Abbreviations:AF (atrial fibrillation), CHIP (Children’s Health Insurance Program), CIED (cardiac implantable electronic device), CoE (center of excellence), CQI (continuous quality improvement), EHR (electronic health record), EMR (electronic medical record), HRS (Heart Rhythm Society), LAA (left atrial appendage), MIPS (Merit-based Incentive Payment System), OAC (oral anticoagulation), PRO (patient-reported outcomes), QI (quality improvement), QoL (quality of life), QPP (Quality Payment Program), SDM (shared decision-making)
Section 1 Introduction
- January C.T.
- Wann L.S.
- Alpert J.S.
- et al.
Section 2 Background and rationale
Opportunities to improve care of AF
- January C.T.
- Wann L.S.
- Alpert J.S.
- et al.
- January C.T.
- Wann L.S.
- Calkins H.
- et al.
- Patti G.
- Lucerna M.
- Pecen L.
- et al.
- Anderson J.L.
- Halperin J.L.
- Albert N.M.
- et al.
Section 3 Building a comprehensive AF program: Components and key opportunities
Goals of AF CoE
Identification of patients
Appropriate clinician roles and resources
Developing a comprehensive care team
|Study||Design||Intervention group||Comparator||Primary endpoint|
|Hendriks et al 2012|
|RCT: 712 pts, 67y, 41% female; mean FU 22 months; single center; outpatient department new-onset AF pts||Nurse-led care with guideline-based, software-supported, integrated care supervised by cardiologist: integrated comprehensive care||Usual care||Composite 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 = 0.029|
|Stewart et al 2015|
|RCT: 335 pts, 72y, 48% female; mean FU 30 months; multicenter;|
pts hospitalized for AF
|Home visit and Holter monitoring 7–14 days after discharge by nurse with prolonged FU and multidisciplinary support as needed: comprehensive care||Usual care||ACM and all-cause hosp. 76% vs 82% (intervention vs usual care), HR 0.97 (95% CI 0.76–1.23); P = 0.85|
|Carter et al 2016|
|Before and after study: 433 pts, 64y, 44% female;|
FU >12 months; multicenter; new-onset AF ED pts
|After phase is nurse-run, supervised by physician AF clinic with group education: comprehensive care||Usual-care 2009–2011 is before phase retrospective||Composite death, CV hosp., AF ED visits, propensity matched: 17.3% vs 26.2% (intervention vs usual care) (OR 0.71, 95% CI 0.59–0.99; P = 0.049); ED visits 13.1% vs 20.8% (P = 0.06); hosp. 6% vs 9.5% (OR 0.60, 95% CI 0.27–1.37; P = 0.22); OAC 88.4% vs 58.5% (P < 0.01)|
|Vinereanu et al 2017|
|Cluster RCT: 2281 pts, 70y, 47% female;|
FU 12 months; multicenter
|Patient and HCP education, regular monitoring, and feedback to HCPs: focus only on antithrombotic therapy||Usual care||Change in % pts on OAC at 1 year: intervention, 68% to 80%; usual care, 64% to 67%; OR 3.28 (95% CI 1.67–6.44) of change in OAC use between groups|
|Gallagher et al 2017|
|Systematic review and meta-analysis: 1383 pts||Reduction in ACM (OR 0.51, 95% CI 0.32–0.80; P = 0.003) and CV hosp. (0.58, 0.44–0.77; P = 0.0002); no impact on AF hosp. (0.82, 0.56–1.19; P = 0.29) or cerebrovascular events (1.00, 0.48–2.09; P = 1.00)|
|Cox et al 2018|
LBCT at AHA 2018 submitted
|Cluster RCT: 1145 pts, 72y, 40% female; FU 12 months; primary care pts; data presented at AHA 2018||CDSS, incorporating guideline-based physician monitoring system proactively and assisting physicians by providing therapeutic recommendations: comprehensive care||Usual care||Composite of AF-related ED visits or unplanned CV hosp., HR 1.02 (95% CI 0.73–1.41); P = 0.93, and ISTH major bleeding, 1.04 (0.38–2.88); P = 0.93|
|Rienstra et al 2018|
|RCT: 245 pts, 64y, 21% female; FU 12 months; multicenter;|
early persistent AF and mild-to-moderate heart failure pts
|Four risk factor therapies: 1) mineralocorticoid receptor antagonists, 2) statins, 3) angiotensin-converting enzyme inhibitors and/or receptor blockers, and 4) CR including physical activity, dietary restrictions, and counseling: comprehensive care||Usual care||Sinus rhythm at 1 year during 7 days of Holter monitoring: sinus rhythm present in 75% of patients in intervention vs 63% in conventional group (OR 1.765, lower limit of 95% CI 1.021; P = 0.042)|
|Parkash et al 2017|
|RCT: 184 pts, 60y, 25% female; FU 14 months; multicenter;|
pts with AAF and BP >130/80 mm Hg
|Aggressive BP (target <120/80 mm Hg) treatment: focus only on BP management||Standard BP (target <140/90 mm Hg) treatment||Symptomatic recurrence of AF/AFL/AT >30 seconds 3 months beyond catheter ablation: 61.4% in aggressive BP vs 61.2% in standard (HR 0.94, 95% CI 0.65–1.38; P = 0.763)|
|Alharbi et al 2019|
|CR (133 pts) compared with specialized AFC (197 pts) and usual care (236 pts): mean age n.a., 40% female; FU 12 months||CR, medically supervised, involving prescribed exercise, cardiac risk factors modification, education, and counseling: comprehensive care||Usual care retrospective||AF-related ED visits and CV hosp.: 7.5% in CR, 16.8% in AFC, and 29.2% in usual care group. Propensity-matched analysis: CR best compared with usual care OR 4.91 (95% CI 2.09–11.53) and compared with AFC 2.75 (1.14–6.6)|
|Hendriks et al 2019|
|RCT: 712 pts, 67y, 41% female; mean FU 22 months; single center, outpatient department new-onset AF pts; post hoc analysis||Nurse-led care with guideline-based, software supported integrated care supervised by cardiologist: integrated comprehensive care||Usual care||ACM 3.7% vs 8.1% in nurse-led vs usual care (HR 0.44, 95% CI 0.23–0.85; P = 0.014); CV mortality in 1.1% vs 3.9% (0.28, 0.09–0.85; P = 0.025); non-CV mortality 2.5% vs 4.2% (0.59, 0.26–1.34; P = 0.206)|
|Wijtvliet et al 2019|
|RCT: 1354 pts; FU 37 months||Nurse-led comprehensive care by specialized nurses using a decision support tool, in consultation with the cardiologist||Usual care|
Specific treatment goals
Evaluating and improving symptoms
Rate and rhythm control
- January C.T.
- Wann L.S.
- Calkins H.
- et al.
Treatment of risk factors
Integration of CIED care, monitoring, and wearables
Development of team-based care pathways
Section 4 Team-based integrated care
- Inglis S.C.
- Clark R.A.
- McAlister F.A.
- Stewart S.
- Cleland J.G.
Section 5 Quality improvement
Importance of measuring performance and quality improvement
Module 4. Approaches to quality improvement.
Protocols for standardized practice
Get With The Guidelines®–AFIB Recognition Criteria.
Achieving stakeholder consensus on specific goals and metrics of care
Establishment of processes to improve care
Section 6 Focus on patient-centered care
Patient decision aids.
Mayo Clinic Shared Decision Making National Resource Center.
Decision support & shared decision making for clinicians & patients at the point of care.
Equity in AF care
Section 7 Efficiency and financial considerations
Opportunities for innovation while improving efficiency
Cost-effectiveness of AF centers
Section 8 Accreditation and options for participation/scope
Section 9 Goals, gaps in care, and challenges
- Schechter J.
- Seiler A.
- Carroll D.
- Young S.
- et al.
Communication and patient education
Atrial fibrillation and AF-related stroke.
Gaps in care
Section 10 Potential role of HRS
- •Establish guideline-driven, consensus-based standards for clinical care of AF and procedural outcomes (ie, success and complications)
- •Create protocols and processes that standardize and improve the quality of delivered AF care by participating AF centers
- •Form best practice outcome metrics that will evolve over time to ensure that the quality of delivered care consistently improves everywhere
- •Develop CQI programs to assist institutions and clinicians to achieve guideline-driven quality care
- •Ensure transparency to prioritize patient outcomes
- •Innovate to generate accurate registry data that minimize inconvenience and cost
Engagement of essential stakeholders
Section 11 Conclusion and next steps
|Writing group member||Employment||Honoraria/speaking/consulting||Speakers’ bureau||Research|
|Ownership/partnership/principal/majority stockholder||Stock or stock options||Intellectual property/royalties||Other|
|Jonathan P. Piccini, Sr, MD, MHS, FHRS (Chair)||Duke University Medical Center, Durham, North Carolina||None||None||None||None||None||None|
|Thomas Deneke, MD, PhD, FHRS (Vice-Chair)||Heart Center Bad Neustadt, Bad Neustadt, Germany||None||None||None||None||None||None|
|James Allred, MD, FHRS||Cone Health, Greensboro, North Carolina||None||None||None||None||None|
|T. Jared Bunch, MD, FHRS||University of Utah School of Medicine, Salt Lake City, Utah||None||None||None||None||None||None||None|
|Thomas F. Deering, MBA, MD, FHRS, CCDS||Piedmont Heart Institute, Atlanta, Georgia||None||None||None||None||None||None||None||None|
|Luigi Di Biase, MD, PhD, FHRS||Albert Einstein College of Medicine at Montefiore Hospital, New York, New York||None||None||None||None||None||None||None|
|Ayman A. Hussein, MD, FHRS||Cleveland Clinic, Cleveland, Ohio||None||None||None||None||None||None||None|
|William R. Lewis, MD, FHRS||MetroHealth System Campus, Case Western Reserve University, Cleveland, Ohio||None||None||None||None||None||None||None|
|Suneet Mittal, MD, FHRS||The Valley Hospital, Ridgewood, New Jersey||None||None||None||None||None||None|
|Andrea Natale, MD, FHRS||Texas Cardiac Arrhythmia Institute, Austin, Texas||None||None||None||None||None||None||None|
|Jose Osorio, MD, FHRS||Arrhythmia Institute at Grandview, Birmingham, Alabama||None||None||None||None||None||None|
|Douglas L. Packer, MD, FHRS||Mayo Clinic Hospital, Saint Mary’s Campus, Rochester, Minnesota||None||None||None||None|
|Christian Ruff, MD||Brigham and Women’s Hospital, Boston, Massachusetts||None||None||None||None||None||None|
|Andrea M. Russo, MD, FHRS||Cooper Medical School at Rowan University, Camden, New Jersey||None||None||None||None||None|
|Prashanthan Sanders, MBBS, PhD, FHRS||University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia||None||None||None||None||None|
|Amber Seiler, MSN, NP, FHRS, CEPS, CCDS||Cone Health, Greensboro, North Carolina||None||None||None||None||None||None|
|David Slotwiner, MD, FHRS||Cardiology Division, New York-Presbyterian Queens, and School of Health Policy & Research, Weill Cornell Medicine, New York, New York||None||None||None||None||None||None||None||None|
|Mellanie True Hills, CSP||StopAfib.org, American Foundation for Women’s Health, Decatur, Texas||None||None||None||None||None||None||None|
|Mintu P. Turakhia, MD, MS, FHRS||Center for Digital Health, Stanford University, Stanford, California, and VA Palo Alto Health Care System, Palo Alto, California||None||None||None||None||None||None|
|Isabelle C. Van Gelder, MD, PhD||University of Groningen, University Medical Center Groningen, Groningen, the Netherlands||None||None||None||None||None||None|
|Paul D. Varosy, MD, FHRS||VA Eastern Colorado Health Care Systems and University of Colorado, Aurora, Colorado||None||None||None||None||None||None|
|Atul Verma, MD, FHRS||Southlake Regional Health Centre, Newmarket, Ontario, Canada||None||None||None||None||None||None|
|Annabelle S. Volgman, MD||Rush University Medical Center, Chicago, Illinois||None||None||None||None||4Apple||None||None|
|Kathryn A. Wood, PhD, RN||Emory University School of Nursing, Atlanta, Georgia||None||None||None||None||None||None||None|
|Peer reviewer||Employment||Honoraria/speaking/consulting||Speakers’ bureau||Research|
|Ownership/partnership/principal/majority stockholder||Stock or stock options||Intellectual property/royalties||Other|
|Chirag R. Barbhaiya, MD, FHRS||NYU Langone Medical Center, New York, New York||None||None||None||None||None||None||None|
|Laurel Kay Racenet, MSN, FNP, FHRS, CEPS, CCDS||Alaska Heart and Vascular Institute, Anchorage, Alaska||None||None||None||None||None||None||None||None|
|Colleen J. Johnson, MD, MS, FACC||Tulane University, New Orleans, Louisiana||None||None||None||None||None||None||None|
|James V. Freeman, MD, MPH, MS||Yale School of Medicine, New Haven, Connecticut||None||None||None||None||None||None|
|John N. Catanzaro, MD, FHRS||University of Florida–Health, Jacksonville, Florida||None||None||None||None||None||None||None|
|Aileen M. Ferrick, RN, PhD, ACNP-C, FHRS||Westchester Medical Center, Valhalla, New York||None||None||None||None||None||None||None||None|
|Michael E. Field, MD||Medical University of South Carolina, Charleston, South Carolina||None||None||None||None||None||None||None|
|Sunny Po, MD, PhD, FHRS||Heart Rhythm Institute, University of Oklahoma, Edmond, Oklahoma||None||None||None||None||None||None|
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