Outpatient Check-In Using an Online Portal.

Background: Despite ongoing digital and technological developments, incorporation of new developments in outpatient care tends to be slow. Regarding an increasing demand for outpatient care, digitalization of health care carries the potential of a much needed more efficient and patient-oriented system. Objective: To optimize classic face-to-face outpatient clinic follow-up consultations and evaluate the added value of an upfront digital consult preparation (DCP). Methods: A cross-sectional observational study was conducted at Rijnstate Hospital (Arnhem, the Netherlands) among all consecutive patients, 18 years or older, who visited the Cardiology (in June 2021) or Neurology (in September 2021) outpatient clinic. All received a DCP survey before their scheduled outpatient clinic appointment, containing three questions regarding their upcoming visit. In addition, the involved health care providers were approached by using a questionnaire to share their experience regarding the DCP. Data concerning the experience of patients and health care providers was anonymous and gathered using Qualtrics.com. Results: All 25 involved health care providers (12 cardiologists, 13 neurologists) provided feedback. According to the health care providers DCP decreased the workload and improved theirs and patients' preparation. In total, 785 of 1626 (48.3%) patients filled-in the DCP before their appointment within a predetermined period. Only 4% of the patients wanted to change or cancel the consultation. A total of 122 of the 300 (40.1%) patients approached, filled-in a questionnaire to reflect on the DCP. Patients experienced DCP as an improvement of consultation, more time-efficient, increasing patients' and health care providers' preparation, increasing a feeling of acknowledgement and improving co-decision on type of consultation. The DCP did not attribute to co-deciding on treatment. Conclusion: DCP was perceived as an improvement of the standard outpatient care by both health care providers and patients with automated integration into the electronic patient record being of key importance.

Self-Reported Mobile Health-Based Risk Factor and CHA2DS2-VASc-Score Assessment in Patients With Atrial Fibrillation: TeleCheck-AF Results.

INTRODUCTION: The TeleCheck-AF approach is an on-demand mobile health (mHealth) infrastructure incorporating mobile app-based heart rate and rhythm monitoring through teleconsultation. We evaluated feasibility and accuracy of self-reported mHealth-based AF risk factors and CHA2DS2-VASc-score in atrial fibrillation (AF) patients managed within this approach. MATERIALS AND METHODS: Consecutive patients from eight international TeleCheck-AF centers were asked to complete an app-based 10-item questionnaire related to risk factors, associated conditions and CHA2DS2-VASc-score components. Patient's medical history was retrieved from electronic health records (EHR). RESULTS: Among 994 patients, 954 (96%) patients (38% female, median age 65 years) completed the questionnaire and were included in this analysis. The accuracy of self-reported assessment was highest for pacemaker and anticoagulation treatment and lowest for heart failure and arrhythmias. Patients who knew that AF increases the stroke risk, more often had a 100% or ≥80% correlation between EHR- and app-based results compared to those who did not know (27 vs. 14% or 84 vs. 77%, P = 0.001). Thromboembolic events were more often reported in app (vs. EHR) in all countries, whereas higher self-reported hypertension and anticoagulant treatment were observed in Germany and heart failure in the Netherlands. If the app-based questionnaire alone was used for clinical decision-making on anticoagulation initiation, 26% of patients would have been undertreated and 6.1%-overtreated. CONCLUSION: Self-reported mHealth-based assessment of AF risk factors is feasible. It shows high accuracy of pacemaker and anticoagulation treatment, nevertheless, displays limited accuracy for some of the CHA2DS2-VASc-score components. Direct health care professional assessment of risk factors remains indispensable to ensure high quality clinical-decision making.

On-demand mobile health infrastructures to allow comprehensive remote atrial fibrillation and risk factor management through teleconsultation.

BACKGROUND: Although novel teleconsultation solutions can deliver remote situations that are relatively similar to face-to-face interaction, remote assessment of heart rate and rhythm as well as risk factors remains challenging in patients with atrial fibrillation (AF). HYPOTHESIS: Mobile health (mHealth) solutions can support remote AF management. METHODS: Herein, we discuss available mHealth tools and strategies on how to incorporate the remote assessment of heart rate, rhythm and risk factors to allow comprehensive AF management through teleconsultation. RESULTS: Particularly, in the light of the coronavirus disease 2019 (COVID-19) pandemic, there is decreased capacity to see patients in the outpatient clinic and mHealth has become an important component of many AF outpatient clinics. Several validated mHealth solutions are available for remote heart rate and rhythm monitoring as well as for risk factor assessment. mHealth technologies can be used for (semi-)continuous longitudinal monitoring or for short-term on-demand monitoring, dependent on the respective requirements and clinical scenarios. As a possible solution to improve remote AF care through teleconsultation, we introduce the on-demand TeleCheck-AF mHealth approach that allows remote app-based assessment of heart rate and rhythm around teleconsultations, which has been developed and implemented during the COVID-19 pandemic in Europe. CONCLUSION: Large scale international mHealth projects, such as TeleCheck-AF, will provide insight into the additional value and potential limitations of mHealth strategies to remotely manage AF patients. Such mHealth infrastructures may be well suited within an integrated AF-clinic, which may require redesign of practice and reform of health care systems.

Stroke and thromboembolism in atrial fibrillation.

We performed a systematic review of the available evidence on the relationship between the individual clinical, echocardiographic and laboratory characteristics of patients with atrial fibrillation (AF) and the risk of stroke. A systematic review was also performed of all published stroke risk stratification models, as well as the accuracy of their discriminative ability between risk strata. Third, we reviewed the literature on cost-effectiveness analyses with oral anticoagulation in AF. From the systematic review on stroke risk factors, a prior stroke or transient ischemic attack (15/16 studies positive, risk ratio [RR] 2.86), hypertension (11/20 studies positive, RR 2.27), aging (9/13 studies positive, RR 1.46 per decade increase), structural heart disease (9/13 studies positive, RR 2.0) and diabetes (9/14 studies positive, RR 1.62) were found to be good independent predictors of stroke. Supportive evidence was found for sex (8/22 studies positive, RR 1.67), vascular disease (6/17 studies positive, RR 2.61) and heart failure (7/18 studies positive, RR 1.85). The various risk stratification schemes classified variable proportions as low, moderate and high risk, but the CHA(2)DS(2)-VASc score classified the smallest proportion of patients as 'low risk'. Anticoagulation with vitamin K antagonists and dabigatran is cost-effective in patients at high risk of stroke, but not in patients without any other stroke risk factor beside AF. Continued efforts are warranted to improve the antithrombotic management of AF patients to identify, and challenge, risk factors and refine risk stratification models in order to realize an individualized tailored, risk factor-based approach.

Atrial fibrillation: A risk score for AF-burning the haystack to find the needle.

The novel risk score for new-onset atrial fibrillation proposed by Schnabel et al. is based on readily identifiable risk factors and provides an excellent 'first draft' to focus primary prevention and halt the pandemic spread of this arrhythmia and its potentially lethal consequences. The risk score does, however, require further validation and sophistication with novel imaging techniques before it can be applied in clinical practice.