Establishing an APP-Led Multidisciplinary Atrial Fibrillation Clinic

In this feature interview, we speak with Dr. Sandeep Jain about the multidisciplinary team approach at the UPMC Center for Atrial Fibrillation, part of the UPMC Heart and Vascular Institute in Pittsburgh, Pennsylvania. 

Tell us about the cardiac electrophysiology (EP) program at the UPMC Heart and Vascular Institute. 

We are a group of 12 electrophysiologists practicing in 4 hospitals in the UPMC system with 6 full-service EP labs in Pittsburgh. We perform roughly 1200 ablations per year, as well as a full range of device procedures such as left atrial appendage occlusion. Most of us spend some time at the main university center and at one of the outreach sites, although they’re all within about 20 minutes of each other. 

How and when did the concept for an Atrial Fibrillation (AF) Clinic come about? When did the clinic open? 

Our original concept for an AF clinic, which came about in 2010 or 2011, was borne from the realization that many of the patients that we were seeing for AF referral were often later in their stage of disease. As you know, the later the stage of AF, the less options we have to offer these patients, and whatever options we do have, the success rates decrease with time. A lot of prevention can be done if AF is caught early. That led us to believe that the way that we were managing and triaging these patients was not ideal — we wanted to be available to patients with atrial fibrillation much earlier in their disease, even if it did not make an immediate change in their management. A lot of places have now adopted an AF clinic model; what makes UPMC unique is the role of our advanced practice providers (APPs) within our AF Clinic. We have three dedicated nurse practitioners (Amanda Kristofik, Whitney Adams, and Erica Byers) who serve as our AF Center directors. 

How is patient education managed?

One of the striking points that we realized over time was that even though a patient may have had a diagnosis of atrial fibrillation for several years, they often weren’t even aware of why they were taking coumadin, for example. Education is paramount to treatment, especially as it relates to lifestyle modification, losing weight, proper diet, and exercise to help prevent recurrences. Therefore, patients are provided with about 30-45 minutes of education by our APPs the first time they’re seen in clinic. Each patient leaves our clinic with specific educational materials customized to the patient. If we’re proposing a certain anticoagulant, they will receive an insert on that medication; if we are speaking of a certain antiarrhythmic or procedure (such as an ablation or LAA device), they will receive an insert on that as well as general information about AF. I think that really engages patients to take some responsibility for their own care, which we increasingly know is more and more important. These are all materials that we have developed locally — the nurse practitioners have put this together from their experience and where they see are the gaps in knowledge that many of these patients have when they first come to us. We offer open-ended follow-up after that. 

People are usually first referred to us for a specific issue, but we also now have different care pathways such as emergency room (ED) referrals from first-time AF patients. We created a pilot program to help offer rapid triage, so that patients with newly discovered AF will be seen within one or two business days within our AF Clinic. The hope here is that when an ED doctor is aware of our services available, it will help them potentially discharge home a stable patient, as opposed to what I think often historically happens, which is reflex admission. We’ve had this pilot program in place for a couple of years now, and are starting to look at the data to see how this impacts healthcare resource utilization.

How many patients are now treated annually at the AF Clinic? 

Our AF providers have seen about 4000 patients in the last 12 months.

Are other subspecialties part of the AF Clinic team as well?

Our dedicated nurse practitioners run the clinic and help oversee everything. Within the UPMC Heart and Vascular Institute, we have access to a clinical nutritionist that we refer patients to often. There is an anticoagulant clinic at our main site as well, although over time with the use of NOACs, that has not been as much of a need. All of our electrophysiologists are part of the center and help manage AF patients. In addition, at some of the hospitals where there are not on-site EP services, there are general cardiologists who partner with us and help drive these same pathways of care. The dietitians are part of the clinic, and we work very closely with our heart failure colleagues at the main sites. We have also been pretty lucky to have buy-in from our cardiac surgery partners to offer surgical options for AF such as the convergent and standalone maze procedure. Our main goal, which I think we have achieved, is that anyone with AF deserves a visit. We also have had a lot of buy-in from internists and general cardiologists, who view this as a useful resource. 

How important was standardization of AF management across your service line and healthcare system?

It’s extremely important, and it was probably one of the biggest challenges when we first started this center. There are virtual clinics within the system as well as approximately 40 UPMC academic, community, and specialty hospitals in Pennsylvania. To have standardization without necessarily brick-and-mortar sites is crucial, so for electronic health records (EHR), we have standardized order sets in addition to flow diagrams of appropriate rate control and anticoagulation according to the guidelines. We also have the ability to query and consult (including virtually) for acute care and inpatient management, and we try to standardize that as much as possible. 

What would you say are the key elements for creating an AF clinic model?

It’s important to have all expertise available in a multidisciplinary clinic to provide every option. Expertise ranging from device implantation, antiarrhythmic therapy, AF ablation, and other newer techniques such as left atrial appendage occlusion are all needed to provide that breadth and depth. In addition, care pathways that follow the standards of care from the national societies need to be in place. A lot of this involves teaching not only the patients but the providers. The first couple of years, I spent a lot of my time talking to every group of physicians that interact with AF patients, such as internists, general cardiologists, hospitalists, neurologists, and ED physicians. I still make those rounds. A baseline level of educational material is also very much needed, so patients can understand what AF is and the scope of their treatment options. A lot of that is available through our societies.

Is there anything else you’d like to add?

The ability of our APPs to independently see these AF patients, even from a rapid ER triage situation, is very important. In most practices, it would be unrealistic to think that electrophysiologists would be able to see AF patients on every level without help. The infrastructure that we have from our APPs is key. Now that this infrastructure is in place, it allows us to explore novel pathways of care and evaluate quality metrics across the system in addition to having real-world data on new procedures and therapies, as all patients seen are tracked in a comprehensive database. 

Disclosures: Dr. Jain has no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Jain reports he is a consultant for Medtronic, as well as a research principal investigator for Abbott, Medtronic, and Boston Scientific.