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IMPROVING PATIENT OUTCOMES AND REDUCING HEALTH CARE BURDEN – THE NEED FOR A NEW PARADIGM OF CARE DELIVERY FOR ATRIAL FIBRILLATION Celine Gallagher RN, MSc Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Medicine Faculty of Health and Medical Sciences The University of Adelaide April, 2019 Table of Contents Table of Contents ..................................................................................................................... 1 Abstract .................................................................................................................................... 6 Statement of Original Authorship ............................................................................................ 8 Acknowledgements .................................................................................................................. 9 Publications and communications to learned societies .......................................................... 10 Chapter 1: Literature Review ............................................................................ 20 1.1 Epidemiology of Atrial Fibrillation ............................................................................. 20 1.2 Hospitalisation Trends for Atrial Fibrillation .............................................................. 21 1.2.1 AF hospitalisations in the Asia Pacific region ................................................... 22 1.2.2 Economic costs of AF........................................................................................ 23 1.2.3 Quality of life in AF .......................................................................................... 25 1.3 Modifiable Risk Factors for Incident AF ..................................................................... 26 1.3.1 Background ........................................................................................................ 26 1.3.2 Established risk factors for incident AF ............................................................ 28 1.3.3 Hypertension ...................................................................................................... 29 1.3.4 Obesity ............................................................................................................... 31 1.3.5 Obstructive sleep apnoea ................................................................................... 31 1.3.6 Diabetes ............................................................................................................. 32 1.3.7 Physical activity ................................................................................................. 32 1.3.8 Dyslipidaemia .................................................................................................... 33 1.3.9 Smoking ............................................................................................................. 33 1.3.10 Alcohol .............................................................................................................. 34 1.3.11 Emerging risk factors for AF ............................................................................. 35 1.3.12 Treatment for AF ............................................................................................... 37 1.3.13 Rate and rhythm control .................................................................................... 37 1.3.14 The evolving role of AF ablation ...................................................................... 38 1.3.15 Anticoagulation ................................................................................................. 41 1.3.16 Cardiovascular risk factors in established AF ................................................... 43 1.3.17 Risk factor management in AF .......................................................................... 44 1.4 Hospitalisations in AF– Opportunities to Reduce Health Care Burden ....................... 50 1.4.1 Hospital readmissions in the AF population ...................................................... 50 1.4.2 Factors associated with repeat hospitalisations ................................................. 50 1.4.3 Strategies to reduce AF related hospitalisations ................................................ 53 1.4.4 Management of AF in the Emergency Department ........................................... 55 1.5 Opportunities to Improve Outcomes in the AF Population ......................................... 57 1.5.1 Exercise based interventions in AF ................................................................... 57 1.5.2 Polypharmacy and adverse outcomes ................................................................ 59 1.5.3 Polypharmacy and AF ....................................................................................... 60 1.5.4 Mobile health technology in AF ........................................................................ 60 1.6 Integrated Care for Atrial Fibrillation .......................................................................... 62 1.6.1 Heart failure management: the role of ambulatory care .................................... 63 1 1.6.2 Ischaemic heart disease: the role of secondary prevention clinics and cardiac rehabilitation ...................................................................................................... 65 1.6.3 Integrated care ................................................................................................... 69 1.6.4 Integrated care for chronic condition management ........................................... 71 1.6.5 Integrated care in AF ......................................................................................... 72 1.6.6 Shared decision making in AF ........................................................................... 74 1.6.7 The role of education in AF ............................................................................... 76 1.7 Conclusions .................................................................................................................. 78 Chapter 2: National Trends in Hospitalisations due to Atrial Fibrillation in Australia ........................................................................................................... 79 2.1 Introduction .................................................................................................................. 79 2.1.1 Background ........................................................................................................ 79 2.1.2 AF hospitalisation trends in the USA and Europe ............................................. 79 2.1.3 AF hospitalisations in the Asia Pacific region ................................................... 80 2.1.4 Economic cost of atrial fibrillation .................................................................... 81 2.2 Methods ....................................................................................................................... 81 2.2.1 Hospitalisation Data .......................................................................................... 81 2.2.2 Procedural Data ................................................................................................. 82 2.2.3 Statistical Analysis ............................................................................................ 83 2.3 Results .......................................................................................................................... 84 2.3.1 AF, MI and HF Hospitalisations ........................................................................ 84 2.3.2 Age and gender subgroup analyses ................................................................... 84 2.3.3 Length of stay and total bed days used .............................................................. 85 2.3.4 Hospitalisation costs .......................................................................................... 85 2.3.5 Procedural trends ............................................................................................... 85 2.4 Discussion .................................................................................................................... 86 2.4.1 Reasons underpinning the growth in AF hospitalisations ................................. 87 2.4.2 Opportunities to reduce AF hospitalisations...................................................... 88 2.4.3 AF hospitalisations in Australia compared to other populations ....................... 89 2.4.4 Procedural trends and their impact on AF hospitalisations ............................... 89 2.4.5 Costs of AF hospitalisations .............................................................................. 90 2.5 Limitations ................................................................................................................... 91 2.6 Conclusions .................................................................................................................. 91 Chapter 3: Alcohol and Incident Atrial Fibrillation ....................................... 98 3.1 Introduction .................................................................................................................. 98 3.1.1 Background ........................................................................................................ 98 3.1.2 Alcohol and health outcomes ............................................................................ 98 3.1.3 Alcohol and AF ................................................................................................

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