Synergistic effect of a universal electronic consultation program and oral anticoagulation on outcomes in patients with atrial fibrillation
Authors: Mazon Ramos P , Portela Romero M , Garcia Vega D , Rey-Aldana D , Rodriguez Manero M , Alvarez Alvarez B , Agra Bermejo R , Lage Fernandez R , Cinza Sanjurjo S , Gonzalez Juanatey J R 
Published: October 2022

Abstract

Background
Recently, the temporal association between episodes of AF and the risk of ischaemic stroke has been assessed, emphasising that the risk is higher in patients who encountered episodes of AF a few days before stroke [1]. In recent years, the use of direct oral anticoagulants (OACs) has increased, which has improved the outcomes of healthcare with important reductions in mortality [2,3].
Despite the growing implementation of telematic consultation models and recommendations to regularly evaluate the quality of care to ensure patient safety, there is scanty evidence to support the quality of healthcare in terms of delays, prognostic impact, and patient and professional satisfaction. We recently published the characteristics of our ambulatory care model for referrals between general practitioners (GPs) and our cardiology department (CD), and the impact on the delay time of care, health care accessibility, and clinical outcomes after the implementation of an e-consultation as a first step in our ambulatory care program [2,4].

Purpose
To evaluate the long-term results of our universal e-consultation program in patients with AF, assessing the impact of the temporal trend in OAC and delay of care on clinical outcomes.

Methods
We included 10488 e-consultations referrals from primary care in patients with diagnoses of AF in this study. We have analysed the outcomes in e-consultation period versus in-person consultation period. We used an interrupted time-series regression on outcomes. To investigate the impact of this program and the use of OAC on the prognosis of AF-related stroke and haemorrhage, the annual incidence of each outcome in both periods was calculated, while deriving the incidence relative risk (iRR) with these incidences. Finally, to individualise the effect of e-consultation and OAC in both outcomes, the analysis was completed using a Spearman correlation between e-consultation or OAC and the incidence of stroke and mortality.

Results
Following e-consultation, the use of OAC increased (iRR 1.56 (1.13–1.99); p&lt;0.001), Figure 1; hospital admissions due to stroke were lower (iRR: 0.09 [95% CI: 0.02–0.41]) with similar incidences of haemorrhagic complications (iRR: 0.32 [95% CI: 0.04–2.58]), figure 2. The total mortality was lower (iRR 0.36 (95% CI: 0.33–0,39). The independent impact on the risk of stroke mortality after the increase in the OAC rates and e-consultation implementation showed an odds ratio (OR) of 0.270 and 0.403, respectively.

Conclusion
Thus, a quicker cardiological evaluation of patients with AF and optimised OAC use influence improved clinical outcomes. The healthcare systems need to merge OAC and outpatient ambulatory management that evaluate the patients quickly to reduce the ischaemic strokes.

Funding Acknowledgement
Type of funding sources: None.