Adherence to the Atrial fibrillation Better Care pathway and the risk of adverse health outcomes in older care home residents with atrial fibrillation: a retrospective data linkage study 2003–18
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PROVIDER: S-EPMC10891424 | biostudies-literature | 2024 Feb
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Project description:The 2020 European Society of Cardiology guidelines endorse the Atrial Fibrillation Better Care (ABC) pathway as a structured approach for the management of atrial fibrillation (AF), addressing three principal elements: 'A' - avoid stroke (with oral anticoagulation), 'B' - patient-focused better symptom management, and 'C' - cardiovascular and comorbidity risk factor reduction and management. This review summarizes the definitions used for the ABC criteria in different studies and the impact of adherence/non-adherence on clinical outcomes, from 12 studies on seven different cohorts. All studies consistently showed statistically significant reductions in the risk of stroke, myocardial infarction, and mortality among those with ABC pathway adherent treatment. The ABC pathway provides a simple decision-making framework to enable consistent equitable care from clinicians in primary and secondary/tertiary care. Further research examining the impact of ABC pathway implementation in prospective cohorts utilizing consistent inclusion criteria and definitions of 'A', 'B', and 'C' adherent care is warranted.
| S-EPMC8502499 | biostudies-literature
Project description:BackgroundAtrial fibrillation (AF) is a complex disease associated with comorbidities and adverse outcomes. The Atrial fibrillation Better Care (ABC) pathway has been proposed to streamline the integrated and holistic approach to AF care.ObjectivesThis study sought to evaluate patients' characteristics, incidence of adverse events, and impact on outcomes with ABC pathway-adherent management.MethodsThe study included consecutive AF patients enrolled in the nationwide, ChioTEAF registry (44 centers, 20 Chinese provinces from October 2014 to December 2018), with available data to evaluate the ABC criteria and on the 1-year follow-up.ResultsA total of 3,520 patients (mean age 73.1 ± 10.4 years, 43% female) were included, of which 1,448 (41.1%) were managed as ABC pathway adherent. The latter were younger and had comparable CHA2DS2-VASc and lower HAS-BLED (mean 71.7 ± 10.3 years of age vs 74.1 ± 10.4 years of age; P < 0.01; 3.54 ± 1.60 vs 3.44 ± 1.70; P = 0.10; and 1.95 ± 1.10 vs 2.12 ± 1.20; P < 0.01, respectively) scores compared with ABC-nonadherent patients. At 1-year follow-up, patients managed adherent to the ABC pathway had a lower incidence of the primary composite outcome of all-cause death or any thromboembolic event (1.5% vs 3.6%; P < 0.01) as compared with ABC-nonadherent patients. On multivariate analysis, ABC pathway-adherent care was independently associated with a lower risk of the composite endpoint (OR: 0.51; 95% CI: 0.31-0.84).ConclusionsAdherence to the ABC pathway for integrated care in a contemporary nationwide cohort of Chinese AF patients was suboptimal. Clinical management adherent to the ABC pathway was associated with better outcomes.
| S-EPMC9627918 | biostudies-literature
Project description:BackgroundIdentifying asymptomatic patients with atrial fibrillation (AF) poses a challenge, and their optimal management is less certain, despite similar outcomes to symptomatic AF patients. The 'Atrial fibrillation Better Care' (ABC) pathway has been recently proposed as a holistic or integrated care approach for the comprehensive management of symptomatic patients with AF. We aimed to determine the use of the ABC pathway on clinical outcomes in asymptomatic patients with AF.MethodsThis is a prospective multicenter registry of patients with non-valvular AF in Thailand conducted between 2014 and 2017. Patients were characterized based on AF-related symptoms at enrollment and their adherence or non-adherence to the ABC pathway. Follow-up data were collected for 3 years to examine the composite endpoint (all-cause death, ischemic stroke/transient ischemic attack [TIA]/systemic embolism [SE], and major bleeding), and the impact of adherence to the ABC pathway.ResultsOf a total of 3405 patients included in the study, 785 (23 %) (mean age 69.0 years, 63.7 % male) were asymptomatic at enrollment. Among these asymptomatic patients, 346 (44 %) were adherent to the ABC pathway. Adherence to the ABC pathway was associated with a significantly lower rate of composite endpoints compared to non-adherence (hazard ratio [HR] 0.63, 95 % confidence interval [CI] 0.45-0.90, p = 0.01). Adherence to the ABC pathway was also associated with lower all-cause mortality rates (HR 0.55, 95 % CI 0.35-0.85, p = 0.007). After adjusting for age, gender, and baseline comorbidities, adherence to the ABC pathway remained significantly associated with a lower rate of composite endpoints (HR 0.69, 95 % CI 0.49-0.98, p = 0.03) and all-cause death (HR 0.58, 95 % CI 0.38-0.90, p = 0.01) compared to non-adherence. Subgroup analyses based on sex, age, AF type, risk scores, and comorbidities consistently demonstrated lower hazard ratios for the composite endpoint among patients who were adherent to the ABC pathway.ConclusionsIn patients with AF who were asymptomatic, adherence to the ABC pathway was associated with a lower composite endpoint of all-cause death, ischemic stroke/TIA/SE, and major bleeding. This benefit was seen irrespective of sex, age, AF type, risk scores, and comorbidities.
| S-EPMC11755037 | biostudies-literature
Project description:BackgroundThe 'Atrial fibrillation Better Care' (ABC) pathway has been proposed to streamline a more holistic or integrated care approach to atrial fibrillation (AF) management. We aimed to analyse the impact of adherence to the ABC pathway on the risk of major adverse outcomes in a contemporary prospective global cohort of patients with AF.MethodsPatients enrolled Phase II and III of the GLORIA-AF Registry with complete data on ABC pathway adherence and follow-up were included in this post-hoc analysis between November 2011 and December 2014 for Phase II, and between January 2014 and December 2016 for Phase III. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). Multivariable Cox-regression and delay of event (DoE) analyses were used to evaluate the association between adherence to the ABC pathway and the risk of outcomes.FindingsWe included 24,608 patients in this analysis (mean age: 70.2 (10.3) years, 10,938 (44.4%) females). Adherence to the ABC pathway was associated with a significant risk reduction for the primary outcome, with greatest magnitude observed for full ABC pathway adherence (adjusted Hazard Ratio [aHR] 0.54, 95% Confidence Interval [CI]: 0.44-0.67, p < 0.0001). ABC pathway adherence was also associated with reduced risk of mortality (aHR: 0.89, 95% CI: 0.79-1.00, p = 0.048), thromboembolism (aHR: 0.78, 95% CI: 0.65-0.94, p = 0.0078), and MACE (aHR: 0.82, 95% CI: 0.71-0.95, p = 0.0071). An increasing number of ABC criteria attained was associated with longer event-free survival in the DoE analysis.InterpretationAdherence to the ABC pathway in patients with AF was associated with a reduced risk of major adverse events, including mortality, thromboembolism and MACE. This underlines the importance of using the ABC pathway in the clinical care of patients with AF.FundingThis study was funded by Boehringer Ingelheim.
| S-EPMC9706520 | biostudies-literature
Project description:BackgroundOral anticoagulants (OACs) are effective in reducing the risk of cardioembolic stroke due to atrial fibrillation. While most nursing home residents with atrial fibrillation qualify for anticoagulation based on clinical guidelines, the net clinical benefits of OACs may diminish as residents approach the end of life.MethodsWe conducted a cross-sectional study of 30,503 US nursing home residents with atrial fibrillation (based on Minimum Data Set 3.0 and Medicare Part A records) who used OACs in the year before enrolling in hospice care during 2012-2016. Whether residents discontinued OACs before hospice enrollment was determined using Part D claims and date of hospice enrollment. Modified Poisson models estimated adjusted prevalence ratios (aPR).ResultsAlmost half (45.7%) of residents who had recent OAC use discontinued prior to hospice enrollment. Residents who were underweight (aPR: 1.02; 95% confidence interval [CI]: 1.01-1.03), those with high bleeding risk (aPR: 1.04, 95% CI: 1.03-1.05), and those with moderate or severe cognitive impairment (aPR: 1.02, 95% CI: 1.02-1.03) had a higher prevalence of OAC discontinuation before entering hospice. Residents with venous thromboembolism (aPR: 0.94, 95% CI: 0.93-0.96), statin users (aPR: 0.88, 95% CI: 0.87-0.89), and those on polypharmacy (≥10 medications, aPR: 0.72; 95% CI: 0.71-0.73) were less likely to discontinue OACs before enrollment in hospice.ConclusionAnticoagulants are often discontinued among older nursing home residents with atrial fibrillation before hospice enrollment; it is not clear that these decisions are driven solely by net clinical benefit considerations. Further research is needed on comparative outcomes to inform resident-centered decisions regarding OAC use in older adults entering hospice.
| S-EPMC10592350 | biostudies-literature
Project description:BackgroundThe benefit of integrated care management was unknown in frail atrial fibrillation (AF) patients. This study evaluated whether compliance with the atrial fibrillation Better Care (ABC) pathway for integrated care management would improve clinical outcomes in frail AF patients.MethodsFrom the Korea National Health Insurance Service database, 262,987 nonvalvular AF patients were enrolled between 1 January 2005 and 31 December 2015. For each patient, the Hospital Frailty Risk Score and category were calculated retrospectively using all available ICD-10 diagnostic codes. Patients were divided into three frailty-based risk categories: low (<5 points, n = 221,542), intermediate (5-15 points, n = 37,341), and high risk (>15 points, n = 4,104).ResultsOver a mean follow-up of 5.9 (interquartile range 3.2, 9.4) years, in high frailty risk patients, the ABC group had lower rates of all-cause death (6.5 vs 17.5 per 100 person-years, P < .001; hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.56-0.97) but was nonsignificant for the composite outcome (10.5 vs 26.0 per 100 person-years, P = .101; HR 0.79; 95% CI 0.59-1.05) compared with the Non-ABC group. When the three frailty categories were compared, the greatest benefit on mortality was seen in the high frailty group (pint < 0.001), but for the composite outcome, there was no statistical interaction for the three frailty categories (pint = 0.063).ConclusionsCompliance with the simple ABC pathway is associated with improved outcomes in AF patients with high frailty risk. Given the high healthcare burden associated with frail AF patients, integrated AF management should be implemented to improve outcomes in these patients.
| S-EPMC7411200 | biostudies-literature
Project description:BackgroundApproximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life. We aimed to quantify the benefits and harms of anticoagulation in this population.MethodsUsing Minimum Data Set and Medicare claims, we conducted a retrospective cohort study with 14,877 long-stay nursing home residents aged ≥66 between 2013 and 2018 who had advanced dementia and AF. We excluded individuals with venous thromboembolism and valvular heart disease. We measured anticoagulant exposure quarterly, using Medicare Part D claims. The primary outcome was all-cause mortality; secondary outcomes were ischemic stroke and serious bleeding. We performed survival analyses with multivariable adjustment and inverse probability of treatment (IPT) weighting.ResultsIn the study sample, 72.0% were female, 82.7% were aged ≥80 years, and 13.5% were nonwhite. Mean CHA2 DS2 VASC score was 6.19 ± 1.58. In multivariable survival analysis, anticoagulation was associated with decreased risk of death (HR 0.71, 95% CI 0.67-0.75) and increased bleeding risk (HR 1.15, 95% CI 1.02-1.29); the association with stroke risk was not significant (HR 1.08, 95% CI 0.80-1.46). Results were similar in models with IPT weighting. While >50% of patients in both groups died within a year, median weighted survival was 76 days longer for anticoagulated individuals.ConclusionPersons with advanced dementia and AF derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding. The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.
| S-EPMC9957933 | biostudies-literature
Project description:AimsCompliance with integrated care based on the Atrial fibrillation Better Care (ABC) pathway has been associated with improved clinical outcomes. The primary objective of this study was to compare clinical outcomes of AF patients according to the compliant status of each component of the ABC pathway in a hierarchical win ratio approach.Methods and resultsWe studied AF patients in the COOL-AF registry. Each patient was followed every 6 months until 3 years. A win ratio analysis was performed, as not all clinical outcomes are equivalent. The hierarchical outcomes were (1) all-cause death, (2) intracranial haemorrhage (ICH), (3) ischaemic stroke/systemic embolism, (4) non-ICH major bleedings, and (5) acute myocardial infarction or heart failure. We also assessed win ratio and win proportion variance over the follow-up time, and the variations over time. A total of 3405 patients (mean age 67.8 ± 11.3; 41.8% female) were studied. Win ratio of ABC-compliant (all three components) vs. ABC-not-compliant was 1.57 (1.35-1.83), P < 0.001. When adding time in therapeutic range (TTR) data for compliant criteria for those who were on warfarin, the win ratio increased to 2.28 (1.89-2.75), P < 0.001. The A-compliant group (plus TTR data), B-compliant, and C-compliant had the win ratio of 1.81 (1.51-2.12), 1.82 (1.53-2.16), and 1.39 (1.18-1.62), all P < 0.001, compared to not compliant group.ConclusionManagement of AF patients according to each component of the ABC pathway is associated with better clinical outcomes compared to those non-compliant to ABC pathway. This finding underscores the importance of a holistic management approach strategy for AF patients.
| S-EPMC11424996 | biostudies-literature
Project description:Background Nursing home residents with atrial fibrillation are at high risk for ischemic stroke and bleeding events. The most recent national estimate (2004) indicated less than one third of this high-risk population was anticoagulated. Whether direct-acting oral anticoagulant ( DOAC ) use has disseminated into nursing homes and increased anticoagulant use is unknown. Methods and Results A repeated cross-sectional design was used to estimate the point prevalence of oral anticoagulant use on July 1 and December 31 of calendar years 2011 to 2016 among Medicare fee-for-service beneficiaries with atrial fibrillation residing in long-stay nursing homes. Nursing home residence was determined using Minimum Data Set 3.0 records. Medicare Part D claims for apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin were identified and point prevalence was estimated by determining if the supply from the most recent dispensing covered each point prevalence date. A Cochran-Armitage test was performed for linear trend in prevalence. On December 31, 2011, 42.3% of 33 959 residents (median age: 85; Q1 79, Q3 90) were treated with an oral anticoagulant, of whom 8.6% used DOAC s. The proportion receiving treatment increased to 47.8% of 37 787 residents as of December 31, 2016 ( P<0.01); 48.2% of 18 054 treated residents received DOAC s. Demographic and clinical characteristics of residents using DOAC s and warfarin were similar in 2016. Half of the 8734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016. Conclusions Increases in anticoagulant use among US nursing home residents with atrial fibrillation coincided with declining warfarin use and increasing DOAC use.
| S-EPMC6512099 | biostudies-literature
Project description:The Atrial fibrillation Better Care (ABC) pathway was proposed for a more holistic or integrated care approach to atrial fibrillation (AF) management. We investigated whether adherence with the ABC pathway reduced the risk of adverse clinical outcomes in real-world AF patients starting vitamin K antagonist (VKAs) therapy. Prospective cohort study including AF outpatients starting VKA therapy from July 2016 to June 2018. Patients were considered as adherent if all ABC pathway criteria (A: Avoid stroke; B: Better symptom control; and C: Cardiovascular risk factors/comorbidities management) were fulfilled. The primary endpoints were all-cause mortality, net clinical outcomes (NCOs), major adverse cardiovascular events (MACE), and composite thrombotic/thromboembolic events at 2 years. We enrolled 1045 patients (51.6% female; median age 77 [70-83] years). Of these, 63.0% (658) were adherent to the ABC pathway and 37% (387) were considered non-adherent. Compared to non-adherent patients, those who were ABC adherent had lower event rates for all-cause mortality (13.76 vs. 6.56; p<0.001), NCOs (19.65 vs. 11.94; p<0.001), and MACE (11.88 vs. 7.75; p=0.006) during the follow-up. Adjusted Cox regression analyses demonstrated that the ABC pathway adherent care reduced the risks of all-cause mortality (aHR 0.57, 95% CI 0.42-0.78), NCOs (aHR 0.72, 95% CI 0.56-0.92), and cardiovascular mortality (aHR 0.54, 95% CI 0.32-0.90). Event-free survivals for all-cause mortality, NCOs (both log-rank p-values <0.001), and MACE (log-rank p-value = 0.004) were also higher in ABC pathway adherent patients. In this real-world prospective cohort of AF patients starting VKA therapy, adherence to the ABC pathway management at baseline significantly reduced the risk of NCOs, all-cause mortality, and cardiovascular death at 2 years.
| S-EPMC9905403 | biostudies-literature