Effect of a virtual self-management intervention for atrial fibrillation during the outbreak of COVID-19.

BACKGROUND: As the pandemic continues to unfold, effective, technology-based solutions are needed to help patients with atrial fibrillation (AF) maintain their health and well-being during the outbreak of COVID-19. METHODS: This single-center, pilot study investigated the effects of a 4-week (eight sessions) virtual AF self-management program. Questionnaires were completed at baseline and 1 week after the intervention, and assessed AF knowledge, adherence to self-management behaviors, mental health, physical function, and disease-specific quality of life in patients with AF. Secondary outcomes included knowledge of COVID-19, intervention, acceptability, and satisfaction. RESULTS: Of 68 patients who completed baseline questionnaires, 57 participated in the intervention and were included in the analysis (mean age of 73.4 ± 10.0 years, 60% male). Adherence to AF self-monitoring behaviors, including monitoring their heart rate (p < .001), heart rhythm (p = .003), and blood pressure (p = .013) were significantly improved at the end of the intervention compared with baseline. Symptom identification (p = .007) and management (p < .001) also improved. Reductions in sleep disturbance (p < .001), anxiety (p = .014), and depression (p = .046) were also observed. Misinformation and inaccurate beliefs about COVID-19 were significantly reduced at the end of the intervention compared with baseline. CONCLUSIONS: This pilot study suggests that a virtual patient education program could have beneficial effects on adherence to guideline-recommend self-care of AF, emotional wellbeing, physical function, and knowledge of COVID-19 in patients with AF. Future randomized studies in larger samples are needed to determine the clinical benefits of the intervention.

Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations.

BACKGROUND: A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied. METHODS: A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level. RESULTS: Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001). CONCLUSIONS: We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.

Development and Feasibility of a Primary Care Provider Training Intervention to Improve Atrial Fibrillation Management.

Background: Disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. Objective: To create a virtual education intervention for PCPs and evaluate its impact on use of stroke risk reduction strategies in AF patients. Methods: A multi-disciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared pre- and post-intervention. Hierarchical logistic regression modeling was used to evaluate change in stroke risk reduction therapies among patients seen by participants before or after training. Results: Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 one-hour sessions. Overall, appropriate use of oral anticoagulation (OAC) therapy (CHA 2 DS 2 -VASc score ≥1 men, ≥2 women) increased from 37% to 46% (p<.001) comparing patients seen pre- (n=1739) to post- (n=610) intervention. Factors independently associated with appropriate OAC use included participant training (OR 1.4, p=.002) and participant competence in AF management (by survey). Factors associated with decreased OAC use included patient age (OR 0.8 per 10 years, p=.008), nonwhite race (OR 0.7, p=.028). Provider knowledge and confidence in AF care both improved (p<.001). Conclusions: A virtual case-based PCP training intervention improved use of stroke risk reduction therapy in outpatients with AF. This widely scalable intervention could improve AF care in under-resourced communities. CONDENSED ABSTRACT: A virtual educational model was developed for primary care providers to improve competency in AF care in their community. Following a 6-month training intervention, the rate of appropriate oral anticoagulation (OAC) therapy among patients cared for by participating providers increased from 37% to 46% (p<.001). Among participants, knowledge and confidence in AF care improved. These findings suggest a virtual AF training intervention can improve PCP competency in AF care. This widely scalable intervention could help improve AF care in under-resourced communities.

Development and Feasibility of a Primary Care Provider Training Intervention to Improve Atrial Fibrillation Management.

The disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. As such, we sought to create a virtual education intervention for PCPs and to evaluate its impact on the use of stroke risk reduction strategies in patients with AF. A multidisciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared before and after the intervention. Hierarchical logistic regression modeling was used to evaluate change in oral anticoagulation (OAC) therapy in the patients seen by participants before or after training. Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 1-hour sessions. Overall, the appropriate use of OAC (for CHA2DS2-VASc score ≥1 man, ≥2 women) increased from 37% to 46% (p <0.001) comparing the patients seen before (n = 1,739) versus after (n = 610) intervention. The factors independently associated with appropriate OAC use included participant training (odds ratio [OR] 1.4, p = 0.002) and participant competence in AF management. The factors associated with decreased OAC use included patient age (OR 0.8 per 10 year, p = 0.008) and nonwhite race (OR 0.7, p = 0.028). Provider knowledge and confidence in AF care improved (p <0.001). In conclusion, we show that a virtual PCP training intervention improves the use of stroke risk reduction therapy in outpatients with AF and could be a widely scalable intervention to improve AF care in under-resourced communities.

Patient Perspectives on Performance of a Smartphone App for Atrial FibrillationSelf-Management.

Introduction: AF self-care requires patients to perform daily self-monitoring for symptoms, practice decision making to address symptom changes, and adhere to prescribed medication, diet, physical activity, and follow-up care. Technology can facilitate these critical self-care behaviors and ultimately improve patient outcomes. We assessed atrial fibrillation (AF) patients' experiences with a smartphone application (app) for AF self-management. Methods: A focus group with 9 AF patients and app users was conducted and analyzed using qualitative research methods. The focus group was recorded, transcribed, and coded using a priori and inductive coding strategies. Participant responses for each code were synthesized to identify primary themes. Results: We identified four superordinate themes from patients' experiences: (1) disconnect between tool and its intended use; (2) app as acknowledged tool for adherence; (3) knowledge as empowerment; (3) motives: self-interest vs supporting research. Results from this qualitative study underscore the need to clarify the app's intended use and to better accommodate patients with different AF experiences. The disconnect between a tool and its intended use can generate frustration for users. Discussion: The study reinforces that participants not only see how the app is a tool for adherence; they also see knowledge they gain via the app as empowering, suggesting a correlation between app use and self-efficacy.

An Atrial Fibrillation Transitions of Care Clinic Improves Atrial Fibrillation Quality Metrics.

OBJECTIVES: This study sought to assess whether an atrial fibrillation (AF)-specific clinic is associated with improved adherence to American College of Cardiology (ACC)/American Heart Association (AHA) clinical performance and quality measures for adults with AF or atrial flutter. BACKGROUND: There are significant gaps in care of patients with AF, including underprescription of anticoagulation and treatment of AF risk factors. An AF specialized clinic was developed to reduce admissions for AF but may also be associated with improved quality of care. METHODS: This retrospective study compared adherence to ACC/AHA measures for patients who presented to the emergency department for AF between those discharged to a typical outpatient appointment and those discharged to a specialized AF transitions clinic run by an advanced practice provider and supervised by a cardiologist. Screening and treatment for common AF risk factors was also assessed. RESULTS: The study enrolled 78 patients into the control group and 160 patients into the intervention group. Patients referred to the specialized clinic were more likely to have stroke risk assessed and documented (99% vs. 26%; p < 0.01); be prescribed appropriate anticoagulation (97% vs. 88%; p = 0.03); and be screened for comorbidities such as tobacco use (100% vs. 14%; p < 0.01), alcohol use (92% vs. 60%; p < 0.01), and obstructive sleep apnea (90% vs. 13%; p < 0.01) and less likely to be prescribed an inappropriate combination of anticoagulant and antiplatelet medications (1% vs. 9%; p < 0.01). CONCLUSIONS: An AF specialized clinic was associated with improved adherence to ACC/AHA clinical performance and quality measures for adult patients with AF.

Likelihood of Spontaneous Cardioversion of Atrial Fibrillation Using a Conservative Management Strategy Among Patients Presenting to the Emergency Department.

Numerous emergency department (ED) atrial fibrillation (AF) protocols have been developed to reduce hospitalizations, focusing on the use of cardioversion in the ED. An alternative strategy of rate control with early specialty follow-up may be more widely applicable. The likelihood of spontaneous cardioversion with such a protocol is unknown. Between 2015 and 2018, 157 patients who presented to the ED with a primary diagnosis of AF and were hemodynamically stable and with low to moderate symptom severity were discharged with early follow-up at an AF specialty clinic. Rhythm at short-term (within 72 hours), within 30-day follow-up, and need for electrical cardioversion was tabulated. Various demographic and co-morbidity variables were assessed to determine their association with likelihood of spontaneous cardioversion. At an average of 2.3 days, 63% and within 30 days, 83% had spontaneous cardioversion. By 90 days, only 6.3% required electrical cardioversion. Diabetes (38% vs 69%, p <0.01), coronary artery disease (39% vs 66%, p = 0.02), reduced ejection fraction (40% vs 72%, p <0.01), dilated right atrium (43% vs 73%, p <0.01) and moderate-to-severely dilated left atrium (38% vs 78%, p <0.01) predicted those who were less likely to convert to sinus rhythm. Most patients who present to the ED with AF will spontaneously convert to sinus rhythm by short-term (2 to 3 days) follow-up with a rate control strategy. In conclusion, aggressive use of electrical cardioversion in the ED may be unnecessary in hemodynamically stable patients without severe symptoms.