Key messages
• Organised care services for atrial fibrillation (AF) probably cause a large reduction in death from all causes and do reduce heart-related hospital admissions, but they probably make little to no difference to hospital admissions from all causes and may not reduce heart-related death compared with routine care (care provided as part of normal practice).
• Organised care services for AF may not reduce complications such as stroke and mini-stroke and major complications related to bleeding in the brain compared to routine care.
• Larger, well‐designed studies are needed to give better estimates of the benefits and potential harms of organised care services for AF.
What is atrial fibrillation?
Atrial fibrillation (AF) is an irregular heartbeat that happens when the electrical signals in the heart fire quickly at the same time. This causes the heart to beat too fast or too slow, which can cause troubling symptoms and serious medical complications, including blood clots that can lead to stroke (where blood flow to the brain is blocked).
How is atrial fibrillation treated?
Atrial fibrillation is treated with lifestyle changes, medication, and procedures, including surgery, to help prevent blood clots, control the heartbeat, or restore the heart's normal rhythm.
What did we want to find out?
Organised care services for AF involve: (i) providing care that is focused on improving people's care experiences, health outcomes, and quality of life; (ii) that is delivered by a team of healthcare providers from various fields of study working together; and (iii) that uses technology to support the integrated approach. Routine care is care provided as part of normal practice.
We wanted to find out if organised care services for AF were better than usual (routine) care in reducing death and hospital admission from all causes.
We also wanted to find out if organised care services for AF were better than routine care in reducing heart-related death and hospital admissions, AF-related emergency department visits, complications such as stroke and mini-stroke, major and minor complications related to bleeding in the brain, AF-related quality of life, AF symptoms, length of hospital stay, and cost related to the services.
What did we do?
We searched for studies comparing organised care services for AF to routine care in adults diagnosed with AF. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 8 studies involving a total of 8205 people with AF, with an average age of 60 to 73 years. The included studies were performed in China, the Netherlands, and Australia. All eight studies reported receiving individual grants or a combination of public funding and funding from industry.
Compared to routine care, organised AF care services:
- prevent one death from all causes for every 37 patients treated and followed for six years;
- prevent one hospital admission from all causes for every 101 patients treated and followed for two years;
- prevent one heart-related death for every 86 patients treated and followed for six years; and
- prevent one heart-related hospital admission for every 28 patients treated and followed for six years; but
- may make little to no difference to complications such as stroke and mini-stroke (one complication prevented for every 588 patients treated and followed for six years) and major complications related to bleeding in the brain (one bleeding complication prevented for every 556 patients treated and followed for six years).
No study assessed minor complications related to bleeding in the brain.
What are the limitations of the evidence?
Our confidence in the evidence for death and hospital admissions from all causes is only moderate because it is possible that some study participants were aware of which treatment they were getting, which could have influenced the results.
We have little confidence in the evidence for heart-related death because the ways treatment was delivered varied across studies, and it is possible that some study participants were aware of which treatment they were getting, which could have influenced the results. We are confident that organised care services for AF reduce heart-related hospital admissions.
We have little confidence in the evidence for complications and bleeding-related complications specifically because the ways treatment was delivered varied across studies, and it is possible that some study participants were aware of which treatment they were getting, which could have influenced the results. Additionally, the small number of studies prevents us from being certain about the results.
How up-to-date is the evidence?
The evidence is current to October 2022.
Moderate certainty evidence shows that organisation of clinical services for AF likely results in a large reduction in all-cause mortality, but probably makes little to no difference to all-cause hospitalisation compared to usual care. Organised AF clinical services may not reduce cardiovascular mortality, but do reduce cardiovascular hospitalisation compared to usual care. However, organised AF clinical services may make little to no difference to thromboembolic complications and major cerebrovascular events. None of the studies reported minor cerebrovascular events. Due to the limited number of studies, more research is required to compare different models of care organisation, including utilisation of mHealth. Appropriately powered trials are needed to confirm these findings and robustly examine the effect on inconclusive outcomes. The findings of this review underscore the importance of the co-ordination of care underpinned by collaborative multidisciplinary approaches and augmented by virtual care.
Atrial fibrillation (AF) is an increasingly prevalent heart rhythm condition in adults. It is considered a common cardiovascular condition with complex clinical management. The increasing prevalence and complexity in management underpin the need to adapt and innovate in the delivery of care for people living with AF. There is a need to systematically examine the optimal way in which clinical services are organised to deliver evidence-based care for people with AF. Recommended approaches include collaborative, organised multidisciplinary, and virtual (or eHealth/mHealth) models of care.
To assess the effects of clinical service organisation for AF versus usual care for people with all types of AF.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL to October 2022. We also searched ClinicalTrials.gov and the WHO ICTRP to April 2023. We applied no restrictions on date, publication status, or language.
We included randomised controlled trials (RCTs), published as full texts and as abstract only, involving adults (≥ 18 years) with a diagnosis of any type of AF. We included RCTs comparing organised clinical service, disease-specific management interventions (including e-health models of care) for people with AF that were multicomponent and multidisciplinary in nature to usual care.
Three review authors independently selected studies, assessed risk of bias, and extracted data from the included studies. We calculated risk ratio (RR) for dichotomous data and mean difference (MD) or standardised mean difference (SMD) for continuous data with 95% confidence intervals (CIs) using random-effects analyses. We then calculated the number needed to treat for an additional beneficial outcome (NNTB) using the RR. We performed sensitivity analyses by only including studies with a low risk of selection and attrition bias. We assessed heterogeneity using the I² statistic and the certainty of the evidence according to GRADE.
The primary outcomes were all-cause mortality and all-cause hospitalisation. The secondary outcomes were cardiovascular mortality, cardiovascular hospitalisation, AF-related emergency department visits, thromboembolic complications, minor cerebrovascular bleeding events, major cerebrovascular bleeding events, all bleeding events, AF-related quality of life, AF symptom burden, cost of intervention, and length of hospital stay.
We included 8 studies (8205 participants) of collaborative, multidisciplinary care, or virtual care for people with AF. The average age of participants ranged from 60 to 73 years. The studies were conducted in China, the Netherlands, and Australia. The included studies involved either a nurse-led multidisciplinary approach (n = 4) or management using mHealth (n = 2) compared to usual care. Only six out of the eight included studies could be included in the meta-analysis (for all-cause mortality and all-cause hospitalisation, cardiovascular mortality, cardiovascular hospitalisation, thromboembolic complications, and major bleeding), as quality of life was not assessed using a validated outcome measure specific for AF. We assessed the overall risk of bias as high, as all studies had at least one domain at unclear or high risk of bias rating for performance bias (blinding) in particular.
Organised AF clinical services probably result in a large reduction in all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89; 5 studies, 4664 participants; moderate certainty evidence; 6-year NNTB 37) compared to usual care. However, organised AF clinical services probably make little to no difference to all-cause hospitalisation (RR 0.94, 95% CI 0.88 to 1.02; 2 studies, 1340 participants; moderate certainty evidence; 2-year NNTB 101) and may not reduce cardiovascular mortality (RR 0.64, 95% CI 0.35 to 1.19; 5 studies, 4564 participants; low certainty evidence; 6-year NNTB 86) compared to usual care. Organised AF clinical services reduce cardiovascular hospitalisation (RR 0.83, 95% CI 0.71 to 0.96; 3 studies, 3641 participants; high certainty evidence; 6-year NNTB 28) compared to usual care.
Organised AF clinical services may have little to no effect on thromboembolic complications such as stroke (RR 1.14, 95% CI 0.74 to 1.77; 5 studies, 4653 participants; low certainty evidence; 6-year NNTB 588) and major cerebrovascular bleeding events (RR 1.25, 95% CI 0.79 to 1.97; 3 studies, 2964 participants; low certainty evidence; 6-year NNTB 556). None of the studies reported minor cerebrovascular events.