‘Easy as ABC’: Telemedicine Improves AF Care in Rural China

LONDON — An integrated care model that uses telemedicine to educate and link doctors working in a rural area of China with atrial fibrillation (AF) specialists in urban hospitals has resulted in greater adherence to guideline-recommended care and significantly improved overall patient outcomes. 
“Village doctors played a leading role in the MIRACLE-AF model, serving as the interface between patients and AF specialists,” Minglong Chen, MD, chief physician at the First Affiliated Hospital of Nanjing Medical University in Nanjing, China, said here at the European Society of Cardiology (ESC) Congress on September 1.
MIRACLE-AF was an open-label, randomized controlled cluster trial, which included 30 village clinics in the Jiangsu province of China. Half of the clinics were randomly allocated to use the intervention and the other half to carry on usual care with intensified education given to patients and their village doctors. 
Through an online platform called The Village Doctor Network, physicians in the intervention group had access to various educational resources and training, a patient databank, facilities to interact and remotely consult with hospital specialists, and were given auditing tools, feedback, and underwent performance evaluations. Patients and their families in the intervention group also received education and information about AF symptoms, medication adherence, and risk factors.
AF Outcomes Improved
The intervention group included 524 patients and 15 village doctors, while the usual care group had 515 patients and 16 village doctors. For inclusion, patients had to be aged 65 years or older; be diagnosed with AF via an ECG, AF specialist, or hospital charge letter; be willing to receive care from the village doctors; and be able to provide written informed consent. Chen told Medscape Medical News that ECGs are part of the standard annual health exam that is available to every citizen in China. 
Results of the MIRACLE-AF study showed that 33.1% of the patients in the intervention group vs 8.7% of those in the usual care group met the criteria of the atrial fibrillation better care (ABC) pathway at 1 year. 
This result was largely driven by 85.2% of patients in the intervention arm vs 20.8% of patients in the control arm meeting criterion “A” of this pathway, which stands for “avoid strokes,” by receiving appropriate oral anticoagulation.
Similar proportions of patients met criterion “B”, which signifies “better symptom management through rate or rhythm control” (91.6% and 94.6%, respectively), and criterion “C”, which signifies “appropriate comorbidity and cardiovascular risk factor management” (43.1% vs. 42.2%, respectively).
The primary outcome of the trial was a composite of cardiovascular death, all stroke types, hospitalization due to worsening of heart failure or acute coronary syndrome (ACS), and emergency hospital visits for AF. The trial found that the patients in the intervention group were 36% less likely to meet this primary outcome at 3 years compared with the control group.
Looking at the components of this endpoint individually, the patients in the intervention group experienced 50% fewer cardiovascular deaths (P = .004), 36% fewer strokes (P = .049), and 31% less needed hospitalization for heart failure or ACS (P = .025). There was a trend towards fewer emergency hospital visits for AF and no increase in the risk for major bleeding. 
Novel Integrated Approach
Village doctors are often the first or only contact for older people living in remote or rural areas who are unable to get to specialist centers. This unique population of patients has low levels of education and little or no access to technology such as smart phones and may not have family nearby to help them.
Chen explained that village doctors in China are generally unskilled when it comes to treating chronic conditions such as AF. However, “through the use of telemedicine, their ability to manage AF was significantly enhanced, highlighting telemedicine’s substantial potential to strengthen rural healthcare services.” 
He told Medscape Medical News that the rationale for the MIRACLE-AF study was really about improving access to quality healthcare for everyone.
“It touches upon the theme of our age — healthcare equity and global health. It is not only in China that we have very big, very old populations [living] in the rural areas. Other low- and middle-income countries also have the rural areas, the mountainous areas, and remote areas,” he said.
“This is not only for a patient with AF, but I think for other chronic diseases and other medical needs where there should be equalization of the healthcare quality. I think this is a very good care model to manage those patients in the special setting where the medical resources are poor or scarce,” Chen added.
‘Easy as ABC’ to Improve AF Care
Professor Gregory Lip, MD, the Price-Evans Chair of cardiovascular medicine at the University of Liverpool, Liverpool, United Kingdom, was a co-investigator for the MIRACLE-AF trial. He told Medscape Medical News that the trial shows that improving AF care really can be as “easy as ABC.”
MIRACLE-AF was an “important trial showing how holistic or integrated care management of AF, delivered as the “atrial fibrillation better care” or ABC pathway, even in rural settings improves outcomes in AF patients,” added Lip. He proposed the ABC pathway in 2017 to help improve awareness and detection of AF and essentially remind clinicians of how best to manage people with the condition. It was subsequently incorporated into multiple guidelines and has become part of everyday clinical practice. 
Lip was also one of the main investigators for the mAFA-II randomized clinical trial that tested the use of a mobile phone-based strategy for improving AF outcomes in China. That was a technologically savvy population of patients, he said, but what MIRACLE-AF has done is deliver the ABC pathway face-to-face by “upskilled, empowered village doctors and patients.”
Isabelle Van Gelder, MD, PhD, of the University Medical Center Groningen, Groningen, The Netherlands, was the invited discussant for the trial and said that MIRACLE-AF “really contributes to the evidence of empowering patients [and delivering] education, not only to patients but also to healthcare professionals.”
She agreed it was an important study with far reaching implications for AF care. “We do most of our studies here in Europe, or the United States, or Canada, but there are so many places where the access to healthcare is so very, very limited,” she said. 
The findings support an updated recommendation in the 2024 ESC guidelines for the management of atrial fibrillation, Van Gelder added, which is that all patients with AF, regardless of gender, ethnicity, and socioeconomic status, should have access to patient-centered care according to AF-CARE which includes the principles of the ABC pathway “to ensure equality in healthcare and improve outcomes.”
MIRACLE-AF was funded by the Chinese government via The Key Clinical Study Project of Jiangsu Province and The Clinical Medicine Expert Team Project of Xuzhou. Chen and Van Gelder reported no financial conflicts of interest. Lip is a consultant and speaker for several pharmaceutical companies but receives no personal fees. 
Sara Freeman is a medical journalist and writer based in London, United Kingdom. She is a regular contributor to Medscape Medical News and other specialist healthcare media outlets. 
 
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