Personalised education delivered in a home setting significantly reduces hospitalisations in patients with atrial fibrillation (AF). This was among the findings of the HELP-AF (Home-based education and learning programme) study, which was presented by Prashanthan Sanders (University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia) in a late-breaking science session at the European Society of Cardiology Congress (ESC 2019; 31 August–4 September, Paris, France). The educational material used in the study was simultaneously published in the Journal of the American College of Cardiology (JACC): Clinical Electrophysiology.
“The initiative was designed to empower patients to understand and take control of their atrial fibrillation—that is, to improve self-management,” Sanders said during his presentation. “Its success in stopping hospital admissions has enormous implications for the delivery of care in atrial fibrillation. As healthcare costs grow due to hospitalisations, such programmes are essential.”
Sanders and his colleagues believed that the involvement of patients in their own care, coupled with helping them to understand their AF and equipping them with the tools to manage it, might prevent hospitalisations.
Writing in JACC: Clinical Electrophysiology, Celine Gallagher (University of Adelaide, Adelaide, Australia) et al point out that rises in AF prevalence and hospitalisations necessitate effective strategies to mitigate these trends.
HELP-AF recruited 627 individuals who presented to emergency departments at six hospitals in Adelaide, principally owing to AF, in a multicentre, randomised controlled trial. Patients were randomised to HELP-AF intervention or usual care. They received follow-ups over a two-year period.
“An educational resource was developed to support delivery of the intervention of the HELP-AF study,” say Gallagher and colleagues. “A literature review was performed exploring patient attitudes, knowledge and beliefs about AF. Additionally, a review of available patient resources for AF was undertaken. With the support of a multidisciplinary team and patient input, key messages were developed to achieve the behavioural goals of the intervention.
Concise educational materials were then developed to support the delivery of the key messages. The educational materials were tested during various stages of the development process on AF patients to ensure they were readable, understandable and received feedback to facilitate modifications. The study version of the educational material was finalised only after approval from the multidisciplinary development team, clinicians, and individuals with AF.”
Four key messages were developed; these covered the importance of taking AF medications as prescribed to reduce symptoms and stroke risk; the appropriate level of coagulation in managing stroke risk; the role that choosing a healthy lifestyle can play in lowering the risk of stroke and of AF becoming more severe; and the management of future AF episodes through a personal action plan, with the aim of conveying that such incidents are not usually medical emergencies.
Patients allocated to the intervention received two educational home visits by a nurse or pharmacist: one occurred two weeks after enrolment and the second six weeks later. A booklet was also supplied.
The results showed that at the two-year point, total unplanned hospitalisations stood at 233 in the HELP-AF group and 323 with usual care, with an incident rate ratio of 0.74 (95% confidence interval (CI) 0.62–0.89, p=0.001), the authors told the session.
After multivariable adjustment, the HELP-AF intervention reduced total unplanned hospitalisations by 26%, AF-related hospitalisations by 31%, and other cardiovascular hospitalisations by 49%, while having no impact on non-cardiac hospitalisations.
Sanders pointed to several components of the scheme as likely having contributed to the fall in hospitalisations. These were that: education was delivered in the comfort of the patient’s home using language they could understand and focusing on areas important to them; patients received a booklet as an ongoing reminder of the four messages; the material listed questions patients could discuss with their physician to help manage their disease; and the booklet outlined the REST (rest, estimate pulse, see action plan and telephone) plan for patients to follow during AF episodes to avoid going to hospital. The latter included recommendations that patients seek personalised advice from a physician and a dedicated telephone service for advice from a cardiologist.
“The study shows that education delivered in a structured and individualised way within the patient’s home has a dramatic impact not only on hospitalisations for atrial fibrillation but on all cardiovascular hospitalisations,” Sanders said.