A White Paper, entitled Reconnecting the Pieces to Optimize Care in Atrial Fibrillation, was recently released by the Centre for Innovation in Complex Care (CICC), of the University Health Network (UHN) in Toronto, Canada. This report identified significant gaps in atrial fibrillation (AF) care in Ontario, discussed challenges for patients and healthcare professionals as well as costs to the healthcare system. The report also describes the launch of the Innovate AFIB project, created to improve atrial fibrillation care and to serve as a model of care for other patients with complex, chronic conditions. In this interview we speak with Dante Morra, MD, MBA, FRCP(C), Medical Director for the CICC and staff physician at Toronto General Hospital, University Health Network, and Dr. Andrew Ha, MD, FRCP(C), staff cardiac electrophysiologist, Toronto General Hospital, University Health Network.
Tell us about the prevalence of atrial fibrillation and stroke in Ontario. What percentage of patients in Ontario has atrial fibrillation?
Dr. Morra: The prevalence of atrial fibrillation (AF) in Ontario is currently about 1%. The prevalence of AF increases with age, which means that most of our patients with AF are older and likely have more co-morbid conditions. The White Paper describes the AF prevalence to be about 100,000 in Ontario, but that is probably a conservative estimate. Some clinicians may think a condition that affects only 1 or 2% of the population is not resource-intensive. However, it is known about half of all healthcare resources is consumed by about 5% of the population. Various chronic diseases such as diabetes, COPD, cancer, and cardiovascular diseases including AF consume about 66% of all healthcare resources. Therefore, in re-designing the healthcare system, we are targeting our efforts upon the “heavy users.” Atrial fibrillation is the most common type of arrhythmia seen in emergency rooms (ER) and is one of the most common chronic conditions to present with acute problems in an ER setting. Conditions where care is generally disorganized and associated with high costs are ideal for interventions to re-design the system in order to deliver high-quality, evidenced-based, and cost-effective care to our patients.
Dr. Ha: As the population ages, AF becomes more prevalent. Fortunately, AF is a disease in which timely and appropriate interventions may prevent important complications such as stroke, hospitalization, and heart failure.
What prompted the White Paper on atrial fibrillation? Also, tell us about the Innovate AFIB project and why it was created.
Dr. Morra: I am a part of the Centre for Innovation in Complex Care, which creates new models of innovation, new technologies, new roles, and new ways of organizing people with chronic disease. Many of our interventions deal with chronic diseases such as AF, diabetes, and other complex conditions. We identified AF as an ideal chronic condition to perform a value-based intervention, which involves analyzing a group of patients and improving their quality of care while minimizing healthcare costs. There are several reasons why AF was chosen. First, it is a very expensive disease to treat. Second, we believe that high-yield interventions can be easily delivered if AF care is correctly organized. One example is the prevention of ischemic strokes in AF patients by prescribing anticoagulant medications in the high-risk subgroup. Third, AF is not “owned” by anyone. In Ontario, the care of many patients with AF is provided by their family doctors or by ER doctors. A smaller portion is provided by internists, cardiologists, or electrophysiologists. Given our previous experience and success in other disease domains, we feel that this is a wonderful opportunity to re-organize our provincial AF care system in order to improve it. With this intention, we approached Boehringer Ingelheim and received an unrestricted grant to work on this project.
Thus, we created the Innovate AFIB project, which is a bold goal to change the system of care for AF, improve quality, and reduce costs. Our first step was to involve all of the stakeholders associated with AF, so we performed interviews with many individuals. Physicians from various disciplines and system leaders all came together to discuss the challenges associated with AF and how best to solve them. We are now in the process of piloting interventions in order to create a new model of care.
Discuss some of the care gaps for atrial fibrillation patients in Ontario that were identified in the White Paper. What challenges were identified in Ontario’s current state of atrial fibrillation care?
Dr. Ha: One recurrent scenario involves a patient who presents to the ER several times a month because of AF. After he/she is acutely treated in the ER, the patient will be discharged with instructions to follow up with his/her family doctor or cardiologist. However, before the patient is seen by his/her doctor, he/she develops another episode of AF and the cycle repeats itself, over and over again. One of the major gaps in AF management is the lack of care continuity and the absence of a mid- to long-term AF management plan for many patients. We should develop a care system in which AF patients who are acutely treated in the ER can be promptly triaged to healthcare professionals who will subsequently support which is specific to that patient’s needs. This may include education, rate- or rhythm-controlling medications, anticoagulant therapy, or even invasive procedures such as an ablation. As Dr. Morra mentioned, nobody really “owns” AF; patients often cannot identify a specific healthcare “champion” for their AF care. This subsequently results in a fragmented model of AF care.
Dr. Morra: In our interviews with stakeholders, additional care gaps included: poor communication, lack of follow up, fragmentation of care delivery, etc. These responses came from our interviews across the system, including rural family physicians, cardiologists, electrophysiologists, and ER physicians. A consistent message which emerged from our dialogue with various physicians is that AF is currently being managed in an episodic fashion. Patients come to the ER and get treated, but there is nobody who consistently deals with the whole continuum of care. Having said that, we must also recognize that there is excellent AF care provided by some of our colleagues in Ontario. However, our vision is to translate this level of excellent AF care on a provincial level. Therefore, we need to create a standardized system in which no matter where the patient touches the healthcare system with AF, he/she will receive high-quality care by being triaged to the “right door” every time.
How will the new streamlined system change the atrial fibrillation patient experience? What are the proposed areas of improvement that atrial fibrillation patients in Ontario will see?
Dr. Morra: The whole idea is that no matter where an AF patient comes in through the system, whether it’s through the ER, from the family medicine clinic, or from a cardiologist, there will be a standardized protocol for healthcare professionals to manage AF. A system will be in place so that once a patient touches the organization, they are referred into a group that will keep an eye out on them — this includes nurse practitioners, pharmacists, etc. — who will follow up with them after they are discharged from the hospital. If a patient presents to the ER with AF and is cardioverted, he/she is referred back to his/her family physician with standardized patient education materials. Follow up will be provided by a nurse practitioner at 1 and 6 months to ensure that the patient is being properly managed. This is analogous to a web, in that no matter where the patient touches the system, his/her existence will be noted and subsequent care will be promptly delivered.
Tell us about establishing a provincial centre of excellence for atrial fibrillation care, including regional atrial fibrillation hubs.
Dr. Morra: So far, we have received a lot of support from the Heart and Stroke Foundation of Ontario, the Ontario Hospital Association, the Cardiac Care Network, the Ontario Stroke Network, and the Ministry of Health. We are developing local interventions with our family health teams, within our ERs and hospitals, and with partner hospitals. Once we have optimized the system at a local level, we will perform evaluations to assess the impact of these interventions. Once that is done, we will look at scaling it across the province. We do not want to have one centre of excellence within certain hospitals where every patient has to see an electrophysiologist — this is not scalable and is certainly not the right use of resources. We want the patient to be properly referred to the healthcare provider who will best address the needs of that patient, be it stroke prevention, rhythm management, or patient education. The term “centre of excellence” tends to refer to big ivory towers that only fit into certain organizations; what we envision is more of a regional network which triages patients to the right parts of the system. So if you are attached to a sophisticated primary care organization with excellent pharmacists and co-management models, this is where the centre of excellence will be for that patient. The term “centre of excellence” implies a certain structural view — however, we see this more as a model of care that can expand out, and patients will get what they need depending on what is available in their locale.
Right now, the main work is occurring at the University Health Network. The Sunnybrook Hospital, Southlake Regional Health Centre, and St. Michael’s Hospital are also actively involved in the Innovate AFIB project. We have done some mapping of their processes there, and we are learning and starting to integrate the AF care system within their infrastructure.
When will these changes be initiated? Tell us about the proposed timeline for establishing this new model of care for atrial fibrillation.
Dr. Morra: Within the next year, we hope to have the local model ready, and by this I mean within across 5–10 organizations. I also expect to have the evaluation started, and we plan to scale the model to other regions in 2 years. Therefore, in 3 years, we hope to have a complete provincial network. It is very important to note that we are not trying to “recreate the wheel” — groups such as the Ontario Stroke Network and Cardiac Care Network already have existing infrastructure that can be leveraged to scale the Innovate AFIB model on a provincial level.
Tell us about some of these existing resources the Innovate AFIB project will use to help streamline care.
Dr. Morra: The Ontario government has invested very heavily in healthcare reform, so there are already many family health teams with nurse practitioners, pharmacists, and resources. This infrastructure can be utilized as part of the AF care system. In addition, groups such as the Cardiac Care Network have existing provincial referral systems for invasive cardiac procedures. Those databases and referral structures can be leveraged to be able to move this project forward on a provincial level. Finally, the Ontario Stroke Network has been very successful at creating stroke centres of excellence within hospitals across the province as well as creating a network of secondary stroke clinics. Therefore, there are already many functional modules in place to help facilitate the Innovate AFIB project on a province-wide level. We feel that the transition of the Innovate AFIB program to such a scale should be feasible. The end result of this endeavor is that AF care can be delivered in a high-quality manner across Ontario, much like the current stroke and cardiac catheterization models.
How did you gather support from atrial fibrillation healthcare professionals to participate in this initiative? Is the program being well received thus far?
Dr. Morra: We have been working with ER doctors, family physicians, pharmacists, electrophysiologists, cardiologists, and neurologists. From the very first day, many people have been involved with this project. We have also worked very closely with our system leaders, including the Heart and Stroke Foundation and the Ontario Hospital Association. Many of these participants were at our initial events and have been instrumental in helping us move forward. I think this inclusive model has allowed this model to be well received.
How will results of the new atrial fibrillation care-delivery system be measured? Will there be a second White Paper be published?
Dr. Morra: We are currently in the process of setting up the model. We are planning on putting out a White Paper on our progress, followed by a final report of our system evaluation.
Is there anything else you’d like to add?
Dr. Ha: I just want to thank you for the opportunity to talk about our work. Personally, I think it is very easy to convince various specialists to agree to work on this project. Atrial fibrillation is a challenging disease to manage, and every physician involved in the care of AF patients often feels frustrated by the fragmented pattern of AF care. Although we can and do provide excellent care to our AF patients as individual specialists, we feel that there must be an easier and better way to coordinate care for these patients on a province-wide level. Provision of universal, high-quality healthcare is a very important ideal in our healthcare system. On the basis of this alone, we are very motivated to get involved in this project.
Dr. Morra: I agree. When a problem is universally frustrating for everyone to manage, it is easy for relevant stakeholders to get together in order to solve it.