Comprehensive Atrial Fibrillation Care: A Clinical Pharmacist’s Role

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EP LAB DIGEST. 2023;23(11):1,10.

Atrial fibrillation (AF) is a chronic, progressive, and expensive disease that costs the United States health care system a staggering $28 billion annually.¹ The cost and number of people diagnosed each year is projected to grow exponentially, affecting 32 million people worldwide by 2050.¹ Health care in the US has become more and more detached, with patients seeing multiple specialty providers for various disease states, rather than receiving comprehensive care for one disease state by integrating multiple disciplines.²

As the AF patient population increases, the number of new outpatient appointment slots for an electrophysiologist (EP) is getting backlogged. This is where a comprehensive and integrative AF care model can be valuable. Heart Rhythm Society has endorsed moving from siloed care models to an integrated and coordinated patient-centered AF care model.³ This type of care heavily relies on physician extenders, typically advanced practice providers (APPs). However, what about clinical pharmacists?

At OhioHealth, we have experienced tremendous success with our team-based care model. The need for a clinical pharmacist was recognized shortly after the success of our outpatient AF clinic. The role of the clinical pharmacist involves providing post-discharge transition-of-care appointments to new drug-load patients, along with longitudinal follow-up to ensure patients taking a class III drug receive ongoing monitoring to ensure safety, to decrease the risk of adverse events and expand access to our ever-growing AF population. Longitudinal monitoring incorporates bloodwork, which offloads burden from the physician inbasket, electrocardiogram (ECG) appointments to assess QTc safety and drug compliance. This alternating visit pattern offsets appointment slots for the primary EP provider to utilize for acute patients or more complex arrhythmia patients, as well as an intermediary checkpoint in an ongoing process to keep patients’ AF at bay.

Incorporating specialty-trained pharmacists into the comprehensive AF care team for longitudinal drug monitoring has helped to offload the burden of routine patient care from the physicians and APPs as well as create more availability for new patient visits. The APPs and EPs provide more acute care per visit, lending to a higher overall charge per visit, while routine care is shifted to the clinical pharmacist, who becomes another colleague in the ever-growing multidisciplinary care of AF. The pharmacist provides thorough medication reconciliation, evaluating data from refill history and patient-reported information when available, to assess medication compliance. Oftentimes, the pharmacist can offer strategies for better medication adherence, leading to better disease state outcomes and symptom management for the patient.

Pharmacist integration provides the opportunity to provide re-education to patients and emphasize where and when to seek care based on symptoms. Direct access to the pharmacist in the antiarrhythmic clinic allows for evaluation of side effects of medications vs symptoms of disease state progression. Patient engagement with the specialty-trained pharmacist also decreases utilization of acute care resources.

Pharmacist intervention is not limited to antiarrhythmic drugs; pharmacists can also be integral in anticoagulation care and monitoring. Providers who take care of AF patients know that lifelong anticoagulation is recommended for stroke risk reduction based on the patient’s stroke risk score. AF guidelines also support use of direct oral anticoagulation agents (DOACs) over warfarin when able. However, data by Arbel et al showed that of patients who were diagnosed with nonvalvular AF and had a subsequent event (eg, stroke, myocardial infarction, all-cause mortality), nearly 40% of these patients were being treated with an off-label, reduced dose DOAC at the time of the event.⁴ At OhioHealth, we have designed checkpoints to ensure that patients are evaluated by our physician extenders (an APP and specialty-trained clinical pharmacist) within 4-6 weeks of discharge from the hospital if they have just completed a new drug load, are newly diagnosed with AF, or post ablation. During these visits, DOAC dosing is evaluated for appropriateness. If any of our patients are on a class III drug, quarterly lab work is another way to not only monitor the appropriateness of the patient’s antiarrhythmic, but also their DOAC dose. Ultimately, reducing the risk of AF-related events due to off-label dosing is a safety measure that the clinic pharmacist and AF clinic APPs strive to mitigate.

The addition of a specialty-trained pharmacist also allows for the opportunity to create new services with revenue-generating potential. We have launched an outpatient sotalol-loading protocol through the pharmacist-led antiarrhythmic clinic, which has allowed low-risk patients to initiate antiarrhythmic drug therapy at home with the utilization of the KardiaMobile 6L (AliveCor). The FDA-cleared device has been instrumental in allowing for real-time QT/QTc monitoring using the same protocols as inpatient monitoring: ECG tracings 2-3 hours post-dose to assess for ECG changes. OhioHealth’s pharmacist-led antiarrhythmic clinic has loaded over 260 patients to date, saving the institution over $1.7 million ($886.30 per outpatient load vs $7571.76 per inpatient load).^5,6 None of these patients were admitted for further monitoring during the loading period due to suspected QT prolongation or adverse events from sotalol use at home.

In summary, the incorporation of a clinical pharmacist into an integrative care model is imperative for the ever-growing population of AF patients. This strategy can expand access and improve quality of AF care, as well as improve drug monitoring. 

Contact the author at @megan_labreck

Disclosure: Ms Labreck has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. She discloses consulting fees from Boston Scientific.

References

1. Kornej J, Börschel CS, Benjamin EJ, Schnabel RB. Epidemiology of atrial fibrillation in the 21st century: novel methods and new insights. Circ Res. 2020;127(1):4-20. doi:10.1161/CIRCRESAHA.120.316340

2. Brandes A, Smit MD, Nguyen BO, Rienstra M, Van Gelder IC. Risk factor management in atrial fibrillation. Arrhythm Electrophysiol Rev. 2018;7(2):118-127. doi:10.15420/aer.2018.18.2

3. Sandhu RK, Seiler A, Johnson CJ, et al. Heart Rhythm Society Atrial Fibrillation Centers of Excellence Study: a survey analysis of stakeholder practices, needs, and barriers. Heart Rhythm. 2022;19(6):1039-1048. doi:10.1016/j.hrthm.2022.02.022

4. Arbel R, Sergienko R, Hammerman A, et al. Effectiveness and safety of off-label dose-reduced direct oral anticoagulants in atrial fibrillation. Am J Med. 2019;132(7):847-855. doi:10.1016/j.amjmed.2019.01.025

5. Roberts C, Sherry M, Labreck M, Amin A, Sullivan D. Evaluation of a program for outpatient sotalol loading with physician and pharmacist monitoring. J Am Pharm Assoc. 2022;62(5):1700-1706. doi:10.1016/j.japh.2022.05.028

6. Labreck M, Billakanty SR, Chopra N, et al. PO-626-05 Pharmacist-lead class III antiarrhythmic clinic: financial and quality of care impact. Heart Rhythm. 2022;19(5):S152. doi:10.1016/j.hrthm.2022.03.870