Masica Andrew, Brown Rachel, Farzad Ali, Garrett John S, Wheelan Kevin, Nguyen Hoa L, Ogola Gerald O, Kudyakov Rustam, McDonald Brandy, Boyd Bethany, Patel Avani, Delaughter Craig
Center for Clinical Effectiveness Baylor Scott & White Health Dallas Texas USA.
Texas Health Resources Arlington Texas USA.
J Am Coll Emerg Physicians Open. 2022 Feb 18;3(1):e12608. doi: 10.1002/emp2.12608. eCollection 2022 Feb.
Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence-based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non-valvular AF (EDAFMP) on hospital use and care process measures.
We deployed a voluntary-use EDAFMP in 4 EDs (1 tertiary hospital, 1 cardiac hospital, 2 community hospitals) of an integrated delivery organization using a multifaceted implementation approach. We compared outcomes between patients with AF treated using the EDAFMP and historical and contemporaneous "usual care" controls, using a propensity-score adjusted generalized estimating equation. Patients with an index ED encounter for a primary visit reason of non-valvular AF (and no excluding concurrent diagnoses) were eligible for inclusion.
Preimplementation (January 1, 2016-December 31, 2016), 628 AF patients were eligible; postimplementation (September 1, 2017-June 30, 2019), 1296, including 271 (20.9%) treated with the EDAFMP, were eligible. EDAFMP patients were less likely to be admitted than both historical (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.45, 0.29-0.71) and contemporaneous controls (aOR, 95%CI: 0.63, 0.46-0.86). ED visits and hospital readmissions over 90 days subsequent to index ED encounters were similar between postimplementation EDAFMP and usual care groups. EDAFMP patients were more likely to be prescribed anticoagulation (38% v. 5%, < 0.001) and be referred to a cardiologist (93% vs 29%, < 0.001) versus the comparator group.
EDAFMP use is associated with decreased hospital admission during an index ED encounter for non-valvular AF, and improved delivery of AF care processes.
心房颤动（AF）具有较高的发病率和死亡率。循证指南已被整合到急诊科（ED）房颤护理路径中，但此类方法的有效性和可扩展性尚未得到充分证实。因此，我们评估了非瓣膜性房颤急诊科管理算法护理路径（EDAFMP）对医院使用情况和护理过程指标的影响。
我们采用多方面实施方法，在一个综合医疗服务机构的4个急诊科（1家三级医院、1家心脏病专科医院、2家社区医院）部署了自愿使用的EDAFMP。我们使用倾向评分调整广义估计方程，比较了使用EDAFMP治疗的房颤患者与历史及同期“常规护理”对照组的结局。以非瓣膜性房颤为主要就诊原因（且无排除性并发诊断）的首次急诊科就诊患者符合纳入条件。
实施前（2016年1月1日至2016年12月31日），628例房颤患者符合条件；实施后（2017年9月1日至2019年6月30日），1296例患者符合条件，其中271例（20.9%）接受了EDAFMP治疗。与历史对照组（调整优势比[aOR]，95%置信区间[CI]：0.45，0.29 - 0.71）和同期对照组（aOR，95%CI：0.63，0.46 - 0.86）相比，EDAFMP组患者入院的可能性较小。实施后EDAFMP组与常规护理组在急诊科就诊及首次急诊科就诊后90天内的医院再入院情况相似。与对照组相比，EDAFMP组患者更有可能接受抗凝治疗（38%对5%，<0.001）并被转诊至心脏病专家处（93%对29%，<0.001）。
在非瓣膜性房颤首次急诊科就诊期间，使用EDAFMP与减少住院率及改善房颤护理过程的实施情况相关。
