Patient‐reported outcomes and subsequent management in atrial fibrillation clinical practice: Results from the Utah mEVAL AF program

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (n=1338). Intervention: Worse baseline Toronto AF Symptom Severity Scale (AFSS) symptom score (above median) vs. Better baseline AFSS symptom score (below median). Primary outcome: Toronto AF Symptom Severity Scale (AFSS) symptom score (0-35) and subsequent composite rhythm control intervention at 6 months (p=<0.001).

Q: What does this research mean for the field?

Worse baseline patient-reported AF symptom severity in routine clinical practice is associated with younger age, female sex, comorbidities, and a higher rate of subsequent rhythm control interventions. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Brian Zenger; Mingyuan Zhang; Ann Lyons; T. Jared Bunch; James C. Fang; Roger A. Freedman; Leenhapong Navaravong; Jonathan P. Piccini; Ravi Ranjan; John A. Spertus; Josef Stehlik; Jeffrey L. Turner; Tom Greene; Rachel Hess; Benjamin A. Steinberg

doi:10.1111/jce.14795

October 30, 2020Journal of Cardiovascular ElectrophysiologyOpen Access

Patient‐reported outcomes and subsequent management in atrial fibrillation clinical practice: Results from the Utah mEVAL AF program

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Why the study?

AF significantly reduces HRQoL, but PROs had primarily been measured in clinical trials rather than routine clinical practice.

What patient factors are associated with worse Toronto AF Symptom Severity Scale (AFSS) scores in routine clinical practice, and does a worse baseline symptom score correlate with subsequent rhythm control management at 6 months in outpatients with atrial fibrillation?

Key Points

Determine clinical factors associated with worse patient-reported symptom scores in routine atrial fibrillation care and examine their relationship with subsequent 6-month clinical management.
Analyzed routine clinical practice data from the Utah mEVAL program in 1338 outpatients with pre-existing atrial fibrillation between October 4, 2016, and January 17, 2020.
Assessed symptom severity using the Toronto Atrial Fibrillation Symptom Severity Scale (AFSS, score 0-35, higher is worse), alongside AF burden and healthcare utilization domains.
Evaluated subsequent 6-month clinical management among 1246 patients with follow-up, assessing rhythm control interventions including antiarrhythmic drugs, cardioversion, and catheter ablation.
Baseline AFSS symptom scores were significantly worse in females (mean 10.27 vs. 7.26 for males; p < .001), patients aged <65 years (9.73 vs. 7.66 for 65–74 and 7.58 for ≥75; p < .001), and patients with heart failure (9.39 vs. 7.67; p < .001), but lower with prior ablation (7.28 vs. 8.84; p < .001).
In multivariable analysis, higher symptom scores were independently associated with age <65 versus ≥75 (mean adjusted difference 2.92, 95% CI 1.97–3.88), female sex (2.57, 95% CI 1.78–3.37), pulmonary disease (1.88, 95% CI 1.06–2.7), and depression (2.49, 95% CI 1.6–3.32).
Patients with baseline symptom scores above the median had higher rates of 6-month rhythm control interventions (37% vs. 25%, p < 0.001), including ablation (15% vs. 7.3%, p < 0.001), antiarrhythmic drugs (28% vs. 19%, p < 0.001), and cardioversion (12% vs. 6.4%, p = 0.002).

Study Design

Type

Cohort (n=1,338)

Multicenter

No

Structured PICO

What patient factors are associated with worse Toronto AF Symptom Severity Scale (AFSS) scores in routine clinical practice, and does a worse baseline symptom score correlate with subsequent rhythm control management at 6 months in outpatients with atrial fibrillation?

P

Population

1,338 adult outpatients with atrial fibrillation (mean age 67, 37% female) evaluated at a University of Utah electrophysiology clinic who completed the Toronto AF Symptom Severity Scale, with 1,246 followed for 6 months.

E

Exposure

Routine clinical collection of patient-reported outcomes using the Toronto Atrial Fibrillation Severity Scale (AFSS) via the Utah mEVAL program (specifically worse/above-median baseline AFSS symptom score, range 0-35)

C

Comparator

Better/below-median baseline AFSS symptom score (for 6-month management comparison) and cross-sectional comparisons across demographic/clinical strata

O

Outcome

Toronto AF Symptom Severity Scale (AFSS) symptom score (7 items on 5-point Likert scales, range 0-35, higher is worse) and subsequent composite rhythm control treatment (prescribed antiarrhythmic drug therapy, incident cardioversion, and/or incident AF catheter ablation) within 6 monthspatient reported

Main Result

Absolute Event Rate: 37.1% vs 24.5%

p-value: p=<0.001

Limitations

Real-time clinical care data with irregular data collection intervals and potentially informative missingness
Single-center study within a highly-motivated health care system which may limit generalizability
Unknown clinically-relevant change in each AFSS domain score and their relationship to clinical outcomes
Inability to ascertain the influence of lifestyle risk factors (e.g., alcohol intake, exercise) on AF symptom status
Physician treatment approach is subject to clinical bias and unmeasured variables from administrative data
Single-center study within a highly-motivated healthcare system, limiting generalizability
Clinically relevant change in AFSS domain scores and relationship to hard clinical outcomes remain unknown
Unable to ascertain influence of lifestyle risk factors such as alcohol intake and exercise
Physician treatment approach is subject to clinical bias and unmeasured confounding in administrative data

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Routine clinical collection of the AFSS patient-reported outcome identifies highly symptomatic AF patients and correlates strongly with subsequent aggressive rhythm control management within 6 months.

Abstract

BACKGROUND: Atrial fibrillation (AF) significantly reduces health-related quality of life (HRQoL), previously measured in clinical trials using patient-reported outcomes (PROs). We examined AF PROs in clinical practice and their association with subsequent clinical management. METHODS: The Utah My Evaluation (mEVAL) program collects the Toronto AF Symptom Severity Scale (AFSS) in AF outpatients at the University of Utah. Baseline factors associated with worse AF symptom score (range 0-35, higher is worse) were identified in univariate and multivariable analyses. Secondary outcomes included AF burden and AF healthcare utilization. We also compared subsequent clinical management at 6 months between patients with better versus worse AF HRQoL. RESULTS: Overall, 1338 patients completed the AFSS symptom score, which varied by sex (mean 7.26 for males vs. 10.27 for females; p < .001), age (<65, 9.73; 65-74, 7.66; ≥75, 7.58; p < .001), heart failure (9.39 with HF vs. 7.67 without; p < .001), and prior ablation (7.28 with prior ablation vs. 8.84; p < .001). In multivariable analysis, younger age (mean difference 2.92 for <65 vs. ≥75; p < .001), female sex (mean difference 2.57; p < .001), pulmonary disease (mean difference 1.88; p < .001), and depression (mean difference 2.46; p < .001) were associated with higher scores. At 6-months, worse baseline symptom score was associated with the use of rhythm control (37.1% vs. 24.5%; p < .001). Similar cofactors and results were associated with increased AF burden and health care utilization scores. CONCLUSIONS: AF PROs in clinical practice identify highly-symptomatic patients, corroborating findings in more controlled, clinical trials. Increased AFSS score correlates with more aggressive clinical management, supporting the utility of disease-specific PROs guiding clinical practice.

Discussion

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Cite This Study

Zenger et al. (2020) conducted a cohort in Atrial fibrillation (n=1,338). Worse baseline Toronto AF Symptom Severity Scale (AFSS) symptom score (above median) vs. Better baseline AFSS symptom score (below median) was evaluated on Toronto AF Symptom Severity Scale (AFSS) symptom score (0-35) and subsequent composite rhythm control intervention at 6 months (p=<0.001).

synapsesocial.com/papers/6a74c4279c92392688b1dbe2 https://doi.org/10.1111/jce.14795

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Patient‐reported outcomes and subsequent management in atrial fibrillation clinical practice: Results from the Utah mEVAL AF program

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Patient‐reported outcomes and subsequent management in atrial fibrillation clinical practice: Results from the Utah mEVAL AF program

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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