A new solution for an old problem? Effects of a nurse-led, multidisciplinary, home-based intervention on readmission and mortality in patients with chronic atrial fibrillation.
BACKGROUND
Atrial fibrillation (AF), the most common chronic cardiac dysrhythmia, is an important cause of cardiovascular morbidity and mortality. However, there is a paucity of studies examining the potential benefits of optimizing the postdischarge management of patients with chronic AF.


OBJECTIVE
To examine the effects of a nurse-led, multidisciplinary, home-based intervention (HBI) on the pattern of recurrent hospitalization and mortality in patients with chronic AF in the presence and absence of chronic heart failure (HF). PATIENT COHORT AND METHODS: Health outcomes in a total of 152 hospitalized patients (53% male) with a mean age of 73 +/- 9 years and a diagnosis of chronic AF who were randomly allocated to either HBI (n = 68) or usual postdischarge care (UC: n = 84) were examined. Specifically, the pattern of unplanned hospitalization and all-cause mortality during 5-year follow-up were compared on the basis of the presence (n = 87) and absence (n = 65) of HF at baseline.


RESULTS
Patients with concurrent HF exposed to HBI (n = 37) had fewer readmissions (2.9 vs 3.4/patient), days of associated hospital stay (22.7 vs 30.5: P = NS) and fatal events (51 % vs 66%) relative to UC (n = 50): P = NS for all comparisons. In the absence of HF, morbidity and mortality rates were significantly lower but still substantial during 5-year follow-up. In these patients, HBI was associated with a trend towards prolonged event-free survival (adjusted RR = 0.70; P = .12) and fewer fatal events (29% vs 53%, adjusted RR = 0.49; P = .08). HBI patients (n = 31) also had fewer readmissions (2.1 vs 2.6/patient) and days of associated hospital stay (16.3 vs 20.3/patient), although this did not reach statistical significance. On the basis of these data, it was calculated that a randomized study of an AF-specific HBI would require 250 patients followed for a median of 3 years to detect a 25% variation in recurrent hospital stay relative to UC.


CONCLUSIONS
These unique data provide sufficient preliminary evidence to support the hypothesis that the benefits of HBI in relation to the management of HF may extend to "high risk" patients with chronic AF in whom morbidity and mortality rates are also unacceptably high. Further, appropriately powered studies are required to confirm these benefits.
Inglis
Sally
S
Division of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.
McLennan
Skye
S
Dawson
Anna
A
Birchmore
Libby
L
Horowitz
John D
JD
Wilkinson
David
D
Stewart
Simon
S
D000359:Aftercare / Q000458:organization & administration; D000368:Aged; D001281:Atrial Fibrillation / Q000401:mortality / Q000628:therapy; D002423:Cause of Death; D002908:Chronic Disease; D003152:Community Health Nursing / Q000458:organization & administration*; D005260:Female; D005500:Follow-Up Studies; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008297:Male; D009017:Morbidity; D015403:Nursing Evaluation Research; D010348:Patient Care Team / Q000458:organization & administration*; D010359:Patient Readmission / Q000706:statistics & numerical data*; D010865:Pilot Projects; D015397:Program Evaluation; D016016:Proportional Hazards Models; D012307:Risk Factors; D013021:South Australia / Q000453:epidemiology; D016019:Survival Analysis