Key result
Nurse-led integrated care shows no benefit over usual care for CV death and hospital admissions.
Why the study?
Nurse-led integrated care was expected to improve outcomes in patients with atrial fibrillation compared with usual-care provided by a medical specialist.
Does nurse-led care reduce cardiovascular death and cardiovascular hospital admissions in patients with atrial fibrillation compared to usual care?
RCT (n=1,375)
Yes
Does nurse-led care reduce cardiovascular death and cardiovascular hospital admissions in patients with atrial fibrillation compared to usual care?
Hazard Ratio: 0.85 (95% CI 0.69–1.04)
Absolute Event Rate: 9.7% vs 11.6%
p-value: p=0.12
Nurse-led care was not superior to usual care for reducing cardiovascular death and hospital admissions in patients with atrial fibrillation, though subgroup analysis suggested potential benefit in experienced centers.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“[For] a single healthcare professional to really address these areas adequately, I think it's almost impossible. It takes a core team consisting of the patient with a cardiologist, nurse, and pharmacist working in collaboration with other specialists to really bring this comprehensive integrated approach to life.”
“For the management of a patient with AF, the effects of nurse-led care on guideline adherence seem promising when compared with standard of care, and the results of the ongoing RACE-4 study (NCT01740037) will increase the evidence on this topic and its potential impact on clinical outcome.”
“AF is both an electrical disease and a consequence of preceding associated diseases.”
Does not support routine adoption of nurse-led integrated care to reduce cardiovascular events; leaves.
BACKGROUND: Nurse-led integrated care is expected to improve outcome of patients with atrial fibrillation compared with usual-care provided by a medical specialist. METHODS AND RESULTS: We randomized 1375 patients with atrial fibrillation (64 ± 10 years, 44% women, 57% had CHA2DS2-VASc ≥ 2) to receive nurse-led care or usual-care. Nurse-led care was provided by specialized nurses using a decision-support tool, in consultation with the cardiologist. The primary endpoint was a composite of cardiovascular death and cardiovascular hospital admissions. Of 671 nurse-led care patients, 543 (81%) received anticoagulation in full accordance with the guidelines against 559 of 683 (82%) usual-care patients. The cumulative adherence to guidelines-based recommendations was 61% under nurse-led care and 26% under usual-care. Over 37 months of follow-up, the primary endpoint occurred in 164 of 671 patients (9.7% per year) under nurse-led care and in 192 of 683 patients (11.6% per year) under usual-care [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.69 to 1.04, P = 0.12]. There were 124 vs. 161 hospitalizations for arrhythmia events (7.0% and 9.4% per year), and 14 vs. 22 for heart failure (0.7% and 1.1% per year), respectively. Results were not consistent in a pre-specified subgroup analysis by centre experience, with a HR of 0.52 (95% CI 0.37-to 0.71) in four experienced centres and of 1.24 (95% CI 0.94-1.63) in four less experienced centres (P for interaction <0.001). CONCLUSION: Our trial failed to show that nurse-led care was superior to usual-care. The data suggest that nurse-led care by an experienced team could be clinically beneficial (ClinicalTrials.gov NCT01740037). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT01740037).
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Wijtvliet et al. (2019) conducted an RCT in atrial fibrillation (n=1,375). Nurse-led integrated care vs. usual-care was evaluated on composite of cardiovascular death and cardiovascular hospital admissions (HR 0.85, 95% CI 0.69 to 1.04, p=0.12). Nurse-led integrated care was not superior to usual-care for cardiovascular death and cardiovascular hospital admissions (9.7% vs 11.6% per year; HR 0.85; 95% CI 0.69-1.04; P=0.12).
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