SAFETY: Impact of a Multidisciplinary Management Program on Recurrent Hospitalization and Mortality in Older Chronic AFib Individuals

A post-discharge management program specific to atrial fibrillation (AFib) has been found to be associated with proportionately more days alive and out of the hospital – though not prolonged event-free survival – relative to standard management, according to results of the SAFETY trial presented Nov. 17 at AHA 2014 and simultaneously published in The Lancet.

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With an increasing number of patients being admitted with chronic AFib, many physicians have felt that disease-specific management could serve as an optimal means of reducing recurrent admissions and prolonging survival. With little evidence to support the application of this therapeutic approach Simon Stewart, PhD, Mary Mackillop Institute for Health Research, Australian Catholic University, Melbourne, and his colleagues initiated their own AFib-specific management strategy – called SAFETY – to determine the practice’s potential benefits.

Performing a multicenter, randomized controlled trial, Stewart et al. recruited 335 participants admitted with chronic, non-valvular AFib without heart failure, and randomly assigning them to either standard management (n=167) or the SAFETY intervention (n=168). While the standard management consisted of routine primary care and hospital outpatient follow-up, the SAFETY intervention comprised of a home visit and Holter monitoring seven to 14 days after discharge by a cardiac nurse with prolonged follow-up and multidisciplinary support as needed.

Results showed that during the median follow-up of 905 days, 49 people died and 987 unplanned admissions were recorded, with a total of 5,530 days in the hospital. Of the 168 patients assigned to the SAFETY intervention, 127 (76 percent) died or had an unplanned readmission (median event-free survival 183 days [IQR 116-409]), while 137 people (82 percent) allocated to standard management died or had an unplanned readmission (199 days [116-249]; hazard ratio 0.97, 95 percent CI 0.76-1.23; p=0.851). Patients assigned to the SAFETY intervention had 99.5 percent maximum event-free days (95 percent CI 99.3-99.7), equally to a median of 900 (IQR 767-1025) of 937 maximum days alive and out of the hospital, while those allocated to standard management had 99.2 percent (95 percent CI 98.8-99.4) maximum event-free days, equally to a median of 860 (IQR 752-1047) of 937 maximum days alive and out of the hospital (effect size 0.22, 95 percent CI 0.21-0; p=0.039).

While such clinically favorable trends in survival and unplanned hospitalization require verification in a larger trial, Stewart and his colleagues conclude that the SAFETY intervention represents a feasible strategy to markedly improve health outcomes in chronic AFib.

Keywords: House Calls, Australia, Heart Failure, Disease Management, Disease-Free Survival, Atrial Fibrillation, Electrocardiography, Ambulatory, Patient Discharge, Hospitalization, Primary Health Care

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