Achievement and quality measure attainment in patients hospitalized with atrial fibrillation: Results from The Get With The Guidelines - Atrial Fibrillation (GWTG-AFIB) registry.

BACKGROUND: The Get With The Guidelines - Atrial Fibrillation (GWTG-AFIB) Registry uses achievement and quality measures to improve the care of patients with atrial fibrillation (AF). We sought to evaluate overall and site-level variation in attainment of these measures among sites participating in the GWTG-AFIB Registry. METHODS: From the GWTG-AFIB registry, we included patients with AF admitted between 1/3/2013 and 6/30/2019. We described patient-level attainment and variation in attainment across sites of 6 achievement measures with 1) defect-free scores (percent of patients with all eligible measures attained), and 2) composite opportunity scores (percent of all eligible patient measures attained). We also described attainment of 11 quality measures at the patient-level. RESULTS: Among 80,951 patients hospitalized for AF (age 70±13 years, 47.0% female; CHA2DS2-VASc 3.6±1.8) at 132 sites. Site-level defect-free scores ranged from 4.7% to 85.8% (25th, 50th, 75th percentile: 32.7%, 52.1%, 64.4%). Composite opportunity scores ranged from 39.4% to 97.5% (25th, 50th, 75th: 68.1%, 80.3%, 87.1%). Attainment was notably low for the following quality measures: 1) aldosterone antagonist prescription when ejection fraction ≤35% (29% of those eligible); and 2) avoidance of antiplatelet therapy with OAC in patients without coronary/peripheral artery disease (81% of those eligible). CONCLUSIONS: Despite high overall attainment of care measures across GWTG-AFIB registry sites, large site variation was present with meaningful opportunities to improve AF care beyond OAC prescription, including but not limited to prescription of aldosterone antagonists in those with AF and systolic dysfunction and avoidance of non-indicated adjunctive antiplatelet therapy.

Exploring Patients' Values and Preferences for Initial Atrial Fibrillation Education.

BACKGROUND: People with a new diagnosis of atrial fibrillation (AF) require knowledge to build skills and confidence to engage in decision making for AF treatment and prevention of AF-related complications. Data to guide development of content and approaches that enable acquisition of knowledge to support effective self-management are lacking. OBJECTIVE: The aim of this study was to explore patients' values concerning the content of initial AF education, describe how providers delivered education, and identify patients' preferences for approaches to education. METHODS: We used a qualitative inductive approach. Twenty-five participants given a diagnosis of AF within 18 months of enrollment were recruited from midwest US healthcare system clinics. Data were collected using a semistructured interview guide and were analyzed using qualitative content analysis. RESULTS: Themes emerging were as follows: (1) important to know, (2) recollections of the how and what of education, and (3) preferences for educational resources. Participants highly valued providers' explanations that AF was not immediately life-threatening and did not require limitations to usual activities. This reassurance from providers decreased fear and then enabled participants to learn about AF management. Verbal explanations were the primary approach to delivering education, but participants consistently expressed preferences for receiving written information and videos to supplement verbal explanations. CONCLUSIONS: Addressing emotional and quality of life concerns at the time of AF diagnosis reduced fear and was critical for enabling participants to attend to discussions about treatment and self-management. The value participants placed on written and video resources as an adjunct to verbal explanation suggests that providers should consider educational approaches beyond verbal explanations.

Initial Psychometric Testing of the Knowledge About Atrial Fibrillation and Self-Management Survey.

BACKGROUND: Guidelines endorse educating patients to self-manage atrial fibrillation (AF) to mitigate AF-related adverse events contributing to personal and societal burden. Published interventions to improve patients' knowledge about AF and self-management are emerging, but evaluations of interventions are limited by lack of a psychometrically sound instrument to measure learning outcomes. OBJECTIVE: We report results of initial psychometric testing of the Knowledge about Atrial Fibrillation and Self-Management (KAFSM) survey. METHODS: Participants (N = 383), from midwest and southeast medical centers, completed the KAFSM survey. Content validity was evaluated by expert review. Construct validity was evaluated using the Pearson correlation procedure for convergent validity with the Knowledge about Atrial Fibrillation test and independent t test for known groups. Factor analysis using principal axis factoring was performed with a tetrachoric matrix. The Kuder-Richardson procedure was used to determine internal consistency reliability. RESULTS: A content validity index of 0.86 resulted from expert review. A positive (r = 0.60) correlation between the KAFSM survey and Knowledge about Atrial Fibrillation test demonstrated convergent validity. Higher KAFSM scores (difference, 3.28; t = 6.44, P < .001) observed in participants who underwent AF ablation compared with those with an AF diagnosis of less than or equal to 6 months supported known groups validity. Factor analysis revealed a single-factor structure explaining 35% of the variance. The Kuder-Richardson coefficient was 0.86. CONCLUSIONS: The KAFSM survey demonstrates content and construct validity and internal consistency reliability. Implementation of the KAFSM in the clinical setting will permit evaluation of the feasibility of its use and value to assess learning outcomes of AF education.

Subclinical and Device-Detected Atrial Fibrillation: Pondering the Knowledge Gap: A Scientific Statement From the American Heart Association.

The widespread use of cardiac implantable electronic devices and wearable monitors has led to the detection of subclinical atrial fibrillation in a substantial proportion of patients. There is evidence that these asymptomatic arrhythmias are associated with increased risk of stroke. Thus, detection of subclinical atrial fibrillation may offer an opportunity to reduce stroke risk by initiating anticoagulation. However, it is unknown whether long-term anticoagulation is warranted and in what populations. This scientific statement explores the existing data on the prevalence, clinical significance, and management of subclinical atrial fibrillation and identifies current gaps in knowledge and areas of controversy and consensus.

Atrial Fibrillation: Community Screening Events Improve Awareness in Older Adults.

Educating older adults during atrial fibrillation (AF) screening events to recognize signs and symptoms and seek evaluation may promote detection of AF that occurs between screenings. The authors evaluated learning outcomes of AF awareness education provided during AF screening using a single-arm, pre/posttest design. Participants completed the Knowledge, Attitudes, Beliefs about Atrial Fibrillation Self-Monitoring and Treatment-Seeking (KABAF-SMTS) survey, participated in AF awareness education, and completed a KABAF-SMTS survey 2 weeks after education. Paired t tests revealed that knowledge of AF symptoms increased (p = 0.007). Scores for recognizing the seriousness of AF (p = 0.003), benefits of self-monitoring (p < 0.001), perception of barriers to self-monitoring (p = 0.002), and confidence (p < 0.001) to recognize AF and seek treatment improved. AF awareness education strengthened knowledge, beliefs, and attitudes that may be conducive to recognition and treatment-seeking for AF. [Journal of Gerontological Nursing, 45(9), 31-38.].

Adherence to Guideline-Directed Stroke Prevention Therapy for Atrial Fibrillation Is Achievable.

BACKGROUND: Efforts to improve prescription of oral anticoagulation (OAC) drugs in patients with atrial fibrillation have had limited success in improving guideline adherence. METHODS: We evaluated adherence to the American College of Cardiology/American Heart Association performance measures for OAC in eligible patients with a CHA2DS2-VASc score ≥2 and trends in prescription over time in the American Heart Association's Get With The Guidelines-AFIB (atrial fibrillation) registry. Adjusted associations with in-hospital outcomes were also determined. The cohort included 33 235 patients with a CHA2DS2-VASc score ≥2 who were admitted for atrial fibrillation and were enrolled at 115 sites between January 1, 2013, and September 31, 2017. RESULTS: The median (25th, 75th percentile) age was 73 years (65, 81 years); 51% were female; and the median (25th, 75th percentile) CHA2DS2-VASc score was 4 (3, 5). At admission, 16 206 (59.5%) of 27 221 patients with a previous diagnosis of atrial fibrillation were taking OAC agents, and OAC drug use at admission was associated with a lower adjusted odds of in-hospital ischemic stroke (odds ratio, 0.38; 95% CI, 0.24-0.59; P<0.0001). At discharge, prescription of OAC in eligible patients (no contraindications) was 93.5% (n=25 499 of 27 270). In a sensitivity analysis, when excluding only strict contraindications (4.6%, n=1497 of 32 806), OAC prescription at discharge was 80.3%. OAC prescription at discharge was higher in those aged ≤75 years, men, those with heart failure, those with previous atrial fibrillation ablation, and those with rhythm control ( P<0.0001 for all). OAC use was lowest in Hispanic patients (90.2%, P<0.0001). Prescription of OAC at discharge in eligible patients improved over time from 79.9% to 96.6% ( P<0.0001). CONCLUSIONS: Among hospitals participating in the GWTG-AFIB quality improvement program, OAC prescription at discharge in eligible guideline-indicated patients increased significantly and improved consistently over time. These data confirm that high-level adherence to guideline-recommended stroke prevention is achievable.

Patient activation for self-management is associated with health status in patients with atrial fibrillation.

BACKGROUND: Higher levels of patient activation for self-managing health are associated with positive clinical and health care utilization outcomes. Identifying a patient's activation level can guide clinicians to tailor interventions to improve their health. Effective self-management of atrial fibrillation (AF) requires patient activation to participate in treatment decisions, prevent complications, and manage risk factors. Yet, little is known about activation in patients with AF. The purpose of this descriptive study was to identify patient activation levels and factors associated with activation in patients with AF. METHODS: Patients (N=123), 66% male, with a mean (SD) age of 59.9 (11.3) years seeking treatment for AF at an arrhythmia clinic completed the Patient Activation Measure (PAM), Atrial Fibrillation Severity Scale, Knowledge about Atrial Fibrillation test, Hospital Anxiety Depression Scale, Godin Leisure-Time Exercise Questionnaire, and Patient Assessment of Chronic Illness Care. Sociodemographic and clinical data were obtained from medical records. PAM scores were categorized into Levels 1-4. Associations among patient-reported outcomes, sociodemographic, and clinical variables were analyzed using Fisher's exact tests and Kruskal-Wallis procedures. RESULTS: The PAM scores of nearly half (45.5%) of the patients were at Level 3, while the scores of 38% were at Level 4. Male sex (P=0.02), higher education (P=0.004), being employed (P=0.005), lower body mass index (P=0.03), tobacco abstinence (P=0.02), less AF symptom burden (P=0.006), less depression (P≤0.0001) and anxiety (P=0.006), greater knowledge of AF (P=0.01), and higher levels of physical activity (P=0.02) were associated with higher activation levels. CONCLUSION: Higher levels of patient activation in those with AF were associated with a more positive health status and educational attainment. Additional research to describe activation in patients with AF is warranted to identify patients at risk for low activation and to tailor interventions to activation level.

Preparation for and Implementation of Shared Medical Appointments to Improve Self-Management, Knowledge, and Care Quality Among Patients With Atrial Fibrillation.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and is associated with an increased risk of stroke, heart failure, and death. Therapy for this pervasive arrhythmia is complex, involving multiple options that chiefly manage symptoms and prevent stroke. Current therapeutic strategies are also of limited efficacy, and can present potentially life-threatening side effects and/or complications. Emerging research suggests that the burden of AF can be reduced by improving patient understanding of the arrhythmia and teaching patients to adopt and maintain lifestyle and behavior changes. Shared medical appointments (SMAs) have been successfully used to deliver education and develop patient coping and disease management skills for patients with complex needs, but there is a paucity of studies examining the use of SMAs for managing AF. Moreover, few studies have examined strategies for implementing SMAs into routine clinical care. We detail our approach for (1) adapting a patient-centered SMA curriculum; (2) designing an evaluation comparing SMAs to routine care on patient outcomes; and (3) implementing SMAs into routine clinical practice. We conclude that evaluation and implementation of SMAs into routine clinical practice requires considerable planning and continuous engagement from committed key stakeholders, including patients, family members, schedulers, clinical staff, nurse educators, administrators, and billing specialists.

Outcomes of a Dignity Therapy/Life Plan Intervention for Patients With Advanced Cancer Undergoing Chemotherapy.

Dignity therapy is a psychosocial intervention provided at the end of life to improve patient outcomes, but many persons cannot complete it because of health decline. Patients also reprioritize their life plans as death becomes imminent. As part of meeting standards to provide psychosocial palliative care simultaneously with cancer treatment, we provided a dignity therapy/life plan intervention to 18 patients with advanced pancreatic or lung cancer receiving cancer treatment. The study aim was to evaluate patient-reported outcomes of dignity therapy/life plan. Dignity therapy entailed interviews during 3 outpatient oncology encounters, which then became a legacy document for family. Participants documented life goals as their life plan. Distress, quality of life, spirituality, dignity, and purpose in life were measured at baseline, immediately after intervention, and 3 months later. No variables were significantly different from baseline to postintervention and 3 months later, except for less distress between baseline and 3 months (P = .04). Although this intervention did not show improvements in outcomes, patients with advanced disease receiving active treatment typically experience worsening symptoms overall. Maintaining psychosocial outcomes may be preventing further morbidity in an advanced cancer population during treatment and bears further exploration. Given our small sample size, further research is warranted.

Patient perspectives of participating in the cardiac CopenHeartRFA rehabilitation program for patients treated with ablation for atrial fibrillation.

PURPOSE: The CopenHeartRFA trial was designed and conducted to explore the effects of rehabilitation on patients treated with ablation for atrial fibrillation (AF). It included a cardiac rehabilitation program consisting of physical exercise and psychoeducational consultations over 6 months. As part of the evaluation of the CopenHeartRFA trial, both quantitative and qualitative data were collected. The intervention was delivered by a multidisciplinary team. AIM: This study aimed to understand the experience of patients treated for AF with ablation who participated in the CopenHeartRFA cardiac rehabilitation program. METHODS: A qualitative descriptive design was used. A purposive sample of 10 patients who had completed the intervention consented to participate. The interviews were conducted face-to-face and were audio-recorded and transcribed. Qualitative content analyses were used to analyze the data. The interviews were analyzed individually by two researchers and themes were constructed and discussed. RESULTS: The sample included 10 participants, mean age 54.6 years. Four categories were identified and labeled: 1) strengthening belief in one's own physical capacity and survival; 2) still struggling with fear of AF symptoms; 3) a need for support to move on; and 4) regaining confidence in one's own mental strength with support from professionals. CONCLUSION: The four themes describe a positive experience from participating in the rehabilitation program. The rehabilitation program promoted self-efficacy for engaging in physical activity and the benefit of a safe environment for processing the emotional responses and the value of the therapeutic relationship between the patient and the rehabilitation provider.

Illness Representation and Self-Care Ability in Older Adults with Chronic Disease.

Chronic illness affects >50% of adults in the United States and accounts for >80% of healthcare spending. The purpose of this study was to determine whether beliefs about one's chronic disease (illness representation) are associated with self-care activation, emergency department (ED) visits, or hospitalizations. Using a cross-sectional design, we recruited older adults with heart failure, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. The Revised Illness Perception Questionnaire (IPQ-R) measured perceptions about disease. The Patient Activation Measure measured self-care activation. ED visits and hospitalizations were measured by self-report. IPQ-R scores were analyzed using latent profile analysis to identify subgroups. Participants included 187 adults (mean age 65 years, 54% female, 74% Black). We found three subgroups (stable, overwhelmed, and confident). Groups did not differ demographically or by disease. The stable group (few consequences, non-fluctuating pattern) had the fewest hospitalizations. The overwhelmed group (many consequences, fluctuating pattern, high negative emotion) had high hospitalizations and low self-care ability. The confident group (high disease control, well-understood) had the highest self-care ability, but also high hospitalizations. ED visits did not differ by group. We found three subgroups that differ in their illness representation and health outcomes. Findings suggest that assessing patients' illness representations may have important implications for subgroup-specific interventions.

Feasibility and Acceptability of a Dignity Therapy/Life Plan Intervention for Patients With Advanced Cancer.

PURPOSE/OBJECTIVES: To determine the feasibility and acceptability of a dignity therapy/life plan intervention in the outpatient oncology setting.
. RESEARCH APPROACH: Pilot descriptive study.
. SETTING: Outpatient clinic in a tertiary oncology center. 
. PARTICIPANTS: 18 patients within 12 months after diagnosis undergoing treatment for advanced pancreatic cancer or non-small cell lung cancer.
. METHODOLOGIC APPROACH: Patients received dignity therapy, consisting of a focused life review/values clarification interview session and two subsequent sessions to produce a generativity document, which they can use later as they wish. Participants also wrote a life plan, in which they listed future hopes and dreams. Intervention feasibility and acceptability for patients and oncology clinician satisfaction were assessed.
. FINDINGS: Among the 18 patients completing the intervention, almost all felt it was worthwhile, would do it again, had their expectations met or exceeded, would recommend it to others, and said the timing was just right.
. INTERPRETATION: This psychosocial intervention was found to be feasible and acceptable to patients with cancer undergoing active treatment.
. IMPLICATIONS FOR NURSING: Nurses may be in an ideal position to offer a dignity therapy/life plan intervention to patients with advanced cancer during treatment.

Feasibility Testing of the Alert for AFib Intervention.

Improving early detection and treatment of atrial fibrillation (AF) is critical because untreated AF is a major contributor to stroke and heart failure. We sought to generate knowledge about the feasibility of conducting a randomized controlled trial to test the effect of the Alert for AFib intervention on knowledge, attitudes, and beliefs about treatment-seeking for signs and symptoms of AF. Adults ≥65 years old (96% White) at risk for developing AF were randomized to receive the Alert for AFib intervention ( n = 40) or an attention control session ( n = 40). Feasibility goals for recruitment, participant retention, adherence, perceived satisfaction and burden, and intervention fidelity were met. From baseline to study completion, knowledge ( p = .005) and attitudes ( p < .001) about treatment-seeking improved more in the intervention group compared with the control group. Results support testing the effectiveness of the Alert for AFib intervention in a large trial.

Older Adults at Risk for Atrial Fibrillation Lack Knowledge and Confidence to Seek Treatment for Signs and Symptoms.

Early detection of atrial fibrillation (AF) is crucial for averting AF-related stroke and heart failure, but treatment is delayed when AF is not recognized. The critical need for early detection and treatment requires education to promote AF awareness. Knowledge deficits, attitudes, and beliefs about AF that should be addressed to improve awareness and reduce treatment-seeking delay in older adults at risk for developing AF have not been well documented. The purpose of this study was to describe knowledge, treatment-seeking attitudes, and beliefs about AF in adults ⩾ 65 years old and identify demographic characteristics associated with knowledge, attitudes, and beliefs. Patients with no history of AF recruited from an academic medical center were interviewed using the Knowledge, Attitudes, and Beliefs about Atrial Fibrillation Survey. Data were analyzed using descriptive statistics and independent t tests. Participants (N = 180) were 63% male with a mean age of ±3.± 6.0 years, and 52% held ⩾ 4-year college degree. About one third could not identify common symptoms of AF including palpitations (31%), chest pain (36%), dyspnea (30%), and fatigue (35%). A majority (84%) lacked confidence to recognize AF, and 58% were not sure when they should seek care for AF symptoms. Nearly a third (32%) believed palpitations are always present with AF, and 74% believed that low energy would not be their only symptom of AF. Higher scores for AF Symptom Knowledge (p = .02) were observed in females, and General Knowledge about AF was greater for younger participants (p < .001). Participants lacked knowledge and confidence to aid decision-making for treatment-seeking for symptoms of AF and held inaccurate beliefs about AF that could hinder early treatment-seeking. Programs to promote AF awareness should explain the spectrum of symptoms that may be manifested by AF and include action plans for responding to symptoms.

Fatigue, dyspnea, and intermittent symptoms are associated with treatment-seeking delay for symptoms of atrial fibrillation before diagnosis.

BACKGROUND: Delay in seeking treatment for symptoms of atrial fibrillation (AF) at onset results in a missed opportunity for vital early treatment of AF which is important for reducing stroke, tachycardia induced heart failure, and treatment-resistant AF. Little is known about factors that contribute to treatment-seeking delay for symptoms of AF. PURPOSE: The purpose of this study was to identify factors associated with treatment-seeking delay for symptoms of AF before diagnosis. METHODS: For this descriptive study, 150 participants with recently detected AF completed structured interviews to collect data about symptoms, symptom characteristics, symptom representation regarding cause, seriousness, controllability of symptoms, responses to symptoms before diagnosis, and time from symptom onset to treatment-seeking. Chi-square analysis was used to identify factors associated with delay (>1 week) versus no delay (⩽1 week) in treatment-seeking after symptom onset. RESULTS: Participants were 51% female (n=76) with a mean age of 66.5 (standard deviation (SD)±11.1) years. A majority (70%, n=105) delayed treatment-seeking. Factors associated with delay included experiencing fatigue, dyspnea, intermittent symptoms, attributing symptoms to deconditioning, overwork, inadequate sleep, and perceiving symptoms as not very serious and amenable to self-management. Responses such as a wait and see approach, working through symptoms, reporting no fear of symptoms, or attempting to ignore symptoms were associated with delay. CONCLUSION: Experiencing fatigue, dyspnea and intermittent symptoms produced symptom representations and emotional and behavioral responses associated with treatment-seeking delay. There is a critical need to develop and test educational interventions to increase awareness of the spectrum and characteristics of AF symptoms and appropriate treatment-seeking behaviors.

Symptom Representation and Treatment-Seeking Prior to Diagnosis of Atrial Fibrillation.

Early treatment-seeking for symptoms of atrial fibrillation (AF) is critical to avert AF-related stroke and heart failure, but early treatment is hindered if symptoms are not accurately interpreted. The purpose of this research was to describe symptom representation and treatment-seeking responses prior to diagnosis of AF. For this descriptive study, 150 participants were surveyed to describe the type and temporality of symptoms, perceptions regarding the cause, seriousness, controllability of symptoms, and responses to symptoms prior to diagnosis. Participants' mean age was 66.5 years, and 51% were female. Participants perceived symptoms as having nondisease-based causes, as not very serious, and as amenable to self-management. The majority took a wait and see response with 69% waiting more than 1 week after symptom onset to seek treatment. Lack of recognition of the seriousness of symptoms of AF and delayed treatment put patients at risk of poorer outcomes.