Key Points:
- Adherence to guideline recommendations for AF management is suboptimal.
- STEEER-AF, the first randomized trial conducted by the ESC, assigned treatment centers across Europe to a short, targeted, and structured educational program or their usual education activities. The outcome was patient level receipt of guideline-concordant care.
- Exposure to the educational program was associated with a significant improvement in adherence to rhythm control, but not stroke prevention, guideline recommendations.
- This trial demonstrated the feasibility and efficacy of using educational initiatives to target implementation gaps in cardiology.
Prior work has demonstrated that adherence to atrial fibrillation (AF) guideline recommendations in Europe is suboptimal. There are multiple barriers to uptake of guidelines recommendations in real-life clinical practice. Healthcare provider (HCP) knowledge gaps are one potentially modifiable barrier to guideline adherence.
On September 1st, 2024, the principal results of the “Stroke prevention and rhythm control Treatment: Evaluation of an Educational program of the European society of cardiology (ESC) in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF)” trial was presented at ESC Congress 2024. The purpose of this randomized trial, the first conducted by the ESC, was to determine whether an educational intervention targeting HCPs improved AF guideline adherence at the patient level.
Treatment centers in France, Germany, Italy, Poland, Spain and the United Kingdom were randomized to receive either a 16 week educational program developed by professional societies in conjunction with an independent medical educational agency focusing on stroke prevention, rhythm control, and the integrated care of AF, or their usual educational activities. The 195 HCPs at intervention centers spent an average of 9.2 hours on the online learning platform, supported by expert local trainers. The co-primary endpoints were assessed at the patient-level, and included adherence to ESC Class I and III recommendation for stroke prevention and rhythm control. Outcomes were evaluated between 6-9 months post-randomization and ascertained by an independent contracted research organization to minimize bias.
Overall, 1,732 AF patients were included, with a mean age of 69 and CHA2DS2-VASc score of 3.2; 37% were female. There was no significant difference in change in guideline adherence for stroke prevention between the two arms (adjusted RR 1.10 [95% CI 0.97-1.24]; p=0.13), however there was a significant improvement in guideline adherence for rhythm control in the intervention arm compared to the control arm vs (63.4% to 67.5% vs. 58.6% to 60.9%, aRR 1.51 [95% CI 1.04-2.18]; p=0.03). The intervention arm also experienced significantly greater gains in secondary patient-reported outcomes that assessed eight domains of integrated AF management.
Professor Dipak Kotecha from the University of Birmingham, UK, concluded: “The STEEER-AF trial demonstrates that targeted education for healthcare professionals can improve patient-level guideline adherence where there are substantial gaps in implementation, as clearly demonstrated for rhythm control in AF. As a result of STEEER-AF, the new 2024 ESC Guidelines for the management of AF incorporate numerous approaches to enhance ‘AF-CARE’, with new patient pathways designed to make implementing recommendations easier and more consistent.”
- Maciej Sterliński, Karina V Bunting, Giuseppe Boriani, Serge Boveda, Eduard Guasch, Lluís Mont, Kim Rajappan, Philipp Sommer, Samir Mehta, Yongzhong Sun, Chris P Gale, Colinda van Deutekom, Isabelle C Van Gelder, Dipak Kotecha, STEEER-AF Trial Team , Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association, EP Europace, Volume 26, Issue 7, July 2024, euae178, https://doi.org/10.1093/europace/euae178