Curbing the Atrial Fibrillation Epidemic Using the AF Clinic Model

Atrial fibrillation (AF) remains the most common cardiac dysrhythmia seen in clinical practice today, estimated to affect about 2 to 3 million Americans. The prevalence by 2050 is projected to be 15.9 million, with greater than half of those suffering being 80 years of age or older. Moreover, AF is not only its own risk factor for mortality, but it also has a significant association of morbidity. Any increase in the incidence of AF will also increase the number of patients affected by stroke and heart failure. In fact, AF worsens the outcome of heart failure by nearly 3%, while increasing the risk of stroke 1.5% in ages 50-59 and 23.5% in those older than 80 years of age. The most serious morbidity is from thromboembolic stroke, which can cause severe debilitation.¹ 

The total cost of AF in the United States was estimated to be $6 billion in 2017, with most attributed to hospitalizations. In particular, patients with AF that had a stroke accounted for $2.6 billion.¹ In reviewing treatment of these patients, 30-50% of those eligible AF patients were found to receive no preventive anticoagulation; among those who did, 52% were outside the optimal range.¹ If just half of these patients were controlled with preventative therapy, such as warfarin, about 19,000 strokes could have been prevented, with a savings of approximately $1.1 billion in overall healthcare costs.¹ In general, hospital costs related to AF patients is also higher due to the frequency of readmission. Nearly 1 out of 8 patients are readmitted within the first year after their index hospitalization. (Figure 1) 

Given these current statistics and the grim future ahead for this condition, hospitals need to consider strategies for this large and growing population, especially given the impact these patients have on the clinical, operational, and financial aspects of a cardiovascular service line. Indeed, this subspecialty is oftentimes ‘lost’ among the larger or more profitable elements of cardiovascular disease; however, there are opportunities to capitalize on treatment for this condition while delivering much needed care to affected patients. 

How Can Hospitals Begin to Address the AF Epidemic?

There is evidence that hospitalizations due to AF can be avoided by shifting services from the inpatient to outpatient setting. Data from the Healthcare Cost and Utilization Project indicate that 60% of hospital admissions for a principal diagnosis of AF come from emergency room visits.¹ To decrease admissions (and readmissions) for AF, some hospitals have chosen to implement evidenced-based practice guidelines that incorporate rate control with medications, emergent cardioversions, and patient referral to a dedicated AF clinic, thus avoiding unnecessary admissions for this condition. This clinical plan of care has provided a more effective and efficient way of delivering care for patients presenting to the emergency room, which reduces costly hospitalizations and eliminates some of the resources required for inpatient treatment. 

Why Develop an AF Clinic?

Corazon recommends a dedicated AF clinic as a means to provide a comprehensive and personalized approach to evaluation and management of patients with AF. A thorough risk assessment, combined with various treatment options, can reduce AF related to stroke, as well as provide treatment options for rhythm management due to electrical abnormalities.  

At their best, AF clinics bring together a multidisciplinary group of physicians in order to provide the best care for patients, which, depending on the hospital, can include general cardiologists, electrophysiologists, interventional cardiologists, and cardiothoracic surgeons. With the right mix of physicians and technology, centers can offer radiofrequency and cryoballoon ablation, along with surgical maze for rhythm management of AF. Percutaneous left atrial appendage closure (LAAC) can be used to reduce stroke risk as an alternative to anticoagulation. 

To begin the process of developing an AF clinic, Corazon recommends identifying a physician lead that can facilitate discussions amongst all subspecialists and primary care physicians. Understanding the points of entry into the healthcare system (i.e., emergency room, urgent care, or primary care office) is important, as this will help to identify algorithms, protocols, and screening mechanisms that need to be developed. Once implemented, patients can be segregated into the appropriate treatment categories for follow-up. 

AF categories consist of the following:

• Paroxysmal AF: Intermittent with episodes that last <48 hours and that stop without antiarrhythmic therapy;
• Persistent AF: last for >1 week if untreated with antiarrhythmic therapy;
• Longstanding persistent AF: last >12 months duration;
• Permanent AF: is no longer corrected with antiarrhythmic therapy.

Treatment of AF focuses on rate and rhythm control with prevention of stroke using oral anticoagulation therapy. However, this only covers those individuals for whom a diagnosis of AF has already been made. Many patients have persistent AF without symptoms, and therefore, may present initially with a stroke. This under-detection of AF represents a major gap in the identification of those with persistent AF. The National Institute for Health and Care Excellence (NICE) suggests opportunistic case finding rather than a screening strategy.² This type of screening can start in the primary care office.  

Corazon believes that AF clinics, working together with the primary care base, can be used to support screening for early detection and provide the basis for a continuum of care model (Figure 2). Screening for AF using opportunistic pulse palpation and confirmatory 12-lead electrocardiogram (ECG) in those with an irregular pulse has been recommended as an intervention to improve the detection of this arrhythmia. Most primary care practitioners are confident in their ability to detect pulse irregularities and interpret 12-lead ECGs. For those practitioners that are not comfortable in ECG interpretation, referral to a specialist should occur.  

Once AF is identified, Corazon advises clients to establish a care pathway that incorporates both pharmaceutical and medical management, in addition to possible referrals for further testing and evaluation from specialists as needed. Patients in the early stages of the diagnosis and management of AF should first be seen by a cardiologist who would continue to work along with the primary care provider. For those needing advanced or complex evaluation, we suggest evaluation and discussion with an electrophysiologist. Patients referred to an AF clinic may only require a one-time consultation, while others may need further treatment and follow-up care. Despite the path followed, specialists must work closely with primary care providers to assure complete and accurate treatment as well as ongoing management of the condition.  

Summary

The prevalence of AF in the United States is likely to continue to increase significantly, especially with the aging population and improved survival rates of those with all types of cardiovascular disease. This condition will continue to significantly challenge the healthcare industry due to the high costs and resource utilization associated with care.  

With the implementation of new treatment and screening protocols as outlined here, AF patients should be able to be identified and placed into the appropriate treatment plans and protocols in order to not only reduce hospitalizations, but also to provide the best care. Only then will hospitals realize lower overall costs with improved care and better patient outcomes. 

Lorraine Buck is a Director at Corazon, Inc., a national leader in strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon offers a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems, and practices of all sizes across the country and in Canada. 

To learn more, visit www.corazoninc.com or call 412-364-8200. To reach the author, email lbuck@corazoninc.com.

References

1. Reynolds MR, Essebag V. Economic Burden of Atrial Fibrillation: Implications for Intervention. Am J Pharm Benefits. 2012;4(2):58-65.
2. Atrial fibrillation: the management of atrial fibrillation. Clinical guideline: Methods, evidence and recommendations. National Institute for Health and Care Excellence. Published June 2014. Available at: https://bit.ly/2Dsa29C. Accessed January 22, 2018.
3. Atrial Fibrillation Fact Sheet. CDC. Published August 22, 2017. Available at https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_atrial_fibrillation.htm. Accessed January 15, 2017.