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The education and communication pillars of integrated care for atrial fibrillation.

Atrial fibrillation (AF) is associated with increased morbidity and mortality. As stated in the 2016 European Guidelines on the management of AF, there is an urgent need for a more structured and efficient care system in this growing AF population in order to reduce the burden on patients, the society, the healthcare system and the economy. A proposed strategy is to deliver care through 'interdisciplinary nurse-led AF centers', that have shown to improve guideline-adherence and outcomes in a cost-effective way. 'Integrated care' requires streamlined communication between stakeholders (cardiologists, general practitioners, other specialists, care givers) on one hand, and improved education of patients on the other hand, to increase their motivation, empower them for more self-care and allowing shared decision-making. However, there are no blueprints available on how this 'integrated care' should be implemented. Hospitals often have no predefined pathways or support systems to evaluate and follow-up AF patients in a systematic way and to communicate their management to different stakeholders. For patient education, a more structured and individualised approach is indispensable. Finally, integrated AF care requires a redesign of daily practice making use of AF nurses to provide patient education, to coordinate care and to facilitate communication between stakeholders.This project aims to evaluate which elements of integrated care contribute most to improved outcomes and how proven therapies can most effectively and most cost-efficiently be delivered to AF patients. We will focus on two main topics: 1) communication within the AF center, and between the AF center and different stakeholders by means of an 'AF passport'; 2) targeted education of patients, aiming for more cost-efficient knowledge increase and better clinical outcomes. We will use a randomised controlled trial design in three large cardiology centers.
Date:1 Oct 2017  →  Today
Disciplines:Cardiac and vascular medicine
Project type:Collaboration project