Atrial fibrillation: nursing’s steadying influence

1 July 2012

CLINICALLY APPRAISED TOPIC (CAT): How does nurse-led care compare with cardiologist care of stable AF patients?

CLINICAL BOTTOM LINE:

Nurse-led care of stable patients with atrial fibrillation (AF) reduced cardiovascular mortality and hospitalisation and increased compliance with guideline recommendations in comparison to usual cardiology care.

CLINICAL SCENARIO:

As part of a move to reduce hospital bed-days, nurse-led care in some chronic conditions has been suggested as effective at increasing compliance with management guidelines and better patient outcomes. Within cardiology, you want to investigate whether nurse-led care in patients with atrial fibrillation may have such an effect.

QUESTION:

Among patients with atrial fibrillation, does nurse-led care decrease hospitalisations compared to routine care?

SEARCH STRATEGY:

PubMed – Clinical queries (therapy/broad search): nurse-led AND atrial fibrillation.

CITATION:

Hendriks JML, de Wil R, Crijns HJGM, et al. Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomised trial of integrated chronic care vs. routine care in ambulatory patients with atrial fibrillation.

STUDY SUMMARY:

Two-arm, parallel group, randomised controlled trial conducted in a university cardiology outpatients’ clinic in The Netherlands between January 2007 and December 2008. Patients with documented atrial fibrillation (AF) were referred from general practices or non-cardiology specialists. The inclusion criterion was age 18 years and over and the exclusion criteria were patients with unstable or uncontrolled hypertension, unstable heart failure (NYHA IV or patient required hospitalisation within previous three months for heart failure), untreated hyperthyroidism, current or foreseen pacemaker, internal defibrillator or cardio-resynchronisation therapy, or cardiac surgery less than three months before inclusion. The trial was registered at clinicaltrials.gov (NCT00753259).

Nurse-led clinic (n=356): care provided by the nurse specialists was guided by decision support software based on guidelines. The decision support tool determined the patient profile based on assessments and proposed appropriate management for AF and associated cardiovascular conditions. Patient education included information about rate and rhythm control, prophylactic vascular therapy, and when to report to hospital. At the end of the first visit, the nurse specialist was supervised by a cardiologist, who reviewed the diagnosis and treatments. Visits were scheduled for 30 minutes with follow up visits planned at three, six, and 12 months and then six monthly thereafter.

Usual care (n=356): Patients were seen by a cardiologist for visits scheduled to last 20 minutes for the first visit and 10 minutes for each subsequent visit.

Outcomes: Primary – combination outcome of death from cardiovascular causes and cardiovascular hospitalisation for heart failure, ischaemic stroke, acute myocardial infarction, systemic embolism, major bleeding, severe arrhythmic events, and life-threatening adverse effects of drugs.

Secondary outcomes included compliance with six guideline recommendations (prescription of antithrombotic treatment, thyroid function testing, echocardiography, appropriate application of rhythm control – none in asymptomatic patients, no rhythm control drugs if contraindicated, and no rhythm control drugs if patient in permanent AF). Patients were followed up for at least 12 months.

STUDY VALIDITY:

A randomised trial using a computer-generated sequence method but the allocation concealment was unclear as not described. There was complete follow-up of 100 per cent of participants and ‘intention-to-treat’ analysis included all participants. The cardiovascular mortality and hospitalisation rates were adjudicated by a blinded committee. The baseline groups were similar in make-up and received equal treatment. Overall, it was a high quality study.

RESULTS:

Overall, 760 patients were screened and 712 (94%) meet inclusion criteria and were randomised. Mean age of the study population was 66.5 years and 59% were female. 83% had symptomatic AF and the proportions with CHADS scores were 28%, 36% and 36% for scores 0, 1 and >1 respectively. There were significantly fewer cardiovascular events in the nurse-led care group than in the usual care group (see table). Cardiovascular death was significantly lower, as was cardiovascular hospitalisation. Compliance with the six guideline recommendations was higher in the nurse-led care group than in usual care: appropriate prescription of anti-thrombotic therapy (99% vs. 83%), thyroid function testing (91% vs. 54%), echocardiography (91% vs. 82%), no rhythm control in asymptomatic patients (95% vs. 85%), no rhythm control drugs if contraindicated (87% vs. 82%), and no rhythm control drugs for permanent AF patients (97% vs. 93%).

COMMENTS:

• Pragmatic trial similar to real world clinical practice.

• Used stable patients referred to cardiology outpatients. Unclear whether effect would be same in unstable patients.

• Visits programmed to be longer with nurse-led care, at least for the first visit compared to usual care visit with cardiologist. However, length of visit may be to accommodate supervision by cardiologist.

• Cost-effectiveness analysis planned but not yet published.

Reviewer: Dr Andrew Jull, RN PhD, Nurse Advisor – Quality, Auckland District Health Board & Associate Professor (School of Nursing).

CLINICALLY APPRAISED TOPIC (CAT):