October 01, 2019
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HELP-AF: Home-based education program reduces unplanned hospitalizations for AF

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Prashanthan Sanders

PARIS — Patients with atrial fibrillation who participated in a home-based structured patient-centered education program experienced a 26% reduction in total hospitalizations, 31% reduction in AF hospitalizations and a 49% reduction in other cardiac hospitalizations, according to 24-month data from the HELP-AF study presented at the European Society of Cardiology Congress.

The educational resources used to develop the intervention used in this trial were simultaneously published in JACC: Clinical Electrophysiology.

“What the educational material show is that these need to be written in simple language and with images that are representative of a spectrum of societal values in order to cater for a wide range of health literacy,” Prashanthan Sanders, MBBS, PhD, FRACP, FESC, FHRS, FAAHMS, director of the Centre for Heart Rhythm Disorders and of cardiac electrophysiology and pacing at The University of Adelaide and Royal Adelaide Hospital in Australia and a National Health and Medical Research Council practitioner fellow, told Cardiology Today. “This also needs to be delivered with education that is targeted at the level that the person understands to be effective.”

In this investigator-initiated, multicenter, randomized controlled trial, researchers recruited 627 patients aged at least 30 years who presented to the ED and had a primary diagnosis of AF. Patients were assigned the intervention (n = 314; median age, 71 years; 54% men) or usual care (n = 313; median age, 69 years; 58% men).

The intervention consisted of two home visits by a nurse or pharmacist at 1 to 2 weeks after enrollment and 7 to 8 weeks after enrollment.

“This was an educator who was trained in the methods of structured educational visiting and upskilled in the management of atrial fibrillation,” Sanders said during the presentation. “This initial interaction was a 60- to 90-minute period, during which there was information exchanged where the educator had to ascertain the health literacy levels of the individual and identify the factors that would achieve behavioral change to enable self-care of atrial fibrillation.”

Four key messages were the focus of the structured educational visits for the intervention group: medications, stroke prevention, lifestyle and AF, and AF episodes. An information booklet was also created for the group.

“This reinforced much of the educator’s visit and allowed the educator to highlight sections that were relevant for that patient,” Sanders said during this presentation. “This was left as a resource for the patient to refer to.”

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The booklet also focused on a four-step plan for patients if they experienced a usual AF episode, which instructed patients to relax and stay calm, estimate their pulse rate, see their personal plan provided by their physician and telephone the HELP-AF line if they required further assistance.

Both groups underwent standard of care with a primary care physician and/or a cardiologist. Phone calls and assessments were performed in both groups at 3, 6, 9, 12, 15, 18 and 24 months.

Coprimary endpoints included total unplanned hospitalizations and health-related quality of life, which was assessed by the SF-36 survey and the AF Effect on Quality of Life (AFEQT) questionnaire. Secondary endpoints were defined as unplanned AF-related hospitalizations, other unplanned cardiac hospitalizations and AF symptom burden quantified by the AF Symptom Severity (AFSS) scale.

During 24 months of follow-up, there were 233 total unplanned hospitalizations in the intervention group vs. 323 in the usual care group. When focusing on AF-related hospitalizations, there were 73 in patients assigned the intervention compared with 109 in those assigned usual care. There were 45 other cardiac hospitalization events in the intervention group vs. 81 in the usual care group.

Poisson regression analyses were also performed. The intervention significantly reduced the risk for total unplanned hospitalizations compared with usual care (incidence rate ratio [IRR] = 0.74; 95% CI, 0.62-0.89). Factors that positively influenced this outcome included the level of education and not living alone.

The intervention also significantly reduced the risk for AF-related hospitalizations compared with usual care (IRR = 0.69; 95% CI, 0.51-0.94). There were no other factors that positively or negatively influenced the outcome of hospitalization. Significant reductions were also seen for other cardiac hospitalizations in the intervention group vs. the usual care group (IRR = 0.51; 95% CI, 0.34-0.75). Several factors positively influenced this outcome, including hypertension, male sex, education level and not living alone. There was no effect on noncardiac hospitalizations.

There were no clinically significant changes in SF-36 in the intervention group during the study duration.

At 12 and 24 months, there was a nonsignificant improvement in AFEQT global score for the intervention group compared with the usual care group. The difference was significant in the symptom and treatment concern domains, but there was no difference between both groups in the activity domain.

For AFSS, global well-being was significantly better at 12 and 24 months among patients assigned the intervention compared with those assigned usual care. There were no reported differences between the two groups for AF frequency, AF duration and AF symptom severity.

“The HELP-AF intervention suggests that we need to focus on personalized structured education as an essential component of the care of individuals with AF,” Sanders said during the presentation. – by Darlene Dobkowski

References:

Sanders P. Late-Breaking Science in Atrial Fibrillation 2. Presented at: European Society of Cardiology Congress; Aug. 31-Sept. 4, 2019; Paris.

Gallagher C, et al. JACC Clin Electrophysiol. 2019;doi:10.1016/j.jacep.2019.08.007.

Disclosures: Sanders reports he is on the advisory board for Abbott Medical, Boston Scientific, CathRx, Medtronic and Pacemate and has received research contracts from Abbott Medical, Boston Scientific and Medtronic. Please see the study for all other authors’ relevant financial disclosures.