Integrated management of atrial fibrillation in primary care: results of the ALL-IN cluster randomized trial

Abstract

Aims To evaluate whether integrated care for atrial fibrillation (AF) can be safely orchestrated in primary care. Methods and results The ALL-IN trial was a cluster randomized, open-label, pragmatic non-inferiority trial performed in primary care practices in the Netherlands. We randomized 26 practices: 15 to the integrated care intervention and 11 to usual care. The integrated care intervention consisted of (i) quarterly AF check-ups by trained nurses in primary care, also focusing on possibly interfering comorbidities, (ii) monitoring of anticoagulation therapy in primary care, and finally (iii) easy-access availability of consultations from cardiologists and anticoagulation clinics. The primary endpoint was all-cause mortality during 2 years of follow-up. In the intervention arm, 527 out of 941 eligible AF patients aged ≥65 years provided informed consent to undergo the intervention. These 527 patients were compared with 713 AF patients in the control arm receiving usual care. Median age was 77 (interquartile range 72–83) years. The all-cause mortality rate was 3.5 per 100 patient-years in the intervention arm vs. 6.7 per 100 patient-years in the control arm [adjusted hazard ratio (HR) 0.55; 95% confidence interval (CI) 0.37–0.82]. For non-cardiovascular mortality, the adjusted HR was 0.47 (95% CI 0.27–0.82). For other adverse events, no statistically significant differences were observed. Conclusion In this cluster randomized trial, integrated care for elderly AF patients in primary care showed a 45% reduction in all-cause mortality when compared with usual care.

Telemedicine-Based Specialized Care Improves the Outcome of Anticoagulated Individuals with Venous Thromboembolism—Results from the thrombEVAL Study

“…In the present study, treatment in CS was associated with a 0.15-fold risk for the primary outcome, 0.09-fold risk for thromboembolic events, 0.15-fold risk for relevant bleeding events, 0.17-fold risk for all-cause mortality and a 0.39-fold risk for hospitalizations compared with RMC during follow-up. These benefits were similar to results reported for integrated care versus primary care in other settings, like atrial fibrillation [ 39 ]. We previously reported significantly improved clinical outcomes for the whole thrombEVAL study sample, comprising all patients with various indications of OAC treatment [ 40 ].…”

Mobile health technology-supported atrial fibrillation screening and integrated care: A report from the mAFA-II trial Long-term Extension Cohort

“…Indeed, an integrated care apporach in the present mAFA II trial long term extension cohort reduced the risk for rehospitalisation by 31%. Other nurse-driven (or nurse-led) integrated care approachs have also been demonstrated to be clinically beneficial for atrial fibrillation patients [19] , [20] , [21] .…”

Age-Related Clinical Outcomes of Patients with Non-Valvular Atrial Fibrillation: Insights from the COOL-AF Registry

“… 33 NVAF can lead to heart failure and vice versa. 35 Recent data showed that integrated care, 36 such as ABC pathway (A = Avoid stroke with anticoagulation, B = better symptom management, and C = Cardiovascular and comorbidity risk management), should be encouraged to reduce the cardiovascular risk of patients with NVAF. 37 Due to the increased risk of clinical outcomes with increasing age, many treatment and preventative strategies should be mentioned.…”