Quality Initiative in Indiana Focuses on Evidence-Based Guidelines for AFib Treatment

Hospital leaders throughout Indiana are collaborating on a new initiative to elevate care for atrial fibrillation (AFib) patients.

The Indiana Atrial Fibrillation Initiative helps hospitals consistently apply the six evidence-based measures of the American Heart Association’s Get With The Guidelines^®-AFib quality improvement program.

“We want to have an impact on atrial fibrillation care because the condition is so pervasive,” said Gregory Poe, the American Heart Association’s (AHA) Director of Quality and Systems Improvement. “As facilities recognize how many cases of AFib they have, it highlights the importance of adherence to recommended treatment guidelines.”

The AHA provided financial support to launch the initiative in Indiana in 2017 with recruitment and accumulation of baseline information. Data through 2018 is being collected, measured, and compared to assess impact of the guidelines.

AFib, which is the most common sustained arrhythmia,¹ affects 2.7 to 6.1 million people in the United States. With an aging population, the number is expected to increase.²

In addition, AFib causes more than 750,000 hospitalizations and contributes to an estimated 13,000 deaths annually.^3,4 The death rate from AFib — as a primary or contributing cause — has been rising for more than two decades.^2,3

Participation and Expectations

Participating hospitals share the structure and objectives of existing AFib programs, collecting data using the Get With The Guidelines-AFib Patient Management Tool.

A representative from each institution is typically a clinical nurse or nurse manager associated with atrial fibrillation, a quality improvement manager, or a physician who serves as an internal champion for the initiative. The members meet every other month to review data, look for opportunities to improve the inpatient setting, and share best practices.

The six measures for the structured, data-driven system are:

1. ACE/ARB/ARNi prescribed prior to discharge (EF <40)
2. Assessment of thromboembolic risk factors
3. Beta-blocker at discharge (EF <40)
4. CHA₂DS₂-VASc risk score documented prior to discharge
5. PT/INR planned follow-up documented prior to discharge for warfarin
6. Statin at discharge for AFib patients with CAD, CVA/TIA, or PVD

From the baseline data, three measures emerged as clear priorities:

• ACE/ARB/ARNi prescribed prior to discharge (EF <40)
• CHA₂DS₂-VASc risk score documented prior to discharge
• Statin at discharge for AFib patients with CAD, CVA/TIA, or PVD   

Early on, the data showed that hospitals were scoring lower than expected on those measures. The CHA₂DS₂-VASc risk score was identified as the greatest opportunity for improvement.

Best practices discussed during the meetings include hard stops in the EHR, a greater focus on CHA₂DS₂-VASc by multidisciplinary committees, spot audits at hospitals, and additional education for physicians.

Dr. Richard Otten, an electrophysiologist with Parkview Health in Fort Wayne, Indiana, is a “big proponent” of documenting the CHA₂DS₂-VASc risk score. “The score helps us to make a joint decision about whether or not to prescribe anticoagulation therapy,” Otten said. “And if not, to document the reason why. That higher stroke risk is the worst thing about AFib, so it’s valuable to document the CHA₂DS₂-VASc score.”

Participating hospitals set a goal of seeing measurable changes by the fourth quarter of 2018. So far, the initiative has collected data for the first three quarters of 2018, and partial data for Q4. The efforts are already showing promise in some participating hospitals.

Angela Raymer, program coordinator at Parkview Heart Institute in Fort Wayne, said they recently began educating emergency department staff and physicians on using a quick reference sheet to create more standard AFib care that guides clinicians on determining the CHA₂DS₂-VASc score and how to apply that number. The sheet also reminds them to document the patient’s score.

Robin Eads, an advanced practice nurse in the arrhythmia clinic at Franciscan Health Indianapolis, said the best practices she’s integrating are improving efficiency by speeding up conversations, referrals, and appropriate treatment.

From July to September, CHA₂DS₂-VASc score reporting at St. Mary Medical Center in Hobart, Indiana nearly doubled, said Lisa Leckrone, Director of Quality and Risk. She attributes the increase to the recent education efforts, particularly those focusing on electrophysiologists, cardiologists, hospitalists, and ED physicians.

Ablation as an Additional Focus

A secondary focus of the initiative is best practices for using cardiac ablation versus pharmacotherapy. Ablation is traditionally a second-line strategy for patients who have tried medications to treat arrythmia without success, experienced serious side effects from medication, have certain types of arrythmia that respond well to ablation, or have a high risk of complications from their arrhythmia.⁵ However, ablation is increasingly a first-line therapy in selected AFib patients.

The initiative will help hospitals proactively manage patients, regardless of the treatment path.

“We are striving to identify and treat those patients with AFib — whether with medication or ablation — right away, as soon as it’s diagnosed,” Poe said. “In the past, AFib was often viewed as a secondary condition to heart failure or other heart condition. We are trying to shift that perspective. Instead of viewing AFib as an adjunct condition, we want it to be seen as a primary condition that needs to be managed aggressively right from the beginning.”

Support for such thinking is growing.

“Over the years, management of symptomatic atrial fibrillation has continued to evolve,” said Dr. Gopi Dandamudi, past medical director of cardiac electrophysiology at Indiana University (IU) Health and past director of the IU Health Atrial Fibrillation Center. “Pulmonary vein isolation has become the cornerstone of ablation therapy. In highly symptomatic paroxysmal atrial fibrillation patients, an early ablation strategy appears to confer good outcomes in maintaining sinus rhythm, thereby precluding the use of long-term antiarrhythmics.”

Looking Ahead

Many of the hospitals’ AFib programs are in their infancy, so participants are collaborating to learn best practices.

If the participating hospitals ultimately show improvement in the six measures by the time the initiative is scheduled to conclude, the AHA may disseminate best practices to other areas of the country.

Widespread adherence to these measures could reduce the risk of stroke in AFib patients. More than one in six ischemic strokes can be traced to AFib.⁶ In people 80 and older, the proportion jumps to one in three.⁶ In addition, strokes that stem from AFib-related clots carry a higher risk of permanent brain damage or death than other ischemic strokes.⁶

Brianne Plewke, AFib coordinator at St. Vincent Evansville Hospital, hopes the program makes a difference in Indiana and beyond, noting that atrial fibrillation “is a real problem across the country — people are undiagnosed.” 

Brett A. Halbleib is a freelance life sciences writer and editor based in Indianapolis, Indiana.

1. Atrial Fibrillation Fact Sheet. U.S. Centers for Disease Control and Prevention. Available at https://bit.ly/2jyUpBV. Accessed October 5, 2018.
2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: Executive Summary. J Am Coll Cardiol. 2014;64(21):2246-2280.
3. Healthcare Cost and Utilization Project (HCUP). Weighted national estimates. HCUP National Inpatient Sample. 2012. Available at http://www.hcup-us.ahrq.gov. Accessed January 4, 2018.
4. About Multiple Cause of Death 1999-2011. U.S Centers for Disease Control and Prevention, CDC WONDER online database. 2014. Available at http://wonder.cdc.gov/mcd-icd10.html. Accessed January 4, 2018.
5. Cardiac Ablation. Mayo Clinic. Available at https://mayocl.in/2jVN8f5. Accessed October 5, 2018.
6. Stroke Risk When You Have Atrial Fibrillation. Harvard Heart Letter. Harvard Health Publishing, Harvard Medical School. Available at https://bit.ly/2SAV9Wc. Accessed October 5, 2018.