for linkage to create longitudinal cohorts to provide more robust evidence.

Optimization of atrial fibrillation care: management strategies and quality measures

Atrial fibrillation (AF) is the most common cardiac arrhythmia and a leading cause of mortality and morbidity. Optimal management of AF is paramount to improve quality of life and reduce the impact on health and social care services. Owing to its strong associations with other cardiovascular and non-cardiovascular comorbidities, a holistic management approach to AF care is advocated but this is yet to be clearly defined by international clinical guidelines. This ambiguity has prompted us to review the available clinical evidence on different management strategies to optimize AF care in the context of performance and quality measures, which can be used to objectively assess standards of care.

High-Risk Medication Use in Older Residents of Long-Term Care Facilities: Prevalence, Harms, and Strategies to Mitigate Risks and Enhance Use

Older residents of long-term care facilities (LTCFs), also known as nursing homes, care homes, or residential aged care facilities, often have multiple health conditions and are exposed to polypharmacy. Use of high-risk medications such as opioids, glucose-lowering medications, antithrombotics, and antipsychotics is prevalent among residents of LTCFs. Ensuring appropriate use of high-risk medications is important to minimize the risk of medication-related harm in this vulnerable population. This paper provides an overview of the prevalence and factors associated with high-risk medication use among residents of LTCFs. Evidencebased strategies to optimize the use of high-risk medications and enhance resident outcomes are also discussed.

High-Risk Medication Use in Older Residents of Long-Term Care Facilities: Prevalence, Harms, and Strategies to Mitigate Risks and Enhance Use

Older residents of long-term care facilities (LTCFs), also known as nursing homes, care homes, or residential aged care facilities, often have multiple health conditions and are exposed to polypharmacy. Use of high-risk medications such as opioids, glucose-lowering medications, antithrombotics, and antipsychotics is prevalent among residents of LTCFs. Ensuring appropriate use of high-risk medications is important to minimize the risk of medication-related harm in this vulnerable population. This paper provides an overview of the prevalence and factors associated with high-risk medication use among residents of LTCFs. Evidencebased strategies to optimize the use of high-risk medications and enhance resident outcomes are also discussed.

Vernakalant hydrochloride for the treatment of atrial fibrillation: evaluation of its place in clinical practice

Vernakalant is an intravenous anti-arrhythmic drug available in Europe, Canada and some countries in Asia for the restoration of sinus rhythm in acute onset atrial fibrillation. Currently, it is not available in USA because the US FDA have ongoing concerns about its safety. Vernakalant has a unique pharmacological profile of multi-ion channel activity and atrial-specificity that distinguishes it from other anti-arrhythmic drugs. This is thought to enhance efficacy but there are concerns of adverse events stemming from its diverse pharmacology. This ambiguity has prompted a review of the available clinical evidence on efficacy and safety to help re-evaluate its place in clinical practice.

Differential glycosylation of the protein (PrP) forming scrapie-associated fibrils

PrP is a glycoprotein found in normal brain. In brain affected by scrapie it forms scrapie-associated fibrils (SAF). PrP from SAF shows considerable heterogeneity of size and charge on two-dimensional gels. It separates into six major regions, the three more acidic regions arising as a result of partial proteolytic degradation. The two more basic higher Mr forms (Mr 34,000 and 29,000) of PrP can be reduced in apparent Mr to a lower Mr form (Mr 25,000) with Peptide-N-glycosidase F. In addition, a series of lectins has been found to bind to PrP. Some bind preferentially to the higher Mr forms whereas others bind more strongly to the lower Mr form. Some of the heterogeneity of PrP is therefore due to differential N-glycosylation. We suggest that one or two N-linked carbohydrate chains are bound to the protein causing some of the differences in Mr. The major cause of heterogeneity of PrP is therefore proteolytic cleavage combined with differential glycosylation at the two potential N-glycosylation sites. The glycolipid moiety attached to PrP may be responsible for some lectin binding to all three bands. Using lectins as a probe to study potential differences in N-glycosylation we have looked at their binding to PrP isolated from SAF, from different strains of scrapie and from different regions of the same brain. No major differences in the N-glycan moieties were found.

Post-mortem immunodiagnosis of scrapie and bovine spongiform encephalopathy

Two polyclonal antisera were raised in rabbits against the scrapie-associated fibril protein (PrP) prepared from sheep and mice which were terminally infected with experimental scrapie. The anti-mouse PrP serum identifies the proteins of scrapie-associated fibrils (SAF) from all the host species studied (mouse, hamster, sheep and goat) and bovine spongiform encephalopathy (BSE) fibrils from cow. The anti-sheep PrP serum displays species restricted immunoreactivity. While it identifies several PrP polypeptides from terminally affected sheep, goat and cow material, only the highest molecular weight band is recognised from hamster and there is no detection of mouse PrP. The use of these antisera in routine laboratory testing at post mortem provides a highly sensitive test for scrapie and BSE and may allow the identification of infected animals prior to the onset of clinical signs.

Structural and biochemical evidence that scrapie-associated fibrils assemble in vivo

Scrapie-associated fibrils (SAF) are a ubiquitous pathological feature of brains affected by scrapie and the other scrapie-like agents. They are composed of PrP, a heterogeneous glycoprotein which is also present in normal brain but not as SAF. The PrP protein associated with SAF is partially resistant to proteinase K, whereas the soluble form is not. It has been proposed that SAF do not exist as such in vivo, but rather self-assemble from subunit structures liberated from membranes by detergent extraction during purification. We have purified SAF by a method that does not employ proteinase K. We show that the PrP protein from infected but not uninfected brain is partially resistant to protease digestion before and after detergent extraction. Likewise, SAF can be sheared by sonication before or after detergent extraction. In addition, SAF from mice infected with different strains of scrapie have different sedimentation properties. Since SAF-dependent properties exist before detergent extraction, then so must SAF. They are therefore not a detergent-induced artefact but most probably assemble in vivo.