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Integrated Management of Atrial Fibrillation in Primary Care
Study Questions:
Is integrated care for atrial fibrillation (AF) in primary care noninferior compared to usual care, as performed by cardiologists and anticoagulation clinics?
Methods:
The ALL-IN trial was a cluster randomized, open-label, noninferiority trial performed in 26 primary care practices in the Netherlands; 15 practices were randomized to the integrated care intervention and 11 to usual care. The integrated care intervention consisted of quarterly AF check-ups by trained nurses focusing on comorbidities, monitoring of anticoagulation therapy, and easy-access consultations from cardiovascular specialists.
Results:
In the intervention arm, 527 out of 941 eligible AF patients aged ≥65 years provided informed consent to undergo the intervention. These 527 patients were compared with 713 AF patients in the control arm receiving usual care. Median age was 77 (interquartile range 72–83) years. The all-cause mortality rate was 3.5 per 100 patient-years in the intervention arm versus 6.7 per 100 patient-years in the control arm (adjusted hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.37–0.82). For noncardiovascular mortality, the adjusted HR was 0.47 (95% CI, 0.27–0.82). For other adverse events, no statistically significant differences were observed.
Conclusions:
When compared with usual care, integrated care for elderly AF patients in primary care had a 45% reduction in all-cause mortality.
Perspective:
The current study showed that integrated AF care in the primary care setting, compared to usual care, was associated with a tremendous decrease in mortality (45%). Inexplicably, however, this decrease was driven by noncardiac mortality, suggesting that the intense integrated AF care arrangement may have been better at managing the patients’ comorbidities, rather than AF itself. A relatively large proportion of patients in both the intervention and the control groups had routine cardiology visits—41% and 48%, respectively. The trial design randomized clinics, not patients, yet the patient cohorts were relatively well matched except that the usual care group had more patients with heart failure and was slightly older. This may have impacted the trial results in favor of the integrated care model. There is palpable value in the general practitioner and nurse-driven frequent assessments and close coordination of care.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Comorbidity, Delivery of Health Care, Integrated, General Practitioners, Geriatrics, Heart Failure, Primary Health Care, Primary Prevention, Referral and Consultation
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