Results from the ESC’s first randomised trial shows education for healthcare professionals can improve guideline implementation

Key take-aways 

• Guideline recommendations support healthcare professionals to provide optimal care; however, they are often poorly implemented. 
• In the STEEER-AF trial, the first randomised controlled trial conducted by the European Society of Cardiology (ESC), adherence to recommendations in patients with atrial fibrillation (AF) was found to be low across six European countries. 
• A short educational programme for healthcare professionals increased patient-level adherence to guideline recommendations on heart rhythm control. 
• Increased efforts are needed to improve guideline implementation and to optimise the care of patients with AF, to prevent the high rate of adverse outcomes. 

London, United Kingdom – 1 September 2024: Adherence to atrial fibrillation (AF) guideline recommendations was found to be poor in clinical practice across Europe, but a structured educational programme for healthcare professionals improved implementation of heart rhythm control recommendations in patients, according to late-breaking research presented in a Hot Line session today at the ESC Congress 2024.¹ 

Explaining why the research was conducted, Chief Investigator, Professor Dipak Kotecha from the University of Birmingham, UK, said: “While guidelines, such as those from the ESC, aim to support healthcare professionals in applying optimal care, their recommendations are often not implemented in clinical practice, with education of healthcare staff identified as a major barrier. We conducted STEEER-AF, the ESC’s first randomised controlled trial,² with the European Heart Rhythm Association (EHRA) and the ESC Council on Stroke, to test whether a structured educational programme for healthcare professionals could improve guideline-adherent provision of AF care across Europe. We found that adherence to guideline recommendations for heart rhythm control was low, but there were improvements using a short and targeted educational intervention for healthcare staff.” 

STEEER-AF was a cluster randomised trial conducted in France, Germany, Italy, Poland, Spain and the UK. Treatment centres, rather than individuals, were randomised to one of two groups. In centres randomised to the intervention group, healthcare professionals received an additional structured education programme over 16 weeks, which targeted stroke prevention, rhythm control and integrated care, with learning supported by expert local trainers.² The intervention was developed by ESC Education, EHRA, external content leads and an independent medical education agency. Healthcare professionals spent an average of 9.2 hours on the online learning platform. In centres randomised to the control group, healthcare professionals received only their existing educational activities. 

The co-primary endpoints were adherence to ESC Class I and III recommendations, at the level of each individual patient, for stroke prevention and rhythm control, re-evaluated 6–9 months after randomisation using objective methods at each centre.  

In total, 1,732 patients with AF were studied from 70 randomised centres. The mean age was 69 years, 37% were women and the mean CHA2DS2-VASc score was 3.2, consistent with a real-world population. 

There was no significant improvement in guideline adherence for stroke prevention, which changed from 63.4% to 67.5% in the intervention group and from 58.6% to 60.9% in the control group (adjusted risk ratio [RR] 1.10; 95% confidence interval [CI] 0.97–1.24; p=0.13). 

Significant 51% improvement was observed in guideline adherence for rhythm control, which increased from 21.4% to 33.9% in the intervention group and from 20.5% to 22.9% in the control group (adjusted RR 1.51; 95% CI 1.04–2.18; p=0.03). 

There was also a significant improvement in the patient-reported secondary outcome that evaluated eight domains of integrated AF management, which improved to 77.0% with the intervention and to 71.0% in the control group (baseline-adjusted 5.1% improvement; 95% CI 1.4 to 8.9; p=0.01). 

“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. Overall, the care of AF was poorly adherent to prior guideline recommendations, requiring a total re-think of how guidelines are constructed, disseminated and implemented. As a result of STEEER-AF, the new 2024 ESC Guidelines for the management of AF^3,4 incorporate numerous approaches to enhance ‘AF-CARE’, with new patient pathways designed to make implementing recommendations easier and more consistent. In addition, we have simultaneously launched a patient version⁵ of the 2024 AF Guidelines, to empower patients and encourage a shared-care approach with multidisciplinary healthcare staff,” concluded Professor Kotecha. 

ENDS