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

T ransitioning E mergency A Fib M anagement: 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 – 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 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.