key: cord-0869203-tdwug3jv
authors: Zenger, Brian; Jared Bunch, T
title: How simple ideas forged in the fire of adversity can change healthcare: telehealth for atrial fibrillation during the COVID 19 pandemic
date: 2021-07-22
journal: Europace
DOI: 10.1093/europace/euab072
sha: 18208a79883420d2aedb99fd3bd27184a54b1e88
doc_id: 869203
cord_uid: tdwug3jv

nan

This editorial refers to 'The European TeleCheck-AF project on remote app-based management of atrial fibrillation during the COVID-19 pandemic: centre and patient experiences.' by D. Gawalko et al. doi:10 .1093/europace/euab050.

Simple ideas imagined in the furnace of adversity can fundamentally alter our society and day-to-day life. Take for example, the invention of George Crum who in 1853 was working as a chef in the Moon Lake Lodge resort in Saratoga Springs, New York. A menu favourite at this resort was their French-fried potatoes. The potatoes were cut lengthwise, fried, and salted. George became increasing frustrated after a customer sent back the potatoes because they were too thick and soggy. Somewhat irritated and bothered by the complaint, the chef cut ultra-thin slices of the potatoes, fried, and salted them, much to the delight of the customer. These Saratago-chips became an international phenomenon and are now recognized as potato chips. 1 We have been immersed in 2020 in a tremendous state of adversity as the COVID 19 pandemic has had effects far and wide. Hospitals, health systems, and countries refocused their efforts on preventing and managing the mass spread of disease throughout their populations. However, this left patients with chronic diseases at a significant disadvantage. First, people with chronic diseases were considered high risk and were instructed to remain isolated and removed from their routine social and personal obligations. This meant routine doctor's visits for said chronic diseases were reduced to a trickle. Furthermore, many important and necessary tests are performed at follow-up visits that were no longer being routinely acquired. Patient status and health became increasingly difficult.

Within healthcare systems and practices, a mad dash to pivot towards telemedicine was undertaken, especially for non-life-threatening chronic disease management like atrial fibrillation (AF). Atrial fibrillation is the most common sustained clinical cardiac arrhythmia and has been associated with significant morbidity and mortality if not recognized, controlled, and treated properly. 2 Patients with AF were profoundly impacted during the pandemic as they are commonly considered high risk because of their age and other cardiovascular comorbidities. Gawalko et al. 3 have implemented and evaluated the effectivenessof the TeleCheck-AF system, which integrates with previous mHealthsystems used in a variety of health practices. The authors should be commended for taking on such an ambitious task. They enrolled and surveyed both healthcare providers and patients from 25 centres across nine countries with a mix of academic and specialized public cardiology or district hospitals. The TeleCheck-AF system is a previously established 7-day system to assess patient cardiac function using a mobile phone app with or without other minimal electrocardiogram (ECG) equipment that was designed from rapid and broad implementation. Patients are instructed to record heart function three times per day and any time they feel additional symptoms. Patients are asked a questionnaire each time they complete the measurement and are reminded if measurements are not performed on time. Following the 7-day period, patients and providers met through video conferencing to discuss the results and modify therapy as needed.

The goal of this study was to assess the success, usability, and patient and provider satisfaction with the TeleCheck-AF system. When they surveyed site principal contacts, they found that most sites thought the system was easy to use, easy to install, and interpretable. Major concerns for long-term implementation were integration into the electronic medical record (EMR), cost of the system, and data management. We found these results striking, in that a complicated system that tracks and updates centres based on AF, etc. could be implemented and perceived as simple to use while simultaneously generating useful clinical data. However, we would note that these surveys were administered to the central site coordinator, not to individual health providers. It would have been helpful to understand how unique and individual providers from diverse backgrounds perceived the usefulness and ease of use, as this type of input would help refine subsequent versions of the tool and its implementation.

A primary concern of integrating these systems into the EMR is always a challenge, especially in the context of remote monitoring, as systems brace to receive an increasing amount of virtual and remote data. Each monitoring company seems to have a different format, duration, patient questionnaire etc. that can be difficult to parse and integrate into the EMR. Not to mention that each individual site, unless under wide institutional or government oversight will have different EMR systems that have unique restrictions and data workflows. Therefore, standard outputs and full integration will have to be performed on a centre-by-centre basis and results may vary.

The authors also surveyed patients and described patient characteristics for individual participants. Of the patients surveyed, just under 60% of patients said they would like to use the Fibricheck app in the future, over 90% found the app easy to use, and over 85% found the installation of the app easy. These findings are crucial to widespread early adoption and durable usage of the mobile app, and for remote heart monitoring to guide clinical decisions. Statistically, older generations are more likely to develop AF and require treatment. For these groups especially, simplicity access and ease of use for technological solutions are keys for broad adoption. The author's highlighted that the 60-69 age group had excellent participation and comments were consistent with the rest of the cohort for ease of use.

One important notion that could be extended beyond the COVID-19 isolation and nature of the pandemic is the use of the Fibricheck system for patients in rural environments. Throughout many parts of the world, AF ablations are performed at central centres upwards of 500 miles away from smaller communities. As high-volume centres often offer the best outcomes in patients with AF, more centralization for ideal disease management has been advocated. 4 Allowing follow-up visits to be held virtually, with some additional data through the TeleCheck-AF system, would significantly benefit the follow-up visit quality and reduce overall patient burden. Furthermore, with no added equipment beyond a smartphone the realities of implementation are much more convincing.

There are some limitations to the current approach. The Fibricheck system as a standalone phone app or synced with standard wearables uses photoplethysmography sensors. Photoplethysmography does not record the electrical activity required to confirm the diagnosis of AF. The authors clearly state that this should not be used as a diagnostic tool; however, further caution of the accuracy of these measurements should always be advised. Screening tests with less than ideal specificity can be problematic when applied in lower-risk populations and the action upon the results can lead to patient anxiety and the potential for unnecessary downstream testing and therapies. 5 The authors also reported patient characteristics and the likelihood of correctly triggering a recording during an episode of AF or noting symptoms during an automatic recording of AF. They found that 54% of patients experiencing AF during a recording did not report any symptoms. In patient-triggered events, only 65.4% of recordings were suggestive of AF. Typical AF symptom correlation with arrhythmia remains suboptimal in patients with AF and varies by gender, age, and in the presence of other coexistent disease states. 6 For example, in a study of 656 patients that completed the Toronto Atrial Fibrillation Severity Scale that had a corresponding ECG (496 patients were in sinus rhythm), 85% responded consistently with their ECG (positive predictive value, 70%; negative predictive value, 89%). Atrial fibrillation symptom score severity correlatedly with the likelihood of being in AF and correctly identifying it. 7 Understanding non-traditional symptom profiles that may correlate higher with arrhythmia in groups at higher risk of poor correlation will be critical to improve patient-activated arrhythmia screening.

Finally, this tool is not a continuous monitor. Periodic testing whether symptomatic or not, may miss AF events. We are beginning to understand the impact of AF burden as a continuous risk factor, but currently, more research is needed to understand what burdens truly associate with lower risk in which therapies can be altered; an understanding critical to how often patient-activated periodic monitors as described in this study need to be used to assess arrhythmia.

In summary, the authors should be commended for implementing and studying a simple concept and tool that is widely available on smartphones and can reach broad populations to assist in disease management and education. The speed of implementation and first uses are equally as impressive. A worldwide pandemic has accelerated the development of many important telemedicine approaches that will be used globally. Finally, the robust assessment of patient and provider satisfaction lends credence to their approach and longterm feasibility.

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The European TeleCheck-AF project on remote app-based management of atrial fibrillation during the COVID-19 pandemic: centre and patient experiences

Rationale, considerations, and goals for atrial fibrillation centers of excellence: a Heart Rhythm Society perspective

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