Atrial Fibrillation Screen, Management, and Guideline-Recommended Therapy in the Rural Primary Care Setting: A Cross-Sectional Study and Cost-Effectiveness Analysis of eHealth Tools to Support All Stages of Screening

Abstract

BACKGROUND: Internationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people >= 65 years of age and oral anticoagulant treatment for those at high stroke risk (CHA(2)DS(2)-VA >= 2). However, gaps remain in screening and treatment. METHODS AND RESULTS: General practitioners/nurses at practices in rural Australia (n= 8) screened eligible patients (>= 65 years of age without AF) using a smartphone ECG during practice visits. eHealth tools included electronic prompts, guideline-based electronic decision support, and regular data reports. Clinical audit tools extracted de-identified data. Results were compared with an earlier study in metropolitan practices (n=8) and nonrandomized control practices (n=69). Cost-effectiveness analysis compared population-based screening with no screening and included screening, treatment, and hospitalization costs for stroke and serious bleeding events. Patients (n=3103, 34%) were screened (mean age, 75.1 +/- 6.8 years; 47% men) and 36 (1.2%) new AF cases were confirmed (mean age, 77.0 years; 64% men; mean CHA(2)DS(2)-VA, 3.2). Oral anticoagulant treatment rates for patients with CHA(2)DS(2)-VA >= 2 were 82% (screen detected) versus 74% (preexisting AF)(P= NS), similar to metropolitan and nonrandomized control practices. The incremental cost- effectiveness ratio for population-based screening was AU$16 578 per quality-adjusted life year gained and AU$84 383 per stroke prevented compared with no screening. National implementation would prevent 147 strokes per year. Increasing the proportion screened to 75% would prevent 177 additional strokes per year. CONCLUSIONS: An AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost- effective. Oral anticoagulant treatment rates were relatively high at baseline, trending upward during the study. Increasing the proportion screened would prevent many more strokes with minimal incremental cost-effectiveness ratio change. eHealth tools, including data reports, may be a valuable addition to future programs.