The Swedish Comprehensive Atrial Fibrillation Network: A Programmatic Approach to Care in a Large Urban Hospital System

The Swedish Comprehensive Atrial Fibrillation Network (SCAN) began out of a need to not only facilitate care of atrial fibrillation (AF) patients at our institution, but also acknowledge and apply the growing body of evidence supporting risk factor modification (RFM) in improving AF care.¹

Our program was generously funded by the John L Locke Charitable Trust, a charitable trust emphasizing supporting cardiovascular research and patient care in the greater Seattle/Puget Sound region.

The program as it is currently configured has 3 components:

1. SCAN program: Patient and caregiver education, protocol development incorporating current best practices, programmatic data collection, and coordination with key noncardiology services, particularly sleep medicine and weight loss services.

2. AF clinic: An outpatient clinic prioritizing referrals from primary care providers, emergency departments (ED), and patients needing expedited follow-up for AF after hospital discharge.

3. Left atrial appendage occlusion (LAAO) program: A centralized portal to facilitate evaluation of patients referred for, and who would benefit from, LAAO for stroke prophylaxis.

SCAN Program

The original concept for the SCAN program was an outpatient clinic focusing on RFM and medical optimization of patients prior to catheter ablation. Over time, the vision broadened to become a structure with the same fundamental philosophy, from which specific programs and efforts could be coordinated. The prelaunch development team included the SCAN medical directors, the program’s advanced registered nurse practitioner (ARNP), the registered nurse (RN) program coordinator, and a cardiovascular data architect, with valuable contributions from other interested stakeholders in the institution. This team was responsible for formulating the vision of the program, writing educational materials for patients, and meeting with physician partners from sleep medicine, endocrinology/weight management, and ED.

Patient education and engagement is key to successful treatment, and we wanted to be able to give all new patients to the program a booklet that not only answered frequently asked questions about AF, but also articulated our specific philosophy around patient engagement and RFM. The level of engagement in their medical care for individual patients runs the gamut from frank indifference through abdication of responsibility to highly focused involvement. For all of these patient types, it was important that we explain why we took this approach and the data supporting it. We wanted our patients to understand that medications and procedures, including ablation, were not alternatives to their participation and effort on behalf of their own health. The value of diet and exercise, weight management, blood pressure control, glucose control, and treatment of obstructive sleep apnea (OSA) in improving outcomes from AF ablation, or even reducing the need for ablation at all, is well substantiated.^2-6 By providing patients with this information, including a bibliography, our hope is that we can specifically improve outcomes for AF as well as overall cardiovascular health.

To this end, we met regularly with interested physicians in both sleep medicine and bariatrics who were enthusiastic in helping develop protocols that would screen appropriate patients for referral as well as expedite evaluation of those patients by departments that were already stretched thin for resources. Both OSA and obesity can be touchy topics with patients, and we knew that every day of delay before a patient was contacted and seen would lead to loss in follow-through.

A data architect/statistician was brought on board as part of the program early on to help identify meaningful data points to track and provide measurable real-time feedback on the success of the program. We wanted to track not only patient characteristics (demographics, referral source, AF type, duration, CHA₂DS₂-VASc score, LA volume and size, and medical comorbidities), but also programmatic outcomes such as time to first appointment, anticoagulant and antiarrhythmic use, referrals to other specialties, referrals for ablation or other procedures, etc. A clinic template was developed in Epic to include specific data fields and smart phrases for structured reporting.

In cooperation with the ED, recommendations for emergency management of acute AF were developed and distributed. This serves as a “cheat sheet” for ED providers regarding cardioversion, anticoagulation, rate control, antiarrhythmic use, etc, as well as contact numbers to reach the on-call cardiologist and electronic medical record referral codes to the AF clinic.

The AF Clinic

As with many high-volume urban medical centers, there is a struggle to keep up with patient demand. This proved to be true even during the worst phases of the COVID-19 pandemic. Given the ever-growing number of AF patients, the limited bandwidth for new patients into general cardiology and the electrophysiology (EP) clinic was generating significant frustration from both patients and referring providers. To address this specific need, a dedicated AF clinic was developed. The focus of this clinic is expedited outpatient evaluation and follow-up of new AF patients referred by primary care providers, EDs, and hospital-based providers with a target of 1 week for hospital/ED follow-up and 2 weeks for outpatient referrals from primary care. Patients from primary care and EDs are especially important, as expedited outpatient evaluation can be the key in avoiding unnecessary inpatient admissions for stable patients. By providing early outpatient follow-up for hospitalized patients who did not already have a cardiologist, we hoped to not only shorten length of stay, but also ensure that individual patients did not fall through the cracks while awaiting new patient appointments in the cardiology clinic.

New patients to the clinic are seen first by the medical assistant, who is responsible for gathering the appropriate medical records and completing initial check-ins, including vitals, medication lists, and STOP-Bang assessment for OSA.⁷ The patient is then seen by a clinic physician or advanced practice clinician (ARNP or physician assistant), who will perform a standard history and physician examination, discuss goals and plans, and initiate workup as appropriate (echocardiogram, stress testing, etc). Patients with a body mass index (BMI) over 35 are encouraged referral to weight loss services, and patients with a STOP-Bang score of 3 or more are encouraged referral to sleep medicine. Subsequently, patients may be followed in the AF clinic, but those who require additional specialized cardiovascular services or consultation will be referred on to general cardiology or the EP service as appropriate.

Our RN program coordinator is the key contact for ongoing coordination with outside providers, screening of incoming referrals, patient inquiries via the web portal, organization of educational programs, and coordination with hospital management and public relations/market development.

The LAAO Program

At our institution, Watchman (Boston Scientific) and Amulet (Abbott) implantations are performed by physicians from both the structural heart program and EP service. Many LAAO referrals come directly to the implanting physicians, but for those that do not, the LAAO program serves as a central contact point for patient inquiries and physician referrals. These referrals are preliminarily screened by the RN program coordinator, with advice from the medical directors as appropriate. They are then distributed as equally as possible among the 4 implanting physicians, taking into account specific patient characteristics and needs that may favor one specialty over another. The program also manages the LAAO database and tracks these patients, ensuring that necessary preoperative evaluation is documented, postimplant transesophageal echocardiograms are scheduled, etc.

Conclusions, Pearls, and Pitfalls

Much of the preparatory work was completed during the COVID-19 shutdown in 2020, with opening of the AF clinic in July 2021. At present, clinic hours are half days from Monday through Friday. To date, we have seen 230 new patients and 450 total visits, with a median referral to first visit time of 8 days. Figure 1 shows current clinic demographics, suggesting that our referral base, primarily ED, and primary care is tilted toward more recent diagnosis in generally younger patients than are seen for AF in our general cardiology or EP clinics. A conscientious effort has been made to refer patients with a BMI over 35 to weight loss services and STOP-Bang over 3 to sleep medicine (Figure 2). We recognize that given the size of the program, we are unlikely to have the statistical power to demonstrate improvement in hard end points such as AF events, strokes, or mortality, but do hope that over time, our data will confirm improved adherence to best practices in AF management.

Overall, we have been very pleased with the success of the program. That said, as a word of caution based on our early experience, it is worth mentioning that for clinicians used to focusing on direct patient care, opening even a small, focused clinical practice within a large established health care system was far more complex than at least the medical directors were prepared for. As with many things in modern medicine, coordination with information services and human resources was a necessary but time-consuming process, and the complexity and frustration of “creating” a new clinic within both Epic and the physical world cannot be understated. Nothing was as simple as it should have been.

Fortunately, payer coverage for clinic visits has proven to be less of an issue than we predicted. We verify coverage before scheduling new patients in clinic. However, an ongoing daily challenge is medication cost, especially for direct oral anticoagulants, which are now a first-line recommendation over warfarin.

To date, we have limited industry involvement in the program. This is in large part to avoid patient and referral provider perception of program bias and industry collusion. While we have certainly found some industry-supplied educational resources and materials to be helpful, industry has been most eager to offer “promotional and consultative” support, rather than the one thing we really need, which is less expensive medications.

Patient ambivalence about both sleep medicine and weight loss services was expected, but remains vexing. Positioning these referrals as either a stick or a carrot depends on the patient, and the messaging is crucial.

Respecting established referral patterns and sensitivities has required some cautious navigation. With new patient wait times of up to 6 months for some busy cardiologists, our intent with the AF clinic was to be a resource and a relief. Nonetheless, until we made the clinic’s goal clear, we were regarded by some as competition.

Acknowledgements. The authors would like to acknowledge the following for their invaluable contributions to the SCAN program’s development and ongoing success: Sally Alfred, ARNP; Jenna Behrman, PA; Christie Craig, RN; Marja Dempsey, ARNP; Jen Farrell, RN; Bob Fletcher; Junvic Obaob. 

For more information, please visit: www.swedish.org/locations/swedish-afib-clinic

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Zivin reports support from the John L Locke Charitable Trust for financial support for the SCAN program, AF clinic, and related staffing and medical directorships; he also reports consulting fees from Philips and Medtronic, and speaking fees from Boston Scientific.

References

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