AIHEMAF-P: An Innovative Healthcare Model for Atrial Fibrillation Patients

Abstract

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias of clinical relevance and a major cause of cardiovascular morbidity and mortality. Following a diagnosis of AF, patients are directed towards therapy with anticoagulant drugs to reduce the thromboembolic risk and antiarrhythmics to control their cardiac rhythm, with periodic follow-up checks. Despite the great ease of handling these drugs, we soon realized the need for follow-up models that would allow the appropriateness and safety of these pharmacological treatments to be monitored over time. This pilot study was conducted at a rural pharmacy. The study comprised 47 patients (average age 71.22 years) with nonvalvular atrial fibrillation (68% being paroxysmal) on NOACs. Twenty percent of the enrolled subjects lived alone and fifty-four percent of the participants stated that they were not independent in managing their treatment. The primary aim was to describe the implementation and the outcomes of an innovative smart clinic model in which a local trained pharmacist is a case manager, and the patient carries out the required checks via telemedicine and point-of-care testing systems (POCT) under the service pharmacy regime; the results of the checks could be shared in real time with the attending general practitioner and the relevant specialist. The secondary aims of this study were to evaluate adherence to the planned controls, the prescriptive appropriateness of the dosages and drugs and adherence to the prescribed therapy, the occurrence of pharmacological problems linked to drug type interactions, the occurrence of hemorrhagic and/or thromboembolic complications, the acceptance by the general practitioners and/or the specialists of the reports made by the pharmacist on the subsequent actions undertaken, the economic and social impact of this model on the National Health Service and on the patient, and the impact on the quality perceived by the patients involved in this innovative monitoring process. Compliance with the planned checks was 93%. The dosage of the anticoagulant drug during enrollment was found to be inappropriate, without apparent clinical reasons, in 11% of the sample. Adherence to the anticoagulant therapy was found to be 98%. In total, 214 drug-drug interactions of varying clinical relevance were detected. No embolic events were detected; however, 13% of the sample reported a major hemorrhagic event, which came to light thanks to the close monitoring of hemoglobinemia. A total of 109 reports were made to the patients' referring doctors in relation to the summarized anomalies, and 84% were accepted by the referring clinicians. Therefore, community pharmacists and pharmacy services represent ideal actors and contexts that, when integrated into the care network, can really favor individual care plan adherence and achieve daily morbidity reductions and cost savings through proper disease control and the early diagnosis of complications.

Keywords: POCT; atrial fibrillation; case management; clinical pathway; community pharmacy; health system transformation; interprofessional care; interprofessional cooperation; pharmacy services; telemedicine.