DOES THE CARE OF PATIENTS WITH ATRIAL FIBRILLATION (AF) DIFFER BETWEEN AF AND GENERAL CARDIOLOGY CLINICS? EVALUATION OF PRACTICE PATTERN VARIATIONS WITH A CHECKLIST OF AMBULATORY AF CARE

The care of patients with atrial fibrillation (AF) is often fragmented and may impede delivery of evidence-based, guideline-concordant care. Accordingly, AF clinics are established to provide ambulatory care in a focused and standardized fashion. We hypothesize that the frequency by which key elements of ambulatory AF care are addressed is higher in AF clinics, when compared to usual care. By consensus, electrophysiologists from 3 hospitals developed a list of 8 “core” elements of ambulatory AF care consisting of: (1) Documentation of AF symptoms, (2) Quality of life (QoL) assessment; (3) Discussion of stroke risk; (4) Discussion of antithrombotic (AT) therapy use; (5) Discussion of bleeding risk; (6) Identification of risk factors for developing AF; (7) Discussion of previous rate/rhythm-control therapies; (8) Recommendation of (a) AT therapy and (b) rate/rhythm-control therapy at the current visit. Using a set of pre-defined criteria, a trained data abstracter categorized if each element was adequately addressed in a “yes/no” fashion. Disagreement was resolved by consensus. From April to December 2012, we retrospectively reviewed the initial consult letters of 278 consecutive patients from the AF clinics of 2 teaching hospitals. The control group consisted of 36 consecutive patients with a primary diagnosis of AF assessed at 4 General Cardiology (GC) clinics. The 2 groups were similar in terms of sex, diabetes, hypertension, and history of heart failure. Patients assessed in AF clinics were younger than those from GC clinics (63.7±13.7 vs. 72.8±11.5 years, p<0.01). Assessment and discussion of AF symptoms and AF therapies occurred frequently (>80%) in both groups. Discussion of QoL occurred in 60% of patients assessed in AF clinics vs. none in GC clinics (p<0.01). In AF clinics, stroke and bleeding risk was discussed in 79% and 16% of patients, compared to 28% and 44% of patients assessed in GC clinics (p<0.01 for both comparisons). (Figure) The use of a “core element” checklist helped to identify patterns and variations in ambulatory AF care between AF and GC clinics. Discussion of AF symptoms and therapies occurred frequently for patients assessed in both clinics. Stroke risk and QoL were more often discussed for patients assessed in AF clinics than those in GC clinics. Bleeding risk was not frequently discussed in both clinics. Further research is required to address whether attainment of these quality metrics will translate to improved clinical outcomes in this patient population.