Atrial fibrillation (AFib) is a leading cause of cardiovascular morbidity and mortality. Disease management is complex, as it includes the assessment and treatment of thromboembolic complications as well as treatment pathways for rate and rhythm control. As the burden of atrial fibrillation continues to grow, the demands on the healthcare system are increasingly strained.1-2 The cost of atrial fibrillation management is well recognized, and driven by increasing utilization of emergency department care and inpatient hospitalizations.3-4
The complexity of the atrial fibrillation patient, limitations in educating patients about when and where to seek care, and the inability to consistently deliver care in the outpatient setting drive inappropriate healthcare resource utilization.
Therefore, coordinating the care for patients with atrial fibrillation is growing increasingly burdensome. Patients are often co-managed by a series of providers, including non-invasive cardiologists, interventional electrophysiologists, and anticoagulation and antiarrhythmic clinics. The interlaced nature of the disease often additionally demands some form of collaboration with heart failure, sleep medicine, and bariatrics. Providing comprehensive care within the constraints of a traditional outpatient cardiovascular visit is a daunting task.
Disease-specific chronic care models have proliferated for a number of chronic diseases, including diabetes, asthma, COPD, and heart failure. The primary goals of care for many of these clinics are to reduce the burden of care in resource-intensive settings while providing longitudinal follow-up with a clear focus on preventative care specific to the disease state. These clinics typically employ a combination of clinical providers led by clinical nursing, including registered nurses and advanced practice providers (APP) working with allied health providers such as pharmacists and respiratory therapy, in collaboration with a physician team. Chronic care disease clinics have been demonstrated to improve outcomes as well as reduce the cost of care for the patients and diseases they serve.5,6
The principles of chronic disease management for heart failure, diabetes, or respiratory disease can be extended to the atrial fibrillation patient. The development of an integrated atrial fibrillation clinic requires diligent preparation and close partnerships with stakeholders throughout the healthcare delivery system. Building trust in a new direction of care can be challenging. A strong alliance with health system administration is critical in developing a functional and sustainable model. These relationships can drive the messaging to clinical stakeholders including cardiologists, emergency department (ED) providers, and primary care providers. Close collaboration between all of these partners is necessary for the success of any disease-specific clinic. While clinic design may be variable depending on the available resources, in our experience, a nurse-led atrial fibrillation clinic allows patients to obtain a comprehensive and coordinated delivery of care.
At OhioHealth Heart & Vascular Physicians, our nurse-led atrial fibrillation clinic takes heavily from European models, which demonstrated nurse-led care of atrial fibrillation patients to be superior to usual care provided by other cardiovascular providers.7 The primary goal was to reduce ED utilization and provide an outlet for low-risk atrial fibrillation patients to be safely discharged from the ED with close clinical follow-up. Secondary goals were to provide a resource for patients to receive in-depth atrial fibrillation education, systematically identify risk factors for atrial fibrillation, and provide measurable goals for attainment. Similarly, we sought to systematically apply guideline-recommended therapies — either medical or interventional — for the management of atrial fibrillation and standardize the approach across our practice. To accomplish this, we dedicated a series of advanced practice practitioners to provide daily appointments for both urgent evaluation and longitudinal evaluation.
Our first task was to create an evidence-based pathway that would allow low-risk atrial fibrillation patients to be correctly identified in the emergency department, and then targeted for safe and effective outpatient management. A number of such pathways have been validated. A U.S. expert consensus panel was convened in 2017 to create a practical framework to guide the process of establishing such protocols; our institution’s emergency department protocol was based on this (Figure 1),8 but modified to meet our specific available resources. The defining principle is safe, effective management with either a rate or rhythm control strategy, a focus on appropriate thromboembolic risk assessment, and disposition to our atrial fibrillation clinic within 24-48 hours. If adequate rate or rhythm control cannot be achieved in the emergency department within a specified time frame, the patient is moved to an observation unit and the protocol continues to remain focused on achieving outpatient management if it is clinically practical.
Our current model allows for up to six acute visits per day, which was expected to be primarily referred from the ED and observation units. Recently, we have seen increasing referrals from outpatient cardiology providers and primary care providers requesting patients be assessed for acute visits to avoid urgent care and ED visits altogether. The patients who are referred for these visits are triaged over the phone by our dedicated AFib clinic nurse. By screening patients prior to their appointment, we determine the potential for a same-day intervention such as transesophageal echocardiogram (TEE), cardioversion, or even ablation. This allows us to prepare the patient for the visit as well as provide preliminary instructions, including the need for fasting or arriving with a driver if an intervention requiring sedation is expected.
Our team of APPs, who are experienced in the inpatient and outpatient management of electrophysiology patients, starts each patient visit with an in-depth overview of atrial fibrillation, review of thromboembolic risk factors, and a thorough overview of management options. The AFib Clinic Management Pathway was constructed with a focus on adherence to guideline-directed therapy and input from our team of expert electrophysiologists. Once an acute treatment plan is established, we systematically assist the patient in identifying the modifiable risk factors that may be contributing to atrial fibrillation, and help to establish clear goals for achievement. Management of modifiable risk factors and comorbid conditions have had a positive outcome on reduction of atrial fibrillation symptoms and freedom from arrhythmia recurrence.9,10 We recognize that this can often be an overwhelming process for patients, as they are expected to organize their immediate cardiac care with multiple other appointments for ongoing evaluation. By positioning our clinic in a physical space close to our structural heart and heart failure clinics, we have been able to share some resources to facilitate immediate evaluation by nutrition or pharmacy services. Similarly, we have been able to gain the cooperation of our colleagues in bariatric and sleep medicine for priority scheduling and treatment when needed. Many of these patients will then have at least one follow-up in 6 weeks to monitor the progress and reinforce education, before returning to their primary care or cardiology provider with the longitudinal goal-directed recommendations.
Patient engagement is critical to the success of an integrated atrial fibrillation clinic. During patient visits, we encourage patients to demonstrate understanding of their thromboembolic risk by calculating their CHA2DS2-VASC score. We also emphasize the use of mobile ECG monitoring to facilitate our patients’ understanding of their symptoms and provide clinicians with accurate data from which to make decisions. We anticipate that our patients initially complete a European Heart Rhythm Association (EHRA) atrial fibrillation score during ECG recording to quantify symptoms to facilitate both their understanding and ours. Ongoing development of patient engagement applications will likely be able to facilitate ECG monitoring, as well as deliver timely education and monitor progress towards risk factor modification.
Assimilating patient data by developing a close relationship with an informatics team can provide insights into the care process. We use patient data including demographics, health system utilization, therapies utilized, and even patient-derived data to elaborate on existing process maps to improve efficiency and efficacy of care delivered. As an example, we used our informatics program to review the timing of add-on transesophageal echocardiograms and cardioversions referred from our AFib clinic, and demonstrated increasing demands in the afternoons and on Mondays. To improve throughput in the imaging and EP labs, as well as facilitate single-day visits and intervention, outpatient TEE and cardioversion volume was shifted to later in the week and morning time slots when possible.
Robust informatics can also drive adherence to therapy. Clinics similar to ours, most notably an AFib clinic in Greensboro, North Carolina, employ a consistent methodology to assess and document stroke risk for AFib patients throughout their system, as well as ensure that patients are appropriately prescribed medical therapy. Similarly, our center has relied on an improved understanding of our patient population to amplify recruitment into our clinical trials program and to identify patients who may benefit from enrollment in one of our other chronic disease clinics, including the heart failure, structural heart, or hypertension clinic.
Comprehensive atrial fibrillation management improves our patients’ care and helps unload the burden on our healthcare system by shifting care from the inpatient to outpatient setting. We anticipated that using streamlined access to evidence-based treatment guidelines with a distinct focus on risk factor modification, clearly defined and attainable goals, and specific referral algorithms for specialty care through an integrated care team, that the symptoms and burden of atrial fibrillation would be improved. Ultimately, our most gratifying finding has been the positive feedback and satisfaction from our patients (Figure 2). Knowing the complexity of this disease and the emotional toll it can bring to a patient trying to navigate a treatment plan for atrial fibrillation, we have found that the individual education and prompt evaluation has gone a long way in increasing their trust in our care. Because of this, among many other reasons, we hope that this model will become a standard of care for treatment of atrial fibrillation.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.
- Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112:1142-1147.
- Aggarwal S, Gupta V. Burden of atrial fibrillation on the hospitals in USA: analysis of nationwide emergency department sample data. Circulation. 2014;130:A15749.
- Wodchis WP, Bhatia RS, Leblanc K, Meshkat N, Morra D. A review of the cost of atrial fibrillation. Value Health. 2012;15:240-248.
- Coyne KS, Paramore C, Grandy S, Mercader M, Reynolds M, Zimetbaum P. Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States. Value Health. 2006;9(5):348-356.
- Hale GM, Hassan SL, Hummel SL, Lewis C, Ratz D, Brenner M. Imapct of a Pharmacist-Managed Heart Failure Post Discharge (Bridge) Clinic for Veterans. Ann Pharmacother. 2017;51(7):555-562.
- Schultz JL, Horner KE, McDanel DL, et al. Comparing Clinical Outcomes of a Pharmacist-Managed Diabetes Clinic to Usual Physician Based Care. J Pharm Pract. 2018;31(3):268-271.
- Hendriks JM, de Wit R, Crijns HJ, et al. Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation. Eur Heart J. 2012;33(21):2692-2699.
- Baugh CW, Clark CL, Wilson JW, et al. Creation and Implementation of an Outpatient Pathway for Atrial Fibrillation in the Emergency Department Setting: Results of an Expert Panel. Acad Emerg Med. 2018;25(9):1065-1075.
- Pathak RK, Middeldorp ME, Meredith M, et al. Long-term effect of goal-directed weight management in an atrial fibrillation cohort: A long-term follow-up study (LEGACY). J Am Coll Cardiol. 2015;65:2159-2169.
- Pathak RK, Middledorp ME, Lau DH, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: The ARREST-AF cohort study. J Am Coll Cardiol. 2014;64:2222-2231.