Disclosure

• FA-CILITER/INTEGRATE are supported by Boehringer Ingelheim Canada.

• Grants for Research and consulting fees: Boehringer Ingelheim/Bayer/Daichi/BMS/Pfizer.

Atrial Fibrillation (AF)

• Irregular heartbeat with blood stagnation in the heart.• Common disease.• 1% of the general population.• 8% of the population over 80 years.

Heart and Stroke Canada

Atrial Fibrillation (AF)

• 8,000 annual hospitalizations in Canada• ($4,700/hospitalization)• Increase 3-5 folds CVA risk.• Each CVA costs at least $70,000 in the first

year.

Stroke & Atrial Fibrillation (AF)

2 x in-hospital mortality

40%less likely to return home†.

20%increase hospital length‡.

*Copenhagen Stroke study, prospective community study. n=1,197**In-hospital mortality: 72 deaths, n=217 with AF vs. 171 deaths, n=968 without AF†Returning home: n=104 with AF vs 662 deaths, n=968 without AF‡Duration of hospital stay: 50.4 days with AF vs 39.8 days without AF Jorgensen, et al. Stroke 1996;27:1765-9.

Compared to other types of strokes,strokes caused by AF

Obstacles to optimal AF care

• Anticoagulation (AC) decreases the risk of stroke of these patients.• However, risk of bleeding is often over-

emphasized and risk of stroke under-emphasized.• Warfarin has several drug and lifestyles

interaction and requires close follow-up.• Novel oral anticoagulants are convenient but

may not be easily available (cost).Humphries et al. Can J Cardiol 2004;20:869-76Tsai et al. Am J Manage Care 2013;19(9):e325-32.Thromb Haemost 2015 Dec 6;115(1):31-9. Epub 2015 Aug 6.

Obstacles to optimal AF care

• Patients with AF remain sub-optimally anticoagulated

(25% in Canada in 2004 (warfarin)).• Furthermore, their persistence on AC is poor (1-year persistence: 60%-80%).• AF care is often fragmented, requiring several

health care professionals.

Humphries et al. Can J Cardiol 2004;20:869-76Tsai et al. Am J Manage Care 2013;19(9):e325-32.Thromb Haemost 2015 Dec 6;115(1):31-9. Epub 2015 Aug 6.

Integrated Multi-Faceted Trans-Disciplinary Knowledge

Transfer

We hypothesize that multi-faceted & trans-disciplinary knowledge transfer (KT) interventions may improve• Adherence to AF guidelines and • Improve patient’s persistence to

anticoagulation.

13 Hospitals1. Implement standardized Canadian

Cardiovascular algorithms for care of patients with AF.

2. Patient empowering with AF information and 1-year follow-up with coordination of care by the liaison nurse (supervised by AF experts).

3. Develop a knowledge transfer network between academic and community institutions.

FA-CILITERMulti-Facet Knowledge Dissemination

Between AF centers and referring hospitals

• Health Outcome Research evaluating the impact of FA-CILITER Program.

• At participating institutions, all patients with AF were offered the program of care FA-CILITER.

• All FA-CILITER patients were invited to share their medical information for INTEGRATE-AF

(ethics and informed consent required).

• Participation in INTEGRATE-AF was optional.

• Patients can be followed by FA-CILITER team without participating in the INTEGRATE-AF.

Primary Objective • Adherence to the most current Canadian

Guidelines for care of patients with Atrial Fibrillation.

Secondary Objectives• Decrease CV hospitalizations• Decrease CV emergency room visits• Improve patient’s quality of life

Interim Results

Patients characteristics

N1 250 patients

Age68±30

Female sex42%

Mean CHADS21.6 (annual stroke risk: 4%)

One-year data on the first 1,250 enrolled patients (target 3,600 patients)

Results

• Prior to first FA-CILITER evaluation: 79% of patients were anticoagulated.

• After the first FA-CILITER evaluation: 92% of patients were anticoagulated.

Results

• 1-year persistence to anticoagulation was 90% in patients eligible for anticoagulation.

• Thromb Haemost 2015 Dec 6;115(1):31-9. Epub 2015 Aug 6. • 1-year-persistence to Warfarin: 64%.• 1-year persistence to new oral anticoagulants:

79%

Major adverse cardiovascular events During the year

precedingFA-CILITER (%)

During the FA-CILITER Year (%)

CV hospitalizations 17.0 5.4

CV ER visits17.8 7.3

Published annual rates in patients with similar CHADS and HAS-BLED

scores

During the FA-CILITER Year (%)

Major bleeds requiring ER visits/hospits

2.8-3.6 2.7

Strokes 2-4 0.4

↓ 68%

↓ 59%

13 Quebechospitals

15 Quebec primary care centers

Health Outcome Research evaluating

the impact of FA-CILITER Program

Program of KT at 15 primary care centers in Quebec• Review of charts of patients with AF.• Presentation of the local results for each center

and comparison with other sites.• Dissemination of the Canadian Cardiovascular

AF guidelines.• Network between primary care centers and FA-

CILITER hospitals.

Results I-FACILITER

Tous les sites I-FACILITER

Laval Montréal Chicoutimi Beauce0

10

20

5.8

0

6.3

13.5

3.3

6.1

1.2

8.4

11.5

5.1

Marked variation of anticoagulation rate in Quebec

% of eligible patients

Conclusions

Multi-faceted KT interventions are associated with • Improved patients persistence to treatment and

outcomes AND• Reduced resource utilization• Less CV ER visits• Less CV hospitalizations

Conclusions

• Considering the demonstrated benefits of these KT interventions,

• Policy-makers should consider implementing multi-faceted, transdisciplinary KT and dedicated AF care to improve patient’s outcomes and resources utilization.

• Integrated KT interventions may also be beneficial in other models of care.

Acknowledgement

We thank

• The participating institutions• Our collaborators, physicians and nurses• Participating patients• Boehringer Ingelheim Canada Ltd. for their

unrestricted support.