Western AF Symposium 2023: Session 8 Roundtable

AF Clinics: Do You Want to be an "A or an F" Student?

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Featured is the Session 8 Roundtable entitled “AF Clinics: Do You Want to be an "A or an F" Student?” from WAFib 2023. 

Moderator: Thomas Deering, MD – Piedmont Healthcare, Medical College of Georgia 
Moderator: Melissa Middeldorp, MD, PhD – University of Adelaide 
Discussant: Cathie Biga 
Discussant: John Day, MD 
Discussant: Ahmad Abdul Karim, MD 
Discussant: Andre Gauri, MD 
Discussant: Rod Tung, MD

Thomas Deering, MD: We're ready to get started for the penultimate session. I appreciate all of you attendees coming to join us. We hope to have a very interactive and engaging session for you. It is called “Do You Want to be an A or An F Student in Terms of Atrial Fibrillation (AF) Clinics.” We have a distinguished panel, and since it's relatively long when we go through it, I'll have each one introduce himself or herself. But I do want to introduce Melissa Middeldorp, who is my cochair for this particular session. So let me get started. Rod Tung is in absentia, and we have an addition here. There are 4 things we want to talk about: the need for change and why AF clinics may be beneficial, what could happen with a multidisciplinary clinic, the role of APP clinics, and economic modeling. So, 4 topics in a half hour. We're going to move at rocket speed here. So let me start with the first one and then we'll go down the panel. I want you to send in your questions to us and also step up to the mic. I'm going to set the stage for about a minute for each one of these. We know that cardiovascular mortality is growing. We also know that the AF population is growing in incidence and prevalence, as is the heart failure population. These are 2 areas we deal with as electrophysiologists. However, the older population is actually becoming less. But when we look at those with AF, we all know that there is a significant overlap in the aging group. If we look at health care spending by group, you can see that over half of the health care spending, including for AF patients, is in those greater than 55 years, and most of our spending is in cardiovascular or oncologic treatment. So, we have an aging population and a higher disease prevalence and incidence. The question to the panel is, what do we need to do differently? We're thinking about AF clinics. They're a new concept. What have you learned by mistake? What have you done that's right? What do we need to change to be able to effectively deliver care given the shortage of doctors, APPs, nurses, personnel, and money? Let's go down the panel and introduce yourselves. I'll let you start us off, Melissa.

Melissa Middeldorp, MD, PhD: I'm Melissa Middeldorp, and I'm from Adelaide, Australia, and I'm currently in Los Angeles. So, I've learned a lot over the last year, in particular, being in the US. It’s a very different health care system. I think that one of the things that stands out to me is that while we're all dealing with the same patient population, we're dealing with very different health care systems. So, the implementation of these clinics can be very tricky. I'm also keen to hear what some of the other panelists who have some of these clinics are going have to say about how they've modeled their clinics. 

Thomas Deering, MD: We’ll get to that, but if I want you just to address what you think are our biggest needs, where these gaps are, and how we go forward.

Cathie Biga: Hi, my name is Cathie Biga, and I'm from Chicago. I work in a 2 different health care systems, Ascension and Advent. We have 14 hospitals that I help run their service line of 110 cardiologists, and the AF clinic is one of our multispecialty clinics that we started. The need is definitely there, and the void right now is that it needs to be team-based care. So, if you don't have a team-based care clinic, it's really, in my opinion, the only way to survive right now in the US with our payment model and our payment system in order to take care of these patients in the most cost-effective manner possible.

John Day, MD: Hi, my name is John Day. I traveled a long way to get here. I'm at a hospital here in Salt Lake City, at St. Mark's Hospital. Where we live, it's a very older population and a very white population, which means a lot of AF. Care is definitely a team sport, and a number of my team members are here at this conference. For us, the number one has been rapid access, getting our patients in as quickly as possible, as early in the disease process as possible, where we have the maximum impact on helping patients.

Ahmad Abdul Karim, MD: Hi, my name is Ahmad Abdul Karim. I'm an electrophysiologist in Chicago. I'm part of a community-based practice. We have about 70 cardiologists and 6 electrophysiologists. I feel that there's a significant need to have an AF clinic to shift management of AF patients through the outpatient. We have a significant number of patients with AF who are presenting to us. We should have an AF clinic to improve patient understanding of the disease and the treatment, and help integrate best practices in the management of AF. So, I really feel that it is imperative that we have an outpatient-based clinic to manage patients with AF, which is a complex disease.

Andre Gauri, MD: My name is Andre Gauri. I'm an electrophysiologist in Grand Rapids, Michigan, at Corewell Health, formerly Spectrum Health. We've been doing AF care, all of us at this meeting, for a long time. The question is, why do we need to change? Because the old model just doesn't work. We've seen so many talks today about getting early treatments, not letting disease progress, and modifying risk factors, all these things of a traditional model of the primary care doctor, the cardiologist, and the electrophysiologist, and not going right to a care model specialized for AF. So, that is the reason we need to change. 

Thomas Deering, MD: Thank you. So basically, we found that there's a need for teamwork, and that rapid access and early access is important. There's a need to get different people to do different things on the team, and things don't work because of the inefficiencies that exist in the system. Henry Ford said, “if I had asked people what they wanted, they would have said faster horses.” We don't want faster horses. We want to do something different. So, let me quickly go to the second of our 4 parts, the multidisciplinary approach. We all know that if you have sleep apnea that is treated around the time of ablation, your outcomes are better. We also know from the Australian group in Adelaide that if you use risk factor modification, you will also have better outcomes post ablation. If in addition to using that component you achieve success, as was shown with weight loss, you have better outcomes in terms of being arrhythmia free. If I were to say, this is a new technology that has been invented, and it looks like pretty good statistics for benefit and helping AF, many of you would say, what is it? I want to do it. Studies that have shown certain approaches are relevant. So, risk modification is a very important part. It is in our guidelines, as many of you already know. In fact, it's not just the North American guidelines. It's in the European guidelines, whereas you can see integrated management is an important and clear cut, clinically relevant consideration with a 2a indication. So, prevention is part of our 4 pillars. In this session, we're focusing on it as being the main pillar. Let's ask the panel. Melissa, would you go first? What are your thoughts on team-based care? Not the APPs, but team-based care. What works and what doesn't work? What have you learned from your mistakes? How would you make it better?

Melissa Middeldorp, MD, PhD: It's a good question. So, I think that one of the misconceptions of our clinic in Adelaide is that we have every single type of physician care needed within our clinic. This is not the case. All patients present to us with different risk factors. So, not all patients are going to require seeing a sleep physician. Not all patients are going to require an endocrinologist and not all patients are going to require that complete bundle of care. It's an individualized approach that needs to be made. The majority of our patients, as we've shown in our studies, are obese, and so that's one of the key factors that we address. With that comes improvement with blood pressure, diabetes, and cholesterol. So, I think that what our approach has been is to manage the individual patient with their risk factors alone, and then refer to those specialists that we need to create that multidisciplinary approach.

Cathie Biga: Our team-based clinic is multidisciplinary. The goal is to have everybody work at the top of their license. But right now, unless it is different for you, there is an enormous staffing shortage from medical assistants all the way to physicians, and a need to make sure everything is financially sustainable. So, in order to have our AF clinic be functional, we need to make sure that we are utilizing everybody and the payment methodologies as efficiently as we can. Also, I think having dieticians involved in the AF clinic is critically important. It is similar to the heart failure clinics that have different disciplines that help you approach the different preventative mechanisms that we can use for AF, as Tom mentioned.

John Day, MD: I like the team-based approach, and every team has a quarterback. Our quarterback is Sherry Fisher. She is our AF nurse coordinator. She makes everything happen in our AF clinic. We have, for example, an APP that does sleep apnea treatment in our clinic. She coordinates whether it's a dietician or bariatric surgery, or whatever the case may be, an individualized approach, because each patient has a different need. She coordinates the care. She makes all the trains run on time, and our goal is to try to get the patient in within one day.

Ahmad Abdul Karim, MD: Definitely, a team-based approach and coordinator are very important. We realized this after a while that we needed a coordinator to help being a liaison between all the different specialties and also between patients and hospitals, so that's very important. Having excellent nurse practitioners who understand the complexity of the disease—their skill in managing this complex disease is very important. As Cathie mentioned, there is a significant staffing shortage. This is one of the major problems that we've been having. We're all fighting over a limited number of skilled staff who are really good in managing this disease. Having sleep medicine and dieticians on board, and doing risk factor modification and alcohol reduction counseling is very important, as well as a relationship with cardiac rehab. So, try to get all other cardiologists on board. They have to buy into this. This is actually one of the major issues that we found, that we are shifting from a single-provider practice to a multidisciplinary approach. For example, you may have a cardiologist who shows some resistance at the beginning with “How am I going to give up my patients?” That's one of the challenges that we found at the beginning.

Andre Gauri, MD: I'll just quickly add that the team-based approach that we're all talking about is key. But the team is not just cardiology and EP. It's not just an AF clinic, it's an AF program. So, early on, having meetings with bariatrics, with sleep medicine, and having a partner in the program is crucial. You have all the building blocks, you have the nurse navigators, you've got your own EP cardiology team, but you must engage other people and have them buy in that this is the best way to modify this disease. That has been our secret—getting lots of people involved.

Thomas Deering, MD: A lot of good thoughts there. Having a diverse group, making sure that you build your team effectively with a quarterback or a train conductor, making sure it's financially stable, and engaging other folks. I know on our side, we don't do sleep apnea, we don't do weight reduction. It's not what EP doctors do. We trained our nurses or APPs and even our MAs to educate. We've engaged our sleep doctors. So, all the doctor has to do is go ahead and go. As my team said, we have it all set up and they handle it. 

Edward Gerstenfeld, MD: I wonder, we all obviously would love to have a team-based approach. It sounds good. You mentioned one thing is financial sustainability. The other is that patients come from all over; they're coming from Fresno or Sacramento, and they don't want to come back for 8 visits. But it's hard. If we send them to weight management, it might be 6 months for a visit. So, if you were anticipating setting up a clinic, does anyone have people all in the same place with a nutritionist and sleep apnea? How can you make that financially viable to the administration? Because if you try and pitch this, they may not want to support it if it can't be reimbursed.

Cathie Biga: Those administrators—they're awful, aren't they? Who invited them? So, the way that we do both our heart failure and AF care is with a lot of telehealth. With the PHE ending in May, we need to make sure telehealth will continue until 2024. If I remember it right, December 31st, 2024. So, that's really the way to get the outreach and those patients engaged. Also, using personal trainers who will Zoom works really well, especially with the elderly population. Even chair yoga for the elderly population works well. We refer. We know of them in the community. It would be great if we had them, we don't.

Thomas Deering, MD: Yes, we do the same thing—we don't employ. But we have a whole list of people that can be referred to.

Audience question: Are cardiothoracic surgeons a part of your team, and if so, what part? 

Andre Gauri, MD: We have a pretty robust hybrid ablation/Convergent program, so the surgeons are integral parts of that team. We used to do it quarterly but now we're doing it every 6 weeks, but we also have an AF heart team meeting. Having a heart team is the buzz word in coronary, vascular, and valvular heart disease, and it's now becoming much more prevalent in the AF world. We discuss cases with our surgeons on a regular basis, and we've got great buy-in with them, because surgeons approach AF doing Mazes and concomitant and other surgeries for AF. It's a class I indication. So, engaging the surgeons on what the proper procedure should be and getting virtual consults before they take the patients to surgery is something that we're developing now. But the surgeons are a key part of our AF program.

Nassir Marrouche, MD: A question to the panel. There are 2 components when I saw the title. Thank you for the great title, Tom. This is a great session. When I think about the AF clinic, it is what John was talking about—an efficient AF clinic. How do I get my patient in, manage them, and send them home? Ablate or cardiovert them? Part of that management strategy is monitoring the patient. We do 2-hour procedures and the team follows up with the patient. The lifestyle modification topic continues to come up every time we talk about it, and this is the first lecture that Prash presented here 10 years ago, and John explained to us the whole idea of your trip to China and what we need to do to avoid AF. That seems out of our control. We talk about it a lot. But we need to start building these cardiometabolic clinics to deal with these patients. I don't see it as an AF clinic problem, to be honest, at this stage. After all this data we have, this is a disease that must be focused on a specialized population to manage cardiometabolic syndrome, including sleep apnea. But for us, what I see in clinic, I need to worry about my patient management, monitoring them, getting the stress test on time, getting their MRIs on time, getting them ablated and followed up with after, and anticoagulate them to prevent the risk of stroke. But for everything else that you showed, we should send them to non-AF. Otherwise, it's becoming bigger and bigger. Every year we have the same discussion. I'm still waiting to see data on a successful clinic, and Prash was supposed to talk about why we don't have the clinics ready yet. That was his title this year, but he's in Australia. Hopefully, next year he will bring ideas of how to bring this into place. 

Cathie Biga: You bring up an excellent point, because we have all these separate clinics—cardiometabolic, resistant hypertension, AF, heart failure, and device. Here's my answer. The reason I think AF is different than cardiometabolic is that the cardiometabolic clinic actually works with our endocrinologists for the most part as it relates to that area, and the AF clinic tends to function or focus specifically on that disease entity. Now, I think the data is fascinating, and we have just designed our scorecard for metrics. So, looking at readmissions and lengths of stay, compliance, and those types of things—that's the kind of data that I think should be at these meetings to really prove that doing that focused clinic makes a difference in the 15- or 20-minute physician office visit.

Thomas Deering, MD: Anyone else want to weigh in on that?

Andre Gauri, MD: I'll just say we tried to send patients to a cardiometabolic wellness program and patients actually gained weight. So, it's really a big challenge. No one has a good answer for this. But once again, we're partnering with the bariatrics program. Not everyone goes and gets surgery, but they're the experts at this. They're the ones who know what's working, and there's so many new classes of drugs now, including GLP agonists. I don't want to be prescribing them, but I want my patients on them. So, we're partnering with bariatrics and developing pathways to get out of our AF clinic, where if their BMI is greater than 40 or whatever the cutoff point is, they get a direct referral to bariatrics, and a lot of them are going on these meds. It's not an “easy” button, but nothing else is working. So, I don't have an answer. John, you've done a lot of work with weight loss and talking about the benefits of that. What's your secret?

John Day, MD: I don't know if we have a secret, but I do agree with Nassir. We need more data. At our center, we've been very much focused on trying to essentially eliminate ER visits in the first month post procedure. By having an AF nurse coordinator working directly with these patients, giving her cell phone out to these patients, it is rare for us to have a patient show up in the ER. So, one thing we're looking at while collecting our data is looking at the readmission rate. If you look at the data, 7%-10% of our patients are seen in the ER in the first month post procedure, which is extremely high. Also, historically, a lot of the data we've published is looking, for example, at dementia and other long-term issues with AF. What we found in our clinics is that even if the ablation wasn't successful, their long-term risk of dementia and these other things were somehow lower than those managed by standard of care. So, there are a lot of points and I think we need to do a better job at documenting the role of this. There is a role. Patients who come through our clinic get better long-term outcomes, but it's hard to pin down. It's almost like you cannot pull out one ingredient of the recipe. It's the whole clinic approach that allows patients to have better outcomes.

Melissa Middeldorp, MD, PhD: I'm going to add to that. We have what we term the risk factor management clinic, because I think what you're saying is that the AF clinic should cover everything, and it is impossible for you as a physician to have a conversation about everything you'll be seeing in the clinic. Each patient will take you over an hour. You won't get through people. So, one is the risk factor clinic, one is the AF team management, which is run by physicians. The risk factor management clinic is run by either a fellow or a nurse or someone who specializes in AF care. I think that probably makes a difference. I know the models here in the US are different. It's tough, and I've seen that from my experience here. Dominik?

Dominik Linz, MD, PhD: Yes. When we think about outcomes, it's probably not just AF outcome in those patients who are ablated. So, I think once you start to assess in a structured way all the risk factors and if you put all of those noncontrolled risk factors into a cardiovascular risk factor calculation, then you will find that most of those patients are not just at high risk of getting AF again, but also of getting a lot of other cardiovascular complications. One thing that is always an eye opener for me is we actually do a CT before every AF ablation, and we almost never do not see calcification. So, almost all those patients have coronary calcification. If you just put this coronary classification in all those cardiovascular risk factor equations, then all of them are at least immediate or high risk. This is also a reason to take care of all those concomitant risk factors, because it's not just AF in those patients, it's also the other thing. Then it comes back to us AF doctors taking care of the risk factors. Probably not just us, right? Because it's also the GP, it is also a lot of other doctors who will see the patients much longer than we do. So, we actually see them in an intensive way around ablation. But in a normal clinic, it's probably maximum one-year follow-up, maybe shorter or a little bit longer. But actually, the cardiovascular risk grows afterwards. So, I think probably the one main role for us electrophysiologists is where we assess the risk factors and make the GP aware this is a patient not just experiencing AF but also at high cardiovascular risk. This is how we are approaching this as well. 

Thomas Deering, MD: Thank you, that was very helpful. Quick response to your comments, Nassir. We don't bring our stakeholders together into one big clinic, and we don't want to, because they overlap in all these areas. But we engage them—the sleep doctors, the people who manage hypertension, and people who have a focus on obesity. So, we send patients to them. We also use virtual, like Cathie said. The second thing that I think is very important is you cannot do everything at once. So, every year or every 2 years, put together a strategic plan. Line out what you're going to do. We cannot boil the ocean, but maybe you want to sail from Nantucket to Boston. The third thing that we do is we set up scorecards so we know where we're going. If we're not getting weight reduction or sleep apnea assessed, we know where we stand.

John Mandrola, MD: I'd like to ask the panel: I have this theory about culture. Is there some institutional role that we're going to do risk factors, we're going to treat holistically, we're going to manage weight loss? Because in my city of about a million people, there's 10 ablators and everybody's getting ablation. I see adverts for “ask your doctor about appendage closure” and “ask your doctor about early AF ablation,” but I don't hear much about the culture of risk factor management. I just wonder what you all think about that.

Cathie Biga: You're probably not going to like my answer. The bottom line is preventive cardiology is not reimbursed. I do think incentives matter. You see them in the private payor. How many of your insurances, if you have a BMI or you smoke, you pay an extra additive on your insurance? You don't see that in Medicare, and you'll probably never see that in Medicare, because Medicare patients vote for those people over in Washington, and until we have compliant patients who have ownership in some of this, much like we do with our private payor patients, I think that's a huge issue. 

John Day, MD: It's holistic care, and I think you talk about aligning incentives. If you treat the entire patient, you're going to get better outcomes and you're going to get a better reputation in the clinic. I will say that with our AF nurse coordinator working one-on-one with the patient, calling them the next day, giving their cell phone to the patient, and working with them on multiple areas of their life, we get better outcomes, they don't bother their referring physician, and the referring physician is happy. Now they're saying, “AF ablations really work,” because we're taking care of the entire patient.

Audience question: I hate to keep trashing our reimbursement system, but if you’re in a fee-for-service system, the best thing you can have is a patient who keeps coming back to the ER. If you look at heart failure, I bet all of us have a great HF program because the government doesn’t pay you and your patient keeps coming back to the hospital right away. So, if you had an AF patient come into the hospital and you didn't get paid the next time they came in, or if you did one ablation and they didn't pay you for the second one, everybody would suddenly be interested in keeping them out of the hospital and getting them to lose weight because we don't want to do a second ablation for free. So, I think there has to be a financial push here to make this all happen in a fee-for-service type system. 

Thomas Deering, MD: It is hard. You don't get reimbursed for it as an entity. But cardiovascular medicine, including AF, usually has a positive contribution margin, and we can look at it in this way, with better outcomes and better contribution margin. We don't have a chance to flush this out, maybe at the next session. Elaine, I know you've got a question.

Elaine Hylek, MD: I only have a comment about a phenomenon that I've been seeing in Boston. There is a downside, I think, for patients to have full access and full digitized records. What I've been seeing lately are patients who are very proactive and asking for their charts to be changed, such as smoking history and why it says heart failure. Because they feel that this is going to change their insurance premiums. I feel that as a physician community, we have to really grapple with this, because it's just unbelievable—the questions that people are starting to pose because they can see their record. They don't trust that it's HIPAA protected. They know that all kinds of teams are seeing their charts and the personal history of their ex-husband. It really is an incredible wave of dissatisfaction, so I just throw that out.

Thomas Deering, MD: I think that's a good point, Elaine. We have 19 seconds for our last panelist, Dr Rod Tung, who has arrived, so we'll let you have the last word on AF clinics. How do you become an A rather than an F student? You have 6 seconds.

Rod Tung, MD: One size fits all. 

Melissa Middeldorp, MD, PhD: That was a great discussion. Clearly, there was a lot to discuss on this topic, so we look forward to talking about it more later. Thank you. 

The transcripts have been edited for clarity and length.