Driving Clinical and Financial Quality in Electrophysiology: A Step-by Step Approach to A-Fib Care

The latest statistics reveal that about one in four Americans over the age of 40 are at risk to develop atrial fibrillation (A-Fib), considered the most common type of arrhythmia treated today. In fact, the American Heart Association projects that by 2050, 12 million individuals will have A-Fib. The average age of a man diagnosed with A-Fib is 66.8 years of age and 74.6 years for a woman¹ — relatively young ages considering the severity of the diagnosis. However, this also means someone with A-Fib can live many years with the condition, which places a toll on the patient as well as the healthcare system at large from clinical, operational, and financial perspectives.

Financial Considerations of A-Fib

Given the current prevalence and anticipated rise in incidence over the next three decades, consider the cost of A-Fib. In 2005, the financial impact of the condition was estimated at $6.65 billion dollars per year.² When adding costs associated with the two most common complications of A-Fib — stroke and heart failure, which are also on the rise independently and are secondary diagnoses of A-Fib — the costs associated with the long-term care and management of these patients can be staggering. Corazon believes that with appropriate diagnosis and treatment, patients will no doubt have increasing options for maintaining or improving their lifestyle. 

A-Fib is a complex disease with varied manifestations. As a result, the treatment options likewise span a long continuum; however, there are six main categories for the management of patients afflicted with A-Fib, listed below from the most simple to most complex: 

Medical therapy – involves anti-arrhythmic medications, rate control medication, or anticoagulation therapies that are prescribed and monitored closely by the patient’s specialist. 

Electrical cardioversion – involves defibrillating or “shocking” the patient with an external delivery of energy to the heart in order to convert heart rhythm back to normal. In many cases, cardioversion is followed by the introduction of anticoagulation therapy.

Radiofrequency ablation – is a more complex procedure that involves isolation of the pulmonary vein, and once the conduction pathway has been identified, the area is ablated or “burned” with energy released through a catheter connected to an external generator. 

Anticoagulation therapy – is usually at the discretion of the specialist, though in many cases, patients afflicted with A-Fib will be on some form of anticoagulation therapy. The type of medication, dosage, and frequency can vary, and must be closely monitored. 

Device therapy – involves the insertion of a permanent pacemaker device, which in many cases can be used in patients with A-Fib who also have a slow heart rate.

Surgical treatment (MAZE procedure) – can be performed on select patients in whom traditional treatments were optimized though were not successful. 

There are many viable options for this patient population; however, the more complex the treatment, the larger the fiscal impact can be to an organization. For example, in Corazon’s experience, programs must become (and/or remain!) fiscally responsible in order to ensure the viability of the program or any expansion. Looking beyond the business and clinical case of an expansion of any magnitude should not be considered lightly. We believe it is critically important to develop fiscal indicators that should be monitored just as closely as the clinical ones. Figure 1 offers some sample fiscal indicators in a dashboard format that can be used to effectively and consistently monitor and track fiscal performance for an EP program. 

Given the staggering statistics and multitude of therapies listed above, many programs that offer, or will be offering, treatment for atrial fibrillation should consider the Center of Excellence concept as a means to organize and manage A-Fib care in a way that will produce optimal clinical results, while being operationally efficient and financially viable. 

We also must consider the current ‘state of the industry’ related to healthcare reform including, but not limited to, the Accountable Care Act. Corazon advocates that all specialty programs, EP included, must prepare for what lies ahead, including many unknowns in terms of both financial and quality requirements.  

A-Fib procedures are usually favorably reimbursed by Medicare, but hospitals should not rely solely on this assumption. Corazon recommends keeping patients’ length of stay (LOS) reasonable, while having case management take an active role throughout the patient continuum of care to ensure positive margins on A-Fib procedures. Additionally, successful negotiations with payors and discussions with the local fiscal intermediary regarding local coverage determination (LCD) for A-Fib procedures will be critical.

There can be great fiscal impact due to the necessary equipment and supplies that are and/or will be utilized to diagnose and treat EP patients. For example, leaders of a program offering device implants might consider expanding upon existing EP services, but that involves significant investment for an EP mapping system, intracardiac echocardiography (ICE), portable ultrasound capabilities, and radiofrequency generator. These and other expenses can add up quickly, and Corazon experience proves the investment can range from $280K and higher depending on specific program needs. Careful consideration and validating the costs of program expansion (or even improvement) cannot be understated. 

Achieving Quality Through a Proven Approach

In terms of a true Center of Excellence concept that ensures financial viability, quality must be the foundation upon which all aspects of the program are built. Of course, one of the most important components of any program is quality, but for a condition like A-Fib, one that has the potential to increase the risk of stroke and other conditions, patients must be carefully monitored throughout their continuum of care as well as at and after discharge to ensure positive clinical outcomes are achieved despite the heightened risks of complications. It has been Corazon’s experience that when patients suffer a stroke during or after an ablative procedure, the patient’s length of stay inevitably increases, which negatively impacts the cost of care along with the clinical outcomes — a lose / lose scenario for all involved.

In the case of an electrophysiology program, especially as related to the atrial fibrillation patient population, the program administrator and team must understand the risk or outcome of a long-term complication, especially stroke and other common complications such as groin complications, tamponade, and, although less common, esophageal injury that progresses to left atrial fistula. It is imperative that clinical indicators be dissected and benchmarks set — ones that are not only acceptable, but achievable — as a means to track and monitor outcomes as key to quality assurance efforts. 

By providing the utmost quality care, patient satisfaction will increase, as will efficiencies that come as a precursor or a result of these QI processes. 

So how can a savvy EP program administrator put it all together and successfully execute a solid quality atrial fibrillation program while remaining a positive bottom line? Corazon believes achieving that goal is possible through the execution of a few proven strategies, outlined with a step-by-step approach to quality and financial excellence within the EP subspecialty. The following steps should always be considered a part of quality assurance and improvement efforts, and successful completion of these can lead to a steady climb toward excellence for A-Fib. 

While this approach seems easily articulated here, there are many details to consider in achieving these goals. Indeed, only with a collaborative and dedicated effort can the true value of this approach for driving quality be realized. 

Step #1 - Develop a collaborative electrophysiology team. 

Identifying key stakeholders who will be involved in patient care across the continuum is critical, and consideration of those clinical staff members caring for this patient population will likewise be vital. Through frequent, consistent meetings, this team should initiate all important communication to problem-solve and make changes as needed for the patient process across all electrophysiology care areas. This team needs to have a defined purpose, structure, and membership with a commitment from those stakeholders mentioned above. Additionally, a schedule of how frequently this team will meet to create and evaluate the necessary metrics that will drive continuous quality improvement (CQI) initiatives is also recommended.

Step #2 - Troubleshoot frequently challenging issues. 

Challenges to meet this measure are many, but can be resolved. Corazon has assisted hospitals with developing patient-tracking tools to determine each step of the process from first arrival of the patient, through set-up in the electrophysiology suite, to ablation, for instance. Adding each “touch point,” be it scheduling, PAT, nurse navigator, discharge planning, case management, emergency department physician (as applicable) as well the referring cardiologist or primary care provider, to the team on an ad hoc basis will provide additional insight on improving patient care. Close evaluation of these “touch points” will enable the electrophysiology team to pinpoint areas of QI opportunity, thus improving overall patient care. 

Value-based purchasing (VBP) efforts, wherein patient satisfaction accounts for approximately 30% of a program’s ability to reap the awards of having a high-quality program, are also important. In the near future, VBP percentage metrics will be changed; even greater focus will be placed on a program’s ability to ensure a superior level of patient satisfaction as well as provide stellar quality outcomes. 

Step #3 – Develop solid program indicators.

The collaborative electrophysiology team must closely evaluate all outcomes measured and share the results with staff during department meetings. This approach will enable the commitment and engagement of all participants, which will no doubt lead to results in improving patient care. Corazon assists many programs in the development of those indicators, and we recommend programs identify the following as potential criteria: market share growth, operational efficiency, clinical outcomes, staffing, patient satisfaction scores, and others. 

Figure 2 shows a sampling of indicators that can be tracked for EP program benchmarking purposes. These data points under categories mentioned above (and perhaps others), should be placed in a detailed format in order to track the anticipated benchmark goal and its source, the source of the data, and the person(s) responsible for measuring and reporting the data. Creating a robust collection of indicators to track, which can become part of a larger program “report card,” will make great strides in tracking performance, identifying opportunities for QI and growth, while also giving a big-picture, at-a-glance snapshot of program operations. Corazon advocates that all stakeholders and direct patient caregivers be involved in the process of developing program indicators, which will also facilitate their commitment to measurement and reporting of said indicators. 

There are several registries offered through the American College of Cardiology that look at the “global” cardiovascular patient population with additional risk factors, or comorbidities associated with their diagnosis; however, other than the PINNACLE-AF registry that continues to be refined, there is no formal report, or executive summary, that is offered to programs who submit to registries such as the ICD or CathPCI. These reports offer programs comparative benchmarks that in Corazon’s experience afford those programs additional avenues for CQI.

The nurse navigator role mentioned above has proven to drive quality and success. In many circumstances, this clinician is with the patient across their entire continuum of care even before the patient enters the facility; in fact, in many cases, they are contacted by the referring physician’s office and begin to dialogue with the patient prior to arrival for their procedure. As part of this role, and through the collaborative electrophysiology team pathways and protocols that have been developed, the nurse navigator can document each “touch point” as well as any risk factors the patient may have. He/she should remain in constant communication with the clinical team, and in many cases, facilitate patient discharge as well. Essentially, the nurse navigator is with the patient at every touch point, which should help to maintain overall clinical and operational consistency of care, and as a result, quality delivery and operational efficiency. 

Corazon fully recognizes the nurse navigator is a resource that many organizations may not currently employ today, though it is one that should be considered as a relatively simple one to implement while impacting patient satisfaction. In fact, employing a nurse navigator strategy alone will greatly assist in driving ongoing quality within electrophysiology. 

In conclusion, the ability to drive quality always comes at a cost, though Corazon believes that the expenditure of financial, human, or other resources is well spent. Quality must be considered more than just “standard reporting;” rather, it must be considered the foundation of the program and remain a top priority of focus at all times, especially as the healthcare industry anticipates growth in the atrial fibrillation population. Combined with evolution in treatment options, the management of this patient population will no doubt become more complex and more demanding. 

As organizations continue to evaluate potential program expansion or improvement of existing services, it is critical to analyze the impact of healthcare reform, and to understand how to approach this and other challenges, regardless of program size or scope. Whether a small community provider or part of a larger health system, all EP programs should work to be proactive in an approach to excellence — only then can true progress be achieved.

Amy Newell is a Vice President at Corazon, a national leader in program development for the heart, vascular, neuro, and orthopedic specialties, offering consulting, recruitment, interim management, and IT solutions across the country and in Canada. To learn more, visit www.corazoninc.com or call 412-364-8200. To reach Amy e-mail anewell@corazoninc.com.

References

1. American Heart Association “Heart and Stroke Statistics” 2013 Update.
2. Ibid.