What is the context of our research?  

The prevalence of atrial fibrillation (AF) amongst Europe’s elderly population is growing. Associated with more severe strokes, AF is an abnormal heart rhythm with rapid and irregular beating. In the context of multimorbidity, improving the management of AF is vital and requires a holistic approach. 

The novel approach underpinning the AFFIRMO project is to focus on clusters of multimorbidity where atrial fibrillation (AF) represents one of the chronic conditions. Improving the management of AF in the context of multimorbidity may benefit individuals on a larger scale, with a holistic approach to optimize clinical management of older AF patients taking into account the multifaceted aspects of individuals’ health, including multimorbidity, polypharmacy, personal preferences, and social context. 

The challenge is to move from fragmentation to an integrated care strategy designed to be patient-centred. AFFIRMO's answer to this challenge is to develop a holistic care approach based on the 'Atrial Fibrillation Better Care'(ABC) model. 

From a current fragmented approach

Multimorbidity is a common condition in older age and can substantially influence people’s health and quality of life, making management more difficult. A single-disease approach with fragmented care is still prevalent in current healthcare systems despite multimorbidity representing a heterogeneous spectrum of disease combinations.

Meanwhile Atrial fibrillation (AF) is the most common type of cardiac arrhythmia worldwide. 1 in 4 adults are at risk of developing AF in their lifetime and the disease is associated with a higher risk of stroke, death, dementia and heart failure. 

Given the widespread development of both conditions among older generations, it is necessary to review our approach in taking care of our patients.

To an integrated care pathway

  • Patient Centered

    Specific attention will be paid to the profile of each patient from their personnal treatment preferences to their social context. AFFIRMO's care pathway also aims to empower them by imparting knowledge, skills and self-confidence and enable patients to become real partners with the clinical team along their care journey.

  • Systematic

    Designed to enhance treatment of patients with multimorbidity, AFFIRMO's care pathway will encourage direct cooperation among different health disciplines and practitionners for each patient. The platform will allow a better visualisation of the spectrum of the patient's conditions and verify the compatibility between treatments.

  • Digital

    The digital platform developed to support AFFIRMO's care pathway will assist physicians in tailoring treatment and promote shared decision-making considering patients’ and caregivers needs and preferences. This digital tool will also help investigate the reciprocal relationship of AF with other comorbidities in the older population.

     

The "Atrial Fibrillation Better Care (ABC)" approach.

The Atrial Fibrillation Better Care model was proposed in 2017 to streamline and simplify the management of atrial fibrillation patients. This simple model focuses on three main components.

A

Avoid Stroke: Refers to the management of thromboembolic and bleeding risks by appropriate prescription and use of specific drugs.

B

Better Symptoms Management: Aims to reduce and control symptom burden by actively involving the patient in the control therapy.

C

Cardiovascular and Comorbidity Management: Address comorbidity and cardiovascular risk factors by optimising the management of these parallel complications.

Objectives

  • Identify different clusters of multimorbidity in older patients with AF.
  • Assess the needs of patients, caregivers, and health professionals for the comprehensive management of multimorbidity including AF, and to examine ways of optimizing care and self-management.
  • Develop, implement and test the effectiveness of a patient-centred approach on older multimorbid AF patients in the clinical practice. We aim to adapt, implement and promote a care pathway, in older patients with multimorbidity.  
  • Develop an interoperable care framework that can facilitate the application of this personalized care pathway, that bridges the continuum between primary and secondary care, with the active involvement of patients with shared decision-making.
  • Model the impact of multimorbidity including AF on healthcare costs and the health economic benefits by the proposed integrated care pathway.
  • Subgroup analyses would assess differences on outcomes of in relation to gender and social inequalities.

Workplan

How is organised our work?

The objectives of WP1 will be the implementation of the activities planned in the project, the timely submission of deliverables and reports, the financial and administrative management, the successful collaboration among partners, and the management and mitigation of risks. WP1 includes also the development of a detailed plan for exploitation of the AFFIRMO results. 

WP2 aims at characterizing how different patterns of multimorbidity are distributed within the population of older individuals with AF, and to identify the needs and prognosis of such persons accounting for their clinical, functional and socioeconomic background.

WP3’s goal is to provide information on medications taken by older adults with multimorbidity (including AF). The same data sources described and exploited in WP2 will be used to determine the occurrence of polypharmacy and to describe the most common drug patterns, potential adverse drug reactions, as well as drug-drug and drug-disease interactions.

This WP aims to evaluate the needs and outcomes identified as indicators of quality of care by an international panel of healthcare professionals, and by specific categories of multimorbid patients and their caregivers. This  will be achieved through implementing three main initiatives:

  1. an international survey addressed to patients, caregivers and health professionals;
  2. qualitative interviews and focus groups involving representative of specific categories of patients and caregivers;
  3. a Delphi process to identify the main needs and QPIs based on the results of the survey, qualitative interviews and focus groups

A new informatics tool, the intelligent, interoperable ABC care framework (iABC), will be developed to help identify the impact of disease on quality of life and treatment goals (shared decision making) consequently facilitating a patient tailored ABC care pathway for the evaluation and management of older AF patients with multimorbidity. 

Both Wps will be dedicated to the design and conduct of an interventional clinical study. Prof Carrol Gamble from the Liverpool Clinical Trials Centre (LCTC, UK), who has specific expertise in patient and public involvement in clinical trials13, will partner WPs 6 and 7 and co-design/co-develop the randomised controlled trial (RCT), in collaboration with empowered patients from WP9.

Based on the results of analyses from WPs 2, 3 and 7 (RCT), streamlined decision-making for a holistic approach to AF management will be modelled to identify how the integrated pathway will impact health outcomes and costs, taking into consideration multimorbidity and frailty aspects.

This WP will achieve two main objectives: 

  1. enabling empowerment initiatives dedicated to the different key stakeholders of the project (e.g., patients, caregivers and healthcare professionals) to improve their engagement in self-management, levels of literacy about AF and its treatment and empower them;
  2. planning and delivering smart communication and dissemination activities to engage all the relevant stakeholders for the AFFIRMO project.