Integrated care pathway

The current healthcare approach to multimorbidity is fragmented. AFFIRMO aims to move from fragmentation to an integrated pathway designed to be Patient-centred, Systemic and Digital


AFFIRMO's care pathway will account of personal preferences for treatment and considers the social context of patients. The treatment strategy will be the result of a shared decision-making process.


AFFIRMO's care pathway will enable synergies and cooperation among the different health disciplines involved in the treatment of patients with multimorbidity.


AFFIRMO's care pathway will rely on a digital platform, based on open standards, developed to assist physicians in applying and tailoring a personalised care strategy.

The workplan

AFFIRMO’s integrated care pathway will focus on Atrial Fibrillation (AF), a cardiac arrhythmia associated with high risk of morbidity. The workplan is structured around three research areas:

Clusters of multimorbidity

Researchers will characterize how different patterns of multimorbidity are distributed within the population of older individuals with AF.

Combining multiple analysis techniques, the team will investigate the reciprocal relationships between the most common diseases and AF. Drug patterns and potential drug reactions will also be addressed.

Stakeholder involvement

The project will assess the needs of patients, caregivers, and health professionals for the comprehensive management of multimorbidity (including AF) and examines ways of optimizing care and self-management.

Data will be collected though surveys and interviews. The goal is to develop a set of quality performance indicators (QPIs) to support the co-designing process of the care approach proposed by AFFIRMO.

Integrated care pathway

AFFIRMO will develop, implement and test patient-cantered approach on older multimorbid AF patients in the clinical practice. The proposed approach will rely on a digital platform designed to bring patients, caregivers, and health professionals closer together through information sharing.

An international clinic study will be performed to assess the effectiveness of the AFFIRMO’s care approach. Researchers will also consider the economic dimension by identifying how the integrated pathway will impact health outcomes and costs.


A multidisciplinary consortium across Europe representing clinical research, epidemiology, data science, biostatistics, pharmacology, economics, psychology and social sciences.


Integrated Care for Atrial Fibrillation Using the ABC Pathway in the Prospective APHRS-AF Registry

Bucci, Tommaso; Proietti, Marco; Shantsila, Alena; Romiti, Giulio Francesco; Teo, Wee-Siong; Park, Hyung-Wook; Shimizu, Wataru; Tse, Hung-Fat; Lip, Gregory; Chao, Tze-Fan

This study sought to investigate the association with outcomes of ABC adherence in the prospective multinational Asia-Pacific Heart Rhythm Society (APHRS) Atrial Fibrillation registry. 

Journal of Clinical Medicine

Atrial Fibrillation and the Risk of Ventricular Arrhythmias and Cardiac Arrest: A Nationwide Population-Based Study

Ameenathul, Mazaya Fawzy; Bisson, Arnaud; Bodin, Alexandre; Hebert, Julien; Lip, Gregory; Fauchier, Laurent

Background: Atrial fibrillation (AF) has been linked to an increased risk of ventricular arrhythmias (VAs) and sudden death. We investigated this association in hospitalised patients in France. Methods: All hospitalised patients from 2013 were identified from the French National database and included if they had at least 5 years of follow-up data. Results: Overall, 3,381,472 patients were identified. After excluding 35,834 with a history of VAs and cardiac arrest, 3,345,638 patients were categorised into two groups: no AF (n = 3,033,412; mean age 57.2 ± 21.4; 54.3% female) and AF (n = 312,226; 78.1 ± 10.6; 44.0% female). Over a median follow-up period of 5.4 years (interquartile range (IQR) 5.0–5.8 years), the incidence (2.23%/year vs. 0.56%/year) and risk (hazard ratio (HR) 3.657 (95% confidence interval (CI) 3.604–3.711)) of VAs and cardiac arrest were significantly higher in AF patients compared to non-AF patients. This was still significant after adjusting for confounders, with a HR of 1.167 (95% CI 1.111–1.226) and in the 1:1 propensity score-matched analysis (n = 289,332 per group), with a HR of 1.339 (95% CI 1.313–1.366). In the mediation analysis, the odds of cardiac arrest were significantly mediated by AF-associated VAs, with an OR of 1.041 (95% CI 1.040–1.042). Conclusion: In hospitalised French patients, AF was associated with an increased risk of VAs and sudden death.