The Effects of Implementing a Mobile Health–Technology Supported Pathway on Atrial Fibrillation–Related Adverse Events Among Patients With Multimorbidity

Abstract

IMPORTANCE The Mobile Health Technology for Improved Screening and Optimized IntegratedCare in Atrial Fibrillation (mAFA-II) trial is a prospective cluster randomized trial that found a significant reduction in the composite clinical outcome of stroke or thromboembolism, all-cause death, and rehospitalization among patients with atrial fibrillation (AF) who used a mobile health (mHealth) technology that implemented the Atrial Fibrillation Better Care (ABC) pathway (ie, A, anticoagulation/avoid stroke; B, better symptom control; and C, cardiovascular disease and comorbidity management) compared with those receiving usual care. Multimorbidity (defined as Ն2 chronic long-term conditions) is common in older patients with AF, but the impact of integrated or holistic care (based on the ABC pathway) on clinical outcomes in this population is uncertain. OBJECTIVE To evaluate whether implementation of the integrated ABC pathway, supported by mHealth technology, would reduce AF-related adverse events in patients with multimorbidity. DESIGN, SETTING, AND PARTICIPANTSThis prespecified ancillary analysis of data from the extended follow-up of the mAFA II trial was conducted between June 2018 and April 2021. Adult patients with AF were included in the analysis if they had at least 2 comorbidities. Participants were enrolled across 40 centers in China. INTERVENTION Integrated care supported by mHealth technology (mAFA intervention) vs usual care. MAIN OUTCOMES AND MEASURES The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Cox proportional hazard modeling was performed for adverse outcomes after adjusting for cluster effect and baseline risk factors. RESULTS Of 1890 patients, 833 (mean [SD] age, 72.0 [12.0] years; 278 [33.4%] women) with multimorbidity were allocated to the intervention group (ABC pathway), with a mean (SD) follow-up of 419 (257) days, and 1057 patients (mean [SD] age, 72.8 [13.0] years; 443 [41.9%] women) with multimorbidity were allocated to usual care, with a mean (SD) follow-up of 457 (154) days. Compared with usual care, the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization was significantly reduced in the intervention group (hazard ratio [HR], 0.37; 95% CI, 0.26-0.53; P < .001), as were rehospitalizations alone (HR, 0.42; 95% CI, 0.27-0.64; P < .001). For the C criterion of the ABC pathway, rates of acute coronary syndrome, heart failure, and uncontrolled blood pressure during follow-up were lower in the intervention group than the usual care group (27 patients [3.2%] vs 145 patients [13.7%]; HR, 0.29; 95% CI, 0.19-0.45; P < .001). Subgroup analyses by age, prior stroke, and sex demonstrated consistently lower HRs for the primary composite outcome (continued) Key Points Question Does implementing mobile health technology-supported integrated care reduce atrial fibrillation (AF)-related adverse events in patients with multimorbidity? Findings In this prespecified ancillary analysis of data that included 1890 ...

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

“…Furthermore, we have provided extensive adjustment of our analyses on the evaluation of the effect of the ABC pathway on the risk of outcomes. While we cannot exclude the contribution of other unaccounted bias, which may have contributed to the results presented, our results are consistent with previous evidence on the effect of ABC pathway in similar scenarios, this further reinforcing our results [ 15 , 37 ]. Finally, our cohort was established across European countries and may not completely reflect other AF populations; therefore, our results may not be immediately applicable to other cohorts and require further evaluation in other geographical settings.…”

Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

“…41 This approach has been repeatedly proved effective, [42][43][44] and its efficacy has also been shown in clinically complex and multimorbidity patients. 45,46…”

Early Rhythm Control and the Risks of Ischemic Stroke, Heart Failure, Mortality, and Adverse Events When Performed Early (<3 Months): A Nationwide Cohort Study of Newly Diagnosed Patients with Atrial Fibrillation

“…24,25 In an analysis of high-risk cohorts (e.g., multimorbidity, polypharmacy), structure care and management based on the ABC pathway was associated with improved outcomes, compared with non-ABC compliant management. 26,27 Indeed, in an analysis from the ESC EORP-AF program, only one-third of patients were eligible for an early rhythm control strategy, and while the latter was associated with a lower rate of major adverse events, this difference was nonsignificant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile. 28 Also, early rhythm control was associated with a higher use of health-care resources and risk of hospital admission.…”