Atrial fibrillation (AF) is a debilitating heart condition, caused by abnormal electrical activity in the heart, which results in a cardiac arrhythmia. AF can be a sustained condition or it can come and go. The impact and consequences of AF are substantial: Those with AF are five times more likely to have a stroke than those without AF, and are at an increased risk of hospitalisation, morbidity and mortality. As a result, AF is a fast growing public health concern, and hospitals have a vital role to play in its management via correct diagnosis and early treatment.
The Impact of AF
Across Europe, six million people have AF, and this number is expected to more than double by 2050. Patients with AF may experience palpitations, shortness of breath, chest pain, tiredness or even loss of consciousness. AF can impact physical functioning, psychological well-being and social functioning meaning patients may experience a poor quality of life. AF is also associated with an increased risk of stroke, heart failure, and mortality, and increased rates of hospitalisation.
Despite these serious consequences, a 2010 independent study which draws upon a rapid evidence review and a survey of patient organisations found that there is a lack of comparable AF information and data across Europe. Commissioned by the Stroke Alliance for Europe (SAFE) and supported by the World Heart Federation, the "How AWARE are you?" report concludes that AF prevalence is likely to be underestimated and that we are missing opportunities to successfully manage AF. Such sub-optimal management negatively impacts both patients and healthcare systems: Patients in terms of preventable morbidity and mortality; and healthcare systems in terms of higher cost.
The report highlights the high costs of AF and the significant resources across both primary and secondary care it uses. Hospitalisations in particular are expensive. Based upon the French estimate of total average cost per patient of 3,220 euro, the total cost for AF can be calculated as 10 billion euro for the European Union. Indirect costs of AF are also of significance as patients may also be limited in their ability to work or may retire early. Appropriate management of AF can however lead to reduced costs.
At the front-line of healthcare delivery, the impact of hospital services on the successful management of AF is considerable. For hospital managers, interventions in the areas of:
- Data collection;
- Healthcare system response; and
- Patient information. could aid the successful management of AF.
The "How AWARE are you?" report suggests that AF prevalence data may not include all cases, since AF is not always symptomatic and can be 'silent', but also because data collection is variable. An accurate understanding of AF incidence and prevalence is however vital to those hospital managers with responsibility for the planning of the provision of cardiac services. AF prevalence must be accurately estimated so the correct number of staff can be allocated for clinical consultations, and the cost of medical therapy and intervention be accurately calculated and budgeted for.
Disease registries are often utilised within other therapy areas, with identified benefits ranging from better aggregation of patient data for practice assessment or quality improvement to the facilitation of clinical research. However, AF disease registries are few and far between across Europe. More are being planned which should help meet some informational gaps. Taking a lead by establishing and using a disease registry within your hospital will aid the collection of important and useful data.
Further data collection to understand the effect of AF on a patient's quality of life, for example their ability to stay in work, is also important for multidisciplinary and crossagency reporting on wider disease context, to input into healthcare policy and contribute to AF's priority setting. Surveying your patients, or collaborating with a national patient group to secure patient insights into the effects of the disease, may therefore be a worthwhile activity for your cardiac team to assess the true burden of the disease in your area and to make the best use of resources for managing patients.
Healthcare System Response
AF is a complex disease to diagnose and manage; patients' symptoms can vary greatly, and a wide range of diagnostic and treatment options are often provided across a range of settings from primary to secondary care. Due to the involvement of a multidisciplinary team, adherence to guidelines is important to ensure the delivery of comprehensive patient care and to contribute to improved patient outcomes, and to reduce demand on healthcare systems.
However, it is recognised that the diversifying nature of medical care within Europe, including differences in the availability of therapies, delivery of care and varying patient characteristics, makes it difficult to formulate guidelines that are valid throughout Europe. Therefore, where possible, hospital managers are encouraged to align services with national guidelines; if following European guidelines, you may wish to consider applying modifications according to your local patient population needs. Despite the existence of a range of both national and European guidelines, the "How AWARE are you?" report reveals that adherence to guidelines is variable. The reasons for this discordance are not well understood; you may wish to explore barriers to adherence within your hospital to establish resolutions. These could include education for clinicians and the provision of information on guidelines to patients.
According to the report, the availability of patient information varies across Europe. In some countries very little is available, while in others there is a variety of patient information including websites and leaflets; there is even a telephone helpline available in the UK. However, what is available tends to be insufficient to meet patient needs. The report also reveals a gap in the understanding of patient preferences, and that patients do not have the information they need to be able to 'partner' with their clinician in their treatment decisions.
Providing training to clinicians on patientphysician partnerships may assist in ensuring an open dialogue regarding the full range of AF treatment options. Conducting an audit in collaboration with patients of the printed or online patient materials available at your hospital may help to ensure that the information is suitable, and presented and disseminated appropriately.
The successful management of AF requires multidisciplinary teams to work together with patients. The AF AWARE campaign calls for European-wide improvements to AF management and urges hospital managers to improve data collection, which will in turn enhance planning and ensure the appropriate allocation of resources to AF prevention, diagnosis, treatment and the provision of patient information. Providing the right services will improve patient outcomes, and reduce the substantial cost of illness both by reducing indirect costs (for example by allowing AF patients to stay in work) and by reducing demand for expensive hospital care.
The "How AWARE are you?" author recognises that the report is not a systematic review or definitive international overview of AF, but rather provides a snapshot and a starting point for further research on this condition across Europe. The AF AWARE campaign aims to expose the poor understanding of AF and to help healthcare professionals, patients, policy makers and the general public understand that comprehensive management of AF should address its multiple impacts.
For more information, please contact:
Corporate Relations Manager
World Heart Federation
The Stroke Alliance for Europe