Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective

Abstract

Atrial fibrillation (AF) remains an important global problem.1Chugh S.S. Havmoeller R. Narayanan K. et al.Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study.Circulation. 2014; 129: 837-847Crossref PubMed Scopus (1733) Google Scholar, 2Guo Y. Tian Y. Wang H. Si Q. Wang Y. Lip G.Y.H. Prevalence, incidence, and lifetime risk of atrial fibrillation in China: new insights into the global burden of atrial fibrillation.Chest. 2015; 147: 109-119Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 3Zulkifly H. Lip G.Y.H. Lane D.A. Epidemiology of atrial fibrillation.Int J Clin Pract. 2018; 72e13070Crossref PubMed Scopus (24) Google Scholar AF continues to lead to poor health outcomes, including reduced quality of life (QoL) and increased risks of heart failure, cognitive impairment, stroke, and death.4January C.T. Wann L.S. Alpert J.S. et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.Circulation. 2014; 130: 2071-2104Crossref PubMed Scopus (1124) Google Scholar,5Kirchhof P. Benussi S. Kotecha D. et al.2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.Eur J Cardiothorac Surg. 2016; 50: e1-e88Crossref PubMed Google Scholar Moreover, it has a significant financial impact on health care systems and their associated economies.6Kim M.H. Johnston S.S. Chu B.C. Dalal M.R. Schulman K.L. Estimation of total incremental health care costs in patients with atrial fibrillation in the United States.Circ Cardiovasc Qual Outcomes. 2011; 4: 313-320Crossref PubMed Scopus (398) Google Scholar, 7Sheikh A. Patel N.J. Nalluri N. et al.Trends in hospitalization for atrial fibrillation: epidemiology, cost, and implications for the future.Prog Cardiovasc Dis. 2015; 58: 105-116Crossref PubMed Google Scholar, 8Coyne K.S. Paramore C. Grandy S. Mercader M. Reynolds M. Zimetbaum P. Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States.Value Health. 2006; 9: 348-356Abstract Full Text PDF PubMed Scopus (307) Google Scholar In order to improve care for patients with AF, there is an increasing recognition that current care must evolve. Health care organizations should move from a system of siloed outpatient and inpatient clinicians and health care facilities to a system of integrated, coordinated, and patient-centered AF centers. The goal of an AF “center of excellence” (CoE) is to improve outcomes by providing a better patient experience and delivering high-quality, guideline-recommended, state-of-the-art care. This manuscript builds on the work of a diverse, multiple-stakeholder Think Tank meeting and multidisciplinary Interpro Forum educational activity held in January 2019, both led by the Heart Rhythm Society (HRS). When examining the current clinical landscape, the Think Tank concluded that there is a clear need for AF CoEs to improve AF care and its delivery. In this manuscript, HRS hopes to accelerate this evolution by reviewing the rationale for AF CoEs, the available evidence for integrated and multidisciplinary care, and future challenges and opportunities. The document also defines the key priorities to be used as a guide for HRS and its diverse stakeholders to build consensus on defining the core components of an AF CoE. AF is the most common arrhythmia throughout the world.1Chugh S.S. Havmoeller R. Narayanan K. et al.Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study.Circulation. 2014; 129: 837-847Crossref PubMed Scopus (1733) Google Scholar, 2Guo Y. Tian Y. Wang H. Si Q. Wang Y. Lip G.Y.H. Prevalence, incidence, and lifetime risk of atrial fibrillation in China: new insights into the global burden of atrial fibrillation.Chest. 2015; 147: 109-119Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 3Zulkifly H. Lip G.Y.H. Lane D.A. Epidemiology of atrial fibrillation.Int J Clin Pract. 2018; 72e13070Crossref PubMed Scopus (24) Google Scholar Demographic trends with an aging population, higher rates of associated comorbidities that predispose to AF, and improvements in detection and treatment9Healey J.S. Alings M. Ha A. et al.Subclinical atrial fibrillation in older patients.Circulation. 2017; 136: 1276-1283Crossref PubMed Scopus (96) Google Scholar, 10Sanna T. Diener H.C. 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Jang E. et al.Increasing trends in hospital care burden of atrial fibrillation in Korea, 2006 through 2015.Heart. 2018; 104: 2010-2017Crossref PubMed Scopus (28) Google Scholar especially among noncardiovascular clinicians, are widely prevalent across all geographies.18Kirchhof P. Nabauer M. Gerth A. et al.Impact of the type of centre on management of AF patients: surprising evidence for differences in antithrombotic therapy decisions.Thromb Haemost. 2011; 105: 1010-1023Crossref PubMed Scopus (69) Google Scholar For example, the majority of patients with known AF who experience an acute ischemic stroke have not received adequate anticoagulation.19Leyden J.M. Kleinig T.J. Newbury J. et al.Adelaide stroke incidence study: declining stroke rates but many preventable cardioembolic strokes.Stroke. 2013; 44: 1226-1231Crossref PubMed Scopus (86) Google Scholar,20Bjorck S. Palaszewski B. Friberg L. Bergfeldt L. Atrial fibrillation, stroke risk, and warfarin therapy revisited: a population-based study.Stroke. 2013; 44: 3103-3108Crossref PubMed Scopus (159) Google Scholar Failure to adhere to evidence-based practice guidelines leaves the public vulnerable to morbidity and mortality that could be avoided. The increased incidence and prevalence of AF also produce a significant economic burden for health care systems and for society as a whole,6Kim M.H. Johnston S.S. Chu B.C. Dalal M.R. Schulman K.L. Estimation of total incremental health care costs in patients with atrial fibrillation in the United States.Circ Cardiovasc Qual Outcomes. 2011; 4: 313-320Crossref PubMed Scopus (398) Google Scholar, 7Sheikh A. Patel N.J. Nalluri N. et al.Trends in hospitalization for atrial fibrillation: epidemiology, cost, and implications for the future.Prog Cardiovasc Dis. 2015; 58: 105-116Crossref PubMed Google Scholar, 8Coyne K.S. Paramore C. Grandy S. Mercader M. Reynolds M. Zimetbaum P. Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States.Value Health. 2006; 9: 348-356Abstract Full Text PDF PubMed Scopus (307) Google Scholar,17Kim D. Yang P.S. Jang E. et al.Increasing trends in hospital care burden of atrial fibrillation in Korea, 2006 through 2015.Heart. 2018; 104: 2010-2017Crossref PubMed Scopus (28) Google Scholar requiring more health care resources21Blomstrom Lundqvist C. Lip G.Y. Kirchhof P. What are the costs of atrial fibrillation?.Europace. 2011; 13: ii9-ii12Crossref PubMed Scopus (15) Google Scholar, 22Wodchis W.P. Bhatia R.S. Leblanc K. Meshkat N. Morra D. A review of the cost of atrial fibrillation.Value Health. 2012; 15: 240-248Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 23Thrall G. Lane D. Carroll D. Lip G.Y. 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Modifiable risk factors and atrial fibrillation.Circulation. 2017; 136: 583-596Crossref PubMed Scopus (152) Google Scholar Effective management of these comorbidities requires the expertise of other medical disciplines and the participation of multiple health care providers, including allied health care professionals. On occasion, AF care may become focused solely on the management or restoration of sinus rhythm while the other aspects of AF may be neglected. In other cases, patients with AF are managed by noncardiovascular specialists who may have difficulty staying up to date on guideline-directed treatment of AF. It is our belief that a patient-centered, multidisciplinary, and integrated model of care can address all aspects of AF in a manner that should create greater value by improving clinical outcomes and decreasing costs.26Deshmukh A. Patel N.J. 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Alpert J.S. et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.Circulation. 2014; 130: 2071-2104Crossref PubMed Scopus (1124) Google Scholar,5Kirchhof P. Benussi S. Kotecha D. et al.2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.Eur J Cardiothorac Surg. 2016; 50: e1-e88Crossref PubMed Google Scholar,28Connolly S.J. Ezekowitz M.D. Yusuf S. et al.Dabigatran versus warfarin in patients with atrial fibrillation.N Engl J Med. 2009; 361: 1139-1151Crossref PubMed Scopus (7405) Google Scholar, 29Patel M.R. Mahaffey K.W. Garg J. et al.Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.N Engl J Med. 2011; 365: 883-891Crossref PubMed Scopus (5737) Google Scholar, 30Granger C.B. Alexander J.H. 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Albert N.M. et al.Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 61: 1935-1944Crossref PubMed Google Scholar,45Gattellari M. Worthington J. Zwar N. Middleton S. Barriers to the use of anticoagulation for nonvalvular atrial fibrillation: a representative survey of Australian family physicians.Stroke. 2008; 39: 227-230Crossref PubMed Scopus (96) Google Scholar and disjointed health care systems all limit the adoption of evidence-based approaches. The establishment of effective quality improvement programs has improved rates of appropriate OAC for eligible stroke-reduction patients to >95%.46Piccini J.P. Xu H. Cox M. et al.Adherence to guideline-directed stroke prevention therapy for atrial fibrillation is achievable.Circulation. 2019; 139: 1497-1506Crossref PubMed Scopus (10) Google Scholar Similar variation exists in coordinating effective rate and rhythm control approaches and in maximizing procedural outcomes. These prevailing circumstances create an important opportunity to improve care in a significant way. Discrepancies in care delivery as a result of race, ethnicity, and sex also have resulted in differences in patient education, clinic access, OAC treatment, antiarrhythmic drug therapy, and ablation.47Heidbuchel H. Dagres N. Antz M. et al.Major knowledge gaps and system barriers to guideline implementation among European physicians treating patients with atrial fibrillation: a European Society of Cardiology international educational needs assessment.Europace. 2018; 20: 1919-1928Crossref PubMed Scopus (16) Google Scholar, 48Bhave P.D. Lu X. Girotra S. Kamel H. Vaughan Sarrazin M.S. Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation.Heart Rhythm. 2015; 12: 1406-1412Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 49Vinereanu D. Lopes R.D. Bahit M.C. et al.A multifaceted intervention to improve treatment with oral anticoagulants in atrial fibrillation (IMPACT-AF): an international, cluster-randomised trial.Lancet. 2017; 390: 1737-1746Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar By establishing programs focused on minimizing these disparities, we believe there is an important opportunity to improve the quality and equality of care and thereby improve outcomes for patients with AF. The existing uncoordinated manner in which AF risk factors (eg, hypertension, diabetes, obesity, sleep apnea, etc) and comorbidities are treated results in greater AF progression and untoward cardiovascular outcomes.50Ruigomez A. Johansson S. Wallander M.A. Edvardsson N. Garcia Rodriguez L.A. Risk of cardiovascular and cerebrovascular events after atrial fibrillation diagnosis.Int J Cardiol. 2009; 136: 186-192Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,51Jani B.D. Nicholl B.I. McQueenie R. et al.Multimorbidity and co-morbidity in atrial fibrillation and effects on survival: findings from UK Biobank cohort.Europace. 2018; 20: f329-f336Crossref PubMed Scopus (0) Google Scholar Randomized trials utilizing a multidisciplinary, integrated AF clinic approach to AF management, with a focus on risk factor management, have resulted in reductions in wait times for specialist assessment, emergency department visits, hospitalizations, and mortality.52Hendriks J.M. de Wit R. Crijns H.J. et al.Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation.Eur Heart J. 2012; 33: 2692-2699Crossref PubMed Scopus (189) Google Scholar The development of these clinics requires expert staff, collaboration, and special resources that carry significant costs. These requirements limit the widespread initiation of these centers. There are four main pillars in the clinical management of AF. These pillars include 1) risk factor management, 2) stroke prevention, 3) rate control, and 4) rhythm control. The goal of AF CoEs is to deliver these crucial pillars of care while providing a better patient experience by delivering patient-centered, high-quality, guideline-recommended, and state-of-the-art treatment. An important first step in creating an AF CoE is the identification and referral of patients who would benefit from integrated and specialty care. While an important goal is for all patients to have access and benefit from these centers, at present this remains an aspirational goal. The unique paradigms and health economics of different health care systems have implications on who can be treated in such centers. However, centers should have a systematic method of identifying at-risk patients who have AF. At-risk patients might include those with risk factors, those not receiving guideline-directed therapy, or those whose risk factors are not adequately or completely treated. Identification of patients who can benefit from integrated and specialty care inherent to an AF CoE can also help ensure that adequate resources can be appropriated to AF clinics. AF CoEs also should have systematic methods of outreach to persons with AF in the community, including educational programs and initiatives to improve awareness of AF. Development of a comprehensive AF CoE requires appropriate staffing and dedicated clinic(s) that focus on the care of patients with AF. Centers should commit to multidisciplinary and broad-based development. Centers may choose to start by addressing specific aspects of the four pillars of care. Some centers may choose to concentrate their initial efforts on patient access to AF clinics, while others may focus on patient selection for ablation or on stroke prevention. Similarly, the development of specific clinical personnel may vary. Nonetheless, relying on a single clinician to manage AF patients is no longer a feasible model in most, if not all, health care systems across the world. As clinician burdens continue to increase, providing comprehensive AF care is best accomplished through a team-based approach. This requires identification, referral, and management of patients with AF in a coordinated fashion. Of particular importance is timely access to care when patients are acutely symptomatic. These patients may present to urgent care, the emergency room, primary care, or cardiology clinics. Additionally, pathways and systems are needed to help ensure continuity of care as patients progress through these care encounters. Alternatively, newly diagnosed asymptomatic AF patients, or those with AF and a rapid ventricular rate, may be discovered in preoperative settings, outpatient clinics, or at home with wearable patient monitors or smartphone-based or direct-to-consumer applications. Appropriate triage in these settings has the potential to minimize unnecessary emergency room visits, hospitalizations, and testing and improve patient satisfaction. This triage may be enhanced by direct phone access to knowledgeable staff, such as an appropriately trained nurse or medical assistant in an AF clinic. Same-day or next-day appointments are frequently required to avoid hospitalization. These appointments are intended to provide guideline-directed management of AF. Having appropriately trained nurses, advanced practitioners, clinical pharmacists, and technicians who can assist physicians to manage patients allows for patients to be seen in a timely manner. For patients presenting to the emergency room, protocols for triage and outpatient management can lead to reductions in hospitalizations and positive outpatient outcomes.53Stiell I.G. Clement C.M. Perry J.J. et al.Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter.CJEM. 2010; 12: 181-191Crossref PubMed Google Scholar,54Vandermolen J.L. Sadaf M.I. Gehi A.K. Management and disposition of atrial fibrillation in the emergency department: a systematic review.J Atr Fibrillation. 2018; 11: 1810Crossref PubMed Google Scholar Long-term management of AF is most efficiently accomplished with coordination between all clinicians, including nurses, advanced practitioners, cardiologists, electrophysiologists, and primary care physicians. Availability of various types of practitioners may vary throughout the world, and the optimal approach may vary by region. CoEs should provide and excel at fundamental AF management, including assessment and implementation of stroke prevention, rate and rhythm management, and risk factor modification. CoEs with electrophysiologists can also provide specialized management options, including initiation and/or adjustment of antiarrhythmic therapy, catheter ablation, and cardiac implantable electronic devices (CIEDs). Primary care physicians must also play an important role in CoEs through engaging patients for assessment and management of noncardiac comorbidities that often drive AF progression as well as ensuring early initiation of anticoagulation upon AF diagnosis in patients at risk. Development of a comprehensive and integrated care team is important to provide patient care along a continuum and in different settings (see Section 4). Patients with AF have multiple touch points within the health care system that are often highly varied across physical geographies, virtual interactions, specialties, and time (Figure 1). Coordinating the activities of all of these health care staff so they are efficient and patient-centered is important when designing integrated AF care programs. Coordination of team members and establishing goals of care are necessary in order to maximize outcomes and avoid inefficiency and miscommunication. Team members should have defined roles and responsibilities within the comprehensive AF program. Preestablished workflows and order sets can allow for standardization of care across providers in the hospital and clinic setting. All management is influenced by patient-specific factors and preferences. Management pathways for stroke risk assessment and treatment, rate control, perioperative anticoagulation bridging, weight loss, treatment of sleep apnea, antiarrhythmic drug initiation, and catheter ablation are just a few examples of care pathways that may be beneficial in the standardization of care for patients with AF. Open lines of communication also are required. Patient care information needs to flow seamlessly and bidirectionally between emergency room/hospital, AF clinic, cardiology office, and primary care. A well-integrated electronic medical record (EMR) can be an engine for team coordination and facilitate team-based care standardization. While the EMR can facilitate access to information, standardization of clinical AF data and reporting would help facilitate coordination of care, particularly between health care systems. AF care coordinators can also help facilitate communication and coordination of care. Administrative support is critically important to ensure that adequate resources are available for development of an AF program. It is also the most important rate-limiting step in most institutions. Necessary resources include provision of staffing, dedicated clinic space, database and registries to track guideline adherence and outcomes, and team coordination. Data from many AF centers have shown that reductions in AF-related admissions, reductions in cardiovascular events, and improvements in patient satisfaction more than justify the operational expenses inherent to an integrated AF program (Table 1). Since most health care systems have resource limitations, initial efforts in a CoE may focus on important gaps and interventions that are less resource intensive.Table 1Evidence for integrated and multispecialty atrial fibrillation (AF) care teamsStudyDesignIntervention groupComparatorPrimary endpointHendriks et al 201252Hendriks J.M. de Wit R. Crijns H.J. et al.Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation.Eur Heart J. 2012; 33: 2692-2699Crossref PubMed Scopus (189) Google ScholarRCT: 712 pts, 67y, 41% female; mean FU 22 months; single center; outpatient department new-onset AF ptsNurse-led care with guideline-based, software-supported, integrated care supervised by cardiologist: integrated comprehensive careUsual careComposite of CV hosp. and CV death 14.3% vs 20.8% (nurse-led vs usual care), HR 0.65 (95% CI 0.45–0.93); P = 0.017. CV death in 1.1% vs 3.9%, 0.28 (0.09–0.85); P = 0.025. CV hosp. 13.5% vs 19.1%, 0.66 (0.46–0.96); P = 0.029Stewart et al 201595Stewart S. Ball J. Horowitz J.D. Marwick T.H. et al.Standard versus atrial fibrillation-specific management strategy (SAFETY) to reduce recurrent admission and prolong survival: pragmatic, multicentre, randomised controlled trial.Lancet. 2015; 385: 775-784Abstract Full Text Full Text PDF PubMed Google Scholar (SAFETY)RCT: 335 pts, 72y, 48% female; mean FU 30 months; multicenter;pts hospitalized for AFHome visit and Holter monitoring 7–14 days after discharge by nurse with prolonged FU and multidisciplinary support as needed: comprehensive careUsual careACM and all-cause hosp. 76% vs 82% (interventi