Socioeconomic and geographic differences in ablation of atrial fibrillation in Norway - a national cohort study.

BACKGROUND: The aim of this study was to analyse whether there are patient related or geographic differences in the use of catheter ablation among atrial fibrillation patients in Norway. METHODS: National population-based data on individual level of all Norwegians aged 25 to 75 diagnosed with atrial fibrillation from 2008 to 2017 were used to study the proportion treated with catheter ablation. Survival analysis, by Cox regression with attained age as time scale, separately by gender, was applied to examine the associations between ablation probability and educational level, income level, place of residence, and follow-up time. RESULTS: Substantial socioeconomic and geographic variation was documented. Atrial fibrillation patients with high level of education and high income were more frequently treated with ablation, and the education effect increased with increasing age. Patients living in the referral area of St. Olavs Hospital Trust had around three times as high ablation rates as patients living in the referral area of Finnmark Hospital Trust. CONCLUSIONS: Differences in health literacy, patient preference and demands are probably important causes of socioeconomic variation, and studies on how socioeconomic status influences the choice of treatment are warranted. Some of the geographic variation may reflect differences in ablation capacity. However, geographic variation related to differences in clinical practice and provider preferences implies a need for clearer guidelines, both at the specialist level and at the referring level.

Readmissions to a cardiology department. / Reinnleggelser ved en hjertemedisinsk avdeling.

BACKGROUND: Patient readmissions may be an indication of inappropriate patient care pathways or quality failure. The aim of the study was to determine whether we could identify improvement areas by reviewing 50 non-planned readmissions. MATERIAL AND METHOD: We reviewed 50 consecutive non-planned readmissions in the Department of Cardiology at the University Hospital of North Norway. The medical records were reviewed based on a simplified version of the '50 most recent deaths' methodology. RESULTS: Altogether 29 patients had at least one extrinsic risk factor for readmission, the most frequent of which were lack of post-discharge follow-up and failure to transfer information to the municipal health service. Insufficient registration and follow-up of abnormal blood test results, new symptoms immediately before discharge, and missing information in discharge summaries and for patients were other risk factors for readmission. INTERPRETATION: Review of readmissions can serve as an instrument to identify areas for improvement of treatment quality in hospitals. Failure in communication between the hospital, municipal health service and patient was the main contributory factor for readmissions.

Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial.

BACKGROUND: Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. OBJECTIVE: The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. METHODS: An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. RESULTS: This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. CONCLUSIONS: This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. TRIAL REGISTRATION: ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX).

Quality of care for remote orthopaedic consultations using telemedicine: a randomised controlled trial.

BACKGROUND: Decentralised services using outreach clinics or modern technology are methods to reduce both patient transports and costs to the healthcare system. Telemedicine consultations via videoconference are one such modality. Before new technologies are implemented, it is important to investigate both the quality of care given and the economic impact from the use of this new technology. The aim of this clinical trial was to study the quality of planned remote orthopaedic consultations by help of videoconference. METHOD: We performed a randomised controlled trial (RCT) with two parallel groups: video-assisted remote consultations at a regional medical centre (RMC) as an intervention versus standard consultation in the orthopaedic outpatient clinic at the University Hospital of North Norway (UNN) as a control. The participants were patients referred to or scheduled for a consultation at the orthopaedic outpatient clinic. The orthopaedic surgeons evaluated each consultation they performed by completing a questionnaire. The primary outcome measurement was the difference in the sum score calculated from this questionnaire, which was evaluated by the non-inferiority of the intervention group. The study design was based on the intention to treat principle. Ancillary analyses regarding complications, the number of consultations per patient, operations, patients who were referred again and the duration of consultations were performed. RESULTS: Four-hundred patients were web-based randomised. Of these, 199 (98 %) underwent remote consultation and 190 (95 %) underwent standard consultation. The primary outcome, the sum score of the specialist evaluation, was significantly lower (i.e. 'better') at UNN compared to RMC (1.72 versus 1.82, p = 0.0030). The 90 % confidence interval (CI) for the difference in score (0.05, 0.17) was within the non-inferiority margin. The orthopaedic surgeons involved evaluated 98 % of the video-assisted consultations as 'good' or 'very good'. In the ancillary analyses, there was no significant difference between the two groups. CONCLUSIONS: This study supports the argument that it is safe to offer video-assisted consultations for selected orthopaedic patients. We did not find any serious events related to the mode of consultation. Further assessments of the economic aspects and patient satisfaction are needed before we can recommend its wider application. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00616837.

Loss of heart phospholipid arachidonic acid without phospholipid peroxidation in anaesthetized rats rewarmed after prolonged deep hypothermia.

Hypothermia-rewarming of the heart results in contractile dysfunction under in vitro as well as in vivo conditions. Increase in reactive oxygen species (ROS), lipid peroxidation and calcium overload are proposed mechanisms. In the first protocol of this study, the effect of putative phospholipase and calcium channel modulator mepacrine during deep hypothermia (4 h 14 degrees C) plus rewarming was tested in an isolated perfused rat heart model previously reported not to involve increase in lipid peroxides. Contractile function was measured under isovolumetric conditions using an intra-ventricular balloon connected to a transducer and recording system. Mepacrine completely reversed hypothermia-rewarming induced contractile failure in this model (LV dP/dt(max): 3236+/-517 vs. 1058+/-185 mmHg/s in untreated hearts). In the second part of the study, lipid peroxidation of the heart was examined in vivo in anesthetized rats subjected to 4h of deep hypothermia followed by rewarming. In this model recovery of heart function judged by cardiac output is decreased whereas blood pressure and heart rate recover fully. Peroxy conjugated diene isomers of unsaturated fatty acids were measured in heart phospholipids. The composition of the non-esterified fatty acids and the phospholipid fatty acid pool was examined in order to reveal signs of membrane remodeling. The results demonstrated no significant changes in phospholipid peroxidation after rewarming (91.07+/-5.23 vs. 88.63+/-7.73 nmol/g dry wt. in control). There was significant relative reduction in the content of arachidonic acid in the phospholipid fraction (29.55+/-1.65 vs. 24.76+/-1.48%). There was marked decrease in non-esterified fatty acids in myocardial tissue (1992+/-291 vs. 1069+/-189 nmol/g dry wt.), but a significant relative increase in arachidonic acid (20:4) in this fraction (3.46+/-0.42 vs. 4.99+/-0.30%). In conclusion, rewarming from deep hypothermia is not associated with increased phospholipid peroxidation. There is, however, a significant remodeling of the phospholipid fraction of myocardial lipids in vivo probably as a result of receptor or calcium stimulated phospholipase activity. Calcium or calcium stimulated phospholipase activity could contribute to posthypothermic contractile dysfunction.

Patient reported outcomes with remote orthopaedic consultations by telemedicine: A randomised controlled trial.

INTRODUCTION: Decentralised services through outreach clinics or modern technology reduce patient travel time and cost to society. Telemedicine consultation through videoconference is one such modality. Here, we compared patient-reported health outcomes and satisfaction between video-assisted remote and standard face-to-face orthopaedic consultations. METHODS: This randomised controlled trial included two parallel groups: (1) patients receiving video-assisted remote consultation at a regional medical centre (RMC); and (2) patients receiving standard consultation at the orthopaedic outpatient clinic of the University Hospital of North Norway (UNN). This study included patients referred to or scheduled for a consultation at the orthopaedic outpatient clinic. After each consultation, patient satisfaction was determined using patient-completed questionnaires containing questions on patient-reported health (three-level European quality of life five-dimension index (EQ-5D-3L)/European quality of life visual analogue scale (EQ-VAS)) and questions from a validated OutPatient Experiences Questionnaire (OPEQ). RESULTS: This study included 389 patients, of which 199 received remote consultation and 190 received standard consultation (total of 559 consultations). In all, 99% RMC-randomised patients and 99% UNN-randomised patients evaluated the consultation as very satisfactory or satisfactory. Moreover, 86% RMC-randomised patients preferred video-assisted consultation as the next consultation. No difference was observed in patient-reported health after 12 months between the two groups. EQ-5D index scores were 0.77 and 0.75 for RMC- and UNN-randomised patients, respectively (p = 0.42). DISCUSSION: We did not observe any difference in patient-reported satisfaction and health (EQ-5D/EQ-VAS) between video-assisted and standard consultations, suggesting that video-assisted remote consultation can be safely offered to some orthopaedic patients. Moreover, a significantly high proportion of patients selected video-assisted remote consultation as their next consultation, thus strengthening the findings of this study. However, economic aspects should be assessed before widely recommending video-assisted consultation.

Comparison of bipolar and unipolar radiofrequency ablation in an in vivo experimental model.

OBJECTIVE: Linear atrial radiofrequency lesions have been used effectively for the treatment of atrial fibrillation. In most cases an endocardial approach has been suggested. A method for epicardial placement of lesions would reduce the complexity of these procedures. We compared lesions created in ovine hearts in vivo using irrigated bipolar or unipolar handheld radiofrequency ablation devices. METHODS: Radiofrequency lesions were produced around a left pulmonary vein, around the left atrial appendage and in the free wall of the right ventricle in ovine hearts. All lesions were created in the beating heart. A bipolar clamping device (n = 7) or a handheld unipolar device (n = 6) was used. Measurements of local electrograms and pacing thresholds were performed before and after ablation at each site to assess the electrical integrity of lesions. Tetrazolium and digital image analysis were used to assess lesion geometry. RESULTS: In atrial tissue continuous transmural lesions were achieved more often with the bipolar than with the unipolar device (92.3 vs. 33.3%, P < 0.02). In atrial tissue the reduction in signal amplitude caused by the lesions was significantly larger with the bipolar than the unipolar device (87.6+/-9.4% vs. 60.6+/-23.7% reduction, P < 0.01). There was a significant relationship between loss of pacing capture and lesion transmurality (P < 0.05). The bipolar device created narrower lesions than the unipolar device (4.1+/-0.9 mm vs. 5.9+/-2.1 mm, P < 0.001). CONCLUSIONS: The bipolar clamping device produces narrower lesions which are more likely to be transmural and lead to electrical isolation of ablated tissue than those produced by the unipolar device. However, both devices failed to consistently produce transmural lesions using the epicardial beating heart technique studied, particularly in thicker tissues. High output pacing within the ablated tissue partially predicts lesion transmurality and be a guide to the need for further ablation. However, endocardial ablation or transmural bipolar ablation are likely to remain the techniques of choice for linear radiofrequency ablation in the atria until improved techniques are developed.

Curative ablation for atrial fibrillation: a systematic review.

OBJECTIVE: To perform a systematic review of randomized controlled trials (RCTs) on catheter ablation for atrial fibrillation (AF). BACKGROUND: Radiofrequency catheter (RF)-ablation around pulmonary vein ostia and in left atrium may reduce or prevent recurrence of AF, as documented in observational studies and registry reports; however, few RCTs are available. METHODS: Using relevant search phrases, Cochrane Library, MEDLINE and EMBASE were searched for RCTs, last time in May 2007. Titles and abstracts were screened. When entry criteria were fulfilled, full-text papers were read and graded according to quality and relevance. RESULTS: One thousand and ninety four abstracts were evaluated, and five RCTs included (578 randomized patients). The studies had moderate quality and relevance, but the results were consistent: ablation is better than drug treatment in preventing AF recurrence; the relative risk (95% CI)) one year after ablation ranged from 0.20 (0.08-0.51) to 0.62 (0.39-0.99). CONCLUSIONS: Results from observational and registry studies are confirmed: RF-ablation reduces recurrence rate of AF, and can be done with few serious complications. Limitations are few patients>70 years, and only one year follow-up.