What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (n=8730). Intervention: Administrative-driven hierarchical management (ADHM) vs. Usual care. Primary outcome: Composite of ischemic stroke, systemic embolism, myocardial infarction, major bleeding, acute heart failure, and cardiovascular death (HR 0.624, 95% CI 0.554-0.703, p=<0.0001).

December 16, 2025Nature Communications1 citationsOpen Access

Administrative-driven hierarchical management of atrial fibrillation on cardiovascular events: a prospective matched cohort study

Q: What are the key findings of this study?

Administrative-driven hierarchical management reduced the composite of cardiovascular events and major bleeding (HR 0.624) compared to usual care in patients with atrial fibrillation.

Q: What does this research mean for the field?

Administrative-driven hierarchical management significantly reduces the composite of cardiovascular events and major bleeding (HR 0.624) compared to usual care in patients with atrial fibrillation. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

MCMu ChenShanghai Jiao Tong University MZMingzhe ZhaoYanshan University YYYuli YangZunyi Medical University

Key Result

Administrative-driven hierarchical management reduced the composite of cardiovascular events and major bleeding (HR 0.624) compared to usual care in patients with atrial fibrillation.

Study Design

Type

Cohort (n=8,730)

Multicenter

Yes

Structured PICO

Does an administrative-driven hierarchical management model reduce cardiovascular events in patients with atrial fibrillation?

Population

8,730 adults with atrial fibrillation (n=1,455 in ADHM cohort, n=7,275 in matched usual care cohort), mean age 76.0, 45.9% female, from Shanghai, China. Mean CHA2DS2-VASc score 4.96, HAS-BLED score 2.66. Inclusion: AF diagnosis, >18 years, Shanghai resident with government medical insurance. Exclusion: life expectancy <3 months, pregnant, requiring immediate hospitalization.

Intervention

Administrative-driven hierarchical management (ADHM) model (ACC-to-ABC pathway) where general practitioners act as voluntary gatekeepers, utilizing an electronic platform for risk stratification, standardized treatment (anticoagulation, symptom control, comorbidity management), and referral.

Comparator

Usual care (UC) cohort, propensity score matched 1:5, observed through database monitoring without intervention, with full autonomy to visit any medical institutions on demand.

Outcome

Composite of ischemic stroke, systemic embolism, myocardial infarction, major bleeding, acute heart failure, and cardiovascular death at 30 months follow-up.composite

An administrative-driven hierarchical management model significantly reduces cardiovascular events and mortality in patients with atrial fibrillation while lowering medical costs.

Main Result

Effect estimate: HR 0.624 (95% CI 0.554-0.703)

Absolute Event Rate: 6.02% vs 9.15%

p-value: p=<0.0001

Limitations

Follow-up period coincided with the shift in China's COVID-19 policies, leading to an interruption in ADHM implementation and excess mortalities.
Endpoint events were identified through diagnostic code scanning and medical record confirmation, which might underreport events in patients who did not seek medical care.
Not a randomized trial due to administrative process involved.
Pattern of AF (paroxysmal, persistent, or permanent) was not able to be differentiated due to the adoption of ICD-10 codes.
Status of rhythm at the end of the study, socioeconomic status and other health behaviors were not available in the database.

Abstract

The administrative-driven hierarchical management (ADHM) refers to the management model that general practitioners act as "voluntary gatekeepers" under local government policy incentives in the non-mandatory hierarchical medical system. However, the impact of ADHM of atrial fibrillation (AF) on cardiovascular events remains unclear. We enrolled 1455 patients with AF in the ADHM cohort and 7275 in the matched usual care (UC) cohort in Shanghai, China. During the 30 months follow-up, the rate of the primary outcome (the composite of ischemic stroke, systemic embolism, myocardial infarction, major bleeding, acute heart failure and cardiovascular death) was significantly lower in the ADHM cohort than the UC cohort (hazard ratio: 0.624; 95% confidence interval=0.554-0.703; p < 0.0001). Comparisons of the secondary endpoints, including all-cause death, cardiovascular death, ischemic stroke, and acute heart failure, also favored the ADHM cohort, while non-cardiovascular death, systemic embolism, myocardial infarction, and major bleeding were similar between cohorts. The medical costs per patient per survival day were lower in the ADHM cohort. In sum, the ADHM model is effective in reducing cardiovascular events in patients with AF. Trial number: ChiCTR2000036931.

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