Building a Comprehensive Atrial Fibrillation Clinic: Rationale and Implementation

Atrial fibrillation (AF) is the most commonly encountered cardiac arrhythmia in clinical practice, and is a major cause of morbidity, mortality, and healthcare expense. The diagnostic and therapeutic approach to AF has changed drastically over the last decade, and it has become increasingly clear that AF is a heterogeneous disease process well-suited to an individualized treatment approach.

Thus, there is increasing interest in establishing clinical frameworks designed to facilitate a more tailored approach to patients with AF, and in this spirit, we recently constructed and launched the Comprehensive Atrial Fibrillation Clinic at Piedmont Heart Institute (PHI).

The rationale for creating an AF clinic is based on several perceived benefits: improved overall quality of care and outcomes, better patient access to providers and resources, standardization and more uniform practice patterns, reduced healthcare utilization and costs, multidisciplinary and cross-disciplinary collaboration, and a more robust research and innovation ecosystem.

Our first task was identifying physician and advanced practice provider (APP) champions, both from within the cardiac electrophysiology section as well as from other specialties. Identifying and involving key stakeholders early is essential for the momentum and success of any large-scale project, and this proved to be the case as we sought to drive our AF clinic forward.

Key stakeholders in these early stages included general cardiologists, emergency medicine providers, hospitalists, internal medicine subspecialists, and various health system administrators. Open discussion and dialogue was facilitated with these stakeholders before implementation of any clinical pathway or systematic change, with the understanding that the success of the program would ultimately depend on buy-in from everyone involved. Understanding potential roadblocks and points of resistance is crucial at these early stages, and care should be taken to modify the structure of the clinic based on feedback from providers that would be directly referring patients to the AF clinic.

Another key priority was recruitment of an AF clinic coordinator. We anticipated from the start that the complexity of our AF clinic would increase exponentially over time, both due to rising patient volumes and increasing logistical complexity. Therefore, a dedicated clinic coordinator is crucial to ensure that the program remains efficient and capable of handling increasing demands over time.

Next, we focused on creating a clinical pathway designed to reduce the number of unnecessary hospital admissions for AF through the emergency department. This required the creation and implementation of several clinical tools, including an AF clinic referral order in the EMR system (“Ambulatory Referral to the AF Clinic”), and a clinical decision-making algorithm for ED providers.

Our design allows for a direct referral to the AF clinic from any touchpoint within the health system, with assurance that each patient referred will be seen by an EP APP or MD within 72 hours. We found it crucial to make the referral process as simple and straightforward as possible, and in our EMR, a referral order to the AF clinic can now be generated by simply typing “atrial fibrillation,” “Afib,” “A-fib,” or “AF” into the order section of the patient’s chart.

Each patient presenting to the emergency room with either a primary or secondary diagnosis of atrial fibrillation is thus routed to the AF clinic during initial intake, and subsequent to this, the treating physician in the emergency department decides whether the patient merits hospital admission or ED discharge based on the AF treatment pathway.

Goals in the ED may include restoration of sinus rhythm by means of direct current cardioversion, initiation of oral anticoagulation, acute rate control (ideally with oral and not intravenous agents), and discharge with either beta or calcium channel blockers for ongoing rate control. As a result, the AF ED treatment algorithm allows for the rapid triage and management of patients with atrial fibrillation, with the goal of reducing hospital admission unless clearly warranted.

The goals of a specialty clinic should always include improved patient outcomes, and in this particular case, a personalized approach to patient management as well. Quality improvement is ensured by standardizing those elements of care that have proven a clear-cut benefit in the majority of patients, such as prescription of oral anticoagulants when warranted, ensuring consistent and adequate rate control during episodes of AF, and mitigation of risk factors associated with AF initiation and progression.

The EMR system at our institution allows for the creation of clinical documentation templates specific to the AF clinic, and these templates include elements that ensure that the above-mentioned quality metrics are addressed during each patient visit. For example, a provider seeing a patient in the AF clinic cannot close the patient encounter without first: calculating a CHA₂DS₂-VASc score for that individual, addressing the need for an oral anticoagulant and then prescribing one when warranted, filling out a STOP-BANG questionnaire and then referring the patient for sleep apnea evaluation when indicated, and addressing whether the patient has been prescribed appropriate agents for rate control. Generally, the goal should be to incorporate management and diagnostic pathways developed by broad-based stakeholder groups emphasizing best practices derived from published guidelines.

We have had to make ongoing modifications and alterations to our AF clinic note template, but standardizing documentation in this way is very useful to ensure consistency and promote high-quality patient care.

The availability of an AF clinic streamlines the overall referral process for atrial fibrillation, which means that patients should be more efficiently directed to electrophysiology for advanced AF treatment options. This should also translate to fewer individuals being seen in a delayed manner once they have developed more advanced or progressive disease. Since it has become evident that both antiarrhythmic drugs and catheter ablation result in better rhythm control outcomes when instituted early rather than late in appropriate candidates, we anticipate that our clinic will ultimately lower the total burden of persistent or permanent atrial fibrillation at our institution.

Patient care is optimal when individual specialties do not operate in silos (ie, when there is free collaboration between specialties). Our AF clinic brings together a multitude of specialties and health-centric programs, with an emphasis on evidence-based, multidisciplinary treatment strategies.

With an emphasis on screening for sleep-disordered breathing, our sleep medicine colleagues have worked with our clinic staff to streamline the referral process and minimize the time interval between presentation to the AF clinic and testing for obstructive sleep apnea when warranted. For instance, one quality initiative would be screening and then treating patients for obstructive sleep apnea before presentation for catheter ablation, if that is the strategy felt most appropriate to achieve rhythm control.

We have also received enthusiastic support from the Wellness Center at our institution, which makes it possible for motivated patients to receive exercise prescriptions, nutritional counseling, and personal fitness training at no cost to them. The downstream systematic healthcare savings of this type of program remain to be determined accurately due to the recent creation of our AF clinic, but it would be hard to imagine that patient outcomes would not be improved by this type of relationship with our fitness and wellness colleagues.

Finally, since there is mounting evidence of a gender gap in AF outcomes and treatments offered, we sought to create a close relationship with the PHI Women’s Heart Program. Women seen in our AF clinic are offered a referral to this unique program during initial intake, and our goal is to carefully track outcomes longitudinally to ascertain whether a support network such as this can close or narrow the gender gap in AF.

It is imperative to prioritize outcomes tracking prospectively, both to ensure that an AF clinic is meeting its pre-defined goals, and also to ensure that it is evolving appropriately over time. Outcomes tracking also facilitates a more robust and useful framework for both retrospective and prospective research projects, which should also be a key component of an AF clinic. We have made it a priority to engage with our industry partners to bring a multitude of AF research trials to the Piedmont Heart Institute, and a well-designed and efficiently run AF clinic makes adoption and implementation of research protocols much more seamless. Diligently tracking outcomes also provides opportunities for investigator-initiated research protocols, and if an AF clinic increases institutional patient volume as expected, participation in multicenter clinical trials is also more likely to occur.

Atrial fibrillation is a heterogenous and progressive disease process, and is well-suited to a personalized treatment approach. A dedicated AF clinic provides a multitude of benefits to both patients with AF and the health systems managing them, and implementation of such a clinic will likely become the standard of care in the future. Immediate goals for any institution building such a program should include engaging physician and APP “program champions”, recruiting an AF clinic/program coordinator, building a simple and efficient referral process, and implementing clinical pathways designed to minimize inefficiencies and reduce unnecessary healthcare utilization.

Attention should then be turned to establishing strong collaborative ties with specialists and institutional programs that can manage risk factors, such as sleep medicine, wellness and nutritional programs, women’s heart programs, general cardiologists, and cardiothoracic surgery. Finally, it is important to conceive of an AF clinic as an evolving entity that should foster innovation and research, and always incorporate updated evidence and best practices.

Disclosures: The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Deering reports research activities with institutional payment but no personal financial conflict (Abbott, Aziyo, Boston Scientific, Medtronic, BIOTRONIK, Milestone, Biosense Webster), an advisory/speaking role (Aziyo, CVRx, PaceMate, Preventice), and support as a clinical trial AE reviewer (Abbott).