Atrial Fibrillation Screen, Management, and Guideline-Recommended Therapy in the Rural Primary Care Setting: A Cross-Sectional Study and Cost-Effectiveness Analysis of eHealth Tools to Support All Stages of Screening

• Published in: Journal of the American Heart Association 2020-09, Vol.9 (18), p.e017080-e017080
• Main Authors: Orchard, Jessica, Li, Jialin, Freedman, Ben, Webster, Ruth, Salkeld, Glenn, Hespe, Charlotte, Gallagher, Robyn, Patel, Anushka, Kamel, Bishoy, Neubeck, Lis, Lowres, Nicole
• Format: Article
• Language: English
• Subjects: Aged; Anticoagulants - economics; Anticoagulants - therapeutic use; Atrial Fibrillation - diagnosis; Atrial Fibrillation - drug therapy; Atrial Fibrillation - economics; Australia - epidemiology; Cost-Benefit Analysis; cost‐effectiveness; Cross-Sectional Studies; Decision Support Systems, Clinical - economics; digital health; Female; general practice; Humans; Male; Mass Screening - economics; Mass Screening - standards; Mobile Applications; Original Research; Practice Guidelines as Topic; primary care; Primary Health Care - economics; Primary Health Care - methods; Primary Health Care - standards; rural; Rural Health Services - economics; Rural Health Services - standards; Smartphone; stroke prevention; Telemedicine - economics
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.120.017080

BACKGROUND Internationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people ≥65 years of age and oral anticoagulant treatment for those at high stroke risk (CHA₂DS₂-VA≥2). However, gaps remain in screening and treatment. METHODS AND RESULTS General practitioners/nurses at practices in rural Australia (n=8) screened eligible patients (≥65 years of age without AF) using a smartphone ECG during practice visits. eHealth tools included electronic prompts, guideline-based electronic decision support, and regular data reports. Clinical audit tools extracted de-identified data. Results were compared with an earlier study in metropolitan practices (n=8) and nonrandomized control practices (n=69). Cost-effectiveness analysis compared population-based screening with no screening and included screening, treatment, and hospitalization costs for stroke and serious bleeding events. Patients (n=3103, 34%) were screened (mean age, 75.1±6.8 years; 47% men) and 36 (1.2%) new AF cases were confirmed (mean age, 77.0 years; 64% men; mean CHA₂DS₂-VA, 3.2). Oral anticoagulant treatment rates for patients with CHA₂DS₂-VA≥2 were 82% (screen detected) versus 74% (preexisting AF)( =NS), similar to metropolitan and nonrandomized control practices. The incremental cost-effectiveness ratio for population-based screening was AU$16 578 per quality-adjusted life year gained and AU$84 383 per stroke prevented compared with no screening. National implementation would prevent 147 strokes per year. Increasing the proportion screened to 75% would prevent 177 additional strokes per year. CONCLUSIONS An AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost-effective. Oral anticoagulant treatment rates were relatively high at baseline, trending upward during the study. Increasing the proportion screened would prevent many more strokes with minimal incremental cost-effectiveness ratio change. eHealth tools, including data reports, may be a valuable addition to future programs. REGISTRATION URL: https://www.anzctr.org.au. Unique identifier: ACTRN12618000004268.