Healthcare is in constant development, as is the treatment of patients suffering from atrial fibrillation (AF). The growing number of AF patients requires a change and improvement in the organization of care for these patients. Against this background, a working group of cardiologists, general practitioners and the ISALA thrombosis clinic, all in Zwolle, and the Julius Center of UMC Utrecht set up a study to find out if treatment of stable AF including anticoagulation care in primary healthcare is safe and effective.
Why this study?
Prevalence increases with age from 5.5% in people aged 55 and over to 17.8% in people aged 85 and over (see under 'Literature', article by Heeringa et al). With a view to the aging population, this is set to increase significantly in coming years. This requires modification and improvement in the organization of care for atrial fibrillation patients, similar to the changes in diabetes care.
There is room for improvement: 20-40% of the patients are not treated in accordance with the oral anticoagulants guideline (see article by Ogilvie et al). An important part of hospital admissions for complications of atrial fibrillation or its treatment (such as strokes or hemorrhages) can be prevented. To achieve this, the fragmentation in atrial fibrillation care as it is currently organized (cardiologists, thrombosis clinics and general practitioners) must be reduced. The ALL-IN project seeks to achieve this by providing comprehensive care for patients suffering from atrial fibrillation in general practice, including anticoagulant care and treatment of the arrhythmia, taking other disorders of the often elderly patient into account.
In many practices, other chronic diseases, such as diabetes (see article by Houweling et al), COPD and CVRM are already successfully treated by the practice nurse. There are indications that structured care of atrial fibrillation by a hospital nurse while not losing sight of other disorders also results in reduced mortality and fewer hospital admissions (see article by Hendriks et al). The effect of integrated treatment of atrial fibrillation in general practice has, however, not been studied yet, which is why the ALL-IN study was set up.
The participating primary care practices will be randomized (drawing lots) between intervention practices and control practices; this is called a cluster randomized controlled trial. In the intervention practices, the practice nurse will provide the care for atrial fibrillation patients under supervision of the general practitioner. This comprises one visit every three months to the practice nurse for a check-up of the atrial fibrillation and, if applicable, NOAC use (non-vitamin K oral anticoagulants, a new type of blood thinner). If the patient uses acenocoumarol or fenprocoumon as anticoagulant, the practice nurse will regularly measure INR and will receive dosage advice from the thrombosis clinic's expertise center in digital form.
The general practitioner sees the patient once a year to check whether the treatment can be optimized given the guidelines, other disorders and medication. In case of questions, the practice nurse or general practitioner can simply contact the thrombosis clinic's expertise center or the dedicated expertise center of cardiologists set up for the ALL-IN project. This means that the patient no longer goes to the cardiologist for the indication atrial fibrillation, unless there are other cardiac disorders. The patients in the control practices, on the other hand, will continue to receive the care they are used to.
After two years of follow up, mortality and hospitalizations will be looked at. In order to be able to compare the quality of life and perform cost/benefit analyses, patients fill in three quality-of-life questionnaires over a period of two years. A primary care DBC (diagnosis/treatment combination) in order to claim expenses for the additional hours of the practice nurse has been agreed.
- Heeringa J, van der Kuip DA, Hofman A, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. 2006;27(8):949-953
- Ogilvie IM, Newton N, Welner SA, et al. Underuse of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review. American Journal of Medicine 2010;123:638-645
- Houweling ST, Kleefstra N, van Hateren KJ, et al. Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial. J Clin Nurs. 2011;20(9-10):1264-72
- Hendriks JM, de Wit R, Crijns HJ, et al. Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation. Eur Heart J. 2012;33(21):2692-2699.
- Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Annals of internal medicine. 2007;146(12):857-867
- Heng C, Rybarczyk-Vigouret MC, Michel B. Anticoagulant-related hospital admissions: serious adverse reactions identified through hospital databases. Pharmacoepidemiology and drug safety. 2015;24(2):144-151
Information for patients
You can download the patient information for the ALL-IN project by means of the link below. Other links help you retrieve background information about atrial fibrillation in the Isala patient leaflet and the answers to FAQs about anticoagulants.
If you use a Non-vitamin K Oral AntiCoagulant (NOAC) blood thinner (apibaxan, rivaroxaban or dabigatran), you can download a handy patient card below that you can take to your check-up by the practice nurse.
Tuesday, October 11, 2016:
The recruitment of practices is going well, with Huisartsenpraktijk Van Lith in Olst and Huisartsenpraktijk Kluft-Wladasch in Haarle having recently joined. That brings the total to 24 practices!
Monday, June 6, 2016:
Huisartsenpraktijk Assendorp in Zwolle and Huisartsenpraktijk Posthouwer in Kampen are also participating in the ALL-IN project - welcome!
Wednesday, February 3, 2016:
The project is extending toward the Hardenberg region, where Huisartsenpraktijk Floralaan-Meeuwenplein, Huisartsenpraktijk Harwig & Van Vlokhoven, Huisartsenpraktijk Beerzerveld, Huisartsenpraktijk De Krim and Huisartenpraktijk Kloosterhaar have registered.
Friday, December 4, 2015:
In Raalte and the surrounding area, several general practices have decided to participate in ALL-IN: Medisch Centrum Heeten, Huisartsenpraktijk Westdorp and Gezondheidscentrum de Parel.
Monday, November 2, 2015:
General practice Veldweg in Wezep has indicated that it wishes to join the ALL-IN project - welcome!
Friday, October 23, 2015:
In Wapenveld, Huisartsenpraktijk De Putter has promised to take part, as the tenth general practice to join us!
Monday, September 14, 2015:
Huisartsenpraktijk Schreurs en Van der Wijk in Oldebroek and Apotheekhoudende Huisartspraktijk Kuinre have also joined - welcome to ALL-IN!
Tuesday, August 25, 2015:
Two new general practices have registered: Huisartspraktijk De Lange and Huisartsenpraktijk Gramsbergen. Welcome to the ALL-IN project.
Thursday, August 6, 2015:
Despite the vacations, registration of general practices is well under way. Meanwhile, we have also welcomed Huisartsenpraktijk Lemelerveld, Huisartsenpraktijk Doornspijk and Gezondheidshuis Stadshagen and Huisartsenpraktijk Appeltern in Zwolle to the ALL-IN project.
Thursday, June 4, 2015:
The first general practice has registered for ALL-IN! We would like to welcome the general practitioners and general practice nurses of Huisartsenpraktijk Elburg to the ALL-IN study!
Do you have any questions or comments after reading the information on this website?
Then send an email to: email@example.com
We can also be contacted by telephone:
drs. Carline van den Dries, research physician: +31 (0)6-38365344 or +31 (0)88-7569620
Dr Ruud Oudega, project leader: +31 (0)6-53152059
Dr Geert-Jan Geersing, lead researcher: +31 (0)6-54394005
University Medical Center Utrecht
Julius Center for Health Sciences and Primary Care
Room number Str. 6.104
Internal mail number Str. 6.131
P.O. Box 85500
3508 GA Utrecht, The Netherlands
ALL-IN working group
The ALL-IN working group consists of the following members:
- Ms. C.J. van den Dries, PhD Candidate General Practice, Julius Center UMC Utrecht
- Dr R. Oudega, general practitioner and ALL-IN project leader, Julius Center UMC Utrecht
- Dr G.J. Geersing, general practitioner and ALL-IN lead researcher, Julius Center UMC Utrecht
- Dr F.H. Rutten, general practitioner and associate professor, Julius Center UMC Utrecht
- Prof. Dr K.G.M. Moons, Professor of Clinical Epidemiology, Julius Center UMC Utrecht
- Prof. Dr R.A.M.J. Damoiseaux, general practitioner and Professor of Education and Evidence Based Medicine in General Practice, Julius Center UMC Utrecht
- Dr J.J.C.M. van de Leur, medical leader Isala thrombosis clinic
- Dr A. Elvan, cardiologist at Isala
- Prof. Dr H.J.G. Bilo, internist at Isala and Professor of Transmural Care
- Mr. J. Dille, Manager of Innovation and Science at Isala Academy
- Mr. Th. Kuiper, medical consultant at Achmea.