Adherence to the Atrial fibrillation Better Care pathway and the risk of adverse health outcomes in older care home residents with atrial fibrillation: a retrospective data linkage study 2003-18

Leona A Ritchie^{1

2

3}, Stephanie L Harrison^{1

2

4}, Peter E Penson^{1

3}, Ashley Akbari⁵, Fatemeh Torabi⁵, Joe Hollinghurst⁵, Daniel Harris^{5

6}, Oluwakayode B Oke⁷, Asangaedem Akpan^{8

9

10}, Julian P Halcox⁵, Sarah E Rodgers¹¹, Gregory Y H Lip^{1

2

12}, Deirdre A Lane^{1

2

12}

Affiliations

¹ Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
² Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L7 8TX, UK.
³ School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK.
⁴ Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
⁵ Population Data Science, Swansea University Medical School, Swansea University, Swansea, Wales SA2 8PP, UK.
⁶ Tritech Institute, Hywel Dda University Health Board, Bynea, Llanelli SA14 9TE, UK.
⁷ Department of Renal Medicine, East Kent Hospital NHS Foundation Trust, Ashford TN24 0LZ, UK.
⁸ Department of Geriatric Medicine, Bunbury Regional Hospital, WA Country Health Service - South West, Bunbury 6230, Australia.
⁹ Division of Internal Medicine, University of Western Australia, Perth WA 6009, Australia.
¹⁰ Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth WA 6845, Australia.
¹¹ Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool L69 3GF, UK.
¹² Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg DK-9220, Denmark.

PMID: 38400634
PMCID: PMC10891424
DOI: 10.1093/ageing/afae021

Adherence to the Atrial fibrillation Better Care pathway and the risk of adverse health outcomes in older care home residents with atrial fibrillation: a retrospective data linkage study 2003-18

Leona A Ritchie et al. Age Ageing. 2024.

. 2024 Feb 1;53(2):afae021.

doi: 10.1093/ageing/afae021.

Authors

Affiliations

¹ Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
² Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L7 8TX, UK.
³ School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK.
⁴ Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
⁵ Population Data Science, Swansea University Medical School, Swansea University, Swansea, Wales SA2 8PP, UK.
⁶ Tritech Institute, Hywel Dda University Health Board, Bynea, Llanelli SA14 9TE, UK.
⁷ Department of Renal Medicine, East Kent Hospital NHS Foundation Trust, Ashford TN24 0LZ, UK.
⁸ Department of Geriatric Medicine, Bunbury Regional Hospital, WA Country Health Service - South West, Bunbury 6230, Australia.
⁹ Division of Internal Medicine, University of Western Australia, Perth WA 6009, Australia.
¹⁰ Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth WA 6845, Australia.
¹¹ Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool L69 3GF, UK.
¹² Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg DK-9220, Denmark.

PMID: 38400634
PMCID: PMC10891424
DOI: 10.1093/ageing/afae021

Abstract

Background: The Atrial fibrillation Better Care (ABC) pathway is the gold-standard approach to atrial fibrillation (AF) management, but the effect of implementation on health outcomes in care home residents is unknown.

Objective: To examine associations between ABC pathway adherence and stroke, transient ischaemic attack, cardiovascular hospitalisation, major bleeding, mortality and a composite of all these outcomes in care home residents.

Methods: A retrospective cohort study of older care home residents (≥65 years) in Wales with AF was conducted between 1 January 2003 and 31 December 2018 using the Secure Anonymised Information Linkage Databank. Adherence to the ABC pathway was assessed at care home entry using pre-specified definitions. Cox proportional hazard and competing risk models were used to estimate the risk of health outcomes according to ABC adherence.

Results: From 14,493 residents (median [interquartile range] age 87.0 [82.6-91.2] years, 35.2% male) with AF, 5,531 (38.2%) were ABC pathway adherent. Pathway adherence was not significantly associated with risk of the composite outcome (adjusted hazard ratio, 95% confidence interval [CI]: 1.01 [0.97-1.05]). There was a significant independent association observed between ABC pathway adherence and a reduced risk of myocardial infarction (0.70 [0.50-0.98]), but a higher risk of haemorrhagic stroke (1.59 [1.06-2.39]). ABC pathway adherence was not significantly associated with any other individual health outcomes examined.

Conclusion: An ABC adherent approach in care home residents was not consistently associated with improved health outcomes. Findings should be interpreted with caution owing to difficulties in defining pathway adherence using routinely collected data and an individualised approach is recommended.

Keywords: atrial fibrillation; care homes; health outcomes; integrated care; older people.

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Conflict of interest statement

S.L.H. has received an investigator-initiated grant from Bristol-Myers Squibb (BMS); P.E.P. owns four shares in AstraZeneca PLC and has received honoraria and/or travel reimbursement for events sponsored by AKCEA, Amgen, AMRYT, Link Medical, Napp and Sanofi; D.H. reports grants and speaker fees from BMS/Pfizer, outside the submitted work; J.P.H. has received grant funding unrelated to this work from Pfizer/BMS and speaker fees and consulting fees from Pfizer, BMS, Boehringer Ingelheim and Bayer; G.Y.H.L. has been a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Anthos and Daiichi-Sankyo; no fees are received personally; D.A.L. has received investigator-initiated educational grants from BMS and Pfizer, has been a speaker for Bayer, Boehringer Ingelheim and BMS/Pfizer, and has consulted for BMS and Boehringer Ingelheim; all outside the submitted work; L.A.R., A.Akb., F.T., O.O., A.Akp. and S.E.R. have no competing interests to report.

Figures

**Figure 1**
Definitions used to assess adherence to individual ABC pathway components at care home entry^a. ^aPrescription of medications within 6 months prior to care home entry used as a proxy for prescription at care home entry; ^bsubsequent hospital admissions for atrial fibrillation identified if ICD10-code ‘I48—atrial fibrillation and flutter’ was listed at any position (including the primary position) within the PEDW episode table after care home entry until end of follow-up (resident died, moved out of Wales or end of study (31 December 2018)); ^cresidents with no cardiovascular comorbidities prior to care home entry were also classified as ‘C’ adherent to maintain representativeness of the cohort.

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References

1. Ritchie LA, Harrison SL, Penson PEet al. . Prevalence and outcomes of atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003–2018. Age Ageing 2022; 51: 1–10. - PMC - PubMed
1. Ritchie LA, Oke OB, Harrison SL, Rodgers SE, Lip GYH, Lane DA. Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review. Age Ageing 2020; 50: 744–57. - PubMed
1. Lip GY, Skjøth F, Nielsen PB, Larsen TB. Non-valvular atrial fibrillation patients with none or one additional risk factor of the CHA2DS2-VASc score. A comprehensive net clinical benefit analysis for warfarin, aspirin, or no therapy. Thromb Haemost 2015; 114: 826–34. - PubMed
1. Ritchie LA, Harrison SL, Penson PEet al. . Anticoagulation in older people with atrial fibrillation moving to care homes: a data linkage study. Br J Gen Pract 2023; 73: e43–51. - PMC - PubMed
1. Torabi F, Harris DE, Bodger Oet al. . Identifying unmet antithrombotic therapeutic need, and implications for stroke and systemic embolism in atrial fibrillation patients: a population-scale longitudinal study. Eur Heart J Open 2022; 2: oeac066. - PMC - PubMed

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Adherence to the Atrial fibrillation Better Care pathway and the risk of adverse health outcomes in older care home residents with atrial fibrillation: a retrospective data linkage study 2003-18

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Adherence to the Atrial fibrillation Better Care pathway and the risk of adverse health outcomes in older care home residents with atrial fibrillation: a retrospective data linkage study 2003-18

Authors

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Conflict of interest statement

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