Towards more integrated care for patients with atrial fibrillation

Ondertitel:Naar meer geïntegreerde zorg voor patiënten met voorkamerfibrillatie.

Atrial fibrillation (AF) is the most common heart arrhythmia and is associated with increased morbidity and mortality. It places an enormous burden on the current society and healthcare system and it is expected that the worldwide prevalence will at least double over the next 50 years. Optimization of AF management will need to be a prime public health focus over the next decades. There is a high need for more efficient care models and a structured approach for the treatment and follow-up of AF patients. A proposed approach to better structure this complex AF management is the establishment of an “interdisciplinary nurse-led AF clinic”. Recent studies have shown that nurse-led integrated care is an efficient and cost-effective manner to improve the care of AF patients. However, hospitals and cardiology practices do not have any predefined and structured guidance how this nurse-led integrated care can be implemented in daily practice. Moreover, from the studies that have shown a positive outcome, it is unclear which aspects of the integrated care had most impact on the improved outcomes. The aim of this thesis was to study the contribution of specific interventions to the effectiveness of an interdisciplinary AF expert program with a focus on four different aspects: (i) screening for AF; (ii) education for patients with AF; (iii) adherence to non-vitamin K antagonist oral anticoagulants (NOACs); (iv) risk factor management. We have shown that the usability and accuracy of handheld electrocardiogram devices to detect AF are not optimal when they are applied in a hospital setting. Nevertheless, making use of a well-planned screening strategy, these devices may provide an effective and cost-effective screening approach (Chapter 1). The Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) was developed and validated within the scope of this PhD thesis. It is a brief but complete questionnaire that can be used to assess patients’ insight into their condition (Chapter 2). The JAKQ revealed major knowledge gaps in the general AF population. Notwithstanding, it is an ideal tool to efficiently guide and target personalized education. A first targeted educational session based on the JAKQ will significantly improve patients’ knowledge level. Additional educational sessions will maintain and even strengthen this effect (Chapter 3). Furthermore, we showed that tailored education via an online platform is also an effective strategy to improve the knowledge level of AF patients about their arrhythmia and the associated treatment (Chapter 4). Although electronic monitoring already revealed an unexpectedly high adherence to NOAC therapy, it was shown that telemonitoring-based rapid and personalized feedback could further optimize adherence. This intervention could be cost-effective when higher risk, poorly adherent patients are targeted and when the used technology would become cheaper (Chapter 5). The Health Buddies app was developed as a tool to improve adherence to NOACs in an elderly AF population by providing a virtual contract with their grandchildren. In a pilot study, it was however shown that only a small proportion of the current AF population was eligible for this innovative app in its current form. Still the app was positively rated by its users on most aspects (Chapter 6). Together with a team of experts in the field we summarized the literature about obstructive sleep apnea testing and management in patients with AF and we came up with a proposal for an integrated care pathway to tackle this cardiovascular risk factor in daily care (Chapter 7). Similar pathways can be developed to provide guidance on how to deal with different modifiable risk factors in AF patients. These results provide further insights and guidance into the practical aspects, workload, feasibility and impact of different aspects of a patient-centered integrated AF care approach. This can be instrumental for future studies with the aim to improve the overall care of AF patients.

Jaar van publicatie:2018

Toegankelijkheid:Open