Changing the Outpatient Clinic Model for Patients with Atrial Fibrillation

Twenty-five years ago, cardiac electrophysiologists (EPs) who performed catheter ablation took care of very different types of patients than they do today. The model then was to see and evaluate patients with Wolff-Parkinson-White syndrome, recurrent supraventricular tachycardia, or atrial flutter who were referred for catheter ablation and to identify those who were appropriate candidates. After the ablation procedure, which was associated with a very high success rate, these patients were usually seen once in follow-up to make sure that they did not have recurrent tachycardia or a problem after the procedure. They would then return to the care of their internist or cardiologist.

Now that a large proportion of patients taken care of by interventional EPs have atrial fibrillation (AFib), things have changed — the number of outpatients with AFib followed longitudinally by EP subspecialists has skyrocketed. Some of these patients are those who are being managed medically. Others have undergone at least one catheter ablation procedure, but continue to follow up in clinic because they continue to have recurrent AFib. Even patients with AFib who have undergone ablation and are doing well are often seen regularly for routine follow-up either because that is their own preference or the preference of the referring physician. Non-electrophysiologists are increasingly uncomfortable following such a patient. This has resulted in a large number of patients with AFib being followed regularly by a cardiac electrophysiologist.

Other factors that have resulted in the growing population of patients with AFib in heart rhythm clinics is that EP now “owns AFib”. As we have increasingly taken on AFib management and developed a growing number of therapeutic options for patients with AFib, including catheter ablation, surgery, and left atrial appendage occlusion, the less comfortable non-electrophysiologists have become managing patients with AFib. For example, when the next step is clearly an electrical cardioversion, it is not uncommon for cardiologists to refer patients to an electrophysiologist rather than simply arranging the procedure themselves. Sometimes the easiest path to get a patient cardioverted is to enter an order in the electronic health record to refer the patient to the EP clinic. It is also common for general cardiologists to be uncomfortable initiating or renewing antiarrhythmic drug therapy. Primary care physicians are also often not comfortable initiating anticoagulation therapy for stroke prevention. More and more, these patients are being referred to a subspecialist for management. One potential explanation for this trend is the minimal time general cardiology fellows now spend on the EP service. The ACGME requirement is now only 2/36 months of training devoted to the EP service.

As programs increasingly market themselves as having expertise in AFib management, patients with AFib are increasingly self-referred. These patients often have no physician whom they identify as their primary care physician, and commonly request routine follow-up with an EP. Many of them do not have active AFib issues.

The main tradeoff to this trend in AFib management by sub-subspecialists is that the proportion of time that heart rhythm specialists are spending in the outpatient clinic environment is growing out of proportion to the time they are spending in the lab performing procedures. This has the potential to have a negative affect on maintenance of technical expertise and procedural proficiency. Unless electrophysiologists want to limit their scope of procedural practice, it is critical that they continue to devote a majority of their time in the EP laboratory performing invasive procedures.

A new outpatient model needs to be developed to follow patients with AFib. A good parallel to consider is the management of patients with implantable pacemakers and defibrillators. In most practices, patients who undergo implantation of a cardiac device are followed in a dedicated device clinic with expert nurses and technicians who function fairly independently. An analogous model is needed for patients with AFib. One model would deploy mid-level providers. The use of more mid-level providers to take care of patients with heart rhythm disorders is increasingly common and has been advocated as a way to improve physician efficiency and patient outcomes. Another potential approach is to create a new type of physician — a noninvasive cardiologist who is an expert in the management of AFib. Historically, many cardiologists fell into this category, but this phenotype now rarely exists. Developing training programs that allow for fellows to devote most of their final year in training to the general care of patients with AFib could create a new and much-needed type of specialist.

Unless interventional electrophysiologists want to continue to devote more and more time outside the EP lab, the burgeoning number of patients with AFib that require longitudinal follow-up by a heart rhythm specialist requires a change in our approach to the outpatient model for these patients. Increasing the number of mid-level providers and developing noninvasive cardiologists who specialize in managing patients with AFib could help address this growing need.