We speak with Dr. David D. McManus, Co-Director (with Dr. Kevin C. Floyd) of the Atrial Fibrillation Treatment Program at UMass Memorial Medical Center in Worchester, Massachusetts, about the American Heart Association’s (AHA) Get with The Guidelines - Atrial Fibrillation (AFIB) program. UMass Memorial Medical Center was recently one of only two hospitals in the state to earn the Get with The Guidelines-AFIB Gold Quality Achievement Award.
Tell us about your EP program. How many EP labs and staff members are there? When was the EP lab started at your institution?
We have three EP lab rooms at the University of Massachusetts campus, and about 15 dedicated nurses and technicians that work with us in the EP lab space. We have six full-time EP attendings on faculty, all of whom are board-certified.
It’s a good group. The program started in the late 1980s/early 1990s, and has really blossomed over the last decade under the leadership of Dr. Larry Rosenthal, our section chief.
What types of EP procedures are performed at your facility? Approximately how many patients with atrial fibrillation does UMass Memorial Medical Center see monthly or annually?
A full complement of EP procedures is performed and we have one of the busiest EP laboratories in all of New England. We perform all procedures for bradyarrhythmias, including pacemaker and CRT implantations, as well as defibrillator implantations for primary and secondary prevention. In terms of ablative options, we treat all sorts of ventricular tachyarrhythmias as well as supraventricular arrhythmias, including atrial fibrillation. We do both de novo and index atrial fibrillation ablation procedures — including some of the more complex arrhythmias that require mapping and more sophisticated techniques for access (i.e., epicardial ventricular tachycardia ablation). To give you a sense of our volumes, we do about 180-200 atrial fibrillation ablation procedures every year. In addition, we perform left atrial appendage closure using the WATCHMAN device (Boston Scientific) in collaboration with our interventional colleagues.
We are very proud of our patient outcomes. We have a registry that we developed 9 years ago that allows us to keep track of how many procedures we’re doing and what our performance is in terms of arrhythmia recurrence and complications rates. This registry positioned us well to participate in the Get With The Guidelines program. However, just to be clear, as we’re talking about our EP lab, the Gold Quality Achievement Award we received actually pertains to a larger group of providers than just the EP lab team. The actual number of atrial fibrillation patients seen in our ambulatory clinic by the cardiology group involved at the time of this award was around 4000 patients in any given year. Our 40 cardiology faculty in the ICU and hospital wards see almost 1000. That is probably a better representation of the number of patients that were included in the Get With The Guidelines-AFIB program.
Why did your facility choose to participate in the Get With The Guidelines-AFIB program?
As co-director of the atrial fibrillation program, I was asked by members of the AHA to participate in a New England Quality Consortium. This really opened my eyes to the AHA’s Get With The Guidelines-AFIB program, what went into it, and some of the benefits of participation. Based on that, I met with our hospital administration, EP section leadership, and cardiology leadership, and everyone was supportive. They helped us with some of the funds necessary to participate, and the AHA gave us a grant as well, so we were able to implement the program and get started. Our quality nurse, Donna Suter, is a superstar, so I knew our hospital would be in good hands should we participate.
What steps were involved in the process for participating in the Get With The Guidelines-AFIB?
The first step was to receive education about the registry and how the data abstraction processes worked, and then undergo training along with our quality nurse Donna on the methods used to do chart extractions and coding. Once we started to actively profile our performance, we also needed to learn about the barriers to effective achievement across some of the performance measures. We met with different stakeholders such as our nurses (including our EP, cardiology floor, and ICU nurses) and the cardiology faculty outside of our EP section who prescribed medications for a number of these patients with atrial fibrillation, because many of the patients coming into our hospital that were tracked using the Get With The Guidelines system were not always seen by an electrophysiologist unless we needed to meet with them regularly. So we wanted to update them about what the guidelines were recommending, what the performance measures were, and help them achieve the guidelines with education and tools, including how to simplify some of the processes around documentation.
How long did the process take?
The Gold Quality Achievement Award required that we track and achieve the quality metrics identified for atrial fibrillation patients by the AHA for two consecutive years. We began this process about two and a half to three years ago, and that ultimately led to me participating in writing the guidelines for evaluating quality of atrial fibrillation care with Dr. Paul Heidenreich and the rest of the ACC/AHA panel.
What are some of the ways your facility’s approach to treating atrial fibrillation has changed since enrolling in the Get With The Guidelines-AFIB program?
The key thing has been an awareness of the need to assess and document stroke risk in any patient with atrial fibrillation, irrespective of whether an anticoagulant is prescribed. I think that in our clinical practice it was almost always being done, but it was inconsistently documented in the electronic medical record, and that led to the appearance of some folks not receiving good care, when really they were — it was just a question of documenting it better.
The next step, and I think a more meaningful intervention, is that many of our patients with atrial fibrillation had comorbidities that were tracked using the Get With The Guidelines-AFIB metrics, and these were quality metrics that extended outside of even the arrhythmia space. For example, one of the metrics for patients with atrial fibrillation was if they had any evidence of heart failure with left ventricular dysfunction that could be treated with an ACE inhibitor or ARB — that was something that the Get With The Guidelines-AFIB mechanism allowed us to track but we should have been doing anyway. So it has really been the vehicle for us to improve our general cardiovascular practice and secondary prevention efforts. We educated our cardiology teams about the importance of using these evidence-based metrics, such as ACE inhibitors or beta blockers for patients with concomitant heart failure or hypertension.
The other piece of the puzzle was that the Get With The Guidelines-AFIB allowed us to indirectly track the quality of transition out of the hospital. For example, scheduling, documenting, and ensuring that INR checks happened for our patients treated with warfarin were things we really put a lot of effort into in order to be able to achieve these performance goals. However, I think it has really improved the handoffs to outpatient primary care providers, cardiology practices, and anticoagulation clinics. Now our cardiology services are reaching out and making these appointments for our patients, which I think makes a big difference in assuring that they happen.
Has participating in Get With The Guidelines-AFIB affected your center’s treatment rates and patient outcomes?
Even before the program, we weren’t performing poorly. When we started out, we were probably getting to the finish line most of the time. However, since we’ve participated, we’ve definitely seen an uptick in our clear documentation of stroke risk assessment and prescription of anticoagulants for appropriate patients. That being said, it’s very difficult to show a difference in outcomes when you are doing the right thing to start with. Therefore, we really do not yet have the mechanism to track how many strokes we prevented, for example. Yes, we want to show that we’re providing evidence-based care, and I believe we have achieved that. But I would really like to get to the point where we can show our patients and our communities real differences in the outcomes that they care about, so if they come to UMass, they are going to get evidence-based treatments. We hope to show to patients that they are generally more likely to do well if they come to UMass rather than to a center that isn’t participating in this program and doesn’t pay as much attention to the details. However, to be clear, our studies to date have not focused on measuring long-term stroke rates or bleeding complications in our patients. We have really focused on these performance measures because they have been linked to these outcomes in other studies. I do not want to overreach in terms of what we’re doing and what that really means for patients.
What does participating in Get With The Guidelines-AFIB mean for the staff at UMass Memorial Medical Center?
It has been a remarkable and surprising outcome of participating in the program. It has truly been a multidisciplinary effort, both in terms of working with our nurses as well as our hospital administrators, a group that generally gets a lot of grief but, in this case (as in many), they were integral to the success of this clinical quality improvement program. Our hospital administrators, particularly Kati Korenda and Jay Cyr, were very much supportive of this at an early stage, when it wasn’t yet clear what the monetarily yield was going to be. Our quality nurses, floor nurses, and hospital administration really adopted this effort as their own. I think the benefits of working as a team also led to a lot of positive morale, and highlighted very good work being done here at UMass. For example, a lot of the discharge planning and documentation is being done by nurses that, in many cases, don’t necessarily get a lot of the credit that they deserve. This award is their award as much as it is for the EP physicians, so in that respect, it’s nice to achieve a metric from a nationally recognized group such as the AHA to recognize the good work being done by our entire heart team. The other positive outcome for our EP staff has been that this has provided them with a mechanism to work outside of the lab with floor nurses and ICU nurses and teams. It provided a little bit of a variety to the types of people they were meeting with in their practice, so it was satisfying for them as well. All in all, participation is something I would strongly recommend to any hospital system with a vibrant arrhythmia service.