EDITORIAL: Modern Atrial Fibrillation Care: Becoming a Pro at Using Pros
Being a pro in the future of cardiac electrophysiology may increasingly involve expertise in understanding and addressing patient reported outcomes (PROs). The field of cardiac electrophysiology has made stunning progress over the last few decades with technological innovation in procedures and devices to identify, manage, and treat arhythmic disorders. The introduction and clinical utilization of PROs extends a health outcome assessment process that may begin to resemble a “dashboard” with a variety of indicators of treatment process and outcomes. The time for routine measurement and integration of PROs in atrial fibrillation (AF) has arrived. However, it is challenging to go beyond measuring PROs alone and toward delivering pathways of care to systematically address patient outcomes and behaviors.
In this issue of JCE , Zenger and colleagues1report on the implementation of the Toronto AF symptom severity scale in all outpatients at the University of Utah spanning 1,338 patients. The authors reported on rates of AF symptoms and compared this symptom report with AF burden and healthcare utilization over the subsequent six months of care. Their results in multivariate models show that AF symptoms were reported at higher rates by patients who were female, of younger age (<65 age), had a history of pulmonary disease, and reported depression. Similarly, younger patients, women and those with pulmonary disease or heart failure reported increased healthcare utilization. Increased symptom scores were also associated with more aggressive rhythm control strategies such as AF ablation, anti-arrhythmic drug (AAD) therapy, and cardioversion. While these results are not surprising, they represent innovation because seeking and valuing patient reports completes the circle of stakeholders. Quantitative patient reports can be more readily addressed if they are sampled! PROs have been employed in cardiology, but their utility has mostly been relegated to clinical research trials and not acted upon in clinical settings.
PROs provide a new perspective to the clinical encounter that may not be consistent with the time-honored metrics, such as device confirmed atrial burden. Measuring AF symptoms is a reasonable variable as a lead-off to initiate PROs, but they represent only a subset of the potential value that PROs could bring. For example, in ORBIT-AF, 61.8% of AF patients reported symptomatic experience, while 39.2% were not aware of any symptoms from AF. Moreover, 16.5% of the symptomatic patients reported that the symptoms were disabling.2This suggests that AF symptom experience is highly individualistic, ranging from asymptomatic with no impact on quality of life to highly symptomatic and disabling. The patient perception of AF symptoms spans processes beyond the physiological and extend to the psychological and behavioral realm. Nonetheless, AF symptoms are an important place to start because AF symptoms drive health care utilization. In short, patients who are symptomatic are both motivated to seek care and to undergo procedures for symptom relief. Attending providers are motivated to intervene to reduce symptoms and suffering. Both seek to implicitly or explicitly improve another important PRO, quality of life (QOL), and prevent harm such as stroke. Indeed, symptom burden has been identified as the driver of QOL decrements,3 yet recent evidence exists that physician and patient correspondence on recognition of AF symptoms may be poor.4 Guideline directed medical therapy can address the medical treatment aspects but may not fully acknowledge or address the patient perspectives on AF.