A Specialized Atrial Fibrillation Clinic

Improving Care and Costs for Patients With Atrial Fibrillation

Michiel Rienstra; Isabelle C. Van Gelder

Disclosures

Europace. 2013;15(8):1065-1066. 

Atrial fibrillation (AF) is a significant burden for healthcare systems due to increased morbidity, mortality, and subsequently healthcare costs.[1,2] The main cost drivers are emergency department visits, hospital admissions, and interventional procedures. Approximately two-thirds of all emergency department visits with a primary diagnosis of AF result in hospital admissions.[3] Hospitalizations rates have dramatically increased in the past decades, which may have been caused by the increasing prevalence of AF or changes in medical practice.[4–9] The majority of AF-related hospitalizations are due to the complications and consequences of AF, including stroke, dementia, heart failure, and mortality. As a result the public health burden is enormous. Prevention of the deleterious consequences of AF may prevent the increasing hospitalization rates and reduce costs of care. Ensuring the adherence to guidelines is an important component.[10] Results of the Euro Heart Survey and the Registry of the German Competence NETwork on AF demonstrated that decisions on anticoagulation, heart failure therapies, and on rate and rhythm control were often not in accordance with the guideline recommendations.[11–14] In addition, it has been demonstrated that the adherence to guidelines may reduce cardiovascular morbidity and mortality.[15] Dedicated outpatient care programmes may help to provide information to patients with AF, avoid complications of AF, prevent hospital admissions, and eventually reduce the cost of care.[6,16,17] Regarding rate vs. rhythm decisions, it has been shown that rate control is more cost-effective than rhythm control for treatment of AF, albeit at times when ablation was only sporadically performed.[18,19]

Recently, very promising results of a prospective randomized controlled trial comparing a nurse-led care vs. usual care for ambulatory patients with AF have been published.[20] In this trial, 356 patients with AF were randomized to nurse-led care arm consisting of guideline-based, software-supported integrated continuous care supervised by a cardiologist. The control arm (n = 356) consisted of patients who remained under the usual care by a cardiologist. After a follow-up of almost 2 years, cardiovascular hospitalizations or cardiovascular death occurred in 14% of the patients in the nurse-led care arm and 21% in the usual care arm. The cardiovascular death rate was reduced by 70% and the hospitalization rate by 35%, both statistically and clinically significant.

In this issue of the Journal, Hendriks et al.[21] published the results of the cost-effectiveness analysis from this trial. A total of 645 patients, 323 in the nurse-led care group and 322 in the usual care group, were included, and a cost per life-year and a cost per quality-adjusted life-year (QALY) analyses were performed. The costs for diagnostic procedures, outpatient care, medication therapy, interventional procedures, inpatient care, and the use of software were considered. The mean total healthcare cost per patient (hospitalizations included), was not statistically different between the nurse-led care (mean €2.302) and the usual care (mean €3.037). The quality of life scores (using the Short Form 36 questionnaire) were converted into utility scores, and then QALYs were calculated by multiplying the utility score by the time the patient was experiencing that utility. The mean QALYs were also not statistically different between the two groups (0.603 in the nurse-led care arm vs. 0.594 in the usual care). When performing cost-effectiveness analyses, considering costs and beneficial effects, nurse-led care was superior to usual care. Costs for nurse-led care were lower, whereas the clinical results were better. Based on present analysis, the nurse-led integrated chronic care programme for patients with AF seems a cost-effective approach.

The authors should be congratulated on their interesting findings; however, there are some limitations that need to be considered. First, this randomized controlled trial is performed in a single, highly specialized AF centre, with well-trained nurses. Whether the results are generalizable to other less specialized cardiology practices or even in general physician practices needs to be determined. Currently, the integRAted chronic care programme at a specialized AF clinic vs. usual CarE in patients with AF, a multicentre randomized controlled clinical trial (RACE 4) study is underway (ClinicalTrials.gov Identifier: NCT01740037) to confirm the results of the Maastricht trial in other hospitals in the Netherlands.

Secondly, the applied treatment strategies (e.g. rhythm or rate control) may impact hospital admissions rates. This information was not available in the present study. Several rhythm vs. rate control studies demonstrated that rate control was more cost-effective than rhythm control, which was mainly driven by a reduction in hospital admissions (for initiation of antiarrhythmic drugs and electrical cardioversions) in the rate control arm.[18,19] An imbalance in the rhythm vs. rate control approaches in the nurse-led and the usual care groups may have explained some of the differences in hospital admission rates and costs of care between the two groups.

Thirdly, it remains unclear how the nurse-led care, focusing on the adherence to guidelines (predominantly regarding antithrombotic therapies), may lead to fewer cardiovascular hospitalizations and death. It is expected that the RACE IV study, aiming to include 1450 patients who will be followed-up for at least 2 years, will have more power and will provide a better insight into the mechanisms through which the nurse-led care may lead to beneficial outcomes.

Finally, because of differences in healthcare systems between different countries, the generalization of these cost-effectiveness results performed in the Netherlands, to other European and North-American countries needs to be determined. An analysis from five European countries that included >200 patients in the Euro Heart Survey, revealed several important differences regarding healthcare costs per patient with AF.[22] In Greece, Italy, Poland, Spain, and the Netherlands, mean costs of a hospital admission of a patient with AF were €1363, €5252, €2322, €6360, and €6445, respectively. Costs of outpatient care of patients with AF were €68, €540, €229, €217, and €114, respectively. In all five countries, inpatient care and interventional procedures were identified as the main cost drivers, accounting for >70% of total annual costs.[22] Care costs of patients with AF in the USA are even higher, the incremental cost per AF patient was estimated as $8075.[23]

In conclusion, efforts to reduce hospitalizations for AF, such as the integrated chronic care programme at a specialized AF clinic,[21] are highly important. Estimates of the economic costs associated with AF and its treatment are essential since the epidemic of AF is still growing, as a result of the advancing age, increased longevity, and the current lifestyle.

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