Project ObjectiveTo enhance the system of care for atrial fibrillation that not only reduces system costs, but improves the experiences of both patients and care providers

Transitioning Emergency AFib Management:The TEAM Study

• Run by• Part of the overall • Principle Investigators:– Dr. Nazanin Meshkat, Emergency, UHN– Dr. Sacha Bhatia, Cardiology, WCH and UHN– Dr. Paul Dorian, Cardiology, SMH

• Collaboration among:

Background• Atrial fibrillation (AFIB) is the most common cardiac arrhythmia

and the incidence is growing as the population ages• AFIB patients are at significantly increased risk of stroke and

heart failure and a decreased quality of life• AFIB is responsible for an increasing number of emergency

department (ED) visits and hospitalizations• The fragmentation of care of this chronic condition is a driver

for avoidable health utilization and costs

We hypothesized that a transition of care intervention for ED patients with primary AF would reduce avoidable hospitalizations

Hospital Rates for Atrial Fibrillation

Tran et. al, 2015

TEAM: Intervention• INTERVENTION - In the ED:

– Acute AF order set and pathway– Patient education package and early referral appointment at discharge

• INTERVENTION - After the ED Visit:– NP-and-Pharmacist-led interdisciplinary program with Internist support

for early post-discharge patient standardized review and treatment (The Atrial Fibrillation Quality Care Program – AFQCP)

– STANDARDIZED guideline-based assessment– Principle of coordination and reintegration back to primary care

provider (PCP) with shared AF one-page Care Plan– Tailored education for patients and patient-friendly Care Plan with

clear advice for acute episode self-management– 1-855 clinician-staffed hotline for patient and PCP support– Facilitated Facilitated access to Cardiology and Electrophysiology

referral if needed.• Ease of access to diagnostic testing

Transitioning Emergency AFIB Management (TEAM)

Intervention in the ED

Care Plans

Results: Patient Characteristics

• Total Eligible patients at index ED visit n=832– Total admitted=546– Total discharged=200

• Total AFQCP patients n= 155 (78%)• Median age 65 years old• 58% were male, 95% had a GP.• 40% had a history of AF, 44% HTN, 9% CAD• 15% on OACs, 28% on anti-platelet agents• 45% CHADS2=0

RESULTS

• Model improves Quality-of-Life*–Mean score at first AFQCP visit: 60.4 ±23.5–Mean score at 3 months: 84.8 ± 15.4• Clinically significant improvement in scores

– Improvement was seen in all subscales:• Symptoms• Activities of daily living • Treatment concern• Treatment satisfaction

*assessed using validated AFEQT tool

RESULTS

• 1-855 Hotline helps avoid ED visits– 56 calls to the hotline• 23 patients• 7 healthcare providers

– 11 ED visits avoided• In the opinion of both the patient and the clinician• 1 ED visit was recommended by the clinician

• Hotline for acute AF advice is feasible• **the call answerers need to be familiar with

the patients or have access to care plans

RESULTS

• The service is valued by patients, primary care providers and ED physicians

• SHARED CARE PLAN– Level of detail was ‘about right’– 64% described the care plan as having a positive or strongly

positive impact on their ability to provide care

• Stroke Prevention Adherence– 85% are on guideline recommended treatment– 4% with clinically valid reason not to take– 9% patients refuse

– Half are related to refusal to stop ASA when not indicated

TEAM: Challenges

• Health Information Access• Referrals from ED– ~38% of eligible patients

• Current remuneration strategies– Providing tailored education, care coordination

and acute access for patients takes time consuming

• Patients co-morbidity and complexity.

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