Health care utilization in a nurse practitioner–led atrial fibrillation clinic : Journal of the American Association of Nurse Practitioners

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Quantitative Research

Health care utilization in a nurse practitioner–led atrial fibrillation clinic

Meyer, David B. BS (Medical Student)1; Larkins, Michael C. BS (Medical Student)1; Taha, Omar BS (Medical Student)1; Seiler, Amber MSN, NP-C FHRS (Adult geriatric NP, Specializing in Cardiology)2; Booth, Sheryl MHA (Executive Director of Heart and Vascular Services)2; Hokanson, Robert B. BA (Sr. Clinical Research Program Manager)3; Allred, James MD, FACC (Cardiologist, Director of Electrophysiology)2

Author Information
Journal of the American Association of Nurse Practitioners: October 2022 - Volume 34 - Issue 10 - p 1139-1148
doi: 10.1097/JXX.0000000000000779
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Abstract

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia, estimated to affect more than 33.5 million people worldwide, including between 3 and more than 9 million in the United States, 8.8 million in the European Union, and 3.9 million in China (Chugh et al., 2014; Miyasaka et al., 2006; Naccarelli et al., 2009; Williams et al., 2017). With the rapid aging of the global population, and with age being among the most powerful predictors for developing AF (Benjamin et al., 1994; Lloyd-Jones et al., 2004), the incidence and prevalence of AF are expected to more than double by 2030–2050 (Miyasaka et al., 2006; Naccarelli et al., 2009). This represents a significant health care challenge given that AF is associated with increases in stroke risk and severity (Kannel et al., 1998), mortality and risk of sudden death (Chen & Alonso 2014; Lubitiz et al., 2013; Miyaska et al., 2006), and heart failure (Carlisle et al., 2019), along with impaired quality of life (QOL) (Witassek et al., 2019).

The primary treatment goals for patients with AF are to prevent thrombosis and reduce the risk of stroke, control heart rate to improve ventricular filling time, restore the heart to sinus rhythm, and relieve AF symptoms to improve patient QOL. Recently, lifestyle modification or risk factor management, such as weight loss, exercise, decreasing blood pressure, smoking cessation, and alcohol abstinence, and management of conditions like obstructive sleep apnea and diabetes have also been used to improve outcomes in AF patients (Abed et al., 2013; Lau et al., 2017; Pathak et al., 2015) and have been included in updated consensus statements for the management of AF (Calkins et al., 2017).

Beyond the patients' clinical experience of AF, the symptomatic presentation of the disease can increase health care utilization, including costly emergency department (ER) visits and hospital admissions. Atrial fibrillation management has an estimated annual direct cost of $26 billion in the United States, with an even greater impact projected in low-income and middle-income countries (Freedman et al., 2021). Costs associated with complications related to AF, such as stroke and embolic events, can be mitigated through early diagnosis. Inadequate disease management can compound these issues by necessitating additional health care utilization, which further increases the financial burden (Wolowacz et al., 2011).

Due to the growing number of affected patients, complexity of the disease, and significant cost burden, modern innovative approaches to managing AF patients are warranted. Recent guidelines highlight the importance of an integrative approach to AF management, using collaborative multidisciplinary teams and comprehensive treatment strategies that include previously underused elements such as lifestyle modifications (January et al., 2019). However, there are few operational examples to guide centers wishing to establish such approaches in AF care. Improvements in outcomes in both heart failure and AF patients support this recommendation (Gallagher et al., 2017; Holland et al., 2005; Phillips et al., 2005). A common element of the integrative care approach is the utilization of nurse-led, physician-supervised, specialty clinics designed to optimize patient management and disease treatment, an approach that has proven to be effective for improving patient care and outcomes in disease states (Bruggink-André de la Porte 2007; Carter et al., 2016; de Souza et al., 2014; Gillis et al., 2008; Hendricks et al., 2012; Lowery et al., 2012; Manoj et al., 2019; Rush et al., 2019; Thompson et al., 2005).

A meta-analysis investigated the use of NPs to treat patients with cardiovascular disease, with low to moderate evidence for a lack of statistically significant difference in outcomes of NP-led versus traditional health care (Smigorowsky et al., 2019). Furthermore, NPs have been identified collectively as valuable and impactful in both acute and critical care settings (Kleinpell et al., 2019). In the realm of pediatric acute care cardiology, for instance, incorporation of NPs was associated with reduced postoperative length of stay (Willis et al., 2020). Given the impact NPs can have in other similar areas of medicine, it is of interest to determine the potential impact of using NPs to treat and manage AF.

Accordingly, a dedicated nurse practitioner (NP)–led AF clinic (NPAFC) was implemented as a free-standing clinic within a private hospital setting to standardize a comprehensive AF care strategy. This study aimed to evaluate patient utilization of the AF clinic and its impact on patient care and outcomes in an integrated not-for-profit network of health care providers in the United States.

Methods

Hospital/atrial fibrillation clinic organization

An AF clinic was designed to serve as an independent clinic for standardizing patient care across a regional hospital system, organized independently from a hospital within this system. A dedicated NP (one full-time equivalent [FTE]) was the primary provider for the AF patients within the clinic, one FTE-certified medical assistant provided additional support, and registration support was shared with an advanced heart failure clinic.

Patient selection and treatment/management approach

Patients ≥18 years referred for AF by a general practitioner or specialist to the outpatient department were eligible. Self-referral was also accepted. During the NPAFC intake, the NP documented the patient's medical history, including conditions such as sleep apnea, hyperlipidemia, hypertension, and diabetes. The practitioner reviewed the pathophysiology of AF, the symptoms associated with the disease, findings from any diagnostics, and treatment options. Lifestyle modification discussions were also performed, including discussion on the importance of regular exercise, weight reduction, and tobacco and alcohol cessation. Guideline-directed medical management was provided by the NP according to the clinical pathway as outlined in Figure 1 (Calkins et al., 2017). The decision regarding the use of antiarrhythmic medicine, rate versus rhythm control, and referral for ablation were made by the NP. No patients seen in the NPAFC were followed solely by NP before being seen; patients treated in the NPAFC were subject to NP judgement with physician consultation and oversight. Oversight was provided by supervising electrophysiology physicians through chart review and by providing consultation through phone. All patients referred for ablation were evaluated by the electrophysiology physicians before the procedure. Patients were referred by primary care, cardiology, electrophysiology, hospitalists, or ER providers from both ambulatory and hospital locations. Referral pathways and health care utilization post AF clinic included cardiovascular surgery, bariatric surgery, an advanced heart failure clinic, a device clinic, the ER, an electrophysiology laboratory, and pharmacy. Patients were offered same-day urgent appointments when needed and longitudinal follow-up visits, with management in conjunction with primary care, cardiology, and electrophysiology. The protocol for referrals from the ER is noted in Figure 2.

F1
Figure 1.:
Atrial fibrillation clinic management pathway. AAD = antiarrhythmic drug; AF = atrial fibrillation; AVN = atrioventricular node; DCCV = direct current cardioversion; ICD = implantable cardioverter defibrillator; OAC = oral anticoagulant; NOAC = novel oral anticoagulant; PPM = permanent pacemaker; PVI = pulmonary vein isolation.
F2
Figure 2.:
Emergency room referral protocol. ACS = acute coronary syndrome; AF = atrial fibrillation; AFL = atrial flutter; ARF = acute respiratory failure; CHF = congestive heart failure; CV = cardioversion; DOAC = direct oral anticoagulant; ECG = electrocardiogram; ER = emergency department; PE = pulmonary embolism; PNA = pneumonia; SBP = systolic blood pressure.

A primary goal of the NPAFC was to follow-up with patients within three days after discharge from the ER to assure appropriate care consistent with evidence-based guidelines and serve as a resource to patients and referring providers. The dedicated, multidisciplinary team comanaged patients with a new onset or primary diagnosis of AF by providing rate/rhythm control, symptom management, education, pharmacological cardioversion, and treatment referrals (Figure 1). For many patients, ongoing follow-up in the NPAFC was planned in collaboration with the patient's primary cardiology physician.

Lifestyle modification was also integrated into patient management, with a focus on weight loss, nutrition, exercise, smoking cessation, decreasing/eliminating alcohol consumption, improving sleep time and quality, lowering blood pressure, and controlling diabetes. A free nutrition class was offered, and education packets were provided to patients. Referrals to sleep apnea management clinics, bariatric surgery, primary care, diabetes management, and smoking cessation were also made available.

Study design

This is an observational cohort evaluation of patients enrolled in the NPAFC, examining feasibility and patient outcomes before and after the implementation of the comprehensive NPAFC care model in a regional hospital system in the United States. The primary outcomes (hospitalizations and ER visits) were evaluated 2 years (720 days) before NPAFC enrollment and two years after enrollment. This study was certified exempt by the hospital-based institutional review board that this study was affiliated with.

Baseline measures and clinic outcomes

Baseline patient demographics obtained following admission to the NPAFC include age, sex, body mass index (BMI), left ventricular ejection fraction, left atrial (LA) size, CHA2DS2-VASc score, years with diagnosed AF, AF classification, and comorbidities as outlined in Table 1. Patient care before AF clinic presentation, as well as referral pathway, were also collected to characterize outcomes following admission. These AF clinic outcomes include the number of clinic appointments per patient, interventions (i.e., medication changes, lifestyle modification, pharmaceutical cardioversion, and treatment/referrals), and patient outcomes. In addition, the outcomes included hospitalizations/ER visits before and after admission to the NPAFC and ER visits avoided. Avoided ER visits were evaluated for up to 2 years after clinic implementation. These visits were defined as an urgent same-day appointment request that under standard practice triage would have been directed to the ER but instead NPAFC referral was recommended, and patients were admitted same day to the NPAFC.

Table 1. - Baseline patient demographics
n = 1,442
Age, years (mean ± SD) 69 ± 13
Male sex, n (%) 778 (54%)
BMI, kg/m2 (mean ± SD) 31 ± 7
LVEF, % (mean ± SD) 56 ± 9
LAD, mm (mean ± SD) 41 ± 7
Creatinine, mg/dL (mean ± SD) 1.12 ± 1.08
CHA2DS2-VASc score (mean ± SD) 3 ± 2
Years with diagnosed AF (mean ± SD) 4 ± 4
AF classification/arrhythmia indication, n (%)
 Paroxysmal AF 652 (45.2)
 Persistent AF 629 (43.6)
 Permanent AF 80 (5.5)
 Reported palpitations 12 (0.8)
 Atrial flutter 62 (4.3)
 PVCs 3 (0.2)
 Atrial tachycardia 4 (0.3)
Comorbidities, n (%)
 Hypertension 1,030 (71.4)
 Obstructive sleep apnea 392 (27.2)
 Diabetes 340 (23.6)
 Previous stroke/TIA 204 (14.2)
 Obesity 51.7%
Note: AF = atrial fibrillation; BMI = body mass index; CHA2DS2-VASc = congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65–74 years, sex category (scores range from 0 to 9, with higher scores indicating greater stroke risk); LAD = left anterior descending; LVEF = left ventricular ejection fraction; PVCs = premature ventricular contractions; TIA = transient ischemic attack.

Statistics

Categorical variables were summarized as counts and/or percentages. Continuous data are reported as mean and SD. Baseline information and relevant medical history were summarized. The primary outcome measures (hospitalizations and ER visits) were defined as a binary dependent variable representing whether the patient had the occurrence before or after admission to the AF clinic. A McNemar test was used for hospitalizations and ER visit pre and post clinic analysis. p values < 0.05 were considered significant. All of our analyses were conducted with Minitab 18.1 (2017; Minitab, LLC).

Results

Patient demographics

A total of 1,442 patients (68.7 ± 12.6 years, 54% male, 41 ± 7 mm LAD, 31 ± 7 kg/m2 BMI) were admitted to the NPAFC between January 2016 and June 2018. Patients had been diagnosed with AF for a mean of 4 ± 4 years. Most patients had paroxysmal AF (45.2%) or persistent AF (43.6%), while 5.5% had permanent AF. A total of 4.3% had atrial flutter as the diagnosis prompting referral. Hypertension was the most common comorbidity (71.4%), followed by obesity defined as BMI ≥ 30 (51.7%), obstructive sleep apnea (27.2%), diabetes (23.6%), and previous stroke or transient ischemic attack (14.2%). Baseline characteristics of the patients are presented in Table 1.

Patient interventions and care at atrial fibrillation clinic entry

Baseline patient care including previous interventions at the time of the first AF clinic visit are summarized in Table 2. Most patients had a primary cardiologist (71.8%), and 64.1% of patients had an electrophysiologist. As part of our integrated approach, careful and frequent communication with the patient's primary care and cardiology physicians was provided to keep practitioners informed and involved in their patients' care. Consultation by the NP with the patient's primary electrophysiologist was performed when needed.

Table 2. - Baseline patient care and interventions at AF clinic entry
n = 1,442
Patient care, n (%)
 Patients with primary cardiologist 1,036 (71.8)
 Patients with electrophysiologist (AF ablation) 700 (48.5)
 Patients with electrophysiologist (non-AF ablation) 225 (15.6)
Previous AF interventions, n (%)
 Ablation 429 (29.8)
 DCCV 688 (47.7)
 TEE 435 (30.2)
 Maze 74 (5.1)
AF clinic referral pathway, n (%)
 Cardiologist 451 (31.3)
 Electrophysiologist 605 (42.0)
 Primary care provider 70 (4.9)
 Triage 40 (2.8)
 Post anesthesia care unit 2 (0.1)
 Cardiac rehabilitation 1 (0.1)
 Neurology 1 (0.1)
 Self 22 (1.5)
 Emergency department 250 (17.3)
Type of AF clinic visit, n (%)
 Newly diagnosed 60 (4.2)
 Scheduled 1,114 (77.3)
 Newly diagnosed and scheduled 268 (18.6)
Note: AF = atrial fibrillation; DCCV = direct current cardioversion; TEE = transesophageal echocardiography.

Of the AF interventions performed before AF clinic admission, direct current cardioversion (DCCV) was the most common with 47.7% of patients having had at least one instance of CV. Transesophageal echocardiography and AF ablation had been performed in 30.2% and 29.8% of patients, respectively. A total of 5.1% of patients had a previous Maze procedure. Most referrals to the NPAFC were from an electrophysiologist (42.0%) or cardiologist (31.3%), and visits were primarily scheduled (77.3%) rather than acute.

Nurse practitioner–led atrial fibrillation clinic outcomes

Outcomes for patients managed in the AF clinic are presented in Table 3. The mean number of appointments per patient was 3 ± 3 (median = 2). Lifestyle modification was initiated by the clinic in 86.9% of patients, making it the most common AF management approach used. This included education from the NP and NPAFC staff. A free nutrition class was offered, and education packets were provided to patients. Referrals to sleep apnea management clinics, bariatric surgery, primary care, diabetes management, and smoking cessation were also made when indicated.

Table 3. - AF clinic management outcomes (n = 1,442)
AF clinic appointments per patient (mean ± SD) 3 ± 3
Lifestyle modification discussions, n (%) 1,253 (86.9)
Pharmaceutical cardioversion, n (%) 4 (0.3)
Medication changes per patient (mean ± SD) 1 ± 1
AAD/anticoagulation usage in clinic, n (%)
 AAD 655 (45.4)
 OAC (warfarin) 220 (15.3)
 NOAC (Xarelto, Eliquis, Pradaxa, Savaysa) 1,038 (72.0)
Patients with ≥1 ER visit pre-AF clinic, n (%) 318 (22.1)
Patients with ≥1 ER visit post-AF clinic, n (%) 66 (4.6)
Patients with ≥1 hospitalization pre-AF clinic, n (%) 435 (30.2)
Patients with ≥1 hospitalization post-AF clinic, n (%) 95 (6.6)
Patients with ≥1 ER visit avoided, n (%) 328 (22.7)
AF clinic-initiated interventions, n (%)
 AADs 51 (3.5)
  Tikosyn 41 (2.8)
  Amiodarone 2 (0.1)
  Sotalol 4 (0.3)
  Flecainide 4 (0.3)
 Patients with ≥1 DCCV scheduled 160 (11.1)
 PVI Referral 121 (8.4)
 Atrial flutter ablation referral 7 (0.5)
 Implantable loop recorder referral 11 (0.8)
 Maze referral 12 (0.8)
 Occlusion device (Watchman) 1 (0.1%)
AF clinic referrals made, n (%) 25 (1.7)
 Bariatric surgeon 4 (0.3)
 Cath laboratory 2 (0.1)
 Cardiovascular surgery 1 (0.1)
 General cardiology 9 (0.6)
 Heart failure clinic 1 (0.1)
 ICD 1 (0.1)
 Neurology 1 (0.1)
 PPM 5 (0.3)
 Social work 1 (0.1)
 Social work/hospice 1 (0.1)
Note: AAD = antiarrhythmic drug; AF = atrial fibrillation; DCCV = direct current cardioversion; ICD = implantable cardioverter defibrillator; OAC = oral anticoagulant; NOAC = novel oral anticoagulant; PPM = permanent pacemaker; PVI = pulmonary vein isolation.

A total of 803 patients (55.7%) had at least one medication change, primarily related to anticoagulation strategy or antiarrhythmic drug (AAD) usage, and the mean number of medication changes per patient was 1 ± 1 (median = 1). Antiarrhythmic drug and anticoagulation usage is reported for the entire cohort, 45.4% of patients were taking an AAD, and 87.3% were prescribed to an oral anticoagulant, 72.0% of which were a direct oral anticoagulant (DOAC) and the remaining 15.3% were warfarin. Patients were not prescribed anticoagulation therapy if not indicated by guidelines, the patient refused prior LA appendage closure had been performed, or if such therapy was contraindicated. A total of 435 patients (30.2%) were hospitalized at least once up to 720 days before AF clinic admission, compared with 95 patients (6.6%) over the course of 720 days after being managed in the AF clinic. Similarly, the number of patients with at least one ER visit decreased from 318 (22.1%) to 66 (4.6%) after AF clinic admission, respectively. Overall, 328 patients (22.7%) avoided at least one ER visit (400 total visits avoided) following admission to the AF clinic. Among the interventions initiated by the AF clinic, 51 patients (3.5%) were prescribed an AAD, 160 patients (11.1%) had at least 1 DCCV scheduled, and 121 patients (8.4%) were referred for a pulmonary vein isolation procedure. Twenty-six patients received alternative AF referrals, 9 of which were for general cardiology, five for a permanent pacemaker, and four for bariatric surgery.

Discussion

Overall nurse practitioner–led atrial fibrillation clinic outcomes

By standardizing AF patient care across the health care system through the AF clinic, both patients and the system benefitted. In addition to patients receiving more integrative and comprehensive care, the AF clinic facilitated more efficient care by providing a stand-alone environment for providing treatment independent of more widely used hospital resources like the ER, cardiology, and electrophysiology. Ensuring that patients receive the appropriate treatment as early as possible is crucial given that AF ablation success rates are lower in patients with more advanced AF (Linz et al., 2021; Quan et al., 2017; Zhao et al., 2016), and earlier ablation after AF diagnosis is associated with improved long-term outcomes, including AF recurrence, repeat ablations, and death (Bunch et al., 2013; Lunati et al., 2018). It is important that nurse-led clinics have been associated with better adherence to AF treatment guidelines and lower wait times for assessment (Abadie et al., 2020; Carter et al., 2016; Gillis et al., 2008; Hendricks et al., 2012). More efficient care improves the overall patient experience and can provide substantial cost reductions, as has been observed with nurse-led clinics for treating AF and heart failure (Bruggink-André de la Porte 2007; Dahle et al., 1998; Hendriks, Tomini, van Asselt, Crijns, & Vrijhoef, 2013; Pathak et al., 2017).

In this study, there was a nearly 80% reduction in the number of patients with at least one hospitalization or ER visit after the AF clinic was implemented, and 23% of all patients avoided at least one ER visit. This reduction is meaningful for both patients and the health care system given that hospitalizations and ER visits are key cost drivers for AF and minimizing excess care improves availability of hospital resources (Wolowacz et al., 2011). These results are consistent with other studies using integrative, nurse-led care for treating AF, which have also found that this strategy is associated with decreased hospitalizations and ER visits (Carter et al., 2016; Gallagher et al., 2017; Gillis et al., 2008; Hendricks et al., 2012; Stewart et al., 2015).

Initiating lifestyle modification in more than 85% of patients was an important patient care element, given the inclusion of this strategy in recent guidelines for managing AF based on the accumulating evidence supporting its efficacy in AF management (Gallagher et al., 2017; Hong & Glover, 2018). The ARREST-AF cohort study reported encouraging outcomes for improving patient care resulting from lifestyle modification/risk factor management (Pathak et al., 2014). In ARREST-AF, a single-center observational study, an additional risk factor management program was offered to patients undergoing AF ablation who had a BMI of ≥27 kg/m2 and ≥1 cardiac risk factor. Risk factor management improved patient weight, blood pressure, glycemic control, and lipid profiles and resulted in better postablation outcomes compared with the control group, including AF frequency, duration, symptoms, and arrhythmia-free survival. Lifestyle modification can also provide benefits before ablation, based on recent findings concerning participation in a 12-week aerobic interval training program, where participants experienced a reduction in mean time in AF from 8.1% to 4.8%, compared with an increase from 10.4% to 14.6% over 12 weeks in the control group, while also significantly reducing AF symptoms and improving QOL with a trend toward fewer hospitalizations with exercise (Malmo et al., 2016).

The predominant comorbidities in this study were hypertension (71% of patients) and obesity (mean BMI = 31 ± 7 kg/m2, median = 30 kg/m2); the lifestyle modifications that were implemented at the NPAFC focused on weight loss, nutrition, and exercise, with additional steps taken to lower blood pressure as needed, reduce stress, screen for sleep apnea, and encourage smoking and alcohol cessation. Thus, the ability of the AF clinic to provide more patient-centered care with an emphasis on additional disease management strategies like lifestyle modification, which are often difficult to employ in standard care, provided a benefit to the patient experience. However, more evidence is needed, particularly from larger, multisystem, randomized trials, to support the growing body of work indicating that lifestyle modification is an effective and important element of treating AF.

This study demonstrates that a structural change in the system of care can improve the efficiency and outcomes for patients and providers. Our study provides a model for systems-based practice improvement and is an example of the Institute of Health care Improvement's of improving processes, outcomes, and costs of care, as well as addressing clinician burnout. Transformational care models such as our AF clinic model are needed on a large scale to address health care challenges to overcome the barriers to efficient patient care access.

Implementing models such as the NPAFC can increase the speed and quality of care patients receive. Specifically, creating a space to address diseases known to impose a burden both economically and on the QOL, using medical providers practicing within their scope to stratify patients and provide appropriate care has proven benefit in the treatment of AF. Nurse practitioners served as valuable contributors in a system created to help treat patients identified as appropriate, to relieve the burden on the other portions of the health care system.

Limitations

This was not a controlled or randomized study. The primary purpose was to provide an example of and characterize the benefits that derive from an NPAFC in the United States. Larger, prospective, randomized, controlled trials are needed to further evaluate the impact of AF clinic implementation on patient care outcomes including the QOL. However, the feasibility and efficacy of the NPAFC is consistent with previous reports (Carter et al., 2016; Gallagher et al., 2017; Gillis et al., 2008; Hendricks et al., 2012; Stewart et al., 2015).

Conclusions

The findings from this study suggest that implementing an NPAFC in the United States is feasible and may provide an overall benefit to patient care, including fewer hospitalizations and ER visits, and regular utilization of integrative care strategies such as lifestyle modification after enrollment in the AF clinic.

Authors' contributions: D. B. Meyer, M. C. Larkins, and O. Taha contributed data analysis and final manuscript creation; A. Seiler and S. Booth contributed data analysis; R. B. Hokanson facilitated data collection; J. Allred served as the principal investigator.

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DOI: 10.1097/0000000000000786

Keywords:

Atrial fibrillation; integrative care strategies; nurse practitioner-led clinic; reduced hospitalizations

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