Author + information
- Received August 5, 2019
- Revision received August 19, 2019
- Accepted August 19, 2019
- Published online October 21, 2019.
- Celine Gallagher, PhDa,b,
- Debra Rowett, B Pharmc,d,
- Karin Nyfort-Hansen, B Pharm, Grad Dip Ed(Health)a,
- Shalini Simmons, RNd,
- Anthony G. Brooks, PhDa,
- John R. Moss, BEc, MSocSci, MBBSe,
- Melissa E. Middeldorp, PhDa,b,
- Jeroen M. Hendriks, PhDa,b,
- Tina Jones, PhDf,
- Rajiv Mahajan, MD, PhDa,g,
- Dennis H. Lau, MBBS, PhDa,b and
- Prashanthan Sanders, MBBS, PhDa,b,∗ ()
- aCentre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- bDepartment of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
- cSchool of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
- dDrug and Therapeutics Information Service, Southern Adelaide Local Health Network, Adelaide, Australia
- eSchool of Public Health, The University of Adelaide, Adelaide, Australia
- fCentral Adelaide Local Health Network, Adelaide, Australia
- gDepartment of Cardiology, Lyell McEwin Health Service, Adelaide, Australia
- ↵∗Address for correspondence:
Dr. Prashanthan Sanders, Centre for Heart Rhythm Disorders, Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia.
• The prevalence of AF has grown exponentially in recent decades and is associated with high hospitalization burden and poor quality of life.
• Education has been advocated as a key component of chronic condition management, yet the role of education on outcomes in the AF population is poorly defined.
• Structured educational visiting, based on the principles of academic detailing, has been associated with improvements in physician prescribing practices with variable effects observed in influencing patient and caregiver outcomes.
• In the HELP-AF study, an educational resource was developed and used to support delivery of education by trained clinicians, using a patient-centered structured educational visiting approach, within the patient’s home.
Education has long been recognized as an important component of chronic condition management. Whereas education has been evaluated in atrial fibrillation (AF) populations as part of multifaceted interventions, it has never been tested as a single entity. The aim of this review is to describe the rationale for and role of education as part of comprehensive AF management. The development and use of educational material as part of the intervention of a randomized controlled trial, the HELP-AF (Home-Based Education and Learning Program in AF) study, will be described. This study was designed to determine the impact of a home-based structured educational program on outcomes in individuals with AF. An educational resource was developed to facilitate delivery of 4 key messages targeted at empowering individuals to self-manage their condition. The key messages focused on strategies for managing future AF episodes, the role of pharmacotherapy in the treatment of AF, the appropriate use of medicines to manage stroke risk and the role of cardiovascular risk factor management in AF. To support structured educational visiting, an educational booklet titled Living Well With Atrial Fibrillation (AF) was developed by a multidisciplinary team and was further refined following input from expert clinicians and patient interviews. Using a structured educational visiting approach, education was delivered by trained clinicians within the patient’s home.
Atrial fibrillation (AF) is an emerging global epidemic associated with significant morbidity and mortality (1). Prevalence of the condition continues to rise and hospitalizations, which are the main driver of cost, have demonstrated upward trends (2,3). Hospitalizations due to AF now outnumber those for both heart failure and myocardial infarction (4). Effective strategies are needed to mitigate these trends. Alternative models of care delivery have demonstrated enhanced patient outcomes in AF, with education a component of these interventions (5–7). However, the role of personalized education, facilitated by the use of educational material, has not been evaluated.
Education and Health Literacy
Education to improve outcomes in chronic illness has long been advocated (8). A United Kingdom biobank study has demonstrated that each additional 3.6 years of education was associated with a 37% reduction in risk of coronary heart disease (9). Whereas approximately one-half of this risk was mediated through traditional risk factors, more than one-half of the protective effect of education remains unexplained (9). Such evidence supports the crucial role of well-designed patient materials in facilitating delivery of health education. Low health literacy has been associated with poor patient outcomes including hospitalizations and emergency department visits, inability to comprehend medication and health-related information, inappropriate medication use, poorer overall health, and higher mortality (10). Therefore, it is of paramount importance to have educational material that can cater to a broad range of literacy levels. This is further confounded by the growing trend of using internet-based health information of varying quality (11). A review of digital health applications for AF highlighted significant variation in quality with validation of scientific content occurring in <16% of cases (12). Furthermore, average reading level of applications intended for non–health care professional use was 12.1 ± 2.6 years, a level significantly above the fifth to sixth grade level which is generally recommended for patient-level material (12).
Education as Part of Structured AF Programs
Structured AF care programs, of which education has formed one component, have delivered varied results (5–7). In a single-center randomized trial, protocol-driven, software decision supported and nurse-delivered management resulted in a reduction in the composite endpoint of cardiovascular death and hospitalizations (5). Another study recruited patients presenting to the emergency department and delivered education by telephone, the opportunity to attend 1 group based education session, followed by 1 nurse-delivered and cardiologist-supported outpatient appointment, resulted in a reduction in the composite endpoint of death, cardiovascular hospitalization, and AF-related emergency visits (6). However, despite education forming a key component, little detail is presented on the development and delivery of the educational components.
The SAFETY (Standard Versus Atrial Fibrillation-Specific Management Strategy) study (7) delivered education with the support of a booklet, as part of a broader management strategy, to individuals who had recently been hospitalized for AF. Although the booklet was published, the development and evaluation of this was not described (7). The booklet contains an explanation and definition of AF, symptoms, diagnosis, possible complications, treatment options, signs requiring urgent hospital presentation, and lifestyle modification (7). The content of education sessions was not standardized, but rather adapted to each individual’s perceived need, with ongoing sessions and support provided in an ad hoc manner. In this randomized trial, the composite endpoint of all-cause death or unplanned hospitalizations was not different, although the co-primary outcome of event-free days favored the interventional arm (7).
The RACE 3 study targeted upstream interventions that included protocol-driven pharmacotherapy and cardiac rehabilitation and resulted in a greater freedom from AF at 12 months (13). Whereas significant detail is provided concerning the cardiac rehabilitation program and counseling provided by a heart failure/rhythm nurse, the educational component of these interventions is not clear (13). Similarly, studies specifically targeting modification of risk factors have demonstrated a reduction in AF symptoms (14), improved maintenance of sinus rhythm (15,16), and reversal of the AF process (17). Whereas these studies have provided detail concerning the counseling provided, and have stated that written and verbal advice was provided, specific detail concerning educational content is lacking.
The impact of education alone in these interventions is difficult to ascertain for several reasons. First, the multifaceted interventions make it difficult to elucidate the contribution of each element. Second, education was not delivered in a standardized manner. Finally, the delivery and nature of education provided in these studies has not been described in detail, or was undertaken in an ad hoc manner, making it difficult to replicate such interventions and therefore limits the reproducibility and scalability of these educational components. The development of the intervention materials for the HELP-AF (Home-Based Education and Learning Program for AF) study is described below to facilitate translation into practice.
Development of Patient-Centric Educational Content for the HELP-AF Study
An educational resource was developed to support delivery of the intervention of the HELP-AF study. A literature review was performed exploring patient attitudes, knowledge, and beliefs about AF (Online Appendix). Additionally, a review of available patient resources for AF was undertaken (Table 1). With the support of a multidisciplinary team and patient input, key messages were developed to achieve the behavioral goals of the intervention. Concise educational materials were then developed to support the delivery of the key messages. The educational materials were tested during various stages of the development process on AF patients to ensure they were readable, understandable, and received feedback to facilitate modifications. The study version of the educational material was finalized only after approval from the multidisciplinary development team, clinicians, and individuals with AF.
Identified gaps in patient knowledge
Several gaps in knowledge were identified and addressed in the development of the educational material. An important theme related to patient uncertainty concerning management of AF episodes. Key messages deemed most relevant to self-management of AF were developed, with delivery of these messages supported by an illustrated educational booklet.
Key messages for the HELP-AF intervention
Four key messages deemed most relevant to management of AF were developed (Central Illustration). These were:
1. Take your AF medications as prescribed to reduce your symptoms and risk of stroke.
2. Stroke preventing medications can reduce your risk of stroke by up to 60% to 70%.
3. Reduce your risk of AF becoming more severe and risk of stroke by choosing a healthy lifestyle.
4. AF episodes are not usually medical emergencies. Follow your personal action plan during an AF episode with usual symptoms.
Message 1: Take your AF medications to reduce your symptoms and risk of stroke
Discussion focused on the role of medication adherence and persistence to manage AF symptoms and reduce stroke risk. Each patient’s medication regimen was recorded prior to the home visit. At the first home visit, individuals were asked to show the educational visitor all their medications and each medicine was discussed in relation to its role in managing AF or associated comorbidities. Over-the-counter and complementary medicines were also discussed with information provided about possible known interactions with prescribed therapy. The role of rate- and rhythm-controlling medications in managing symptoms was discussed. Individuals were encouraged to maintain an up-to-date list of their medicines and, if required, a medication list was provided to facilitate this.
Message 2: Stroke preventing medications can reduce your risk of stroke by up to 60% to 70%
The educational visitor and patient together calculated a CHADS2 (Congestive Heart Failure, Hypertension History, Age ≥75 Years, Diabetes Mellitus History, Stroke or Transient Ischemic Attack) score and information was conveyed about resultant stroke risk. To reinforce the role of anticoagulation, anticoagulants were referred to as “stroke preventers” in the booklet. Focus was on the role of appropriate anticoagulation in managing stroke risk. All patients with a CHADS2 score of 1 or more were advised to discuss the role of anticoagulation with their treating physicians. As the CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) score became more widely utilized, this score was also calculated to assist in determining and conveying stroke risk.
If individuals were prescribed warfarin, the importance of maintaining the international normalized ratio within the therapeutic range was discussed and barriers to achieving this were reviewed. A review of diet and medication interactions was undertaken. Patients were encouraged to maintain a written record of their international normalized ratio results and a record booklet was provided if necessary. Those prescribed direct acting oral anticoagulants were given information specific to their agent. Patients were encouraged to ensure they had regular checks with treating physicians to address any bleeding risks and ensure the appropriateness of drug dosing.
Message 3: You can reduce your risk of AF becoming more severe and risk of stroke by choosing a healthy lifestyle
This emphasized the role of cardiovascular risk factor management in AF. A baseline profile of each patient’s cardiovascular risk factor profile was undertaken prior to the home visit. Based on this and dependent on patient need, a targeted discussion with practical steps concerning weight-loss, dietary modification, alcohol reduction, improving exercise capacity, smoking cessation, improving glycemic control and addressing dyslipidemia was undertaken.
Message 4: AF episodes are not usually medical emergencies. Follow your personal action plan during an AF episode with usual symptoms
The final message was developed in response to a patient-identified gap in knowledge and focused on strategies for managing future AF episodes. The aim of this message was to convey that episodes of AF with “usual symptoms” are not medical emergencies and do not generally require hospital presentation. A discussion of each patient’s usual AF symptoms occurred in addition to teaching how to palpate the pulse to assist in recognition of episodes (Figure 1). Each patient was given an action plan to develop with their treating physician to assist in managing their AF episodes. This was provided on an A4 sheet of paper and wallet card (Figure 2). The plan used the acronym REST whereby:
R: the patient was encouraged to rest and recognize any potential triggers.
Estimate pulse: this was done to confirm that this was an AF episode.
See action plan: this was the personalized component of the plan where patients were encouraged to follow advice from their treating physicians concerning steps they should take when AF episodes recur. Specific advice was not provided by the educational visitors for this component of the plan, but advice already received was discussed. Patients were asked to obtain individualized written advice from their treating physicians.
Telephone: this was a 24-h telephone line that patients could call for advice for managing their AF episode if they were unsure despite following the first 3 steps of their plan. This telephone line was held by an on-call cardiac electrophysiology team.
The intention of the REST plan was not for individuals to avoid hospitalizations regardless of symptomatology, but rather to highlight that an episode of AF with usual symptoms and appropriate advice provided by treating physicians could be employed to manage AF episodes with usual symptoms. Participants were advised to seek tailored advice from their treating clinicians, as this would include discussion of “usual symptoms” and scenarios that may require hospital presentation. Additionally, comorbid status and literacy levels could also be taken in to account, with advice tailored to each individual.
Utility of educational resource
The educational material was formatted as a graphical aid in the form of an illustrated booklet titled Living Well With Atrial Fibrillation (AF) (Online Appendix). The purpose of this resource was to support messages delivered by the educational visitor and ensure consistency of key messages between visitors. The booklet developed for the HELP-AF study differed from other patient educational resources in that figures were designed as graphical aids to support interaction with the patient and reinforce key messages, underpinned by social marketing principles. The figures were chosen to reflect a broad range of demographics to connect to a wide range of individuals. The booklet content centered around the key messages, with other content used to enhance patients’ understanding of their condition and provide background information.
Principles outlined by the U.S. National Institute on Aging for making print materials senior friendly were used (Online Appendix). This included use of the active voice, use of direct and specific actionable steps, reinforcement of key messages with questions, avoidance of jargon, larger font, simple layout, short sentences and paragraphs, plenty of white space on the page, double spacing, left justification, and narrow or multiple columns to limit line length. In addition, words no longer than 3 syllables were used wherever possible. In accordance with these principles, the educational booklet developed for the study was suitable for a broad range of literacy levels. In this regard the booklet developed for this study is thus unique in comparison to other patient resources specific to AF.
Content of the Educational Resource
The educational booklet contained extensive background information presented in simple language. This included a discussion of AF pathophysiology supported by a diagram and electrocardiogram tracing. Common symptoms experienced with AF were presented in written and figure form (Figure 3). Causes and types of AF were also discussed supported by a basic explanation of AF. Common triggers for paroxysmal episodes were also identified.
Common complications arising from AF were documented in written and pictorial form. Risks of increased stroke (Figure 4), heart failure, syncope, and falls was discussed with strategies to avoid or minimize risk of development of these complications.
Treatment for AF
An extensive review of treatment for AF was provided, with a focus on use of pharmacotherapy including rate and rhythm medications and oral anticoagulation. The booklet included a table to allow estimation of stroke risk using the CHADS2 score, allowing discussion of appropriate use of anticoagulation according to guidelines current at the time (Figure 5). The importance of re-evaluation of this score over time was emphasized.
A review of common cardiovascular risk factors was undertaken in addition to strategies to address each factor. Practical steps were summarized in addition to contact details of external organizations that may be able to assist patients in improving their cardiovascular risk factor profile.
Medications and glossary
An extensive summary table of commonly used AF medications was provided including generic and brand names, reasons for use, mode of action, and common side effects. A glossary of terms relevant to AF with definitions in simple language was also provided.
Questions for my doctor
A 2-page section was dedicated to a list of questions that patients may wish to discuss with their treating physicians. During discussion with the patient, the educator highlighted questions that were most relevant for the individual. Space was provided for clinicians to provide written answers to these questions (Figure 6).
The booklet was designed to be used interactively during structured educational visiting (SEV) and to empower individuals to self-manage their condition through several practical steps. A summary of these steps was listed in both the educational booklet and, in brief on the AF action plan, to act as a prompt for individuals (Figure 7).
The HELP-AF Intervention
The HELP-AF study
The methodology for the HELP-AF study has been previously described (18). In brief, this was a multicenter randomized controlled trial in which 627 individuals presenting to the emergency departments of 6 hospitals in Adelaide, South Australia, primarily due to AF, were recruited. Patients were randomized 1:1 to the HELP-AF intervention or usual care. Follow-up occurred over a 24-month period.
The study was approved by the Human Research Ethics Committees of each participating institution. The study is registered at the Australian New Zealand Clinical Trials Registry (ACTRN12611000607976).
Rationale for SEV
SEV is based on the principles of academic detailing and social marketing. Academic detailing is also referred to as “educational outreach” and “educational visiting” with the term “academic detailing” becoming widely adopted following an early study by Avorn and Soumerai (19). Academic detailing has been influential in changing prescribing habits with evidence that this approach may be translatable to clinician-patient interactions (20). However, SEV has never been tested in an AF population.
In addition to treatment as per usual care pathways, the intervention group in the HELP-AF study received 2 home visits using a SEV approach. Delivery of key messages is constructed around areas of behavior change to influence outcomes. An exchange of information occurs throughout the visit with the educational visitor skilled in developing an understanding of the patient’s values, needs, and preferences to influence behaviors.
Influencing patient behaviors using educational outreach visiting is a relatively novel concept that has been tested in a limited number of studies. In a palliative care trial, the use of educational outreach visiting delivered over 2 home visits by palliative care nurses at the point of functional decline, resulted in better performance status but did not have an impact on pain levels or hospitalizations (19). In a trial of educational outreach visiting for carers of individuals with advanced respiratory disease using long-term oxygen therapy, 2 home visits delivered by nurses 6 weeks apart resulted in improved quality of life for patients but was associated with higher mortality in the intervention group compared with the control group (21). Given the impact of educational outreach visiting on improving clinician-centered outcomes, further studies evaluating the impact of this approach in patient-based interventions are warranted.
Key components of the intervention
Two key elements underpinned delivery of the intervention: 1) clinical characterization of the patient; and 2) patient-centered structured educational visiting (PC-SEV).
This was undertaken via a medical record review of each patient and telephone discussions between the visiting researcher clinician and patient prior to the first home visit. Extensive information was collected including:
• Management and events leading up to the index presentation for AF and any scheduled follow-up care;
• AF history including when the condition was diagnosed, usual symptomatology, prior and planned interventions;
• Sociodemographic history including current living conditions, social network, and education level;
• Comorbid conditions;
• Current medications;
• Previously trialed medications;
• Cardiovascular risk factor profile;
• Current beliefs and knowledge about AF and its management.
This pre–home visit contact assisted in establishing early rapport between the educational visitor and patient and formed a basis for targeting key behaviors.
Two PC-SEV were the central component of the intervention in the HELP-AF study. The first visit occurred 1 to 2 weeks following enrolment with the second occurring 6 weeks later.
The intervention was delivered by either a pharmacist or nurse. Clinicians delivering the intervention attended a 3-day training session from the Drug and Therapeutics Information Service, Adelaide, Australia, on the principles of academic detailing and the application of PC-SEV. A video-recorded mock home visit was performed at this training session to provide feedback to the educational visitor on areas for improvement. Additionally, clinicians were upskilled in the current management of AF.
To ensure standardization of the SEV, educational visitors completed a report for each visit, including the time spent discussing each key message and areas of patient interest. Weekly meetings were held for the study team to assess any issues related to delivery of the intervention. Four meetings were held throughout the delivery of the interventional phase of the study to ensure fidelity by each of the clinicians to the intervention. A random review of home visit reports undertaken by each clinician was reviewed to ensure consistency in intervention delivery.
Quality Assessment of Patient Educational Resources
To address variability in patient educational information, several tools have been developed. The Patient Education Materials Assessment Tool (PEMAT) provides a structured approach to assessing the understandability and actionability of educational material (22). A recently published review of 35 Internet-based patient resources for anticoagulants demonstrated that the majority of patient resources identified on popular search engines rated highly on understandability but performed poorly on actionability according to the PEMAT guidelines (23). Lack of actionability is a recurring theme through other patient resource reviews. A review of 25 decision support aids for primary cardiovascular disease prevention demonstrated high scores on the PEMAT for understandability but performed poorly for actionability (24). The lack of actionability inherent in many patient resources to date has been addressed in the current study through specific and explicit steps individuals can take to self-manage their condition.
In the new era of personalized medicine, the HELP-AF intervention provides a novel approach for patient-centered education for AF. The intervention is unique in its approach to education by combining clinical characterization and home-based SEV provided by clinicians, supported by a booklet with actionable steps patients can take to self-manage their condition. The HELP-AF study will provide unique insights into this novel approach to personalized education and empowerment of individuals with AF.
Current models of care delivery are inadequate in meeting the needs of the AF population with exponential increases in hospitalizations. Structured care programs have demonstrated enhanced patient outcomes in AF populations, but the role of education is unclear. Whereas education forms a pivotal component of chronic condition management, the development and validation of educational resources for AF has not been well described. Several studies have utilized educational resources as a component of multifaceted interventions, but the replication of such interventions is limited due to a lack of detail concerning development and delivery of this education. The aim of the HELP-AF study is to evaluate the role of a novel approach, using clinical characterization and structured educational visiting, on clinically relevant outcomes in a contemporary cohort of patients with AF. This study will provide the most comprehensive evidence to date concerning the efficacy of home-based patient-centered structured education in AF.
This study was supported by a South Australian Cardiovascular Research Network Grant jointly funded by the National Heart Foundation and the Government of South Australia. The sponsor of the study is the University of Adelaide. Several of the authors are employees of the University of Adelaide. The sponsor has had no direct involvement in the design and conduct of the study, collection, management, analysis and interpretation of the data, preparation, review or approval of the manuscript; or the decision to submit the manuscript for publication. Dr. Gallagher is supported by fellowships from the University of Adelaide. Dr. Brooks has received honoraria from MicroPort; and accepted a continuing position at MicroPort CRM (formerly LivaNova Australia Pty Limited) subsequent to the design and commencement of the study. Dr. Middeldorp is supported by fellowships from the University of Adelaide. Dr. Hendriks has received lecture and/or consulting fees paid to his institution from Medtronic and Pfizer/BMS; and is supported by the Future Leader Fellowship from the National Heart Foundation. Dr. Mahajan has received lecture and/or consulting fees paid to his institution from Medtronic, Abbott, Pfizer, and Bayer; has served on the Advisory Board of Abbott; has received research funding paid to his institution from Medtronic, Abbott, and Bayer; and is supported by a fellowship from the National Health and Medical Research Council of Australia. Dr. Lau has received lecture and/or consulting fees paid to his institution from Abbott, Boehringer Ingelheim, Biotronik, Medtronic, and Pfizer; and is supported by the Robert J. Craig Lectureship from the University of Adelaide and a mid-career fellowship from the Hospital Research Foundation. Dr. Sanders has served on the Advisory Boards of Medtronic, Boston Scientific, Abbott Medical, Pacemate, and CathRx; has received research and/or lecture fees paid to his institution from Boston Scientific, Medtronic, Abbott Medical, and MicroPort; and has received a practitioner fellowship from the National Health and Medical Research Council and National Heart Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Abbreviations and Acronyms
- atrial fibrillation
- patient-centered structured educational visiting
- Patient Education Materials Assessment Tool
- structured educational visiting
- Received August 5, 2019.
- Revision received August 19, 2019.
- Accepted August 19, 2019.
- Chugh S.S.,
- Havmoeller R.,
- Narayanan K.,
- et al.
- Freeman J.V.,
- Wang Y.,
- Akar J.,
- Desai N.,
- Krumholz H.
- Gallagher C.,
- Hendriks J.M.,
- Giles L.,
- et al.
- Hendriks J.M.,
- de Wit R.,
- Crijns H.J.,
- et al.
- Carter L.,
- Gardner M.,
- Magee K.,
- et al.
- Carter A.R.,
- Gill D.,
- Davies N.M.,
- et al.
- Hesse B.W.,
- Nelson D.E.,
- Kreps G.L.,
- et al.
- Ayyaswami V.,
- Padmanabhan D.L.,
- Crihalmeanu T.,
- Thelmo F.,
- Prabhu A.V.,
- Magnani J.W.
- Rienstra M.,
- Hobbelt A.H.,
- Alings M.,
- et al.,
- for the RACE 3 Investigators
- Pathak R.K.,
- Middeldorp M.E.,
- Meredith M.,
- et al.
- Pathak R.K.,
- Middeldorp M.E.,
- Lau D.H.,
- et al.
- Middeldorp M.E.,
- Pathak R.K.,
- Meredith M.,
- et al.
- Hendriks J.M.,
- Brooks A.G.,
- Rowett D.,
- et al.
- Abernethy A.P.,
- Currow D.C.,
- Shelby-James T.,
- et al.
- O'Brien M.A.,
- Rogers S.,
- Jamtvedt G.,
- et al.
- Sladek R.,
- Woodman R.,
- Effing T.,
- et al.
- Yiu A.,
- Ng K.K.,
- Lee V.W.,
- Bajorek B.V.
- Bonner C.,
- Patel P.,
- Fajardo M.A.,
- Zhuang R.,
- Trevena L.
- Shea J.B.,
- Sears S.F.
- Maccallum L.,
- McGaw H.,
- Meshkat N.,
- et al.
- Central Illustration
- Education and Health Literacy
- Education as Part of Structured AF Programs
- Development of Patient-Centric Educational Content for the HELP-AF Study
- Content of the Educational Resource
- The HELP-AF Intervention
- Rationale for SEV
- Quality Assessment of Patient Educational Resources