Integrated care pathway

The current healthcare approach to multimorbidity is fragmented. AFFIRMO aims to move from fragmentation to an integrated pathway designed to be Patient-centred, Systemic and Digital

Patient-centered

AFFIRMO's care pathway will account of personal preferences for treatment and considers the social context of patients. The treatment strategy will be the result of a shared decision-making process.

Systemic

AFFIRMO's care pathway will enable synergies and cooperation among the different health disciplines involved in the treatment of patients with multimorbidity.

Digital

AFFIRMO's care pathway will rely on a digital platform, based on open standards, developed to assist physicians in applying and tailoring a personalised care strategy.

The workplan

AFFIRMO’s integrated care pathway will focus on Atrial Fibrillation (AF), a cardiac arrhythmia associated with high risk of morbidity. The workplan is structured around three research areas:

Clusters of multimorbidity

Researchers will characterize how different patterns of multimorbidity are distributed within the population of older individuals with AF.

Combining multiple analysis techniques, the team will investigate the reciprocal relationships between the most common diseases and AF. Drug patterns and potential drug reactions will also be addressed.

Stakeholder involvement

The project will assess the needs of patients, caregivers, and health professionals for the comprehensive management of multimorbidity (including AF) and examines ways of optimizing care and self-management.

Data will be collected though surveys and interviews. The goal is to develop a set of quality performance indicators (QPIs) to support the co-designing process of the care approach proposed by AFFIRMO.

Integrated care pathway

AFFIRMO will develop, implement and test patient-cantered approach on older multimorbid AF patients in the clinical practice. The proposed approach will rely on a digital platform designed to bring patients, caregivers, and health professionals closer together through information sharing.

An international clinic study will be performed to assess the effectiveness of the AFFIRMO’s care approach. Researchers will also consider the economic dimension by identifying how the integrated pathway will impact health outcomes and costs.

Consortium

A multidisciplinary consortium across Europe representing clinical research, epidemiology, data science, biostatistics, pharmacology, economics, psychology and social sciences.

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Clinical complexity and the impact of the ABC pathway in patients with atrial fibrillation

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EUR Observational Research Programme in AF General Long-Term Registry

Humanising health care: towards a customised approach to diseases

A humanised care system, which considers each individual patient, emerged as an urgent need during the 2022 edition of the conference “Il tempo della salute”, held at the National Museum of Science and Technology in Milan.

European Heart Journal (2022) 00, 1–3

A multinational European network to implement integrated care in elderly multimorbid atrial fibrillation patients: the AFFIRMO Consortium
Søren P. Johnsen, Marco Proietti, Aldo P. Maggioni, and Gregory Y.H. Lip , on behalf of the AFFIRMO Consortium and Investigators

The increasing ageing of the general population has led to a significant burden of multimorbidity in the general population, requiring significant changes to healthcare and management, as well as clinical approaches. Hence, increasing attention to the progressively increasing burden of multimorbidity and the need for more integrated care management in patients with chronic long-term conditions. Even in the most common heart rhythm disorder, atrial fibrillation (AF), the presence of multimorbidity has proven to significantly influence clinical management and prognosis.

BMC Med 20, 326 (2022)

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC‑EHRA EURObservational Research Programme in AF General Long‑Term Registry
Giulio Francesco Romiti, Marco Proietti, Marco Vitolo, Niccolò Bonini, Ameenathul Mazaya Fawzy, Wern Yew Ding, Laurent Fauchier, Francisco Marin, Michael Nabauer, Gheorghe Andrei Dan, Tatjana S. Potpara, Giuseppe Boriani & Gregory Y. H. Lip

Background

Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients.

Methods

From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses.

Results

Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome.

Conclusions

An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients.