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“Novel Clinical Concepts in Thrombosis”: Integrated Care for Stroke Management—Easy as ABC
Stroke care often involves a multidisciplinary effort, including the stroke physician, internist, neurologist, interventionist, cardiologist, radiologist, vascular surgeon, neurosurgeon, emergency room physician, primary care physician, general practitioner, and rehabilitation team (including physiatrist and therapists), as well as nurses, patient carers, and next of kin ([Fig. 1]). Ultimately, the patient is central to all this, receiving information from different health care professionals. The patient “journey” requires a simple and uniform approach to the priorities of poststroke management, which can be uniformly and consistently described by different health care professionals, allowing patient (and carer) engagement and empowerment with regards to their care.
Such an “integrated care” approach has been applied in other chronic conditions. For example, the ABC (Atrial fibrillation Better Care) pathway has been proposed as an integrated approach to improve the management of patients with atrial fibrillation (AF). This has three central pillars: “A”—avoid stroke (with anticoagulants); “B”—better symptom management, with patient-centered decisions on rate or rhythm control; “C”—cardiovascular and comorbidity risk optimization. This concept was first proposed to promote a streamlined approach to management that can be applicable to whether the AF patient is managed by any health care professional, the general practitioner, or the hospital-based specialist (whether cardiologist or noncardiologist).
This integrated care approach to AF management is promoted in patient pathways to improve diagnosis and management of AF patients, and would facilitate discussion and patient engagement on the principles of AF care (“easy as ABC…”) and importantly, minimizes the possibility of conflicting information from health care professionals. Such conflicting information when dealing with patients has been associated with poorer patient adherence with their management plan.
The ABC pathway has been well validated in posthoc analyses of clinical trials, prospective cohort studies, and a prospective randomized trial. In a recent systematic review, AF patients treated according to the ABC pathway showed a lower risk of all-cause death (odds ratio [OR]: 0.42, 95% confidence interval [CI]: 0.31–0.56), cardiovascular death (OR: 0.37, 95% CI: 0.23–0.58), stroke (OR: 0.55, 95% CI: 0.37–0.82), and major bleeding (OR: 0.69, 95% CI: 0.51–0.94). Improved clinical outcomes with ABC pathway compliance are evident, even in clinically complex patients such as those with multimorbidity, polypharmacy, and hospitalizations.
The mAFA-II trial was a prospective cluster-randomized trial of patients randomized to receive usual care, or integrated care based on the ABC pathway. Rates of the composite outcome of “ischemic stroke/systemic thromboembolism, death, and rehospitalization” were lower with the mAFA intervention compared with usual care (1.9 vs. 6.0%; hazard ratio [HR]: 0.39; 95% CI: 0.22–0.67; p < 0.001). Rates of rehospitalization were also lower with the mAFA intervention. In the mAFA-II trial long-term extension cohort, these beneficial effects were maintained, and there was a high adherence (>70%) and persistence (>90%) with the mAFA app-based intervention based on the ABC pathway. The mAFA-II trial also reported that this holistic app-based management with dynamic risk monitoring and reassessment of the bleeding risks (using HAS-BLED score) reduced the risks of major bleeding (mAFA vs. usual care, 2.1 vs. 4.3% at 1 year) and increased total oral anticoagulation (OAC) usage from 63 to 70%.
* The review process for this paper was fully handled by Christian Weber, Editor-in-Chief.
Received: 26 August 2021
Accepted: 27 August 2021
02 September 2021 (online)
© 2021. Thieme. All rights reserved.
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