Multidisciplinary Integrated Care in Atrial Fibrillation (MICAF): A Systematic Review and Meta-Analysis

  • Clinical Medicine & Research
  • December 2022,
  • 20
  • (4)
  • 219-
  • 230;
  • DOI: https://doi.org/10.3121/cmr.2022.1702
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Abstract

Objective: To assess the effectiveness of multidisciplinary integrated care in the clinical outcomes of atrial fibrillation patients.

Methods: Medline, EMBASE, and the CENTRAL trials registry of the Cochrane Collaboration were searched for articles on multidisciplinary integrated care in atrial fibrillation patients. The systematic review and meta-analysis included six and five articles, respectively, that compared the outcomes between the integrated care group and control group.

Results: Multidisciplinary integrated care was concomitant with a decrease in all-cause mortality (OR 0.52, 95%CI 0.36-0.74, P=0.0003) and cardiovascular hospitalization (OR 0.66, 95%CI 0.49-0.89, P=0.007). Multidisciplinary integrated care had no significant impact on major adverse cardiovascular event (MACE) (OR 0.76, 95%CI 0.37-1.53, P=0.44), cardiovascular deaths (OR 0.49, 95% CI 0.21-1.17, P=0.11), atrial fibrillation (AF)-related hospitalization (OR 0.76, 95%CI 0.53-1.09, P=0.14), major bleeding (OR 1.02, 95%CI 0.59-1.75, P=0.94), minor bleeding (OR 1.12, 95%CI 0.55-2.26, P=0.76), and cerebrovascular events (OR 0.72, 95%CI 0.45-1.18, P=0.19).

Conclusion: In comparison to usual care, a multidisciplinary integrated care approach (i.e., nurse-led care along with usual specialist care) in AF patients is associated with reduced all-cause mortality and cardiovascular hospitalization.

Keywords:

Atrial fibrillation (AF) is the most common sustained arrhythmia, but premature ventricular complexes are much more common.1,2 The prevalence of AF in the United States is estimated to increase from ~5.2 million in 2010 to 12.1 million in 2030.3 It poses a significant economic burden on healthcare systems, accounting for a large number of hospital admissions. According to an estimate, hospitalizations due to AF increased by 23% from the year 2000 to 2010.4 The patients are at higher risk of developing congestive heart failure (CHF), stroke, and systemic thromboembolism.5

Wagner and colleagues6 introduced a chronic care model establishing that chronic disease management requires a different approach in contrast to standard medical care. Multidisciplinary care represents the comprehensive case management strategy with a greater number of medical and social support personnel. Multidisciplinary care involves a multidisciplinary team that includes the primary care provider, other physicians, nurses, dietitians, pharmacists, and social workers that provide long-term care to patients with chronic disease.7 These programs also integrate a coaching plan, in which the health physician promotes patient empowerment for attaining treatment adherence and behavior modification.8 For the coordination of integrated care programs, a clinical nurse specialist can play an important role.5

In patients with heart failure and coronary heart disease, significant improvement has been observed due to the multidisciplinary approach.9,10 The management of AF is often difficult due to a lack of adherence to recommendations.11 Such multidisciplinary plans are essential for the provision of guideline-based AF management with the collaboration of different physicians.5 An AF program should include diagnostic tests, heart rate, and rhythm control, anticoagulation, management of associated disorders, patient education, and counseling for self-management.12

The integrated healthcare methodology has a background in the chronic healthcare model with the understanding that chronic disease management requires an unusual approach, in contrast to standard usual models of healthcare delivery. This prototypical set-up gives the patient the principal emphasis, with various significant essentials/components, including a multidisciplinary team and supports from the community, to warrant that the patient population is dynamically engaged regarding their treatment. Augmenting patient-related consequences incorporating this delivery strategy is reached through redesigning usual clinical practice to confirm healthcare is provided tailor-made to the patient’s requirements and founded on existing data.6

There are five cornerstones of an effective multidisciplinary AF program. These are “comprehensive assessment, systematization of medical care, patient education, coordination of care and evaluation of care plan execution.”5 A detailed assessment of the patient is essential for making a suitable management plan.13 Systemization involves the coordination of diagnostic work-up, treatment plan, and follow-up.5 The systemization of medical care will improve the excellence of care delivery, patient contentment, and the use of means.14 Patient education leads to dynamic patient involvement and adherence to treatment. An AF program must be effectively coordinated for the implementation of the management plan. The last and the most critical aspect is the evaluation of care plan execution.5

There is a need for integrated systems of healthcare delivery for various chronic cardiovascular afflictions, like heart failure and acute coronary syndrome; there are hardly any for the AF population. This systematic review and meta-analysis was planned to assess the effectiveness of multidisciplinary integrated care in the clinical outcomes of AF patients including all-cause mortality, major adverse cardiovascular event (MACE), cardiovascular deaths, cardiovascular and AF-related hospitalizations, cerebrovascular episodes, and major and minor bleeding.

Objective

Atrial fibrillation is linked with substantial morbidity and mortality. Cardiovascular illnesses in chronic settings have shown improved patient-specific outcomes from integrated structures of healthcare, although the practice of this very methodology in AF patients is a relatively new idea. Current data have recommended that the integrated healthcare methodology may be of advantage in the AF population, while still not broadly realized in routine medical management. This systematic review and meta-analysis aimed to assess the effect of multidisciplinary integrated care systems of healthcare provision in the AF patient population on outcomes including all-cause mortality, MACE, cardiovascular deaths, cardiovascular and AF-related hospitalizations, cerebrovascular episodes, and major and minor bleeding.

Materials and Methods

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were adhered to for this systematic review and meta-analysis (Appendix A, available online). The study is registered with the PROSPERO International Prospective Register of Systematic Reviews (PROSPERO registration number CRD42018110613).

Study Design

Systematic review and meta-analysis.

Eligibility Criteria

Studies included were randomized controlled trials (RCTs), including cluster RCTs. We excluded controlled (non-randomized) clinical trials (CCTs) or cluster trials, cross-sectional studies, case series, case reports, interrupted time series (ITS) studies, prospective and retrospective comparative cohort studies, and case-control or nested case-control studies.

Participants

Studies including the general adult human population (18 years or older) of either gender diagnosed with and treated for AF, defined as “recurrent paroxysmal, persistent, or permanent atrial fibrillation”.

Interventions

Multidisciplinary integrated healthcare intervention, emphasis on all-inclusive and far-reaching AF treatment and management with at least a 6-month follow-up period. Intervention is defined as “a coordinated patient-centered approach by interdisciplinary specialists to improve AF outcomes.”15 “Integrated care facilitates treatment of AF patient’s population in all five spheres of management: acute stabilization, detection and management of primary cardiovascular co-morbidities and risk dynamics, apposite oral anticoagulation for stroke prevention, and treatment with rate and/or rhythm control therapy.”11,16

Comparators

The patients in the comparator group were treated according to the usual standards of clinical care, regular medical care, outpatient management, and pharmacotherapy. The management was ‘not integrated’ or ‘multidisciplinary.’

Outcomes

The major outcomes/endpoints for meta-analysis were: All-cause mortality, MACE, Cardiovascular mortality, Cardiovascular hospitalization, AF-related hospitalization, Major Bleeding, Minor Bleeding, Cerebrovascular accidents (stroke).

Timing

Studies inclusion was based on the follow-up of outcomes. For all-endpoint outcomes, RCTs had a follow-up time of at least 6 months, with further analysis at follow-up of 1 year.

Setting

Any kind of setting with no restrictions.

Language

Included RCTs reported in the English language only.

Information Sources

Medical Literature search strategies were devised using medical subject headings (MeSH) and text words linked to atrial fibrillation. The articles were searched on MEDLINE (PubMed and OVID interface, 1948 onwards till 2017), EMBASE (OVID interface, 1974 onwards till 2017) (Appendix B, available online), and the Cochrane Central Register of Controlled Trials (Wiley interface). The scientific literature search was limited to the English language and human subjects.

Search Strategy

Medline, EMBASE, and the CENTRAL trials registry of the Cochrane Collaboration were searched for keywords, including ‘atrial fibrillation’, ‘integrated healthcare’, ‘multidisciplinary’, ‘outpatient’, ‘interdisciplinary’, ‘treatment outcome’, ‘treatment adherence, ‘death’, ‘mortality’, ‘fatal’, ‘hospitalization’, ‘hospital admissions’, ‘quality of life’ and ‘symptom burden’ (Appendix C, available online).

Data Management, Selection Process, and Data Collection

Investigators individually evaluated all pertinent articles to categorize studies meeting the criteria for inclusion. Any inconsistencies were deliberated and a consensus verdict was obtained. The search results from each database were saved in EndNote X9 and duplicates were removed.

Data Items

Data were extracted into a standard recording form (Microsoft EXCEL datasheet) that was initially tried to confirm clarity and uniformity between authors. This empowered the authors to evaluate the quality of studies and integrate the findings. Data identified and tabulated from appropriate articles included: author, data collection year, publication year, participants, gender, mean age, follow-up duration, and outcomes studied.

Outcomes and Prioritizations

Outcomes extracted from the selected studies included all-cause mortality, cardiovascular mortality, MACE, cerebrovascular accidents, and major and minor bleeding.

Data Synthesis

A quantitative synthesis of data and meta-analysis was conducted for selected studies with similar study designs and sufficient available outcome parameters to perform a statistical analysis using the STATA/SE 15.0 statistical program (StataCorp, Texas, USA). Assuming a variation of the true effect sizes in the selected studies - due to different study populations and different integrated care models (as obvious in many integrated care models), we chose to perform a random-effect meta-analysis model to gain the pooled estimates of effects. For the summary statistics, we used exclusively dichotomous data, and the results were expressed by using odds ratio (OR) with a 95% confidence interval (CI). A two-tailed value of P<0.05 was considered statistically significant. The presence of publication bias was visually assessed using funnel plots. Non-quantitative data was presented descriptively. To test statistical heterogeneity between the studies, the chi-square (χ2) test and the I2 statistic were applied. Figure 1 shows the PRISMA flow diagram.

Figure 1.
Figure 1.

Risk of Bias of Individual Studies

Cochrane Collaboration tool (The RoB 2.0 tool http://www.riskofbias.info/) was used to assess the risk of bias for every RCT, which screens the randomization process, deviation from intended intervention, missing outcome data, and selective result reporting (Table 1).

View this table:
Table 1.

Risk of bias of studies included in the meta-analysis

Results

The search generated an aggregate of 506 articles that were evaluated by title and abstract. We excluded 484 articles because they did not fulfill the inclusion criteria. We examined nine articles for full-text assessment, and five articles were included in the meta-analysis. Primary and secondary outcomes, as shown in Table 2, were tabulated for easy reference, and the selection for qualitative and quantitative analysis was marked as per the formal inclusion/exclusion criteria.

View this table:
Table 2.

Characteristics of studies included in the systematic review and meta-analysis (continued on page 223)

Key characteristics of the various studies screened, shortlisted, and selected are tabulated in Table 3. Parameters obtained from the studies included for meta-analysis were all-cause mortality, MACE, cardiovascular mortality, cardiovascular hospitalizations, AF-related hospitalizations, cerebrovascular events (stroke), and major and minor bleeding episodes.

View this table:
Table 3.

Parameters of included studies

All-Cause Mortality

The forest plot showed integrated care model played a significant role to decrease the risk of all-cause mortality (P=0.0003). Studies conducted by Hendriks et al,12 Carter et al,16 Stewart et al,17and Fuenzalida et al,19 and showed statistically significant results. The heterogeneity test results I2=0% showed the studies are not statistically heterogeneous (Figure 2). The funnel plot showed the studies are evenly distributed and indicates there is no publication bias in the study (Figure 3).

Figure 2.
Figure 2.
Figure 3.
Figure 3.

Major Adverse Cardiovascular Event (MACE)

The results showed a reduction of MACE in favor of the integrated care approach. But as the P value is greater than 0.05 (P=0.44), the results are statistically insignificant.

AF-Related Hospitalization

The forest plot indicated integrated care had an insignificant effect on the AF-related hospitalization (P=0.14). Moreover, I2=62% represents substantial heterogeneity (Figure 10). The funnel plot showed the studies are evenly distributed, and there is no publication bias (Figure 11).

Figure 4.
Figure 4.
Figure 5.
Figure 5.
Figure 6.
Figure 6.
Figure 7.
Figure 7.
Figure 8.
Figure 8.
Figure 9.
Figure 9.
Figure 10.
Figure 10.
Figure 11.
Figure 11.

Major Bleeding

Integrated care had no effect on major bleeding. The studies conducted by Carter et al,16 Vinereanu et al,18 Fuenzalida et al,19 and Hendriks et al21 did not favor the results. The overall effect was statistically insignificant (P=0.94). The heterogeneity test results I2=0% showed the studies are not statistically heterogeneous (Figure 12). Funnel plot of the study reporting major bleeding is shown in Figure 13.

Figure 12.
Figure 12.
Figure 13.
Figure 13.

Minor Bleeding

Integrated care was ineffective in reducing minor bleeding (P=0.76). Studies conducted by Carter et al16 and Fuenzalida et al19 did not favor the results (Figure 14). The graphical display of the funnel plot showed that there is no publication bias and the studies are evenly distributed (Figure 15).

Figure 14.
Figure 14.
Figure 15.
Figure 15.

Cerebrovascular Events (Stroke)

There was no significant evidence of the reduction of stroke in integrated care group. Results of the studies conducted by Carter et al,16 Vinereanu et al,18 and Hendriks et al21 favored the outcome, but the overall effect was statistically insignificant (P=0.19). The heterogeneity test (I2=0%) showed the studies are not statistically heterogeneous (Figure 16). The studies are evenly distributed, and there is no publication bias (Figure 17).

Figure 16.
Figure 16.
Figure 17.
Figure 17.

Discussion

Integration and collaboration between outpatient and inpatient departments and physicians play a vital role in the provision of excellent patient care.24 The multidisciplinary approach has become increasingly important in the last few decades as a result of advancements in diagnostic and therapeutic techniques.25 The purpose of integrated care is to strengthen the coordination in healthcare organizations, enhance the patients’ experience, and clinical outcomes, and upgrade the efficiency of health systems.26

The results of our systematic review and meta-analysis reported improved outcomes in integrated care patients. Our results showed that integrated care was associated with a decrease in the risk of all-cause mortality. Similar results were reported in studies by Hendriks et al,12 Carter et al,16 Stewart et al,17and Fuenzalida et al19 In a randomized controlled trial conducted in the Netherlands, 712 patients with atrial fibrillation were randomly allocated to usual care and nurse-led care group. Each group had 356 patients. All-cause mortality occurred in 4 (1.1%) patients receiving integrated care in contrast to 14 (3.9%) patients receiving usual care.12 A multicenter randomized controlled trial was conducted in Australia in which 335 patients were enrolled. There were 168 patients in the SAFETY intervention group, and 167 in the standard management group. In the SAFETY group, 19 (11%) patients died and 30 (18%) in the standard group.17 A before-and-after study done in Nova Scotia included 413 patients with AF. They included 185 patients in the AF clinic group, and 228 patients were enrolled in usual care group. Death was reported in four (1.8%) patients in usual care group; whereas no patient died in the AF clinic group.16 In a randomized controlled study by Fuenzalida et al,19 240 atrial fibrillation patients were recruited. Included in the intervention group were 116 patients, and 124 were enrolled in the control group. Death occurred in 18 (10.43%) and 26 (20.96%) patients in the intervention and control groups, respectively. A cluster-randomized controlled trial was conducted by Vinereanu et al18 in which 48 clusters were enrolled from five countries. The intervention and control groups included 1184 and 1092 patients, respectively. Death occurred in 5% of the patients in both the intervention and control groups.

The effect of integrated care on MACE was insignificant. The studies conducted by Carter et al,16 Stewart et al,17 and Fuenzalida et al19 also showed insignificant results. Stewart et al17 reported that the median event-free survival was greater in the SAFETY group as compared to the standard group. The length of hospital stay in each admission was less in the SAFETY participants (2.8 days) in contrast to standard management patients (3.6 days).17 In another study, a total of 116 patients had emergency (ED) visits with 51 (43.96%) patients in the intervention group, and 65 (51.61%) patients in the control group. The most common complication was heart failure occurring in 19 (16.37%), and 33 (26.61%) patients in the intervention and control groups, respectively. The difference in other complications between the two groups was not significant.19

The integrated care also resulted in an insignificant reduction in cardiovascular mortality. Two studies by Hendriks et al12 and Fuenzalida et al19 reported an insignificant effect on this outcome. In a randomized controlled study by Fuenzalida et al,19 240 AF patients with age ≥18 years were recruited. Included in the intervention group were 116 patients, and 124 were enrolled in the control group. The follow-up period was 1 year. Death occurred in 18 (10.43%) and 26 (20.96%) patients in the intervention and control groups, respectively. A total of 116 patients had emergency department visits, with 51 (43.96%) patients in the intervention group and 65 (51.61%) patients in the control group. There were 74 patients who had hospital admissions, with 31 (26.72%) in the intervention group and 43 (34.67%) in the control group. The most common complication was heart failure, occurring in 19 (16.37%) and 33 (26.61%) patients in the intervention and control groups, respectively. The difference in other complications between the two groups was not significant.19

The integrated care approach led to a significant reduction in cardiovascular hospitalization. Hendriks et al,12 Carter et al,16 and Fuenzalida et al19 favor the results. In a randomized controlled trial conducted in the Netherlands, 712 patients with AF were randomly allocated to usual care and nurse-led care group. Each group had 356 patients. The follow-up period was a minimum of 1 year. The patients with AF of age ≥18 years were eligible. Cardiovascular hospitalizations occurred in 48 (13.5%) and 68 (19.1%) patients in the nurse-led and usual care groups, respectively. Death occurred in 4 (1.1%) patients receiving integrated care, in contrast to 14 (3.9%) patients receiving usual care.12

In our study, the effect of integrated care on major and minor bleeding was insignificant. Carter et al16 and Fuenzalida et al19 reported no effect on major and minor bleeding in the integrated care group. There was no significant evidence of the reduction of stroke in integrated care group (P=0.19). Hendriks et al,12 Carter et al16 and Vinereanu et al18 reported reduced events of stroke in integrated care. In a study conducted Hendriks et al,12 three patients died from a stroke in usual care group, whereas none of the patients died from a stroke in the nurse-led group. Carter et al16 reported that stroke occurred in four (2.2%) patients in the AF clinic group and eight (3.5%) patients in usual care group. A cluster-randomized, controlled trial was conducted by Vinereanu et al18 in which 48 clusters were enrolled from 5 countries. The follow-up period was 12 months. The patients with AF who were ≥18 years and had an indication of oral anticoagulation were included. The intervention and control groups included 1184 and 1092 patients, respectively. In the intervention group, oral anticoagulant use increased from 804 (68%) patients at baseline to 943 (80%) patients; whereas, in the control group, the oral anticoagulant use increased from 703 (64%) patients to 732 (67%) patients after 1 year. There was a marked decrease in stroke in the intervention group (11%) in contrast to the control group (21%).

Our results indicated that integrated care had an insignificant effect on the AF-related hospitalization (P=0.14). Another study reported that 25 (13.5%) and 54 (23.7%) patients had AF-related emergency department visits in the AF clinic group and usual care group, respectively. A greater percentage of patients were prescribed oral anticoagulants in the AF clinic group (57.7%) as compared to usual care group (39.3%).16 A multicenter randomized controlled trial was conducted in Australia in which 335 patients were enrolled. The minimum follow-up period was 24 months, with 168 patients in the SAFETY intervention group and 167 in the standard management group. There were 264 (79%) participants who had an unplanned admission or death, out of which 127 were in the SAFETY group and 137 were in the standard group. There were 19 (11%) patients who died in the SAFETY group and 30 (18%) in the standard group. The median event-free survival was greater in the SAFETY group as compared to the standard group. The length of hospital stay in each admission was less in the SAFETY participants (2.8 days) in contrast to standard management patients (3.6 days). There was no statistical difference in readmissions for atrial fibrillation (54 [32%] in the SAFETY group versus 57 [34%] in the standard group).17

A before-and-after study done in Nova Scotia included 413 patients with AF with age ≥18 years. They included 185 patients in the AF clinic group, and 228 patients were enrolled in usual care group. The follow-up time was 21.5 months in the AF clinic and 28 months in the usual care group. Death was reported in four (1.8%) patients in usual care group whereas no patient died in the AF clinic group. There were 20 (8.8%) patients who had a hospital admission for a cardiovascular cause in the usual care group and 11 (5.9%) in the AF clinic group. In the AF clinic group, 25 (13.5%) patients and 54 (23.7%) patients in usual care group had AF-related emergency (ED) visits. A greater percentage of patients were prescribed oral anticoagulants in the AF clinic group (57.7%) as compared to the usual care group (39.3%).16

In another randomized study, 31 patients were randomly allocated to the intervention group and 34 patients to the usual care group. The follow-up period was 5 years. The patients in the intervention group had a longer event-free survival of 34 months as compared to 17 months in the control group. The patients in the intervention group had fewer hospital readmissions (1.9%) as compared to 2.5% in the usual care group. Similarly, the associated hospital stay was 16.3% in the intervention group in contrast to 20.3% in the usual care group.20

A meta-analysis was done by Gallagher et al27 to evaluate the role of integrated care in AF patients. The inclusion criteria were randomized and non-randomized studies on integrated care in AF patients with the control group and a minimum follow-up of 6 months. Three studies conducted by Hendriks et al,12 Carter et al,16 and Stewart et al17 were included. The outcomes assessed were all-cause mortality, cardiovascular and AF-related hospitalizations, and cerebrovascular events. The results of the meta-analysis showed that there was a 49% and 42% decrease in all-cause mortality and cardiovascular hospitalizations, respectively, with integrated care. However, integrated care did not affect AF-related hospitalizations and cerebrovascular episodes. Further analysis revealed that 19 patients need to be treated by the integrated approach to prevent one death. With aspect to hospitalizations, the treatment of 18 patients will decrease one hospital admission.27 In the ATHERO-AF cohort study, Pastori et al28 evaluated the risk reduction in cardiovascular events by implementing the Atrial fibrillation Better Care (ABC) pathway. The ABC pathway is an integrated care management program and includes the prevention of stroke with anticoagulation, better management of symptoms, and cardiovascular risk management. The study recruited 907consecutive patients with AF using vitamin K antagonists. The follow-up duration was 36.9 months. The patients managed using the ABC pathway had a lower risk of cardiovascular events. Pastori et al29 also estimated the effect of the ABC pathway on healthcare costs showing significantly lower health-related costs. A post-hoc analysis of the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) trial was done between the ABC and a non-ABC group of patients. The analysis showed that the patients managed with the ABC pathway had a lower risk of all-cause mortality, cardiovascular mortality, major bleeding, stroke, and first hospitalization.30 Yoon et al31 included 204,842 non-valvular AF patients in Korea with a follow-up duration of 6.2±3.5 years. The patients were allocated into the ABC and non-ABC groups. The results reported lower rates of all-cause mortality, cardiovascular mortality, stroke, major bleeding, myocardial infarction, and major bleeding in the ABC group in contrast to the non-ABC group. The IMPACT-AF study was a randomized cluster trial conducted in Canada to assess the improvement in care and outcomes in AF patients using the electronic Clinical Decision Support System (CDSS). It showed the integrated management program run by CDSS can be more cost-efficient as compared to usual AF care.32

Strengths and Limitations

The outcomes of the meta-analysis reiterate the importance of integrated care as an exceedingly effective system of patient management. Analyzing results in RCTs and comparing the control group to usual care provides significant evidence of the efficacy of the integrated care approach. In comparison to usual care, a multidisciplinary integrated care approach (i.e., nurse-led care along with usual specialist care) in AF patients is associated with reduced cardiovascular hospitalization and all-cause mortality.

This study does have limitations:

  1. It is not clear which component of integrated care is responsible to make the difference.

  2. Atrial fibrillation patients have co-morbidities and its uncertain as well as difficult to establish one system of integrated care.

This emphasizes the significance of the multidisciplinary integrated care approach by having AF patients central to the concept and sustenance systems to assist the provision of optimum practice and primarily recommendations and guideline supported care. There is a need to further define the integrated care approaches and refine them in the best interest of the patient. It should further stress and strongly advocate as a part of guidelines in AF-care.

Conclusion

In comparison to usual care, a multidisciplinary integrated care approach (i.e., nurse-led care along with usual specialist care) in AF patients is associated with reduced all-cause mortality and cardiovascular hospitalization.

Footnotes

  • Study registration: PROSPERO registration number CRD42018110613

  • Disclosure: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have reported no conflicts of interest.

  • Received June 20, 2021.
  • Revision received March 12, 2022.
  • Revision received July 22, 2022.
  • Accepted August 9, 2022.

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Clinical Medicine & Research
Clinical Medicine & Research

Vol. 20, Issue 4

1 Dec 2022

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    Multidisciplinary Integrated Care in Atrial Fibrillation (MICAF): A Systematic Review and Meta-Analysis
    • Clinical Medicine & Research
    • Dec 2022 ,
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    • 219-
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    • DOI: 10.3121/cmr.2022.1702
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Keywords

Atrial fibrillation, Clinical outcomes, Multidisciplinary integrated care