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Keeping atrial fibrillation patients out of the hospital

Improving access to specialty care through UNC Health’s AFib Care Network

April 25, 2022

As the world struggles with the challenges of Covid, it has never been more important to keep people out of the hospital who don’t absolutely need to be there. For example, say you find yourself experiencing heart palpitations, chest pain, and shortness of breath. A heart attack, and a scary trip to the nearest emergency room, right? Actually, in many cases these symptoms are signs of atrial fibrillation (AFib) – and with the right kind of treatment in the ER, you won’t be admitted but will be able to go home to rest, with a follow-up appointment with your doctor already scheduled.

At least, in Canada this is usually the case. In that country, about 90% of patients who go to the hospital with AFib are discharged in the ER. In the United States, however, only about 20% go home, with the rest admitted into the hospital. And given that an estimated nearly 3 million people in the U.S. have the disease, that represents quite a burden on our healthcare system.

Dr. Anil Gehi, a cardiologist at the UNC School of Medicine in Chapel Hill, North Carolina, knew it didn’t have to be this way. “If the admission rate is so variable from country to country – and from hospital to hospital – you know there must be something wrong,” he said. Dr. Gehi committed himself to finding out what was wrong and doing what he could to fix it. He soon found significant support, in the form of a $1.7 million grant from the Bristol Myers Squibb Foundation, as part of its mission to promote health equity.

That’s how Dr. Gehi launched the AFib Care Network. The AFib Care Network has multiple approaches to improving AFib care in the community. Hospital ERs are paired with local cardiology AFib specialists so that appropriate patients can be discharged from the ER and set up with an expedited appointment. Primary care physicians, who are the major caregiver for a large number of AFib patients, are trained in best practices for AFib management. And patients are offered the opportunity to educate themselves about AFib to encourage them to get involved in their care and learn to self-manage the disease. Through the efforts, the program has led to a significant reduction in hospital admissions for atrial fibrillation within the UNC Health Care system. The impact has been felt the most among citizens of the state’s underserved communities, who have less access to specialists and are more likely to be treated exclusively by primary care physicians.

This translates into being more likely to head to the ER when it’s not necessary. As Dr. Gehi explained: “The AFib treatment guidelines are constantly evolving, and it’s very hard for a primary care physician to keep up. That leads to a lot of care variation. We knew that if we went directly to the primary care community and trained them, we could have a huge impact. So we ended up attacking this issue from two sides: from the patient side, with education and awareness, and from the care side, with streamlining and standardization.”

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The diagnosis for AFib isn’t complicated, but how you manage it gets to be extraordinarily complicated.

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Dr. Gehi and his team created a new program, launched via Zoom right in the middle of the pandemic, in which two groups of forty physicians, nurse practitioners, and physician assistants spent six months with weekly video conferences, being educated on AFib treatment best practices. The impact has been significant. “If we train 40 providers, that translates to 2,500 patients getting better care,” said Dr. Gehi. “And that means fewer strokes, fewer ER visits, and better quality of life for a lot of people.”

If you traveled due east 150 miles from Chapel Hill to the small town of Lenoir, in the foothills of the Blue Ridge Mountains, you’d find a family doctor who would agree wholeheartedly.

Dr. Robert Reichling has been serving that community for more than twenty years, with a practice that serves mostly elderly patients, who are at increased risk of atrial fibrillation and therefore of the strokes that are the most dangerous consequence of the heart condition. He estimates that he sees three or four AFib patients every day. Dr. Reichling recently completed the UNC training program, officially called the Atrial Fibrillation and EKG Interpretation TeleECHO Clinic.

“The diagnosis for AFib isn’t complicated, but how you manage it gets to be extraordinarily complicated,” Dr. Reichling said. “The range of treatments available has just exploded in the years since I was in medical school. But if you’re not in a university hospital, you don’t necessarily know enough about all the treatments that are available, whether it is left atrial appendage occlusion, or ablation, or even standardized templates for reading EKGs. I’m now much better equipped to manage the care of my AFib patients. And when they do have to see a cardiologist, I’m able to give the specialist a much more in-depth picture of the patient so that they don’t have to start from scratch developing a treatment plan.”

Dr. Gehi’s goal has been to improve the standard of care for atrial fibrillation patients, especially among underserved communities like the one Dr. Reichling serves. It’s clear he’s benefiting not only patients but the healthcare providers as well.

“Sometimes you kind of trudge through your day and don’t think you’re making any impact,” said Dr. Reichling. “But the UNC program really reinforced the importance of the primary care physician and gave me tools to help me provide the level of care my patients deserve.”

The success of the AFib Clinic has Dr. Gehi thinking about what’s next. “What we’d really like to do is expand our outpatient provider training program across a lot more of North Carolina, but focused on underserved communities. We think that’s where we have the most potential impact moving forward.” If what Dr. Gehi and UNC Health Care have accomplished so far is any guide, North Carolinians can expect to see some very positive developments in the understanding and treatment of AFib.