Primary care physician continuity improve survival in patients with atrial fibrillation: a retrospective analysis of 15,000 patients with atrial fibrillation

Background

Patients with atrial fibrillation (AF) deserve an early diagnostic and personalized treatment particularly the use of oral anticoagulation (OAC) after a comprehensive clinical assessment for identify other conditions associated with the arrythmia and the high comorbidity burden frequently present in those patients1. Due to the increased prevalence of AF, it is needed an integrated patient-care pathway with primary care physicians (PCP) playing the central role1. Continuity of care (COC) by PCPs involves an ongoing relationship between a patient and a PCP, who takes responsibility for the patient’s medical needs. Longitudinal PCP-COC is defined as the persistence of contact between physicians and patients over time, has been associated with lower mortality rates, fewer hospital admissions, less use of emergency department visits, and fewer referrals for specialist consultation. The aim of our study is to assess the impact of Continuity of Care (COC)—care provided by the same Primary Care Physician (PCP)—on outcomes in patients with atrial fibrillation (AF).

Methods

We conducted a retrospective cohort study including all patients with AF referred by PCPs (n=17,889) between January 2010 and December 2023 in the Santiago de Compostela healthcare area (Spain). COC was categorized as "PCP stability" (care by the assigned PCP) or "interrupted COC" (care by multiple rotating PCPs). The association between COC and outcomes (hospitalization, mortality, stroke, and haemorrhage) was estimated using Cox regression and Fine-Gray competing risk models, adjusted for potential confounders.

Results

Patients with PCP stability had a significantly lower annual referral rate (1.5 vs. 1.8, p<0.001) and a higher rate of adequate Oral Anticoagulation (OAC) indication according to the CHA₂DS₂-VASc score (79.5% vs. 69.1%, p<0.001). COC was independently associated with reduced all-cause mortality (Hazard Ratio [95% CI]: 0.79 [0.69–0.91]), and also all-cause (HR: 0.85 [0.80 - 0.91]), CV (HR: 0.85 [0.78 - 0.93]) and HF (HR: 0.70 [0.55 - 0.90]) hospitalizations. A benefit that remained robust after sensitivity analyses. No significant differences were observed in stroke (HR: 1.06 [0.75-1.50]) or haemorrhagic complications (HR: 1.29 [0.98-1.69]); however, competing risk analysis suggests that the higher mortality rate in the interrupted COC group likely precluded the observation of non-fatal events in this high-risk subset.

Conclusions

Longitudinal COC in Primary Care is associated with improved clinical management, including better OAC indication, and a significant reduction in all-cause mortality among patients with AF. The survival benefit of seeing the same physician appears to extend beyond anticoagulation optimization, highlighting the pleiotropic value of the patient-physician relationship.

Figure. Forrest plot represents the hazard ratio of hospitalizations and mortality associated to COC in PCFigure