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

Abstract

Aim: To assess the effects of organised clinical service delivery models for AF on all-cause mortality and hospitalisation, 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. Randomised controlled trials involving adults (≥ 18 years) with any type of AF were included. Primary outcomes were all-cause mortality and all-cause hospitalisation. Secondary outcomes included cardiovascular mortality and hospitalisation, 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. Organised AF clinical services likely resulted in a substantial reduction in all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89; moderate certainty) and cardiovascular hospitalisation (RR 0.83, 95% CI 0.71 to 0.96; high certainty) compared to usual care. However, these services probably made little to no difference to all-cause hospitalisation (RR 0.94, 95% CI 0.88 to 1.02; moderate certainty) and may not reduce cardiovascular mortality (RR 0.64, 95% CI 0.35 to 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 organised clinical services for AF likely lead to a large decrease in all-cause mortality but probably have minimal impact on all-cause hospitalisation. While cardiovascular hospitalisations were reduced, the effect on cardiovascular mortality remains uncertain. Further research is needed to compare different care organisation 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.