Confronting Atrial Fibrillation With a Unique “Outpatient” Approach: The AF ER

At this time last year, could anyone have thought that the world would be facing a global pandemic caused by a novel coronavirus (COVID-19)? In consideration of this current shortage of hospital beds, now more than ever the healthcare industry as a whole needs to be mindful of unique ways in which we can safely care for various patients in the outpatient setting, saving hospital beds for those patients requiring more advanced levels of care. 

Relatedly, this brings us to the topic of atrial fibrillation (AF), which is the most-treated cardiac arrhythmia and a condition that places tremendous burden on the healthcare system. AF has been considered a key public health priority given its prevalence and strong association with cardiovascular morbidity and mortality.

Just the Facts

From 2007 to 2014, annual emergency room visits for AF increased by 30.7% (from 411,406 visits to 537,801), hospitalizations increased 15.7% (from 288,225 to 333,570), and hospital-related charges for patients admitted with AF increased by 37% (from $7.39 billion to $10.1 billion).⁵ Estimates reveal that 2.3 million adults in the United States have AF, and that number will increase close to 6 million by the year 2050. Most strikingly, the mortality rate in patients >65 years with incident AF was 19.5% within one year after AF presentation and 48.8% at five years. Other complications at five years included heart failure (13.7%), new-onset stroke (7.1%), and gastrointestinal hemorrhage (5.7%).^3,8   

These unfortunate statistics reveal that although AF is a cardiovascular condition, patients are oftentimes subsequently diagnosed with other conditions, so AF itself has the potential to affect both the cardiac service line and others in a hospital across various settings of care. Each year in the United States, more than 454,000 hospitalizations have AF as the primary diagnosis. In 2017, 166,793 patients had AF mentioned on their death certificates, with 26,077 of those having AF as the underlying cause of death.⁹  

The Challenge 

Although there have been multiple clinical and technological changes within the treatment of AF over the last decade, it remains an extremely difficult condition to treat in the short term and manage in the long term. For emergency medicine and general physician practitioners, atrial fibrillation remains the most common cardiac arrhythmia they manage. Many of these patients can be safely treated in the emergency department or by cardiologists (as opposed to general practitioners) without the need for hospitalization; however, there is significant variation in the overall treatment and management of the condition, especially for those presenting with acute atrial fibrillation. These differences in care happen across the country, varying by region, by hospital, and sometimes, by practitioner within the same hospital. 

In fact, some of the major challenges faced by physicians during this initial care phase include: 

• Incomplete understanding of the pathophysiology
• Increasing prevalence of AF
• Rate versus rhythm control as the primary management approach
• Methods of rate control and/or rhythm control
• Use of ancillary pharmacologic agents
• Anticoagulation 

Subsequent challenges include: 

• Defining therapeutic success
• Suboptimal use of antithrombotic therapy to assist in prevention of stroke
• The lack of efficacy of antiarrhythmic pharmacological agents 
• Adverse effects from the above treatment
• Effective ongoing management of this chronic condition 

All of these factors complicate not only the care delivery, but also the subsequent post-discharge plan for these patients, most of which are likely to have a recurrent acute episode or subsequent related conditions as outlined. 

Identifying the Need for Change

Because of the reasons noted above, the healthcare system continues to be plagued by patients being admitted unnecessarily, which drives inpatient care costs up above where they need to be. There is a 60-70% higher cost associated with those patients admitted with AF versus those without an inpatient stay.

However, there is also a vast majority of AF patients that present in the outpatient setting. In Corazon’s experience, if these patients are not identified and referred in a timely manner, they experience delayed treatment, which has high potential to result in negative outcomes, increased healthcare costs, and not to mention, patient dissatisfaction. However, we believe that providers have a variety of opportunities to reconsider traditional AF treatment and instead implement new strategies in order to avoid inpatient hospitalization without compromising quality outcomes. Such thinking may possibly even enhance quality and the patient experience. 

An Innovative Example

At Naples Heart Rhythm Specialists, P.A. (NHRS), the leadership made a decision approximately two years ago to try a new and different approach for their AF patients. As a team of board-certified cardiac electrophysiologists, Kenneth Plunkitt, MD, FACC, FHRS and Andrew Yin, MD took a progressive outpatient approach to managing AF. The anticipated results of this change included decreasing the burden on the healthcare system, cutting costs, improving overall patient satisfaction and outcomes, and minimizing complications secondary to inpatient admissions. 

This private cardiology practice is staffed by four physicians (two board-certified in nuclear cardiology and two in electrophysiology) and eight advanced practice providers (APPs). All of these highly trained physicians and APPs are on staff at Physicians Regional Medical Center, a nearby 101-bed acute care facility located in Naples, Florida. Traditionally, with new-onset AF, many patients present to the emergency room, at which time the ER physicians manage these patients with rate versus rhythm control mainly due to resource requirements in the ED. Many of these patients are consulted by an electrophysiologist and then seen as an inpatient in order to identify the appropriate treatment options beyond the immediate care provided upon arrival during the acute episode.

However, the team began to consider what might happen if an innovative strategy was put in place — one that would appropriately classify patients based on clinical presentation in order to minimize patients being sent to the emergency room for AF evaluation and follow-up. This outpatient program would also assist general practitioners who attempt to manage these patients, but who at times are hesitant when confronted by continually evolving evidenced-based protocols being published based on patient presentation. This brainstorm led Drs. Plunkitt and Yin to develop what they called the “AF ER”. While this is not a separate physical emergency room space for AF patients, this approach is instead a means to describe a specific care program that offers emergent consultative and treatment options to general practitioners on an outpatient basis when seeing patients with acute-onset atrial fibrillation. 

A Preventative Medicine Approach 

First, it is important to understand the different classifications and definitions of AF, as they lead to different treatment and management protocols. These classifications are defined as follows: 

• Paroxysmal AF is self-terminating, lasting less than a week. Nicknamed “holiday heart syndrome,” it may follow a bout of heavy drinking or periods of extreme stress, as is seen around the holidays. 
• Persistent AF is not self-terminating and usually lasts longer than a week. It may stop on its own, or may need to be treated with medications or electrical cardioversion. 
• Long-standing persistent AF lasts longer than a year and does not go away. Because medications and electrical cardioversion may not stop the AF, treatment may lead to ablation. 
• Permanent chronic AF cannot be corrected by treatments; therefore, the goal is focused on rate control and reducing the odds of having a stroke. 

The focus of this novel approach was initially on acute AF patients seen by general practitioners, meaning those that needed to be seen, evaluated, and treated within 48 hours of arrhythmia onset for optimal outcomes. This included using evidenced-based care to appropriately initiate anticoagulation therapy as indicated, attempting to terminate the arrhythmia as quickly as possible (as this correlates with increased success of converting patients out of AF), and initiating strategies to prevent future recurrence. 

Initiating an AF ER 

While an AF ER might not be right for every organization, this concept is gaining traction as a means to more consistently regulate the care of a patient population that has traditionally been plagued with misdiagnoses, treatment delays, and a lack of timely ongoing follow-up. Depending on AF case volume and the overall treatment plans in place for patients, organizations may not have the staff to implement this approach. Electrophysiologists typically drive these programs, but without this subspecialist(s) on staff, hospitals should consider identifying a progressive cardiologist who can drive treatment plans and protocols that include EP referrals to outside facilities, depending on patient clinical presentation.

Corazon recommends focusing on the following factors when considering the development of an outpatient treatment plan related to the diagnosis and rapid treatment of AF patients (Figure 1).

To launch the program, the physicians and staff at NHRS initially focused on general education and marketing specifically targeting referring general practitioners. Numerous “lunch ‘n’ learns” and open meetings were held, with an EP physician participating along with marketing personnel from the practice. The goal: to provide specific AF education to groups of general practitioners in order to fine-tune their diagnosis skills as well as their ability to make treatment decisions. During these educational/marketing meetings, the physicians would be provided with business cards, pens, and tablets that included a direct phone number, which addressed the communication/access issue. This has proven to be a successful way to spread the concept. 

The practice added a “direct contact” iPhone manned by one of the clinicians, providing expert clinical support at all times. This direct, toll-free number is used for new-onset, symptomatic, high-priority AF consults. The clinician triages the call from the referring provider and is given a time for the patient to report to the office for a same-day consultation; more often than not, they are instructed to come to their office directly from the referring physicians. 

Regarding patient management/flow, patients that need to be seen are referred to the practice supervisor, who begins the process of contacting the referring physician’s office to obtain all necessary medical records, demographics, and insurance information. This information is directly faxed to their electronic medical record (EMR) and/or brought with the patient. Patients are entered into the color-coded scheduling system, which alerts the staff to the reason for the visit, thereby prioritizing the urgency. Simultaneously, the office staff works to obtain appropriate insurance authorization. If the patient becomes unstable at any point during this process, they are immediately referred to the emergency department. 

The practice keeps at least one board-certified EP in the office, along with four to five APPs during normal business hours to accommodate these same-day patient consultations. With this staffing, the office has been able to successfully absorb the additional strain these patients put on the clinic without too much difficulty. The exception arises with late afternoon referrals or when multiple AF ER referrals occur in a day. 

Outcomes 

Patient satisfaction has been pivotal in standardizing the concept with the referring physicians. When a patient is able to be seen and treated right away without incurring prolonged time in the ED and possibly the hospital, the burden on the healthcare system is drastically reduced. This allows the emergency room and hospital to better utilize space and physician/staff resources for urgent, unstable patients to be treated. Hospital staffing is less stressed and healthcare costs are minimized, all while reducing the risk to patients related to nosocomial infections and complications. Additionally, established patients with a smartwatch app can turn on heart rate notifications that enable irregular rhythm notifications. This information can be sent to the practice for appropriate evaluation and follow-up, possibly eliminating the need for an initial first visit completely. 

With more and more success stories, referring physicians have become quick to support the concept, making the practice the “first call” made for known or suspected AF patients. When beginning this program, the typical AF patient volume referred to the practice was approximately one per month. Now, NHRS is seeing one to two of these patients daily. 

Conclusion

There is no doubt that managing AF patients in specialty clinics can reduce the incidence of AF-related hospitalizations as well as strokes, while also having a significant positive impact on patient outcomes. NHRS has taken an individualized focused approach to care by developing a unique direct referral process that serves to quickly evaluate and rapidly implement an individualized treatment plan, which includes patient education, medication management, and follow-up to improve outcomes and decrease costs. 

In the words of Kenneth Plunkitt, MD, FACC, FHRS: “To streamline the care is our goal. Preeminent doctors delivering state-of-the-art care has always been our mission statement. AF ER is merely a form of vertical integration of this process as it pertains to the AF model. It prevents costly ER visits and improves patient access issues in this very unpredictable disease course. AF is often spontaneous with very little warning. Access is key. Now, we can achieve all of this and more within 24 hours. In my opinion, 90% of new-onset AF cases can be treated in this outpatient vertically integrated manner, and at as least as high a quality too.”

Disclosures: The authors have no conflicts of interest to report regarding the content herein.

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