Clinical service organisation for adults with atrial fibrillation: Cochrane systematic review and meta-analysis

Abstract

Aims This study aims to assess the effects of organized clinical service delivery models for atrial fibrillation (AF) on all-cause mortality and hospitalization, as well as cardiovascular outcomes, thromboembolic events, bleeding complications, quality of life, symptom burden, healthcare costs, and length of hospital stay. Methods and results A systematic search was conducted across several databases, including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL, and clinical trial registries. Randomized controlled trials involving adults (≥18 years) with any type of AF were included. Primary outcomes were all-cause mortality and all-cause hospitalization. Secondary outcomes included cardiovascular mortality and hospitalization, AF-related emergency department visits, thromboembolic and bleeding events, quality of life, symptom burden, cost of intervention, and length of hospital stay. Eight studies (8205 participants) investigating collaborative, multidisciplinary, or virtual care models for AF were included. The mean age of participants ranged from 60 to 73 years. Organized AF clinical services likely resulted in a substantial reduction in all-cause mortality [risk ratio (RR) 0.64, 95% confidence interval (CI) 0.46–0.89; moderate certainty] and cardiovascular hospitalization (RR 0.83, 95% CI 0.71–0.96; high certainty) compared with usual care. However, these services probably made little to no difference to all-cause hospitalization (RR 0.94, 95% CI 0.88–1.02; moderate certainty) and may not reduce cardiovascular mortality (RR 0.64, 95% CI 0.35–1.19; low certainty). The effect on thromboembolic complications and major cerebrovascular events appeared minimal. Minor cerebrovascular events were not reported in any of the included studies. Conclusion Moderate certainty evidence suggests that organized clinical services for AF likely lead to a large decrease in all-cause mortality but probably have minimal impact on all-cause hospitalization. Whilst cardiovascular hospitalizations were reduced, the effect on cardiovascular mortality remains uncertain. Further research is needed to compare different care organization models and to confirm findings for inconclusive outcomes, particularly regarding the role of mHealth in AF management. The findings highlight the importance of coordinated care through collaborative, multidisciplinary, and virtual approaches. Registration Cochrane Database for Systematic Reviews (2019): https://doi.org/10.1002/14651858.CD013408. Citation to published full Cochrane review: Ferguson C, Shaikh F, Allida SM, Hendriks J, Gallagher C, Bajorek BV, Donkor A, Inglis SC. Clinical service organisation for adults with atrial fibrillation. Cochrane Database of Systematic Reviews 2024, Issue 7, Art. No.: CD013408. https://doi.org/10.1002/14651858.CD013408.pub2. Citation to published Cochrane review protocol: Ferguson C, Hendriks J, Gallagher C, Bajorek BV, Inglis SC. 2019. Clinical Service organisation for adults with atrial fibrillation: Protocol – Intervention. 2019, Issue 8, Art No.: CD013408. https://doi.org/10.1002/14651858.CD013408.