Multidisciplinary Integrated Care in Atrial Fibrillation (Micaf ): ASystematic Review and Meta-Analysis

Integrated Care in Abstract Objective: To access the effectiveness of multidisciplinary integrated care in the clinical outcomes of atrial fibrillation patients Methods: Medline, EMBASE and the CENTRAL trials registry of the Cochrane Collaboration were searched for articles on multidisciplinary integrated care in atrial fibrillation patients. The systematic review and meta-analysis included 6 and 5 articles, respectively that compared the outcomes between the integrated care group and control group. Results: Multidisciplinary integrated care was concomitant with a decrease in all-cause mortality (OR 0.65, 95%CI 0.44 to 0.95, p=0.028), MACE (OR 1.39, 95%CI 1.19 to 1.62, p=0.000), AF-related hospitalization (OR 1.36, 95%CI 0.99 to 1.87, p=0.056), cardiovascular hospitalization (OR 0.66, 95%CI 0.49 to 0.89, p=0.007) and cardiovascular mortality (OR 0.49, 95%CI 0.21 to 1.17, p=0.109). The result was not statistically significant for cardiovascular mortality as only 2 studies reported this outcome. Multidisciplinary integrated care had no significant impact on the major bleeding (OR 1.02, 95% CI 0.59 to 1.75, p=0.945) or minor bleeding (OR 0.90, 95%CI 0.66 to 1.24, p=0.52) and cerebrovascular events (OR 1.38, 95%CI 0.84 to 2.27, p=0.20). Conclusion: In comparison to the usual care, a multidisciplinary integrated care approach in atrial fibrillation patients is associated with reduced MACE/NACE, cardiovascular and AF-related hospitalizations & mortality and all-cause mortality. Study registration: PROSPERO study eligibility participants, and interventions; study appraisal and synthesis methods; limitations; conclusions and implications of key findings; systematic review registration


re in Atrial
ibrillation (Micaf): ASystematic Review and Meta-Analysis
2642-1747July 14, 202119F13C35B8E28DF00526FCAD55A0250410.34297/AJBSR.2021.13.001887.Received: May 10, 2021;PROSPERO registration number CRD42018110613 Multidisciplinary integrated careAtrial fibrillationClinical outcomes
Objective: To access the effectiveness of multidisciplinary integrated care in the clinical outcomes of atrial fibrillation patients Methods: Medline, EMBASE and the CENTRAL trials registry of the Cochrane Collaboration were searched for articles on multidisciplinary integrated care in atrial fibrillation patients.The systematic review and meta-analys s included 6 and 5 articles, respectively that compared the outcomes between the integrated care group and control group.Results: Multidisciplinary integrated care was concomitant with a decrease in all-cause mortality (OR 0.65, 95%CI 0.44 to 0.95, p=0.028),MACE (OR 1.39, 95%CI 1.19 to 1.62, p=0.000),AF-related hospitalization (OR 1.36, 95%CI 0.99 to 1.87, p=0.056), card ovascular hospitalization (OR 0.66, 95%CI 0.49 to 0.89, p=0.007) and cardiovascular mortality (OR 0.49, 95%CI 0.21 to 1.17, p=0.109).The result was not statistically significant for cardiovascular mortality as only 2 studies reported this outcome.Multidisciplinary integrated care ad no significant impact on the major bleeding (OR 1.02, 95% CI 0.59 to 1.75, p=0.945) or minor bleeding (OR 0.90, 95%CI 0.66 to 1.24, p=0.52) and cerebrovascular events (OR 1.38, 95%CI 0.84  to 2.27, p=0.20).Conclusion:In comparison to the usual care, a multidisciplinary integrated care approach in atrial fibrillation patients is associated with reduced MACE/NACE, cardiovascular and AF-related hospitalizations & mortality and all-cause mortality.

Introduction

Atrial fibrillation (AF) is the commonest cardiac arrhythmia diagnosed in nearly 30 million patients globally [1].In the Un ted States, an approximately 2.3 million people suffer from atrial fibrillation [2].It is a global public health problem and is expected to rise in the coming years [3].It poses a significant economic burden on healthcare systems accounting for a large number of hospital admissions.According to an estimate, hospitalizations due to AF increased by 23% from the year 2000 to 2010 [4].The patients are at higher risk of developing congestive heart failure (CHF), stroke and systemic thromboembolism [5].

Wagner and colleagues introduced a chronic care model establishing that the chronic disease management requires a different approach in contrast to the standard medical care [6].Multidisciplinary care represents the comprehensive case manageme t strategy with a greater number of medical and social support personnel.Multidisciplinary care involves a multidisciplinary team that includes the primary care provider, other physicians, nurses, dietitians, pharmacists and social workers that provide long-term care to patients with chronic disease [7].

These programs also integrate a coaching plan, in which the health physician promotes patient empowerment for attaining treatment adherence and behavior modification [8].For the coordination of integrated care programs, a clinical nurse specialist can play an important role [5].

In patients with heart failure and coronary heart disease, significant improvement has been observed due to the multidisciplinary approach [9,10].The management of atrial fibrillation is often difficult due to lack of adherence to recommendations [11].Such multidisciplinary plans are essential for the provision of guid

ine-based AF manageme
t with the collaboration of different physicians [5].An AF program should include diagnostic tests, heart rate and rhythm control, anticoagulation, management of associated disorders, patient education and counseling for self-management [12].

The integrated healthcare methodology has b

kgrounds from
the chronic healthcare model with th

understanding that ch
onic disease management requires an unusual approach n contrast to standard usual models of healthcare delivery.This prototypical set-up gives the patient the principal emphasis, with various significant essentials/components, including a multidisciplinary team and supports from the community, to warrant that the patient population is dynamically engaged regarding their treatment.Augmenting patient-related conseq

nces incorpor
ting this delivery strategy is reached through redesigning usual clinical practice to confirm healthcare is provided tailor-made to the patient's requirements and founded on existing data [6].

There are five cornerstones o

an effective m
ltidisciplinary atrial fibrillation program.These are "comprehensive assessment, systematization of medical care, patient education, coordination of care and evaluation of care plan execution" [5].A detailed assessment of the patient is essential for making a suitable management plan [13].Systemiz tion involves coordination of diagnostic work-up, treatment plan and follow-up [5].Systemization of medical care will improve the excellence of care delivery, patient contentment and the use of means [14].Patient education leads to dynamic patient involvement and adherence to treatment.An AF program must be effectively coo

inated for t
e implementation of the management plan.The last and the most critical aspect is the evaluation of care plan execution [5].The cornerstones of multidisciplinary atrial fibrillation program are shown in (Figure 1).


Materi

and Meth
ds

Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) guidelines were adhered for this systematic review and meta-ana ysis.

e study is registered with PR
SPERO International Prospective Register of Systematic Reviews (PROSPERO registration number CRD42018110613).


Study design


Systematic review and meta-analysis


Eligi

lity criteria
tudies were selected as per the following criteria:

Studies included were randomized controlled trials (RCTs), including cluster RCTs.

We excluded controlled (non-randomized) clinical trials (CCTs) or cluster trials, cross-sectional studies, case series, ca e reports, interrupted time series (ITS) studies, prospective and retrospective comparative cohort studies, and case-control or nested casecontrol studies.


Participants

Studies including the general adult human population (18 years or older) of either gender diagnosed with and treated for Atrial Fibrillation; defined as "recurrent paroxysmal, persistent, or permanent atrial fibrillation".


Interventions

Multidisciplinary integrated healthcare intervention, mphasis on all-inclusive and far-reaching AF treatment and management with at least a 6-month follow-up period.Intervention is defined as "a coordinated patient-centered approach by interdisciplinary specialists to improve AF outcomes" [15]."Integrated care facilitates treatment of AF patient's population in all five spheres of management: acute stabilization, detection and management of primary cardiovascular co-morbidities and ri

dynamics, apposite oral anticoa
ulation for stroke prevention, and treatment with rate and or rhythm control therapy" [11,16] (Figure 3).


Comparators

The patients in the comparator group were treated according to the usual standards of clinical care, regular medical care, outpatient management and pharmacotherapy.The management was Not Integrated or Mult disciplinary.


Outcomes

The major outcomes/en

oints for meta-analys
s were MACE; major adverse cardiovascular

ent(s) a
d/or NACE; net adverse clinical event(s) a.

All


Data management, selection process and data collection

Investigators individually evaluated all pertinent articles to categorize studies meeting criteria for inclusion.Any inconsistencies were deliberated and a consensus verdict was obtained.The search results from each database were saved in EndNote X9 and duplicates were removed.


Data items

Data was extracted into a standard recording form (Microsoft EXCEL datasheet) which was initially tried to conf rm clarity and uniformity between authors.This empowers the authors to evaluate the quality of studies and integr te the findings.Data identified and tabulated from appropriate articles included: author, data collection year, publication year, participants, gender, mean age, follow-up duration and outcomes studied.


Outcomes and prioritizations

Outcomes that were extracted from the sele

ed studies included all-cause mortality, c
rdiovascular mortality, MACE, cerebrovascular accidents, major and minor bleeding.


Data synthesis

A quantitative synthesis of data and meta-analysis was conducted for selected studies with similar study design and sufficient available outcome parameters t

perform a statistical ana
ysis using the STATA/SE 15.0 statistical program (StataCorp,

exas, USA).

Assuming a var
ation of the true effect sizes in the selected studies -du

to different study populations
nd different integrated care models (as obvious in many integrated care models), we chose to perform a random-effect meta-analysis model to gain the pooled estimates of effects.For the summary statistics, we used exclusively dichotomous data and results were expressed by using odds ratio (OR) with 95%

nfidence interv
l (CI).A two-tailed value of p<0.05

was considered statistically significant.The presence of publication bias was visually asses ed using funnel plots of effect size against SE.Non-quantitati

data was prese
ted descriptively.To test statistical heterogeneity between the studies, the chi-square (χ2) test and the I² statistic were pplied.If a high level of heterogeneity was detected (I² >= 50%), a narrative synthesis

studies will be appropriate (Fi
ure 4).


Risk of bias individual studies

Cochrane Collaboration tool (The RoB 2.0 tool http://www.

riskofbias.info/) was used to assess the risk of bias for every RCT, which screens: randomization process, deviation from inte

ed intervention, missing outcome data and selective result reporting
Table 1).


Results

The search generated an aggregate of 506 articles that were evaluated by title and abstract.Four eighty four articles were excluded as they did not fulfill the inclusion criteria.Nine articles were examined for

ll-text assessment with five fulfilling the criteria
for inclusion in the meta-analysis.Primary and secondary outcomes, as shown in table 2 below, are tabulated for easy referenc and the selection for qualitative and quantitative analysis mark d as per the formal inclusion/exclusion criteria.Key characteristics of the various studies screened, shortlisted and selected are tabulated in (Tables 2 and 3).

Parameters that were obtained from the studies included for meta-analysis were all-cause mortality, MACE, cardiovascular mortality, cardiovascular hospitalizations, AF-related hospitalizations, cerebrovascular events (stroke) and major & minor bleedin

s with an acceptab
e heterogeneity among the studies (I 2 =45.5%, p=0.119) which showed a significant 35% reduction of all-cause mortality in the integrated care model (OR 0.65, 95% CI 0.44 to 0.95; p=0.028) (Figure ).


Major adverse cardiovascular event (MACE)

Five studies reported on this outcome.There was a significant reduction of MACE in favor of the integrated care approach (OR 1.39, 95% CI 1.19-1.62,p-value 0.000; I-squared > 0.05).No e idence of significant heterogeneity (I 2 =32%, p=0.208) (Figure 6).


Cardiovascular mortality

Two studies reported on his outcome, favoured integrated care (OR 0.49, 95%CI 0.21 to 1.17, p=0.109).But the result was not statistically significant as only 2 studies reported this outcome.

Significant heterogeneity not established (I 2 =47.1%, p=0.169) (Figure 7).


AF-related hospitalization

Three studies reported about AF-related hospitalization.AFrelated

spitalizati
n had not been significantly influenced by the integrated care model, however, there was a trend favoring the integrated care approac (OR 1.36, 95% CI 0.99 to 1.87; p=0.056), no evidence for heterogeneity could be observed (I 2 =0.0%, p=0.414) (Figure 8).


Cardio ascular hospitalization

Three studies reported cardio

scular hospitalization.The
integrated care approach led to a significant 34% reduction of CV hospitalization compared to standard care (OR 0.66, 95% CI 0.49 to 0.89; p=0.007), see Figur

reporting on th
s outcome, didn't favour significantly multidisciplinary integrated care over educational integrated care (OR 1.38, 95%CI 1.2

care delivery
n atrial fibrillation patients and advocate its practice as an applicable and effectual intervention.Nevertheless, several queries remai

unrequited and additional exploration
s requisite to report how provision of this methodology is applied in the best possible manner and approach.

Integration and collaboration between outpatient & inpatient departments and physicians play a vital role

n the
rovision of excellen patient care [17].The multidisciplinary approach has become increasingly import

t in the last few decade
as a result of advancements in diagnostic and therapeutic techniques [18].


Am J Biomed Sci & Res


American Journal of Biomedical Science & Research Copy@ Adnan Khana

The purpose of integrated care

s to strengthen the coordinatio
in healthcare organizations, enhance the patients' experience, clinical outcomes and upgrade the efficiency of health systems [19].

A meta-

alysis
was done by Gallagher et  between the two groups was not significant [23].

A cluster-randomized, controlled trial was conducted by Vinereanu et al. in which 48 clusters

d from 5 countries.
he follow-up period was 12 months.The patients with atrial fibrillation who were ≥18 years and had an indication of oral anticoagulation were included.The interven

on and control group incl
ded 1184 and 1092 patients, respectively.In the intervention group, oral anticoagulant use increased from 804(68%) patients at baseline to 943(8 %) patients whereas, in the control group, the oral anticoagulant use increased from 703(64%) patients to 732(67%) patients after 1 year.

e deat
occurred in 5% of the patients in both the intervention and control group.There was a marked decrease in stroke in the intervention group (11%) in contrast to the control group (21%).There was no difference in other secondary outcome

the two groups [24].

In
another randomized study, 31 patients were randomly allocated to the intervention group and 34 patients

the u
ual care group.The follow-up pe iod was 5 years.The patients in the intervention group had a longer event-free s

vival
f 34 months as compared to 17 months in the control group.The patients in the intervention group had fewer hospital readmissions (1.9%) as compa

the usual care group.Si
ilarly, the associated hospital stay was 16.3% in the intervention group in contrast to 20.3% in the usual care group [25].

In the ATHERO-AF cohort study, Pastoriet al. evaluated the isk reduction in cardiovascular events by implementing the Atrial fibrillation Better Care (ABC) pathway.The ABC pathway is an integrated care management program and includes p

vention of stro
e with anticoagulation, better management of symptoms and cardiovascular risk management.The study recruited 907consecutive

th AF using
vitamin K antagonists.The follow-up duration was 36.9 months.The patients managed using the ABC pathway had a lower risk of cardiovascular ev