Mobile health–enabled outpatient–ward–home integrated care for atrial fibrillation: real-world implementation and 1-year outcomes of a multicomponent hospital-wide digital pathway

Objective Atrial fibrillation (AF) requires continuous, multidisciplinary, and patient-engaged management across screening, inpatient care, discharge transition, and long-term follow-up. Although mobile phone–based outreach, SMS text messaging, and digitally supported integrated care models have shown promise in AF management, evidence remains limited regarding hospital-wide pathways that connect outpatient identification, ward-based collaborative care, AI-assisted follow-up, and home-based longitudinal management within routine workflows. This study evaluated the real-world implementation and 1-year outcomes associated with a multicomponent outpatient–ward–home digital integrated care pathway for AF (OWHD-AF). Materials and methods We conducted a hospital-wide before-and-after real-world implementation study at Weifang People’s Hospital. Patients hospitalized with AF before implementation in 2023 were compared with patients managed after deployment of OWHD-AF in 2024. The pathway integrated electronic medical record–based AF identification, electrocardiographic report screening, automated clinical prompts, fast-track electrophysiology referral, interdepartmental specialist coordination, guideline-directed risk assessment, anticoagulation optimization, AI-assisted telephone follow-up, SMS reminders, manual escalation for predefined risk signals, and dashboard-supported quality monitoring. Digital follow-up engagement was assessed using outreach and care-conversion indicators. Monthly process indicators were assessed using interrupted time-series analysis, and 1-year clinical outcomes were evaluated using Kaplan–Meier curves and multivariable Cox proportional hazards models. Results A total of 10,607 hospitalized patients with AF were included, with 5146 in the pre-implementation phase and 5461 in the post-implementation phase. After implementation, AF diagnosis, CHA₂DS₂-VASc assessment, and HAS-BLED assessment showed significant positive slope changes in interrupted time-series analyses (all P <.001). Monthly risk assessment documentation increased from consistently low levels before implementation to more than 80% during the late post-implementation period. The system delivered 20,932 outbound AI-assisted follow-up calls, of which 7440 were connected (35.5%), and 9550 SMS reminders, of which 9454 were successfully delivered (99.0%). At 12 months, OWHD-AF implementation was associated with lower risks of major adverse cardiovascular events (3.72% vs. 5.11%; adjusted hazard ratio [aHR] 0.72, 95% CI 0.60–0.86; P <.001) and heart failure readmission (3.42% vs. 4.66%; aHR 0.71, 95% CI 0.59–0.86; P <.001). All-cause mortality was numerically lower, and major bleeding was not significantly increased. Conclusions In this hospital-wide real-world implementation study, OWHD-AF provided a scalable mobile health–enabled pathway integrating outpatient AF identification, ward-based collaborative management, and home-based AI-assisted follow-up. Implementation was associated with improved guideline-directed care processes and favorable 1-year outcomes.