Navigating the Rhythm of Change in Atrial Fibrillation Care: An Anticipatory Tale

Illustration: Lee Sauer

In nursing school many years ago, I had an instructor known for her bold educational approach. During one clinical rotation, six of my fellow classmates and I dutifully trailed her down the hall of an orthopedic unit when she suddenly thrust herself against the wall. Several of us stumbled into one another as we came to an abrupt halt. She looked at us with a sideways glance and forcefully whispered, "Anticipate!" While I'm not sure there was a way to predict her sudden move, there have been many times in my career when I've heard the echo of her voice saying, "Anticipate!"

In the ever-evolving landscape of healthcare, anticipation is a powerful skill. For leaders steering the ship of cardiovascular care, it is essential to be able to foresee and embrace change and its impact on care delivery. Anticipating the impact of scientific advances critically impacts how we prepare, strategize and ultimately offer services to our patients.

For example, in the final weeks of 2023, two events impacted atrial fibrillation (AF) care. The first was the publication of the updated AF guidelines.¹ The revised guidelines emphasize maintaining sinus rhythm and minimizing AF burden and assign an upgraded Class of Recommendation for catheter ablation in appropriately selected patients.

The second event was the U.S. Food and Drug Administration (FDA) approval of the first pulsed field ablation (PFA) catheter in the U.S.²  Soon, the availability of PFA, a nonthermal ablation method, will provide a safer and more efficient way to treat paroxysmal and persistent AF. In the PULSED AF clinical trial, most cases were completed safely and effectively in under one hour.³

The synergism between these two events should not go unnoticed by clinicians and administrators alike. Neither should the significant increase in left atrial appendage closure (LAAC) procedures, which also received an upgraded recommendation in the AF guidelines. Currently, LAAC procedures are indicated only in patients who cannot tolerate oral anticoagulation. But with ongoing clinical trials evaluating the efficacy of LAAC as an alternative to direct oral anticoagulation (DOAC) in non-valvular AF, the demand could grow.

The number of people with AF in the U.S. is increasing, with the number of new cases projected to increase from 1.2 million in 2010 to 2.6 million in 2030, potentially exceeding 10 million by 2050.^5,6 A variety of forces contribute to this projection, with an aging population as one of them. This increase in AF along with guidelines that emphasize minimizing AF burden sets the playing field for an increased demand for AF ablation and LAAC procedures. Further, clinical trials investigating LAAC as not only first-line therapy but also as a concomitant procedure in AF ablation may impact procedure teams. But what every cardiovascular service line (CVSL) knows is that procedural care does not exist in isolation. This is particularly true for patients with AF. The need for comprehensive, coordinated care is not new to this patient population, but the accelerated demand for these services and the collateral impact may be.

So how does a CVSL anticipate the collateral impact? The process begins with forming a multidisciplinary team to thoroughly assess current processes and workflows to understand where the gaps are. Key activities to evaluate for the potential impact of these changes in the care of patients with AF include:

• Referral Management: Implement timely patient capture from primary care providers, emergency department (ED), and inpatient sources, as well as communication of findings back to referring providers.
• Clinic Access: Develop appropriate referral guides for when to consult electrophysiology (EP) providers and use team-based care to support patient scheduling and top-of-license work.
• Patient Navigation: Use coordinators/nurse navigators who guide and support the patient's journey, ensuring timely pre- and post-procedure care and education.
• Pre-Procedure Planning: Coordinate care to ensure authorizations and timely scheduling along with advance testing to minimize procedural cancellations and delays.
• Technology Acquisition and Supply Chain Management: Integrate new technology into the departmental budget planning and streamline the approval process.
• Information Technology: Revise order sets, charge codes and clinical documentation to support new procedures, streamline existing workflows and facilitate coding capture.
• Staff Planning and Credentialing: Anticipate the need for and timing of additional clinic and procedural staffing needs, including physician recruitment and/or credentialing for new procedures.
• EP Lab Utilization and Access, Including Prep and Recovery Space Needs: Consider changes in procedure length, intra-procedure support of other physicians and ancillary staff, along with prep and recovery throughput to support the use of same-day discharge.
• Team Training: Provide training to clinic, procedural and post-procedural care teams with enduring content that supports new team member education in the event of staff turnover.
• Performance Management: Standardize care, monitor clinical and operational metrics to assess and support safety, efficiency and financial success.
• Marketing and Communications: Tell your story effectively so the community is aware of ways to better manage their health.

While the creation of new treatment guidelines and technology is exciting, it can also cause us to stumble forward, unprepared for what is on the horizon. Preparing for those changes and developing a thoughtful plan to embrace the impact can set health systems apart, enhance patient outcomes and create value – a true example of the transformative power of anticipation.

Resources

• Cardiovascular Advanced Practice Providers Education Series: Electrophysiology
• On-Demand Webinar: EP Studies, Ablations and Device Coding and Billing for Physicians: The Least You Need to Know
• CV Business White Paper: Best Practices in Transcatheter LAAO Programs: A Case Study Approach
• Case Study: The Case for a Focused Approach to the Management of Atrial Fibrillation Patients

References

1. Writing Committee Members, Joglar, J, Chung, M. et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024;83(1):109-279.
2. Medtronic creates history with FDA approval of its novel PulseSelect™ Pulsed Field Ablation System to treat atrial fibrillation. Medtronic.com. Published December 13, 2023. Accessed December 22, 2023. https://news.medtronic.com/2023-12-13-Medtronic-creates-history-with-FDA-approval-of-its-novel-PulseSelect-TM-Pulsed-Field-Ablation-System-to-treat-atrial-fibrillation.
3. Verma A, Haines DE, Boersma LV, et.al. Pulsed field ablation for the treatment of atrial fibrillation: PULSED AF pivotal trial. Circulation. 2023;147(19):1422-1432.
4. Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112:1142–1147.
5. Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114:119–125.